A 43-year-old man comes to the emergency department with severe abdominal pain and vomiting for the last several days. He has been drinking wine heavily since separating from his wife recently. He was admitted to the hospital for alcohol-related seizures a year ago and left against medical advice. The patient's medical problems also include chronic low back pain and nephrolithiasis. He takes over-the-counter painkillers. His temperature is 38.3 C (101 F), blood pressure is 112/70 mm Hg, pulse is 105/min, and respirations are 18/min. Physical examination is significant for jaundice in the eyes and skin. Breath sounds are normal. The abdomen is distended, with significant tenderness in the right upper quadrant to palpation. There is dullness to percussion in bilateral flank regions.
Laboratory results are as follows:

Which of the following is the most likely diagnosis?

Question

A 43-year-old man comes to the emergency department with severe abdominal pain and vomiting for the last several days.  He has been drinking wine heavily since separating from his wife recently.  He was admitted to the hospital for alcohol-related seizures a year ago and left against medical advice.  The patient's medical problems also include chronic low back pain and nephrolithiasis.  He takes over-the-counter painkillers.  His temperature is 38.3 C (101 F), blood pressure is 112/70 mm Hg, pulse is 105/min, and respirations are 18/min.  Physical examination is significant for jaundice in the eyes and skin.  Breath sounds are normal.  The abdomen is distended, with significant tenderness in the right upper quadrant to palpation.  There is dullness to percussion in bilateral flank regions.
Laboratory results are as follows:

Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec193a_9612_4508_853d_e7ef37f2de5d_MD0002_00 This patient's presentation is consistent with alcoholic hepatitis (AH). AH patients typically have a history of excessive alcohol use for >20 years, but they may increase their intake acutely in response to stressful situations. AH typically presents with acute jaundice, fever, anorexia, right upper-quadrant/epigastric pain, and abdominal distention due to ascites. Malnourished patients may also develop muscle wasting with proximal muscle weakness. Laboratory studies usually show elevated aspartate aminotransferase (AST) and alanine aminotransferase (ALT) (usually <300 U/L), AST:ALT ratio >2, elevated gamma-glutamyltransferase and international normalized ratio, and low albumin (if malnourished). The serum ferritin is also elevated due to acute inflammation, sometimes >1000 ng/mL. Abdominal imaging may show fatty liver. (Choice A) Acute cholecystitis can present with fever, right upper-quadrant pain, nausea, vomiting, and anorexia. However, jaundice indicates cholangitis and is not typically seen in cholecystitis. (Choice C) For reasons that are unclear, alcoholic liver disease can lead to increased iron in the liver, resembling hemochromatosis. However, hereditary hemochromatosis (HH) has much higher serum iron levels and transferrin saturation is usually >50%. In addition, HH does not have the AST:ALT ratio >2 seen in alcoholic liver disease. (Choice D) Hepatic abscess can present with fever, abdominal pain, anorexia, nausea, vomiting, and elevated liver function tests. However, this patient's extensive use of alcohol and AST:ALT ratio are more suggestive of alcoholic hepatitis. (Choice E) Tylenol toxicity can present with jaundice and abdominal pain. However, it usually causes AST and ALT >500 U/L and does not present with an AST:ALT ratio >2, as seen in this patient. Educational objective: Alcoholic hepatitis (AH) usually presents with acute jaundice, fever, anorexia, right upper-quadrant/epigastric pain, and abdominal distention due to ascites. Patients should have other causes of acute hepatitis excluded. An aspartate aminotransferase:alanine aminotransferase ratio >2 in an alcoholic patient usually distinguishes AH from other causes. __________ References: Review article: the diagnosis and management of alcoholic hepatitis. (http://www.ncbi.nlm.nih.gov/pubmed/19416132) Alcoholic hepatitis. (http://www.ncbi.nlm.nih.gov/pubmed/19553649)

A 43-Year-Old Man Comes to the Emergency Department with Severe