A 45-year-old man comes to the emergency department with poor appetite and nausea for the last 3-4 weeks. He admits to drinking vodka daily. He attempted to quit on several occasions over the last year but relapsed each time. Two years ago, he was admitted for seizures but has had no medical follow-up since. The patient takes no medications and does not use any illicit drugs. He has had no recent sexual encounters. He has no recent unintentional weight loss. His temperature is 37.2 C (99 F) , blood pressure is 120/70 mm Hg, and pulse is 102/min. His sclerae appear icteric. The liver is enlarged and mildly tender. The gallbladder is not palpable, and Murphy's sign is negative. The patient has no abdominal distension, peripheral edema, spider angiomas, gynecomastia, or asterixis. Which of the following laboratory findings are most likely to be present? AST = aspartate aminotransferase; ALT = alanine aminotransferase; GGT = gamma-glutamyltransferase.

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11ec25c8_d3d8_089c_bc81_eb448985be6b_MD0003_00 This patient, who has an extensive history of alcohol use, most likely has alcoholic hepatitis with jaundice, anorexia, and tender hepatomegaly. There is no evidence of ascites or cirrhosis (eg, spider angiomas, gynecomastia, asterixis). He has no weight loss or systemic symptoms to suggest malignancy, and there are no signs of infection. Alcoholic liver disease is generally characterized by modest elevations in aspartate aminotransferase (AST) and alanine aminotransferase (ALT), usually <300 IU/L and almost always <500 IU/L. A ratio of AST to ALT >2 (thought to be due to hepatic deficiency of pyridoxal 5'-phosphate, an ALT enzyme cofactor) is very common in alcoholic liver disease (>90% in one study). However, it is rarely seen with other forms of liver disease, in which ALT is typically higher than AST. This can be used as an important diagnostic marker. There is no correlation between the degree of elevation and liver disease severity. Elevations in gamma-glutamyltransferase (GGT), an enzyme present in liver and other cells, and in ferritin, an acute phase reactant, would likely be seen in alcoholic liver disease. Normal values of AST and ALT (Choice E) or of GGT and ferritin (Choice D) would be less likely. (Choices B and C) If marked elevations (>25 times the upper limit) of AST and ALT are present, toxin-induced (eg, acetaminophen), ischemic, or viral hepatitis should be suspected. Educational objective: Alcoholic hepatitis is generally characterized by a ratio of aspartate aminotransferase (AST) to alanine aminotransferase (ALT) >2, elevated gamma-glutamyltransferase, and elevated ferritin. The absolute values of AST and ALT are almost always <500 IU/L in alcoholic liver disease. References: Diagnosis and management of alcoholic hepatitis. (http://www.ncbi.nlm.nih.gov/pubmed/23101979)

A 45-Year-Old Man Comes to the Emergency Department with Poor