A 50-year-old man is admitted to the hospital with worsening jaundice, anorexia, general malaise, and right upper quadrant abdominal pain over the past 3 days. The patient's other medical problems include major depression with an attempted suicide 30 years ago. His temperature is 38.3 C (101 F), blood pressure is 130/86 mm Hg, pulse is 86/min, and respirations are 16/min. Cardiopulmonary examination is unremarkable. Scleral icterus and tender hepatomegaly are present. Laboratory results are as follows: Which of the following would be the most helpful in establishing a diagnosis in this patient?

Question

A 50-year-old man is admitted to the hospital with worsening jaundice, anorexia, general malaise, and right upper quadrant abdominal pain over the past 3 days.  The patient's other medical problems include major depression with an attempted suicide 30 years ago.  His temperature is 38.3 C (101 F), blood pressure is 130/86 mm Hg, pulse is 86/min, and respirations are 16/min.  Cardiopulmonary examination is unremarkable.  Scleral icterus and tender hepatomegaly are present.  Laboratory results are as follows:  Which of the following would be the most helpful in establishing a diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_d3d8_56be_bc81_6744fc4e1e44_MD0003_00 Alcoholic hepatitis (AH) best explains this patient's presentation with fever, jaundice, anorexia, tender hepatomegaly, mild (<300 U/L) elevation in aminotransferases (aspartate aminotransferase [AST] and alanine aminotransferase [ALT]) with an AST:ALT ratio ≥2:1, macrocytic anemia (mean corpuscular volume [MCV] >100/µm³), bilirubin elevation, thrombocytopenia, and mild elevation in the International Normalized Ratio. Alcohol use should be confirmed and quantified by first obtaining the patient's social history and discussing substance use. Patients with AH commonly have a history of chronic, heavy alcohol use (>7 drinks/day) and sometimes develop AH symptoms after an acute increase in consumption. Diagnosis is clinical and often does not require further studies in patients with consistent history and laboratory results. Patients with risk factors for diseases such as acute viral hepatitis require further investigation. Radiographic imaging may reveal fatty liver disease, cirrhosis, or ascites. Treatment involves abstinence, supportive care (eg, hydration and nutrition support), and acid suppression. Liver biopsy can be helpful if there is diagnostic uncertainty. (Choice A) Family history can be helpful in identifying causes of inherited liver disease (eg, Wilson disease, hemochromatosis); however, an AST:ALT ratio ≥2:1 in the setting of acute hepatitis (tender hepatomegaly, fever) is highly suggestive of AH. In addition, this patient's age makes inherited disease less likely. (Choice B) Methotrexate could cause elevated MCV, bone marrow suppression (anemia, thrombocytopenia), and liver function test abnormalities; however, an AST:ALT ratio ≥2:1 makes AH more likely. (Choice C) Cholangitis can cause fever, abdominal pain, and jaundice (Charcot's triad) and could be evaluated with a right upper quadrant ultrasound. However, cholangitis would typically cause a more severe presentation (eg, sepsis) with a marked elevation in the alkaline phosphatase level; in addition, an AST:ALT ratio ≥2:1 with tender hepatomegaly and an elevated MCV are atypical for cholangitis and more suggestive of heavy alcohol use with AH. (Choices D and F) Acetaminophen intoxication and travel-associated diseases (eg, viral hepatitis, malaria, leptospirosis) may present similarly; however, these conditions do not explain the macrocytic anemia and AST:ALT ratio >2:1. In addition, aminotransferase levels are typically >1,000 U/L in acetaminophen intoxication and viral hepatitis. > Educational objective: Alcoholic hepatitis (AH) is most commonly seen in patients with a history of chronic heavy alcohol use. AH is characterized by fever, jaundice, anorexia, and tender hepatomegaly with laboratory results showing an aspartate aminotransferase to alanine aminotransferase ratio of ≥2:1. References: Alcoholic hepatitis: Challenges in diagnosis and management. (http://www.ncbi.nlm.nih.gov/pubmed/25955457) Diagnosis and management of alcoholic liver disease. (http://www.ncbi.nlm.nih.gov/pubmed/26356792)

A 50-Year-Old Man Is Admitted to the Hospital with Worsening