A liver case

This is a cholestatic pattern of elevated liver function tests. Compare the alk phos and the ALT/AST and determine which has the higher elevation over the upper limit of normal. If it is ALT/AST then it is in a hepatocellular pattern. If alk phos, as in this case, it is a cholestatic pattern.

DDX of a cholestatic hepatitis:
1. anatomic obstruction- common bile duct stricture or stone or ampullary mass( or equivalent). Obstruction of an intrahepatic duct by a mass (e.g., abscess or tumor- bilirubin may not be significantly elevated in this case).
2. infiltation into liver- sarcoid, amyloid, tumor diffusely ( a mass might not be seen on imaging. might only detect it onliver biopsy)- small cell cancer, lymphoma are examples)
3. infectious infiltation into liver- fungal , TB
4. medication side effect- e.g. Augmentin
5. PSC or PBC
6. granulomatous hepatitis

Sometimes alcoholic hepatitis can produce this pattern but the alk phos usually isn’t this elevated ( I have seen it in the alk phos = 500 range). mono could do it also but alk phos seems too high in this case.

I bet this patient has a pancreatic head mass causing CBD obstruction.