RUQ pain and abnormal labs

OK, I’m a rank amateur, but six things stand out to me:

1) The AST is 3X the ALT.

2) the GGT is like 8X what I would be used to seeing

3) The Albumin is ridiculously low

4) The Bilirubin is modestly elevated.

5) Sludge doesn’t clog the gallbladder.

6) The Alk Phos is high, but so are lots of other things, and usually obstructive problems would present with disproportionately high Alk Phos, no?

Thus, I’m thinking this patient has alcoholic hepatitis. It was my first thought based on the AST/ALT ratio, and my suspicions are strengthened by the GGT and the low albumin and relatively high INR.

Treatment? Start with total abstinence from alcohol with appropriate supports. I’m not sure if people with acute hepatic issues should receive Vivitrol or topiramate, but it seems like providing pharmaceutical support for her sobriety would be highly beneficial. Nutritional status should be improved. Consider supplementation with the various B vitamins, as excessive alcohol consumption is linked with B vitamin deficiencies that have their own issues.

There seems to be some evidence to support anti-TNF-alpha therapy in alcoholic hepatitis, but given the high cost of the treatment, I’d have to wonder aloud if there’s an opportunity to address this without resorting to biologicals.

Feel free to laugh at my wanderings in amateur internal medicine.

Agree, likely alcoholic hepatitis. Treat with nutritonal support and if discriminant factor high enough, as in this case, add steroids or pentoxiphylline 400 mg po tid ( my preference given minimal side effects). #2 on DDX is autoimmune hepatitis.

PS: I assume “…presents with RUQ, fatigue…” should be “…presents with RUQ pain, fatigue…”

Alcoholic with endstage liver disease.

Treatment? Pray.

Don’t even think about checking a HIDA (just kidding, I know you will)

I’m no grammar expert but “should” should be “showed”

A TBili of 22.4 is hardly a “modest” elevation. Also, an indirect hyperbilirubinemia (such as from hemolysis) shouldn’t drive your bilirubin much higher than 5.0. The transaminases are unimpressive.

I’d want a travel history, including any exposures to fresh water or animals. I think she might have leptospirosis. If this is confirmed, I’d treat with either penicillin, ceftriaxone, or doxycycline (in that order of preference).

Happy Hospitalist: end stage liver disease shouldn’t cause RUQ pain. Cirrhosis doesn’t hurt.