Alcoholic Liver Disease 1

Question

Vignette: A 25-year-old male presents to the emergency department with severe abdominal pain. He reports that the pain is concentrated in the upper right quadrant and has been worsening over the last few hours. He admits to consuming large amounts of alcohol over the past week. Physical examination reveals tenderness in the right upper quadrant that is exacerbated by inspiration. His liver enzymes show an AST:ALT ratio of 2:1. Based on his history and physical examination findings, what is the most likely explanation for this patient's symptoms?

Choices

A) Biliary tract obstruction

B) Acute hepatitis

C) Acute pancreatitis

D) Alcoholic cirrhosis

E) Gastric ulcer

Answer

B) Acute hepatitis

Explanation

The patient's symptoms, coupled with his recent history of excessive alcohol consumption and liver enzyme results, strongly suggest a diagnosis of acute alcoholic hepatitis. alcoholic hepatitis often presents with right upper quadrant pain, hepatomegaly, jaundice, and an increased AST:ALT ratio, usually greater than 2:1. This ratio is often seen in alcoholic liver disease because alcohol metabolism preferentially damages mitochondria in zone 3 of the liver acinus where AST is located. ALT is located in the cytoplasm, and is less affected by alcohol. This patient's presentation does not fit with biliary tract obstruction (which would present with jaundice, fever, and fluctuating pain), acute pancreatitis (which would more likely present with mid-epigastric pain radiating to the back), alcoholic cirrhosis (which would present with long-term symptoms of liver failure), or a gastric ulcer (which would present with burning epigastric pain that improves with eating).