Differential Diagnosis
- Single most likely diagnosis
- Acute alcoholic hepatitis: The patient's history of heavy alcohol use, recent onset of fatigue, abdominal pain, dark urine, and jaundice, along with elevated liver enzymes (AST > ALT) and bilirubin, are consistent with acute alcoholic hepatitis. The INR of 2.1 also suggests some degree of liver dysfunction.
- Other Likely diagnoses
- Viral hepatitis: Although less likely given the patient's alcohol history, viral hepatitis (e.g., hepatitis A, B, or C) could present with similar symptoms and laboratory findings. However, the pattern of liver enzyme elevation (AST > ALT) is more typical of alcoholic liver disease.
- Drug-induced liver injury: The patient's history of alcohol use could be complicated by the use of other hepatotoxic substances, including medications or herbal supplements, which could contribute to her liver injury.
- Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
- Acetaminophen overdose: Although the patient's alcohol use is a significant factor, acetaminophen overdose can cause severe liver injury and is a critical diagnosis not to miss. The administration of N-acetylcysteine is indicated in this scenario, making it a crucial consideration.
- Wilson's disease: This rare genetic disorder can cause liver disease and presents with similar symptoms, including jaundice and elevated liver enzymes. It's essential to consider Wilson's disease, especially in younger patients, as it requires specific treatment.
- Rare diagnoses
- Autoimmune hepatitis: This condition can present with elevated liver enzymes and bilirubin but is less likely given the patient's alcohol history and the pattern of liver enzyme elevation.
- Budd-Chiari syndrome: This rare condition, characterized by hepatic vein thrombosis, can cause liver dysfunction and should be considered in patients with risk factors for thrombosis, although it is less likely in this scenario.
Regarding the provided options:
- Administration of pentoxifylline + prednisolone may be considered in acute alcoholic hepatitis, but the evidence for pentoxifylline is not as strong as for prednisolone.
- Liver transplantation is not contraindicated in this patient if she meets criteria for transplantation, such as having a severe alcoholic hepatitis not responding to medical therapy.
- The mortality of acute alcoholic hepatitis at 90 days can indeed be up to 40% in severe cases, as indicated by the discriminant function (DF) score or the Model for End-Stage Liver Disease (MELD) score.
- Administration of N-acetylcysteine is indicated for acetaminophen overdose, which, although less likely, is a critical diagnosis not to miss.