Differential Diagnosis
The patient presents with jaundice, fever, right upper quadrant pain, and a history of alcohol consumption, among other symptoms. Based on the provided information, the differential diagnosis can be categorized as follows:
Single Most Likely Diagnosis
- Acute Cholecystitis: This diagnosis is supported by the patient's symptoms of right upper quadrant pain, fever, and jaundice. The presence of a possible Murphy sign, which is tenderness in the right upper quadrant that worsens with deep inspiration, is a classic indicator of acute cholecystitis. The abdominal ultrasound showing gallbladder wall thickness of 3 mm and minimal sludge in the common bile duct also supports this diagnosis.
Other Likely Diagnoses
- Ascending Cholangitis: Although less likely than acute cholecystitis given the absence of clear biliary obstruction signs, ascending cholangitis is still a consideration due to the patient's jaundice, fever, and abdominal pain. The presence of minimal sludge in the common bile duct could potentially lead to or be associated with cholangitis.
- Acute Alcoholic Hepatitis: Given the patient's history of regular alcohol consumption, acute alcoholic hepatitis is a possible diagnosis. However, the liver function tests (LFTs) showing an AST:ALT ratio of approximately 2.9 (170:58) supports this diagnosis, as an elevated AST:ALT ratio is often seen in alcoholic liver disease. The patient's symptoms and the echogenic liver on ultrasound also align with this condition.
Do Not Miss Diagnoses
- Drug-Induced Liver Injury (DILI): Although the patient's acetaminophen use is described as occasional, DILI is a critical diagnosis not to miss due to its potential severity. The patient's elevated LFTs could be consistent with DILI, and given the wide range of drugs that can cause liver injury, this diagnosis should be considered, especially if other causes are ruled out.
- Sepsis or Septic Shock: The patient's fever, elevated white count, and tachycardia (pulse rate 105) could indicate a systemic infection. Sepsis or septic shock, potentially secondary to an intra-abdominal infection like cholecystitis or cholangitis, is a life-threatening condition that must be promptly identified and treated.
Rare Diagnoses
- Other Causes of Obstructive Jaundice: Conditions like pancreatic cancer, ampullary cancer, or bile duct stones could cause the patient's symptoms but are less likely given the information provided. These diagnoses would typically require further investigation, such as endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance cholangiopancreatography (MRCP), to confirm.
- Autoimmune Hepatitis or Other Autoimmune Conditions: These conditions could present with elevated LFTs and jaundice but are less common and would require specific autoantibody testing and possibly a liver biopsy for diagnosis.