Differential Diagnosis

• Single most likely diagnosis
  • Hemochromatosis: The patient's high iron and very high ferritin levels (450) are indicative of iron overload, a hallmark of hemochromatosis. The presence of jaundice and an enlarged liver also supports this diagnosis. Although the patient is alcoholic, the absence of significant elevations in AST and ALT (only mildly elevated) and the lack of other symptoms suggestive of alcoholic hepatitis (such as fever, abdominal pain) make hemochromatosis a more likely primary diagnosis.
• Other Likely diagnoses
  • Alcoholic Hepatitis: Given the patient's history of alcoholism, alcoholic hepatitis is a consideration. However, the mild elevations in liver enzymes (ALT, AST) and the absence of other typical symptoms (fever, abdominal pain) make it less likely than hemochromatosis. The high bilirubin could be consistent with alcoholic hepatitis, but the very high ferritin levels point more towards hemochromatosis.
  • Chronic Hepatitis B: Although the patient is HBsAg negative and HBsAb positive (indicating past infection or vaccination), the possibility of a false-negative HBsAg due to mutant strains or a very low viral load cannot be entirely ruled out without further testing (like HBV DNA). However, the clinical presentation and lab findings do not strongly support chronic hepatitis B as the primary diagnosis.
• Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
  • Cholangitis: Although the patient does not have fever or abdominal pain (typical symptoms of cholangitis), any condition that could lead to biliary obstruction should be considered, especially in the context of jaundice. The absence of significant elevations in ALP (only mildly elevated) makes this less likely, but it should not be entirely dismissed without further evaluation.
• Rare diagnoses
  • Wilson's Disease: This is a rare genetic disorder leading to copper accumulation in the liver. While it could present with liver dysfunction and elevated liver enzymes, the specific pattern of enzyme elevation and the clinical context (high iron and ferritin) make hemochromatosis more likely. Wilson's disease typically presents at a younger age and with different laboratory findings (low ceruloplasmin levels, high 24-hour urinary copper excretion).
  • Alpha-1 Antitrypsin Deficiency: Another rare genetic disorder that can cause liver disease. It is less likely given the patient's presentation and the lack of specific findings that would point towards this diagnosis (such as lung disease or a family history of similar conditions).