Differential Diagnosis for Middle Aged Indian Female with Transaminitis, High Bilirubin, Increased ALP, and GB Wall Edema

• Single Most Likely Diagnosis

  • Acute Cholecystitis: This condition is characterized by inflammation of the gallbladder, often due to gallstones causing obstruction. The presence of gallbladder (GB) wall edema on ultrasound, along with elevated liver enzymes (transaminitis), high bilirubin, and increased alkaline phosphatase (ALP), supports this diagnosis. The clinical presentation and imaging findings are consistent with acute cholecystitis, making it the most likely diagnosis.

• Other Likely Diagnoses

  • Choledocholithiasis: This condition involves the presence of gallstones in the common bile duct, which can cause obstruction leading to elevated liver enzymes, bilirubin, and ALP. The negative viral markers help to shift the focus towards obstructive causes.
  • Primary Biliary Cholangitis (PBC): Although less common, PBC can present with elevated ALP and bilirubin. However, it typically has a more chronic course and might not fully explain the acute presentation and GB wall edema.
  • Primary Sclerosing Cholangitis (PSC): This is a chronic liver disease characterized by inflammation and scarring of the bile ducts, which could lead to the observed laboratory abnormalities. However, it is less common and might not directly explain the GB wall edema.

• Do Not Miss Diagnoses

  • Pancreatic Cancer: Although less likely given the presentation, pancreatic cancer can cause obstructive jaundice and elevated ALP. It's crucial to consider this diagnosis due to its significant implications on prognosis and treatment.
  • Cholangiocarcinoma: A malignancy of the bile duct, which can present similarly to other obstructive causes. Given its severity, it's essential to rule out this condition.
  • Sepsis or Septic Shock from an Infectious Source: In cases where the clinical presentation could be attributed to an infectious process, missing sepsis or septic shock could be fatal. Although the focus is on hepatobiliary pathology, considering the patient's acute presentation, an infectious cause should not be overlooked.

• Rare Diagnoses

  • Autoimmune Hemolytic Anemia (AIHA) with Liver Involvement: This condition could explain the elevated bilirubin but would not directly account for the GB wall edema or the significant elevation in ALP.
  • Sarcoidosis Involving the Liver and Bile Ducts: Sarcoidosis can cause granulomatous inflammation in various organs, including the liver and bile ducts, leading to elevated liver enzymes and ALP. However, it's a rare cause of these specific findings.
  • IgG4-Related Sclerosing Cholangitis: A rare condition characterized by inflammation and scarring of the bile ducts, which could present with similar laboratory abnormalities. It's part of the IgG4-related disease spectrum and is essential to consider in cases where common causes have been ruled out.