Differential Diagnosis

The patient's presentation suggests a complex clinical picture with multiple potential diagnoses. Here's a categorized differential diagnosis:

• Single most likely diagnosis

  • Alcoholic Cardiomyopathy: The patient's history of ethanol (ETOH) abuse, significantly reduced left ventricular ejection fraction (LVEF < 10), and symptoms of heart failure (indicated by acitis, which could imply ascites, a common finding in advanced heart failure) point strongly towards alcoholic cardiomyopathy. The normal liver enzymes (ALT) but elevated bilirubin could be consistent with congestive hepatopathy due to right heart failure.

• Other Likely diagnoses

  • Alcoholic Hepatitis: Although the ALT is normal, the elevated AST and bilirubin levels, in the context of ETOH abuse, could suggest alcoholic hepatitis. However, the absence of significantly elevated liver enzymes makes this less likely than cardiomyopathy.
  • Decompensated Cirrhosis: The patient's ascites and elevated bilirubin could also suggest decompensated cirrhosis, especially with a history of alcohol abuse. However, the normal creatinine and GFR suggest that liver dysfunction is not significantly impacting renal function, which might be expected in advanced cirrhosis.

• Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)

  • Cardiac Tamponade: Although less likely, given the absence of specific symptoms like pulsus paradoxus, cardiac tamponade could present with hypotension (BP 100/70) and tachycardia (90bpm) and would be a medical emergency.
  • Fulminant Hepatic Failure: Despite the relatively preserved liver function tests, the elevated bilirubin and history of alcohol abuse necessitate consideration of fulminant hepatic failure, which would require urgent liver transplant evaluation.

• Rare diagnoses

  • Hemochromatosis: This genetic disorder leading to iron overload could cause both cardiomyopathy and liver dysfunction. However, it would be less likely given the patient's presentation and the absence of other suggestive findings like diabetes or skin pigmentation changes.
  • Wilson's Disease: Another rare genetic disorder affecting copper metabolism, which can cause liver disease and cardiomyopathy. It's less likely given the patient's age and the absence of neurological symptoms or Kayser-Fleischer rings.