Differential Diagnosis for 50-year-old patient with ALT 128, AST 195, pruritus, and pedal edema
Single most likely diagnosis:
- Chronic Liver Disease (e.g., Cirrhosis): Elevated liver enzymes (ALT and AST) along with symptoms like pruritus and pedal edema suggest liver dysfunction. Pruritus can be associated with cholestasis, a condition often seen in liver diseases.
Other Likely diagnoses:
- Alcoholic Liver Disease: Given the significant elevation in AST compared to ALT, this pattern is suggestive of alcoholic liver disease, although other causes of liver injury should also be considered.
- Non-Alcoholic Fatty Liver Disease (NAFLD): This condition can lead to elevated liver enzymes and is associated with metabolic syndrome, which might also explain the pedal edema due to associated cardiovascular risks.
- Cholestasis: Conditions causing cholestasis, such as primary biliary cholangitis or primary sclerosing cholangitis, can lead to pruritus and elevated liver enzymes.
Do Not Miss (ddxs that may not be likely, but would be deadly if missed):
- Budd-Chiari Syndrome: A rare condition caused by thrombosis of the hepatic veins, leading to liver dysfunction, which can present with ascites (potentially causing pedal edema) and liver enzyme elevations.
- Wilson's Disease: An inherited disorder that leads to copper accumulation in the liver, causing liver dysfunction. It can present with a wide range of liver enzyme abnormalities and should be considered in younger patients but can occasionally be diagnosed later in life.
- Autoimmune Hepatitis: Although less common, this condition can present with elevated liver enzymes and should be considered, especially if other causes are ruled out.
Rare diagnoses:
- Alpha-1 Antitrypsin Deficiency: A genetic disorder that can cause liver disease and might present with elevated liver enzymes.
- Hemochromatosis: A condition of iron overload that can lead to liver dysfunction and might present with elevated liver enzymes, although it typically has other systemic manifestations.
- Drug-Induced Liver Injury (DILI): Certain medications can cause liver injury, leading to elevated liver enzymes. The history of medication use is crucial in diagnosing DILI.