How should a 72-year-old male with nausea, vomiting, fatigue, anemia, liver dysfunction, and risk of malnutrition be treated?

Treatment Approach for 72-Year-Old Male with Nausea, Vomiting, Fatigue, Mild Anemia, and Elevated Liver Enzymes

Immediate Priority: Identify and Address the Underlying Cause

The first step is to determine whether this represents acute infectious mononucleosis (EBV), drug-induced liver injury, autoimmune hepatitis, or another hepatic process, as treatment differs fundamentally—immunosuppression for autoimmune hepatitis versus supportive care for EBV versus drug discontinuation for DILI. 1, 2

Critical Diagnostic Workup Required Now

• Viral hepatitis panel: Check HBsAg, anti-HBc, anti-HCV with reflex HCV RNA, HAV IgM, and EBV serologies (VCA IgM, VCA IgG, EBNA) to exclude viral causes before any immunosuppression 2
• Autoimmune markers: Obtain ANA, smooth muscle antibody (SMA), anti-LKM1, and serum IgG levels—approximately 85% of autoimmune hepatitis patients have IgG >1.5× upper limit of normal 2
• Comprehensive medication review: Document all prescription, over-the-counter, and herbal medications taken in the past 6 months, as 9% of suspected autoimmune hepatitis cases are actually drug-induced liver injury 2
• Calculate albumin and globulin separately: The low total protein (5.9 g/dL) and low albumin (3.6 g/dL) with A/G ratio of 1.54 suggests either hypergammaglobulinemia (autoimmune hepatitis) or synthetic dysfunction (advanced liver disease) 2

Symptomatic Management While Awaiting Diagnosis

Nausea and Vomiting Control

• First-line: Ondansetron 4-8 mg every 8 hours orally or IV, as 5-HT3 antagonists are effective for nausea with minimal hepatic metabolism concerns 3
• Alternative: Prochlorperazine 5-10 mg every 6-8 hours if ondansetron ineffective, though monitor for QT prolongation 3
• Avoid: Metoclopramide initially given elevated liver enzymes and potential for worsening if this is autoimmune hepatitis requiring immunosuppression 3

Nutritional Support and Malnutrition Prevention

• Initiate early nutritional intervention: This patient has low total protein (5.9 g/dL) and low albumin (3.6 g/dL), indicating risk of malnutrition which worsens outcomes in liver disease 3
• Start with oral intake: Encourage small frequent meals (4-6 meals/day) with adequate protein (1.2-1.5 g/kg/day) and calories (30-35 kcal/kg/day), including a nighttime snack between 7-10 PM 4, 5
• Monitor for refeeding syndrome: Check phosphate, magnesium, potassium, and thiamine at baseline and daily for first 3 days, supplementing even mild deficiencies, as this patient has multiple risk factors (low albumin, poor intake with nausea/vomiting) 3
• Do NOT restrict protein: Even if hepatic encephalopathy develops, protein restriction is contraindicated and worsens outcomes 4

Liver Function Monitoring

• Repeat complete liver panel in 2-4 weeks: Include AST, ALT, alkaline phosphatase, total and direct bilirubin, albumin, total protein, and PT/INR to establish trend 1
• Monitor electrolytes closely: Target sodium 140-145 mmol/L (current 137 mmol/L is acceptable but monitor), correcting no faster than 10 mmol/L per 24 hours 1
• Check glucose every 2 hours initially: Hypoglycemia is a known complication of severe liver dysfunction 1

Medication Management

Hepatotoxic Medication Review

• Discontinue any potentially hepatotoxic drugs immediately: NSAIDs, statins (if taking), certain antibiotics, and herbal supplements should be stopped 1
• If on Augmentin or similar antibiotics: Stop immediately given AST 59 IU/L and ALT 48 IU/L (both elevated), as amoxicillin-clavulanate carries significant hepatotoxicity risk 6
• Stopping rules: Discontinue any suspect medication if ALT/AST ≥5× ULN, ALT/AST ≥3× ULN with bilirubin ≥2× ULN, or development of jaundice 6

Supportive Pharmacotherapy

• Stress ulcer prophylaxis: Use agents with minimal hepatic metabolism (famotidine 20 mg twice daily preferred over PPIs) 1
• Avoid osmotic laxatives: Do not use lactulose or non-absorbable antibiotics prophylactically for ammonia lowering 1

Specific Treatment Pathways Based on Diagnosis

If EBV/Infectious Mononucleosis Confirmed

• Supportive care only: Adequate hydration, antiemetics, and symptom management 1
• Monitor liver enzymes every 2-4 weeks: Continue until complete normalization, as 84% remain abnormal at 1 month 1
• Do NOT use corticosteroids: Immunosuppression is contraindicated and can worsen viral replication 2
• Expected course: Most cases resolve spontaneously within 4-8 weeks 1

If Autoimmune Hepatitis Confirmed

• Initiate immunosuppression promptly: Prednisone 40-60 mg/day with or without azathioprine 50 mg/day, as untreated autoimmune hepatitis progresses to cirrhosis and death 2
• Obtain liver biopsy before treatment: Unless acute liver failure requires immediate therapy, biopsy confirms diagnosis and excludes competing diagnoses 2
• Monitor response: Check AST, ALT, and IgG every 2-4 weeks initially, with goal of complete normalization of both transaminases and IgG 2

If Drug-Induced Liver Injury Confirmed

• Discontinue causative agent immediately: Most DILI improves within 1 month of drug cessation 2
• Monitor closely: Repeat liver panel weekly initially, as some cases can progress despite drug discontinuation 6
• Consider N-acetylcysteine: If severe hepatotoxicity (ALT >1000 IU/L or INR >1.5), though current values don't meet this threshold 1

Red Flags Requiring Immediate Escalation

• Hepatic encephalopathy: Altered mental status, confusion, or asterixis requires urgent hepatology consultation 1
• Coagulopathy: INR >1.5 or PT prolongation suggests synthetic dysfunction and potential acute liver failure 2
• Rising bilirubin: Direct bilirubin already at upper limit (0.41 mg/dL); further elevation to >2 mg/dL with transaminases >3× ULN indicates severe hepatotoxicity 6
• Persistent elevation >12 weeks: Requires hepatology consultation and possible liver biopsy 1

Follow-Up Timeline

• 48-72 hours: Review diagnostic test results (viral serologies, autoimmune markers, IgG)
• 1 week: Reassess symptoms, repeat basic metabolic panel and liver enzymes if clinically worsening
• 2-4 weeks: Repeat complete liver panel, CBC, and creatinine to establish trend 1
• Continue monitoring: Until complete normalization of all liver enzymes 1