What is the diagnosis and management for a 40-year-old male with dyspnea, jaundice, severe epigastric pain, and oliguria, with a recent history of undocumented fever, nausea, and decreased appetite?

Acute Hepatobiliary Emergency with Suspected Leptospirosis or Acute Hepatitis

This patient requires immediate hospitalization with urgent diagnostic workup for acute hepatobiliary disease, most likely acute hepatitis (viral, drug-induced, or leptospirosis given occupational exposure) or ascending cholangitis, with cardiac causes ruled out first given the chest pain and dyspnea.

Immediate Life-Threatening Exclusions

Cardiac causes must be excluded first despite the gastrointestinal presentation. 1, 2, 3

• Obtain ECG within 10 minutes and serial troponins at 0 and 6 hours, as myocardial infarction can present atypically with epigastric pain, especially in men with risk factors (obesity, BMI 29.4). 1, 2, 3
• The chest pain described as "heaviness or pressure" with dyspnea is concerning for acute coronary syndrome, which affects 10-20% of patients presenting with epigastric symptoms. 2
• Vital signs show relative stability (BP 110/70, HR 80, RR 16, O2 98%), but this does not exclude ACS. 3

Primary Diagnostic Considerations

Most Likely: Acute Hepatitis (Viral, Drug-Induced, or Leptospirosis)

The triad of jaundice, severe epigastric pain, and oliguria with recent fever and occupational exposure strongly suggests acute hepatobiliary disease. 1, 4, 5

Clinical Features Supporting Hepatitis:

• Rapid onset jaundice (scleral then cutaneous) appearing on day of admission 1
• Severe epigastric pain (10/10) with nausea and decreased appetite 1, 2
• Oliguria suggesting hepatorenal syndrome or acute kidney injury 1
• Red-orange urine with sandy sediments three days prior, consistent with bilirubinuria and possible hemolysis 6
• Undocumented fever with chills for 2 days 1
• Yellow conjunctiva and oral mucosa on examination despite "anicteric sclera" notation (likely examination error given jaundice complaint) 1

Specific Etiologies to Consider:

Leptospirosis (Weil's Disease):

• Occupational exposure as [PROFESSION] with access to [WATER_SOURCE] is high-risk 1
• Classic presentation: fever, jaundice, renal failure (oliguria), myalgias, headache 1
• Epigastric pain, nausea, vomiting are common presenting symptoms 1
• Timeline fits: 3-6 day incubation, then biphasic illness with recrudescence 1

Viral Hepatitis (A, B, E):

• Acute onset with fever, jaundice, epigastric pain, nausea 1, 4
• Hepatitis E can cause acute liver failure with renal involvement 4
• Frequent consumption of [FOOD_TYPE] may be relevant for hepatitis A or E transmission 1

Drug-Induced Liver Injury:

• [MEDICATION] use "around the clock" for 2 days could cause acute hepatotoxicity if acetaminophen 6
• Dose and frequency critical to determine—if >4g/day, acute liver failure possible 6

Autoimmune Hepatitis:

• Can present acutely with jaundice, epigastric pain, nausea 1, 7
• Less likely given rapid onset without prior symptoms 1

Alternative: Ascending Cholangitis with Choledocholithiasis

The "sandy sediments" in urine three days prior could represent passed gallstones. 1

• Classic Charcot's triad: fever, jaundice, right upper quadrant pain 1
• Reynolds' pentad adds hypotension and altered mental status (not present) 1
• However, liver span of 6cm is normal, making hepatomegaly from obstruction less likely 1
• Murphy's sign negative argues against acute cholecystitis 1
• Epigastric pain (not RUQ) is atypical for biliary disease 1, 8

Urgent Diagnostic Workup

Immediate Laboratory Tests:

Complete metabolic panel with specific attention to: 1, 4, 5

• Total and direct bilirubin to determine conjugated vs unconjugated hyperbilirubinemia 4
• AST, ALT, alkaline phosphatase, GGT to differentiate hepatocellular (AST/ALT >1000) vs cholestatic (ALP >3x normal) pattern 1, 4
• Serum creatinine and BUN to assess renal function given oliguria 1
• Prothrombin time/INR to assess synthetic liver function and severity 1, 5
• Serum albumin for chronic vs acute process 1

Additional critical tests: 1, 6, 4

• Complete blood count with differential (leukocytosis in infection, thrombocytopenia in severe hepatitis) 1
• Peripheral blood smear to evaluate for hemolysis given red-orange urine 6
• Reticulocyte count, haptoglobin, LDH if hemolysis suspected 6
• Lipase to exclude acute pancreatitis (can present with epigastric pain, jaundice) 2
• Urinalysis to confirm bilirubinuria and assess for proteinuria/hematuria 1

Infectious and immunologic workup: 1

• Leptospira IgM antibodies and blood/urine cultures for leptospirosis 1
• Hepatitis A IgM, Hepatitis B surface antigen and core IgM, Hepatitis E IgM 1, 4
• Hepatitis C antibody (though acute HCV rarely causes jaundice) 1
• Antinuclear antibody (ANA), anti-smooth muscle antibody (ASMA) for autoimmune hepatitis 1, 7
• Blood cultures if cholangitis suspected 1

Imaging Studies:

Right upper quadrant ultrasound immediately: 1, 4, 5

• Assess for biliary ductal dilatation (CBD >6mm suggests obstruction) 1
• Evaluate for cholelithiasis or choledocholithiasis 1
• Assess liver echogenicity and size 4
• Evaluate for ascites (suggests severe hepatic dysfunction) 1
• Sensitivity 73% for CBD stones, but 91% specificity 1

If ultrasound shows ductal dilatation or high clinical suspicion for obstruction: 1

• MRCP (sensitivity 93%, specificity 96% for CBD stones) or EUS (sensitivity 94%, specificity 95%) 1
• MRCP preferred if patient stable, non-invasive, no sedation required 1

CT abdomen/pelvis with IV contrast if diagnosis unclear: 2

• Identifies pancreatitis, perforation, vascular emergencies 2
• Can detect hepatomegaly, ascites, biliary pathology 4

Immediate Management

Supportive Care:

Aggressive fluid resuscitation: 1, 5

• IV crystalloids to maintain urine output >0.5 mL/kg/hr given oliguria 1
• Monitor for fluid overload in setting of potential hepatorenal syndrome 5

Discontinue all hepatotoxic medications: 1, 6

• Stop [MEDICATION] immediately if acetaminophen-containing 6
• Avoid NSAIDs, which can worsen renal function 6

NPO status initially: 1, 5

• Until biliary obstruction excluded and if considering endoscopy 1, 8

Empiric Antibiotic Therapy:

If leptospirosis suspected (most likely given presentation): 1

• Penicillin G 1.5 million units IV every 6 hours or ceftriaxone 1g IV daily 1
• Start empirically while awaiting serology—treatment within 4 days improves outcomes 1

If ascending cholangitis suspected: 1

• Broad-spectrum antibiotics covering gram-negative and anaerobic organisms 1
• Piperacillin-tazobactam 3.375g IV every 6 hours or ceftriaxone 2g IV daily plus metronidazole 500mg IV every 8 hours 1

Specific Interventions Based on Etiology:

If acetaminophen toxicity confirmed: 6

• N-acetylcysteine loading dose 150 mg/kg IV over 1 hour, then maintenance protocol 6
• Contact poison control and consider hepatology consultation 6

If biliary obstruction confirmed: 1

• Urgent ERCP within 24 hours for stone extraction and biliary decompression 1
• Delay increases mortality significantly in cholangitis 1

If autoimmune hepatitis diagnosed: 1, 7

• Prednisone 40-60mg daily after excluding infection 1, 7
• Requires liver biopsy confirmation when stable 1

Critical Pitfalls to Avoid

Do not dismiss cardiac causes despite gastrointestinal symptoms. 1, 2, 3

• Atypical ACS presentations are common in patients with obesity and metabolic syndrome 1, 2
• Troponins must be obtained before attributing symptoms solely to hepatobiliary disease 1, 3

Do not delay imaging if peritoneal signs develop. 2

• Fever, tachycardia, or abdominal rigidity require immediate surgical consultation 2
• Perforated ulcer mortality reaches 30% with delayed diagnosis 2

Do not assume viral hepatitis without excluding leptospirosis. 1

• Occupational exposure and clinical presentation strongly suggest leptospirosis 1
• Delayed antibiotic treatment worsens outcomes in Weil's disease 1

Do not perform endoscopy without first ruling out biliary obstruction. 1, 8

• ERCP is therapeutic for choledocholithiasis; EGD is diagnostic only 1, 8
• Wrong procedure delays definitive treatment 1

Disposition and Monitoring

Admit to monitored bed with: 1, 5

• Continuous telemetry until cardiac causes excluded 1, 3
• Strict intake/output monitoring given oliguria 1, 5
• Serial liver function tests every 12-24 hours to assess trajectory 1, 5
• Daily INR to monitor for acute liver failure 1, 5

Hepatology consultation within 24 hours for acute hepatitis management 1, 5

Gastroenterology consultation if biliary obstruction confirmed for ERCP 1

Infectious disease consultation if leptospirosis confirmed for antibiotic optimization 1

ICU transfer criteria: 1, 5

• INR >1.5 suggesting acute liver failure 1
• Encephalopathy development 1
• Hemodynamic instability 5
• Worsening renal function despite resuscitation 1, 5