How should I assess and manage a young adult female with a history of alcohol use who presents with abdominal pain, nausea, dry heaving, tenesmus, occasional bright‑red rectal bleeding, mildly elevated aspartate aminotransferase (AST 74 U/L) and alanine aminotransferase (ALT 39 U/L) with normal hemoglobin, and who had an intrauterine device placed two weeks ago?

Assessment and Management of Young Woman with Alcohol History, Abdominal Pain, and Mildly Elevated Transaminases

This patient requires immediate evaluation for alcohol-related liver disease with non-invasive fibrosis assessment, exclusion of IUD-related complications (including pelvic infection and perforation), and investigation of the rectal bleeding source, while simultaneously implementing alcohol cessation interventions.

Immediate Assessment Priorities

Alcohol-Related Liver Disease Evaluation

• Order gamma-glutamyl transferase (GGT) immediately, as it detects 75% of habitual drinkers and is more sensitive than transaminases for chronic alcohol use, and the AST/ALT ratio of 1.9 already suggests possible alcoholic liver injury (ratios >1.5-2.0 are characteristic). 1, 2

• Do not rely on the mildly elevated transaminases to exclude significant liver disease—ALT levels can be normal in more than 50% of patients with advanced fibrosis from alcohol, and AST/ALT levels rarely exceed 300 IU/L in alcoholic liver disease. 3, 1

• Obtain a complete liver panel including total and direct bilirubin, albumin, INR, and platelet count to assess synthetic liver function and screen for advanced disease, as normal transaminases do not exclude cirrhosis. 3, 1

• Calculate precise alcohol consumption using the formula: [amount consumed (mL) × alcohol by volume (%) × 0.785 × drinking days per week] ÷ 7, and document whether intake exceeds 20 g/day (the threshold for liver disease risk in women). 1, 4

• Order phosphatidylethanol (PEth) testing if available, as whole blood PEth levels of 20-200 ng/ml detect alcohol use of 20-60 g/day with 89% sensitivity and 89% specificity, providing objective confirmation of recent alcohol exposure over the past 2-6 weeks. 4

• Arrange non-invasive fibrosis assessment (FibroScan or equivalent) rather than relying on transaminases alone, as this is essential for detecting advanced liver disease in heavy drinkers; refer to hepatology if liver stiffness >16 kPa. 3, 2

IUD-Related Complications

• Perform urgent pelvic examination and transvaginal ultrasound to assess IUD position, exclude uterine perforation (which can cause abdominal pain and nausea), and evaluate for pelvic inflammatory disease, as the 2-week post-insertion timeframe is within the window for insertion-related complications. [@general medicine knowledge@]

• Check complete blood count with differential to assess for leukocytosis suggesting infection, and verify the hemoglobin of 12.5 g/dL is stable (not actively dropping from ongoing bleeding). [@general medicine knowledge@]

• Obtain cervical cultures for gonorrhea and chlamydia if pelvic inflammatory disease is suspected, as ascending infection can occur post-IUD insertion. [@general medicine knowledge@]

Gastrointestinal Source Evaluation

• Investigate the rectal bleeding and tenesmus with digital rectal examination (after ensuring no contraindications) to assess for hemorrhoids, fissures, or masses, as bright red blood with wiping suggests distal colorectal pathology. 4

• Consider that alcohol-related acute inflammatory bowel disease can present with abdominal pain, nausea, vomiting, and rectal bleeding in the context of chronic alcohol exposure, which has deleterious effects on intestinal mucosa. 5

• Rule out other gastrointestinal emergencies associated with binge drinking, including alcoholic gastritis, Mallory-Weiss tears (given dry heaving), pancreatitis (though AST/ALT pattern less typical), and esophageal pathology. 6, 7

Alcohol Cessation Intervention

• Implement the AUDIT (Alcohol Use Disorders Identification Test) questionnaire immediately, as all women of childbearing age should be screened for alcohol use disorder; scores ≥4 indicate problematic use in women. 4, 2

• Apply motivational interviewing with an empathic, non-judgmental approach, presenting objective feedback about the relationship between her alcohol consumption, current symptoms, and long-term health risks including liver disease progression. 3

• Emphasize that achieving alcohol abstinence is the single most effective intervention to reduce liver enzyme abnormalities, prevent progression of alcohol-related liver disease, and improve overall outcomes. 1, 4

• Consider pharmacotherapy for alcohol use disorder with naltrexone or acamprosate if AUDIT score indicates moderate-to-severe alcohol use disorder, as limited data show no fetal abnormalities with these agents (though disulfiram is contraindicated). 4

• Screen for alcohol withdrawal risk given the acute presentation with nausea and vomiting, as withdrawal syndrome should be treated with benzodiazepines if indicated. 4

Additional Diagnostic Workup

• Exclude other causes of elevated transaminases including viral hepatitis (hepatitis B surface antigen, hepatitis C antibody), autoimmune markers (ANA, anti-smooth muscle antibody), iron studies (ferritin, transferrin saturation), and metabolic syndrome components (fasting glucose, lipid panel, BMI calculation). 3, 1, 8

• Assess for metabolic cofactors that accelerate liver disease progression in alcohol users, including obesity, diabetes, and dyslipidemia, as these have synergistic effects with alcohol. 3, 2

• Order complete metabolic panel including serum creatinine and electrolytes, as alcohol-related gastrointestinal inflammation can cause severe hypokalemia and metabolic derangements. 5

Management Algorithm Based on Findings

If Non-Invasive Fibrosis Assessment Shows Advanced Disease (F3-F4 or >16 kPa):

• Refer urgently to hepatology for cirrhosis surveillance protocols, including upper endoscopy for variceal screening and hepatocellular carcinoma surveillance with ultrasound ± AFP every 6 months. 3

• Initiate nutritional support with high-protein diet (1.2-1.5 g/kg/day), adequate calories (30-35 kcal/kg/day), and B vitamin supplementation (thiamine, folate, B12). 3

If IUD Complications Identified:

• Remove IUD immediately if perforation, severe infection, or malposition is confirmed, and initiate appropriate antibiotic therapy for pelvic inflammatory disease if present. [@general medicine knowledge@]

If Rectal Bleeding Requires Further Investigation:

• Arrange flexible sigmoidoscopy or colonoscopy if bleeding persists, is significant in volume, or if examination suggests inflammatory bowel disease or other structural pathology beyond simple hemorrhoids. 4

Follow-Up Monitoring

• Recheck complete metabolic panel including liver enzymes, albumin, bilirubin, and INR in 2-4 weeks after alcohol cessation to assess for improvement, as GGT levels recover slowly following abstinence. 1, 2

• Repeat hemoglobin if rectal bleeding continues to ensure stability and exclude occult significant blood loss. [@general medicine knowledge@]

• Schedule follow-up pelvic examination 4-6 weeks post-IUD insertion to confirm proper positioning and resolution of any insertion-related complications. [@general medicine knowledge@]

• Arrange addiction medicine or psychiatry referral if AUDIT score >19, indicating alcohol dependency requiring specialized alcohol treatment services. 2

Critical Pitfalls to Avoid

• Do not assume normal or mildly elevated liver enzymes exclude advanced fibrosis—cirrhosis can exist with normal biochemistry, particularly in alcohol-related disease, making non-invasive fibrosis assessment mandatory. 3, 1, 2

• Do not attribute all symptoms solely to alcohol without excluding IUD-related complications, as uterine perforation or pelvic infection can present with similar abdominal pain and nausea in the post-insertion period. [@general medicine knowledge@]

• Do not overlook the rectal bleeding as a minor symptom, as alcohol-related inflammatory bowel disease, ischemic colitis, or other serious pathology can present with these symptoms in the context of alcohol use. 5

• Do not delay alcohol cessation counseling until diagnostic workup is complete, as immediate intervention is critical for preventing disease progression and improving outcomes. 4, 1