Enlarged Liver and Elevated Liver Function Tests
Answer: A
Although elevated liver function tests (LFTs) may be found in asymptomatic patients undergoing routine screening, patients with abnormal LFTs in the ED require a thorough history and physical exam. Important historical questioning includes: medications (including herbal therapies), presence of arthralgias, rash, anorexia, weight loss, abdominal pain, fever, pruritus, changes in urine and stool, drug use, sexual activity, occupational exposure, tattoos, travel history, and alcohol consumption.
Physical exam features to observe include: muscle wasting, stigmata of chronic liver disease (spider nevi, palmar erythema, gynecomastia), enlarged lymph nodes, abdominal tenderness, jugular venous distention, and pleural effusion.
The differential diagnosis of abnormal LFTs is vast and beyond the scope of this question. However, broad categories such as alcoholic, viral, drug-mediated, autoimmune, and genetic cover the commonest causes.
The pattern of LFT abnormalities may help to reveal the etiology, but a true test of synthetic function is coagulation testing, such as INR (A). Exposure to food-borne agents or other fecal-oral means of transmission would prompt testing for viral hepatitis (B); the results of these tests are typically not available in the ED.
If a striated muscle disorder is suspected, screening labs such as CK, LDH, and aldolase are available in the ED; muscle biopsy is considered after more common causes are ruled out (C). Similarly, liver biopsy (D) is an option only after other causes are excluded, and the risk for coagulopathy and bleeding is assessed.
This patient will likely need alcohol intervention and counseling. However, this pattern of liver injury is unusual and warrants further investigation before the assumption of a purely alcoholic hepatitis is made (E). Referral for outpatient follow-up and repeating his LFTs (especially his indirect and direct bilirubin levels) after a period of abstinence from alcohol may help to narrow his outpatient differential diagnosis.
Although elevated liver function tests (LFTs) may be found in asymptomatic patients undergoing routine screening, patients with abnormal LFTs in the ED require a thorough history and physical exam. Important historical questioning includes: medications (including herbal therapies), presence of arthralgias, rash, anorexia, weight loss, abdominal pain, fever, pruritus, changes in urine and stool, drug use, sexual activity, occupational exposure, tattoos, travel history, and alcohol consumption.
Physical exam features to observe include: muscle wasting, stigmata of chronic liver disease (spider nevi, palmar erythema, gynecomastia), enlarged lymph nodes, abdominal tenderness, jugular venous distention, and pleural effusion.
The differential diagnosis of abnormal LFTs is vast and beyond the scope of this question. However, broad categories such as alcoholic, viral, drug-mediated, autoimmune, and genetic cover the commonest causes.
The pattern of LFT abnormalities may help to reveal the etiology, but a true test of synthetic function is coagulation testing, such as INR (A). Exposure to food-borne agents or other fecal-oral means of transmission would prompt testing for viral hepatitis (B); the results of these tests are typically not available in the ED.
If a striated muscle disorder is suspected, screening labs such as CK, LDH, and aldolase are available in the ED; muscle biopsy is considered after more common causes are ruled out (C). Similarly, liver biopsy (D) is an option only after other causes are excluded, and the risk for coagulopathy and bleeding is assessed.
This patient will likely need alcohol intervention and counseling. However, this pattern of liver injury is unusual and warrants further investigation before the assumption of a purely alcoholic hepatitis is made (E). Referral for outpatient follow-up and repeating his LFTs (especially his indirect and direct bilirubin levels) after a period of abstinence from alcohol may help to narrow his outpatient differential diagnosis.