68 year old female presents to ED c/o nausea and dizziness. She is found to be jaundiced

The liver function tests show a hepatocellular pattern abnormality, with a raised ALT out of proportion to the raised ALP. The ALT is 90 times the upper limit of normal.  Values 25 times the upper limit of normal or higher are seen primarily in hepatocellular diseases.  The INR is raised and therefore confirms that the synthetic function of the liver is affected.  The albumin is within normal limits which means the liver dysfunction is likely to be acute.

Even though the patient has marked liver dysfunction with a raised INR, she is not in acute liver failure as she is not encephalopathic. Acute liver failure is characterized by acute liver injury, hepatic encephalopathy, and an elevated prothrombin time/international normalized ratio (INR).

There are multiple possible causes for this patients liver dysfunction and investigations (bloods and imaging) should be directed accordingly:

Drugs – paracetamol (taken for her headache)

Infection- viral hepatitis –hep A, B, C, HIV, EBV, CMV

Alcohol hepatitis – but this would have a chronic component and the albumin would be low. (AST to ALT ratio of 2:1 or greater is suggestive of alcoholic liver disease)

Malignant infiltration (history of breast CA)

Vascular disease – Budd Chiari, veno-occlusive disease

Autoimmune

Other causes less likely – sepsis, heat stroke, Wilsons Disease, other toxins – mushroom poisoning

In this case the following complications need to be excluded

• Associated renal dysfunction (hepatorenal syndrome)
• Liver failure –ammonia level, however patient not encephalopathic therefore unlikely to be raised)
• Bleeding – intracranial (previous headache and on going dizziness)
•                  -GI bleed (postural dizziness)