Transaminitis: a classic AM report

Morning report today was a case of a patient presenting with fever, abdominal pain, and a transaminitis over 1000.

We reviewed the case presentation focusing questions and looking for physical signs that center around our differential diagnosis.

DDx of liver disease in general

1. Drugs/Toxins
- Consider both prescribed and non-prescribed
- Acetaminophen being a classic example, as well as EtOH
2. Infection
- Viral hepatitis especially Hep A. B, C can be acute, but often more chronic picture. D is associated with B. E has high mortality in pregnancy. HIV, CMV, EBV, (VZV) all other viral causes.
- Bacterial infection more often associated with abscess, but less so with acute hepatitis in and of itself.
- Parasitic infections, an example is "Katayama fever", which is acute schistosomiasis
3. Vascular: 
- including ischemia (shock liver), cardiac cirrhosis (don't forget! look at JVP, ?TR)
- thrombosis either hepatic vein (Budd-Chiari) or portal vein
4. Metabolic: 
- Wilson's disease: think of in younger patients, with concomitant hemolysis, neuro-psychiatric symptoms 
- Hemochromatosis: think of if DM, heart disease, joint disease
5. Autoimmune
- "True" AIH, especially in patient with other autoimmune conditions
- PBC (females, 40s), PSC (hx of IBD)
6. Structural 
- Stones, CBD stone in particular
7. Malignancy
- Not often causing hepatitis
- Discussed rare cases of lymphomas causing hepatitis.

DDx of transaminitis > 1000
1. Ischemia
2. Infection 
3. Toxin
4. Stone
5. AIH

Ultimately this case focused on the DDx, the investigations were ordered for the above, all was ruled out, and given this patient's history of choledocolithiasis it was felt by our hepatology service to be in keeping with a passed stone. 

Incidentally the patient grew E.Coli bacteria in their blood and was treated in with beta-lactam antibiotics, and subsequently developed a mild cholestatic pattern of elevation. This has been well described with beta-lactams. The patient recovered during her hospital stay and was discharged home.

Check out this CMAJ review article  on elevated liver enzymes.