USMLE Step 1 Question 300

Question:

A 55-year-old male is complaining of increasing right upper quadrant pain and jaundice. His physical exam is notable for mild scleral
icterus, a 12 cm liver span and vague right upper quadrant pain on palpation. His laboratory values are as follows:

AST: 454
ALT: 206
Alkaline phosphatase: 126
Gamma GT: 174
Total bilirubin: 2.5
Direct bilirubin: 1.8

What is the most likely diagnosis?

Correct Answer: B.  Alcoholic steatohepatitis

In alcoholic steatohepatitis (option B), the most notable feature is that the AST:ALT>2 and that the AST is usually about 500. In addition the patient will sometimes present as jaundiced with RUQ tenderness. In the beginning stages of cirrhosis the liver is enlarged, but as the liver becomes more scarred and fibrotic, the liver span is often difficult to estimate. In viral hepatitis (option E) the AST and ALT rise about the same and the levels are often above 500. In comparison to acetaminophen overdose (option A) where the liver enzymes will be increased significantly, often >1000.

NASH (option D) is usually a diagnosis of exclusion. It presents in a similar fashion of alcoholic steatohepatitis, but there is no history of alcohol abuse, the AST:ALT<2 and the GGT is usually not greater than the alkaline phophatase.

Ascending cholangitis is recognized by Charcot's Triad: fever, jaundice and right upper quadrant pain. In addition the AST and ALT can be increased, but usually they are not to levels seen in this patient and there is no ratio of 2:1 seen.