Amber

A 49-year-old man presents with worsening confusion since waking up six hours ago. His wife noticed that his eyes have been yellow-tinged for the same duration.

Further questioning reveals multiple bouts of nausea and vomiting, insomnia, daytime drowsiness, agitation, and irritability during the preceding four days.

His medical and surgical histories are unremarkable. He is not on any medications. There is no history of allergies.

He has regularly consumed an estimated 10 units of alcohol per week for the last two decades and had almost doubled his intake over the last three months, after losing his job as a manual worker. There is no history of promiscuity, recreational drug use, or suicidal ideation or attempts.

A complete blood count is only significant for a hemoglobin level of 10.5 g/dL (normal:11-18). Serum electrolytes and renal functions are within normal parameters.

Select Relevant Investigations
Liver profile

Performed

AST: 1670 IU/L (8-48)
ALT: 2100 IU/L (7-55)
ALP: 653 IU/L (45-115)
Total bilirubin: 5.6 mg/dL (0.2-1.2)
Direct bilirubin: 4.2 mg/dL (0.1-0.4)
INR: 8.0 (0.8-1.3)
Acute Hepatitis Panel

Performed

Hepatitis A antibody (HAAb): negative
Hepatitis B core antibody (HBcAb): negative
Hepatitis B surface antigen (HBsAg): negative
Hepatitis C antibody: negative
Serum acetaminophen levels

Performed

Serum acetaminophen levels are not elevated.
Ultrasound + color doppler abdomen

Performed

The ultrasound confirms the presence of hepatomegaly, with a normal echotexture. No other abnormalities are seen. A doppler study shows normal blood flow in the portal venous system and hepatic vasculature.

Select Relevant Management
ICU admission
N-acetylcysteine
Benzodiazepines
Lactulose