1. Drug Induced Hepatitis

2. Clinical Presentation
68 year old woman
Jaundice
Mild epigastric pain
Fatigue
Pruritus
Dark urine/light stools
Diarrhea X 41/2 months
6 months prior
7 days

3. Colonoscopy bx  mild colitis
Diarrhea
LFTs  nl stools  C&S, O&P, Giardia
2 months
Flagyl X 2 weeks
2 months
Colonoscopy bx  mild colitis
mesalamine (2.4 g/d)
2 months
Jaundice

4. Medications Social History Family history
Metoprolol, perindopril, diovan
Synthroid
Mesalamine
Social History
No alcohol
No recent travel
Family history
Non contributory

5. Physical Exam BMI = 32 Marked scleral icterus
Mild abdominal tenderness RUQ
No hepatomegaly/splenomegaly
No ascites, spider angiomata, palmar erythema, asterixis

6. Laboratory/Imaging Labs AST 1105, ALT 1005 AlkP 312 Tbil 16.7 Dbil 10
INR 1.3, Alb=3.0
Imaging
Ultrasound  mildly echogenic liver
Serology
Acute viral hepatitis A, B serology  NL
Autoimmune serology  NL

7. All meds stopped AST 1105 ALT 1005 AP 312 Tbil 16.7
2 weeks
AST 987 ALT 818 AP 324 Tbil> 30
AST 487; ALT 410 AP 292 Tbil> 30
2 weeks
Laparoscopy Ursodeoxycholic acid
AST 483 ALT 282 AP 254 Tbil 14
3 weeks
AST 38 ALT 43 AP 176 Tbil 1.4
6 weeks
AST 25; ALT 24 AP 90 Tbil 0.9

8. Laparoscopy

10. All meds stopped AST 1105 ALT 1005 Tbil 16.7
2 weeks
AST 987 ALT 818 Tbil> 30
AST 487; ALT 410 Tbil> 30
2 weeks
Laparoscopy Ursodeoxycholic acid
AST 483 ALT 282 Tbil 14
3 weeks
AST 38 ALT 43 Tbil 1.4
6 weeks
AST 25; ALT 24 Tbil 0.9