A 42-year-old man has anorexia, nausea, fever, icterus, and dark urine. Laboratory pattern shows ALT and AST markedly elevated, ALP slightly elevated, GGT slightly elevated, total bilirubin moderately elevated, urine bilirubin positive, and fecal urobilinogen decreased. What is the most likely diagnosis?

• A. Acute hepatitis
• B. Alcoholic cirrhosis
• C. Metastatic carcinoma of the pancreas
• D. Obstructive jaundice

Answer: (A)

The main idea here is how liver injury patterns show different types of damage. ALT and AST are enzymes released when hepatocytes are injured, so a hepatocellular injury typically causes a large rise in these transaminases. ALP and GGT rise more with cholestasis or bile flow blockage. So when ALT and AST are markedly elevated and ALP/GGT are only mildly elevated, the pattern points to hepatocellular damage rather than a bile flow obstruction.

In this case, the patient has markedly high ALT/AST with only slight increases in ALP and GGT, along with fever and systemic symptoms—hallmarks of an acute inflammatory/hepatic process such as acute hepatitis. The bilirubin is elevated and urine bilirubin is positive, indicating conjugated bilirubin in the blood, which can occur with acute hepatitis as the liver’s processing is impaired. The decreased fecal urobilinogen also fits with impaired bilirubin handling by the liver and reduced delivery of bilirubin breakdown products to the gut.

These features fit acute hepatitis best. In obstructive jaundice, you’d expect a clearer cholestatic pattern with much higher ALP/GGT and often pale stools due to lack of stercobilin in the gut. Chronic alcohol-related disease would typically show a different enzyme profile (AST often higher than ALT but not with such dramatic ALT/AST elevations) and signs of chronic liver damage. Metastatic pancreatic cancer would usually present with an obstructive picture as well, not a primary hepatocellular injury pattern.