Save by the DILI

Abstract

Case of a 67-year-old Hispanic male with past medical history of Diabetes, coronary artery disease and dyslipidemia who arrived to the emergency department (ED) after noticing cola like urine, acholic stools and jaundice. Laboratories were remarkable for elevated liver enzymes; ALT 1,395 U/L, AST 793 U/L, total bilirubin 3.2 mg/dL and alkaline phosphatase of 837 U/L. CBC was within normal limits. Abdominal echo performed at ED showed normal caliber of common bile duct (CBD) and no cholelithiasis. Physical examination was only remarkable for jaundice without chronic liver disease stigmata. During interview, patient reported that symptoms started 2 weeks after completing antibiotic treatment with Augmentin-Clavulanate due to an upper respiratory tract infection. Viral hepatitis profile and serum drug toxicology were unremarkable. Patient was discharged 48 hours later with diagnostic impression of drug-induced liver injury (DILI). One week upon discharge, patient was noticed with worsening jaundice and liver enzymes significative for improving trend in transaminase: ALT 178 U/L, AST 76 U/L, but elevation of total bilirubin at 7.9 mg/dL. CT with liver protocol requested was remarkable for a pancreatic head mass of 2.3 cm x 2.3 cm with secondary dilatation of the CBD, intrahepatic and extra hepatic bile ducts. ERCP was performed due to obstructive jaundice, revealed a distal CBD stricture in favor of a pancreatic head neoplasm. Brushings from the stricture were inconclusive. Surgery service was consulted and patient underwent Whipple's procedure. Pathology report showed evidence of adenocarcinoma of pancreas with T2N1 staging and negative margins. PET scan performed after study, which showed no avid lesions. Patient had an uneventful recovery. Augmentin-Clavulanate is a widely used antibiotic and a frequent cause of idiosyncratic DILI. The onset of presentation is typically on average 3 weeks after antibiotic exposure and commonly presents as cholestatic liver injury. However, DILI is a diagnosis of exclusion for which other causes of hepatic injury should be sought. Hepatobiliary malignancy should be maintained high in differential, especially in an elderly patient. We present an interesting case of pancreatic adenocarcinoma which was found unexpectedly after an initial normal hepatobiliary imaging and negative workup evaluation for acute he patitis secondary to DILI.2266 Figure 1. Pancreatic Mass