What is THAT on your liver?

A 44 year-old female with a past medical history of hypothyroidism and obesity presents with acute onset right upper quadrant abdominal pain radiating to the back and sternum. Associated symptoms include nausea and lightheadedness with standing. Her medications include Levothyroxine and an oral contraceptive pill (OCP).

Lab work-up reveals total bilirubin 0.2 mg/dL, alkaline phosphatase 150 U/L, ALT 113 U/L, AST 104 U/L, INR 0.9, WBC 14.3 K/uL, hemoglobin 9.3 g/dL, platelet count 488, Lactate 4.5 mmol/L.

On physical exam hepatomegaly is palpable and she is significantly tender to palpation in the epigastrium and right upper quadrant.

What is the next best step?

Hepatic Abscesses: Where Hepatology meets Infectious Disease

A 63-year-old female presents to the ER with right upper quadrant pain and jaundice. History is notable for a hepatic abscess thought to be secondary to acute cholecystitis three months ago at an outside hospital. At that time, AST was 300 U/L, ALT 200 U/L, alkaline phosphatase 113 U/L, and total bilirubin of 3.5 mg/dL. Hospital course was complicated by Escherichia coli bacteremia. The hepatic abscess was ultimately drained and culture results were positive for Klebsiella pneumoniae and Escherichia coli. The patient was discharged on antibiotics and told to follow up with surgeons for a cholecystectomy. The patient now re-presents with pain and jaundice. On exam, the patient is febrile to 38.9°C, BP 120/60, heart rate 96 bpm. Labs are now significant for conjugated hyperbilirubinemia of 8.8 mg/dL, alkaline phosphatase of 1844 U/L, AST 418 U/L, and ALT 215 U/L. No leukocytosis or eosinophilia is present. An ultrasound in the ER reveals signs of chronic cholecystitis and a large fluid collection in the right lobe of the liver.