Drug-Induced Liver Injury: A Case of Amoxicillin-Clavulanate-Induced Liver Injury

Document Type

Conference Proceeding

Publication Date

10-2024

Publication Title

American Journal of Gastroenterology

Abstract

Introduction: Drug-induced liver injury (DILI) is the most common cause of acute liver failure, commonly caused by antibiotics and supplements, with symptom relief after several months. Diagnosis of DILI is one of exclusion, not requiring liver biopsy. Management includes immediate cessation of the offending agent with supportive care with n-acetylcysteine (NAC) and ursodiol, although there is little evidence to support their use. This is a unique case of amoxicillin-clavulanate induced DILI supported by liver biopsy. Case Description/Methods: A 59-year-old man with ulcerative colitis on balsalazide presented with nausea, vomiting, fatigue, jaundice, scleral icterus, and pruritis. Social history revealed alcohol use disorder (24 beers/week). Five days prior to arrival, he used prophylactic amoxicillin-clavulanate 875mg/125mg over 3 days for a root canal. Labs were notable for an INR 1.2, total bilirubin of 7.9 U/L, direct bilirubin 6.1 mg/dL, aspartate aminotransferase (AST) 42 U/L, alanine aminotransferase (ALT) 63 U/L, and alkaline phosphatase (ALP) 196 U/L. Serology ruled out other etiologies of liver injury. Imaging showed hepatic steatosis, ruling out ductal stricture, choledocholithiasis, biliary ductal dilatation, primary sclerosing cholangitis, and portal vein thrombosis. He was discharged and advised to stop both amoxicillin-clavulanate and alcohol. He returned to the Emergency Department 6 days later with a total bilirubin of 17.2 mg/dL and worsening jaundice. He was admitted and treated with ursodiol 300mg 3 times daily. His total bilirubin peaked at 20.3 mg/dL, remaining atypically elevated, leading to the pursuit of a liver biopsy, consistent with drug-induced bile metabolism (Table 1, Figure 1). Alcohol involvement may have contributed to the elevated bilirubin, supported by an elevated phosphatidylethanol level of 31 ng/mL and hepatic steatosis. Following ursodiol 300mg 3 times daily, he had complete symptom resolution and total bilirubin decreased to 1.6 mg/dL after 8 weeks. Discussion: This is a case of drug-induced liver injury secondary to amoxicillin-clavulanate with a component of alcohol use. Despite cessation of the offending agent, the patient’s atypically rising bilirubin necessitated liver biopsy for diagnosis confirmation and to rule out other causes. While the utilization of ursodiol is not well studied in DILI management, this case highlights its successful use, as well as the importance of liver biopsy in atypical cases to confirm and rule out other etiologies.

Volume

119

Issue

10S

First Page

S2779

Comments

American College of Gastroenterology Annual Scientific Meeting, October 25-30, 2024, Philadelphia, PA

Last Page

S2780

DOI

10.14309/01.ajg.0001046676.39046.97

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