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Drug-induced liver injury — ESEGH MCQ

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ModerateHepatologyDrug-induced liver injuryESEGH

A 71-year-old woman develops jaundice and generalized pruritus 3 weeks after completing a course of co-amoxiclav for sinusitis. She has pale stools but no abdominal pain. Blood tests show bilirubin 118 micromol/L, ALP 640 IU/L (upper limit of normal 120 IU/L), ALT 96 IU/L (upper limit of normal 40 IU/L) and eosinophils 0.9 × 10^9/L. Abdominal ultrasound shows no biliary dilatation. What is the most likely cause?

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Correct answer: C — Idiosyncratic drug-induced cholestatic liver injury

The correct answer is C. Co-amoxiclav is a well-recognised cause of idiosyncratic cholestatic DILI, which may first present several weeks after the antibiotic has been stopped. The disproportionately raised ALP, jaundice, pruritus and pale stools establish a cholestatic phenotype; eosinophilia further supports a drug-related hypersensitivity mechanism. Persistent choledocholithiasis is less likely without pain or biliary dilatation, although further imaging may be required clinically if obstruction remains a concern. Acute hepatitis E more commonly produces a hepatocellular pattern with substantially greater aminotransferase elevation, but should still be excluded during a complete DILI assessment. Gilbert syndrome causes isolated unconjugated hyperbilirubinaemia without cholestasis. Primary sclerosing cholangitis is not suggested by this acute temporal relationship or the absence of supportive biliary features.

Reference: Sandoz Limited. Co-amoxiclav 500/125 mg Tablets: Summary of Product Characteristics, sections 4.4 and 4.8. Revised 15 April 2026. https://www.medicines.org.uk/emc/product/6544/smpc