A patient presents with nausea and RUQ tenderness along with marked transaminase elevations; what is the most likely diagnosis?

• A. Viral hepatitis
• B. Acute pancreatitis
• C. Biliary colic
• D. Chronic liver disease

Answer: (A)

Acute hepatocellular injury causes a sudden, marked rise in aminotransferases, and when the patient has nausea with right upper quadrant tenderness this pattern most strongly points to viral hepatitis. The liver-specific enzyme ALT is typically prominent, reflecting hepatocyte injury, and the RUQ discomfort can occur from stretching of the liver capsule during inflammation.

Pancreatitis would more likely present with epigastric pain radiating to the back and a rise in pancreatic enzymes (lipase, amylase) rather than a dominant transaminase elevation. Biliary colic tends to cause postprandial RUQ pain with only mild or normal transaminases and a pattern suggesting biliary obstruction (elevated alkaline phosphatase and bilirubin) rather than marked hepatocellular injury. Chronic liver disease usually shows a different picture, with signs of long-standing liver dysfunction and less abrupt, extreme transaminase elevations.

Thus, the combination of RUQ tenderness with marked transaminase elevations best fits acute viral hepatitis.