A 48-year-old man has noticed increasing abdominal girth and a yellowish color to his skin over the past 5 months. On physical examination, he has scleral icterus and generalized jaundice. His abdomen is distended, and a fluid wave is present. Laboratory studies include total serum bilirubin of 5.2 mg/dL, direct bilirubin of 4.2 mg/dL, AST of 380 U/L, ALT of 158 U/L, alkaline phosphatase of 95 U/L, total protein of 6.4 g/dL, and albumin of 2.2 /dL. The prothrombin time is 18 seconds, and the partial thromboplastin time is 30 seconds. The blood ammonia level is 105 mmol/L. What is the most likely cause of these findings?

The elevated transaminase levels, some loss of liver function with abnormal prothrombin time, and cholestasis are not specific for a given type of liver injury. An AST level that is higher than the ALT level is characteristic, however, of liver cell injury associated with chronic alcoholism. In this patient, the disease is decompensating, as evidenced by the elevated blood ammonia level. HAV is typically a mild disease without a preponderance of direct bilirubin. Choledocholithiasis results in conjugated hyperbilirubinemia, but without the high ammonia level that is evidence of liver failure. Metastases are unlikely to obstruct all biliary tract drainage or lead to liver failure severe enough to cause elevations of blood ammonia. Primary biliary cirrhosis is rare, particularly in men, and the alkaline phosphatase level would be much higher.