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Acute liver failure (ALF) is a rare initial presentation of metastatic liver disease and is associated with high fatality. Our case report describes acute hepatic decompensation from an occult pancreatic malignancy. A 64-year-old man presented with abdominal distension for 2 weeks associated with decreased appetite and a weight loss of 13.6 kg, over the past 8 months. Significant admission labs were serum creatinine 6.15 mg/dL, serum bilirubin 27 mg/dL, aspartate aminotransferase (AST) 316 u/L, alanine aminotransferase (ALT) 198 u/L and se
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