Chapter II-7

A 60-year-old woman presented to the ED with progressive weakness that developed over two weeks.

Several days earlier, she noted that her eyes were yellow. She also had mild upper abdominal discomfort. She was previously healthy and took no medications. She had had a hysterectomy many years earlier.

On examination, she was an overweight woman in no apparent distress. She was afebrile and her vital signs were normal. There was scleral icterus. Her abdomen was nontender.

The urine dipstick was negative for bilirubin, and the urobilinogen was normal.

Her abdominal radiographs are shown in Figure 1.

###### Figure 1

• What was the cause of this patient’s jaundice?

An abdominal radiograph is not often helpful in the diagnostic evaluation of a patient with jaundice. In this patient, the radiograph provided worthwhile information before other laboratory results were available.

The most frequent cause of jaundice is decreased elimination of bilirubin due to either hepatocellular dysfunction or mechanical obstruction of the extrahepatic biliary tracts. Less frequently, jaundice is due to increased production of bilirubin, as occurs with destruction of red blood cells in hemolytic anemia.

Liver enzyme blood levels can distinguish hepatocellular from obstructive jaundice. In hepatocellular dysfunction, elevation of the hepatocellular enzyme aminotransferases predominates. In obstructive jaundice, elevation of the biliary canalicular enzyme, alkaline phosphatase, is greater. The serum bilirubin profile—direct (conjugated) versus indirect (unconjugated)—is not helpful in distinguishing obstructive from nonobstructive jaundice. In both, there is elevation of direct and indirect bilirubin.

When jaundice is due to increased bilirubin production, as occurs in hemolytic anemia, only unconjugated (indirect) bilirubin levels are elevated (Figure 2). Conjugated bilirubin is excreted into the bile and the serum direct bilirubin is therefore not elevated. Liver enzyme tests are normal and LDH of red blood cell origin is elevated.

###### Figure 2

Bilirubin metabolism.

Hepatocyte Function:

1. Uptake of unconjugated bilirubin from the systemic circulation.

2. Conjugation by glucuronyl transferase.

3. Excretion of conjugated bilirubin into the bile. (This is the rate limiting step.)

4. When there is hepatocellular dysfunction or bile flow is totally obstructed, conjugated bilirubin “leaks” into the systemic circulation.

In Patient 7, the absence of urinary bilirubin on the bedside dipstick urinalysis suggested that the jaundice was due to hemolysis because the bilirubin was all unconjugated (indirect) and not excreted into the urine.

The abdominal radiographs provide support for the diagnosis of hemolytic anemia by showing a massively enlarged spleen (Figure 3). There is a large round soft tissue mass ...

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