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
Her abdominal radiographs are shown in Figure 1.
- What was the cause of this patient’s
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
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
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.
1. Uptake of unconjugated bilirubin from the systemic
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 in the left upper quadrant,
which compresses the stomach ...