Subjective:

Ms. B is a 56 y/o female. Chief complaint of yellowing of her skin and eyes

• Started two weeks ago.
• experiencing dark urine, light colored stools, anorexia, and fatigue
• denies vomiting, abdominal pain, nausea, or fever
• PMH – Helicobacter pylori – positive gastric and duodenal ulcers 6 years ago treated with eradication therapy, blood transfusion in Latvia in 1996
• PSH – none
• NKDA
• Meds – none
• FHx – none
• SHx – 2 glasses to 1 bottle of wine daily for years, no tobacco or drug use

Objective:

Gen – A/O x 3; slender female

Eyes – Scleral Icterus

Skin – Jaundice

Ext – no peripheral edema

Gastrointestinal – hepatomegaly measuring 7 cm below costal margin; across the midline; Spleen tip is palpable; no abdominal tenderness or distension

Assessment:

Ms. B is a 56 y/o female with Scleral Icterus, Jaundice, dark urine, light colored stool, anorexia, and fatigue. Physical exam revealed hepatomegaly and splenomegaly. R/O conjugated hyperbilirubinemia. R/O Hepatitis.

Plan:

– CBC w/ Liver enzyme test and hepatitis antibodies

– Ultrasound or CT Abdomen

– Advise to abstain from drinking

– Follow up within a week

 

Ms. B is a 56-year-old woman who comes to your office because her skin and eyes have been yellow for the past 2 weeks.

Ms. B also tells you she has dark urine, light-colored stools, anorexia, and fatigue. She has no nausea, vomiting, abdominal pain, or fever.

Ms. B’s physical exam shows scleral icterus and jaundice as well as hepatomegaly, with her liver edge palpable 7 cm below the costal margin. The liver extends across the midline, and the spleen tip is palpable. There is no abdominal tenderness or distention. There is no peripheral edema, and the rest of her exam is normal.

Given the pivotal historical points (dark urine and light colored stools) and the physical exam findings of jaundice, hepatomegaly, and splenomegaly, you are confident that Ms. B has hyperbilirubinemia and suspect that it will be primarily conjugated.

You obtain the following initial tests: total bilirubin, 13 mg/dL; direct bilirubin, 9.6 mg/dL; AST, 250 units/L; ALT, 113 units/L; alkaline phosphatase, 503 units/L; albumin, 2.8 g/dL; prothrombin time (PT), 15.4 s (control 11.1 s); WBC = 22,000 cells/mcL with 80% PMNs, 16% lymphocytes, and 4% monocytes. The platelet count is normal.

Ms. B had a blood transfusion in Latvia in 1996. She has no history of injection drug use, tattoos, or smoking, but she has consumed between 2 glasses and 1 bottle of wine daily for years. Her past medical history is notable only for Helicobacter pylori–positive gastric and duodenal ulcers 6 years ago, treated with eradication therapy. She is taking no medications.

Ms. B’s transaminases are consistent with, but not diagnostic of, ALD. An imaging study is necessary not to rule in ALD but rather to exclude alternative diagnoses.

As discussed in Chapter 3, Abdominal Pain, ultrasound is the best first test to look for stones in the gallbladder, although the sensitivity is less for common bile duct stones. However, in this patient, pancreatic cancer or other malignancies are more likely causes of extrabiliary obstruction than stones; therefore, an abdominal CT scan or MRCP would be a better first test. Tests for hepatitis are necessary in all patients with liver disease and are especially important in Ms. B because of her history of a blood transfusion.

Ms. B has an abdominal CT scan, which shows an enlarged, nodular liver, moderate ascites, and a normal pancreas. Her ANA, hepatitis A IgM antibody, HBsAg hepatitis B IgM core antibody, and hepatitis C antibody are all negative.

Her liver biopsy showed acute alcoholic hepatitis with cirrhosis. Because her mDF was > 32, she was treated with prednisolone. She was also advised to abstain from alcohol. She completed the course of prednisolone and has remained abstinent. Several weeks later, her bilirubin was normal and she felt well.

Summary:

Ms. B with her chief complaint, associated symptoms, and physical exam findings points towards a hyperbilirubinemia. The dark urine that Ms. B is experiencing helps us to narrow down our type of hyperbilirubinemia to a conjugated hyperbilirubinemia. This is because if it was unconjugated then you would not find any bilirubin in the urine. In normal physiology unconjugated bilirubin is bound to albumin in the blood stream and it cannot get filtered in the kidneys. Additionally, Ms. B experienced light color stool which also indicates that the patient might have a extrahepatic obstruction which is preventing bilirubin from entering the intestine. A liver enzyme test also helped in further narrowing down our differential but there is some overlap in the abnormalities of hematological diseases and disorders so the best thing is to use it as a guide. If there are elevated liver enzymes levels then you compare the transaminase levels with alkaline phosphatase levels. If alkaline phosphatase levels are greater than the transaminase levels it indicates a cholestatic pattern. If the levels of alkaline phosphatase were lower than transaminase levels then it would be indicative of hepatocellular pattern. For Ms. B, her disease follows a cholestatic pattern based upon the results of the liver enzyme test. The next step would be to obtain a ultrasound, CT, or Magnetic resonance cholangiopancreatography(MRCP) to help further narrow down whether there are extrahepatic or intrahepatic obstruction as well as if the biliary ducts are dilated or normal. With all of these procedures combined with the patient’s history of alcohol abuse helps us prioritize ALD (Alcoholic Liver Disease) as the primary contributor to the patient’s symptoms.