Question

Carolyn, a 58-year-old female, came into your clinic with a chief complaint of acute abdominal pain in the upper right quadrant. Murphy’s sign was positive, marked jaundice was observed, and history revealed recent weight loss, fatigue, and increased alcohol consumption due to a recent divorce. Carolyn denies IV drug use. Lab results show increased bilirubin, AST, ALT, and decreased serum albumin. A rapid HIV test was negative. List 3 differential diagnoses and include your reasoning behind each. What is the best diagnosis? Explain how you came to this conclusion. Explain the pathophysiology of the following symptoms: increased bilirubin, fatigue, and weight loss.

Answer 1

Pathophysiology means the disordered physiological processes associated with disease or injury.

High total bilirubin that is mostly unconjugated (indirect) may be caused by:

Bilirubin is a tetrapyrrole produced by the normal breakdown of heme. Most bilirubin is produced during the breakdown of hemoglobin and other hemoproteins. Accumulation of bilirubin or its conjugates in body tissues produces jaundice.

Acute stress reaction symptoms include shortness of breath, anxiety, nervousness, sense of doom and more. Lack of exercise. Lack of exercise is a common cause of fatigue, weight gain, and muscle weakness.

• Anemia.

• Cirrhosis.

• A reaction to a blood transfusion.

• Gilbert syndrome -- a common, inherited condition in which there is a deficiency of an enzyme that helps to break down bilirubin.

• Viral hepatitis.

• A reaction to drugs.

• Alcoholic liver disease.

Signs/symptoms of unconjugated hyperbilirubinemia include the following:

• Ineffective erythropoiesis (early labeled bilirubin [ELB] production) - Characterized by the onset of asymptomatic jaundice

• Crigler-Najjar (CN) syndrome type 1 - Jaundice develops in the first few days of life and rapidly progresses by the second week; patients may present with evidence of kernicterus, the clinical manifestations of which are hypotonia, deafness, oculomotor palsy, lethargy and, ultimately, death

• Crigler-Najjar syndrome type 2 - Usually, no clinical symptoms are reported with this disease entity

• Gilbert syndrome - May manifest only as jaundice on clinical examination; at least 30% of patients with Gilbert syndrome are asymptomatic, although nonspecific symptoms, such as abdominal cramps, fatigue, and malaise, are common

• Physiologic neonatal jaundice - Clinically obvious in 50% of neonates during the first 5 days of life.