Skip to main content

Acute Hepatitis and Obstructive Juandice: Clinical Presentation and Biochemical Correlations




PBL case objective
a)Differential Diagnosis of Jaundice
b)Biochemical basis for the diagnosis of acute liver disease
c) Biochemical basis for the diagnosis of obstructive jaundice

Clinical case 1: 
A 52-year-old male patient arrived at the medical facility with complaints of nausea, vomiting, abdominal pain, and yellowing of the skin (icteric jaundice) that had persisted for one week. Upon conducting a physical examination, the patient was found to have stable vital signs, and there were no signs of hepatic encephalopathy (a condition affecting brain function due to liver disease). The patient exhibited yellowing of the sclera (the white part of the eyes) and tenderness in the right upper quadrant of the abdomen when touched.
The laboratory investigation results are presented below.
Total serum Bilirubin - 15.4 mg/dL
Direct bilirubun-11.5 mg/dl
Aspartate transaminase- 720 U/L
Alanine transaminase - 1625 U/L
Alkaline Phosphatase- 211 U/L
Total Protein- 7.3 g/dl
Serum Albumin- 3.8 g/dl
Prothrombin time : 12 seconds

Clinical Case 2: 
A 34-year-old female patient came to the medical facility with a medical history involving jaundice, fever, and abdominal pain. During the physical examination, the patient exhibited yellowing of the sclera (scleral icterus) and tenderness in the right upper quadrant of the abdomen upon palpation, without experiencing pain upon taking a deep breath.
The laboratory investigation results are presented below.
Total Bilirubin: 5.2 mg/dL
Direct Bilirubin: 4.5 mg/dL
Alanine aminotransferase: 180 U/L
Aspartate aminotransferase:210 U/L
Alkaline phosphatase: 750 U/L,
gamma-glutamyltransferase: 999 U/L

Discussion:


Differential Diagnosis of Jaundice


Jaundice is defined as the discoloration of skin, eye, and sclera with serum bilirubin >3mg/dL. Based on the etiology, jaundice can be classified into pre-hepatic (hemolytic jaundice), hepatocellular jaundice, and post-hepatic (obstructive) jaundice. In pre-hepatic jaundice, the unconjugated bilirubin markedly increased in the serum because the production of bilirubin exceeds the conjugation capacity of the liver. In hepatocellular jaundice, the unconjugated and conjugated bilirubin is increased because of leakage of bilirubin from affected hepatocytes. 
The increase in bilirubin is accompanied by markedly increased alanine transaminase and aspartate transaminase. Measurement of albumin and prothrombin time helps to differentiate chronic liver disease from an acute condition. In the case of obstructive jaundice, the conjugated bilirubin is increased due to obstructed biliary flow and regurgitation of bilirubin. An elevated serum alkaline phosphatase and 5'-nucleotidase activity are suggestive of obstructive jaundice.


Differential Diagnosis of Jaundice (Adapted from Harrison's Internal Medicine-16th ed)

Biochemical basis for the diagnosis of acute liver disease

Case 1: The clinical case presentation and biochemical test results are suggestive of acute hepatitis. The total and direct bilirubin are markedly increased. The transaminases are also elevated with ALT >20 times the upper reference limit showing that the viral infection may be caused by lysis of hepatocytes and leakage of bilirubin and transaminases.  
In addition, serum albumin and prothrombin time are within normal reference intervals suggesting the acute nature of the disease. To confirm the etiology and type of infected virus, the antibody detection assay against different class hepatitis virus, serological test, and PCR identification of virus serotype are recommended.

In chronic hepatic diseases, the ALT and AST are elevated (generally less than 7X URL), with a decrease in serum albumin and prolonged prothrombin time. The decreased serum albumin and prolonged prothrombin time are a result of compromised liver function.


Biochemical basis for a diagnosis of Obstructive jaundice

Case 2: The clinical case presentation and biochemical test results are suggestive of obstructive jaundice. The total and direct bilirubin mildly increased with significant hyperbilirubinemia. The transaminases  (ALT & AST) are mildly elevated with approximately 4-5 X URLs with a marked rise in alkaline phosphatase and gamma-glutamyl transferase. The direct hyperbilirubinemia with elevated serum alkaline phosphatase and gamma-glutamyl transfer are suggestive of cholelithiasis.  The enzyme activity of ALP is also elevated in Paget disease (bone) and cancer etc. GGT is also not the specific marker for obstructive jaundice and is elevated in patients with alcoholic liver disease
Therefore, measurement of 5'-nucleotidase and ultrasonography of liver and gallbladder area is preferable for confirmatory diagnosis.

Summary

The measurement of bilirubin, liver enzymes, and enzymes of biliary track enable the differential diagnosis of hepatocellular and obstructive jaundice. The measurement of albumin and prothrombin time provide additional evidence on the occurrence and duration of the disease. The detection and identification of viral serotypes in acute viral hepatitis are important for the treatment of viral hepatitis. Advancement in medicine has made the treatment of some type of hepatitis possible.

Comments

Popular posts from this blog

Carbohydrate Metabolism: MCQs and answers on Glycolysis & Gluconeogenesis

                                      MCQ on Glycolysis & Gluconeogenesis 1) Which of the following enzyme is not involved in galactose metabolism? a) Glucokinase b) Galactokinase c) Galactose-1-Phosphate Uridyl transferase d) UDP-Galactose 4- epimerase 2) Which of the following enzyme is defective in galactosemia (type I) - a fatal genetic disorder in infants? a) Glucokinase b) Galactokinase c) Galactose-1-Phosphate Uridyl transferase d) UDP-Galactose 4- epimerase 3) In the liver, the accumulation of which of the following metabolite attenuates the inhibitory of ATP on phosphofructokinase? a) Glucose-6-Phosphate b) Citrate c) Fructose-1,6-Bisphosphate d) Fructose-2,6-Bisphosphate 4) Mutation in which of the following enzymes leads to a glycogen storage disease known as "Tarui’s disease"? a) Glucokinase b) Phosphofructokinase c) Phosphoglucomutase d) Pyruvate Kinase 5) E...

MCQs and Answers on cultivation (culture/incubation), Isolation and Identification of microorganisms: Medical Microbiology

40 plus questions - Multiple Choice Questions on Classification, Culture, and Identification of the microorganisms 1. Which of the following microorganism has the cocci cell shapes and sizes arranged usually in tetrad structures? a)  Streptococcus pneumoniae b)  Staphylococcus aureus c)  Chlamydia trachomatis d)  Neisseria meningitidis 2. What are the different growth morphology and cell structures used for the classification of fungi? Select all the correct answers: a) Yeast b) Mold c) Mycelia d) Protozoa 3. Which of the following media is formulated with additional nutrients to support the growth of fastidious or nutritionally demanding bacteria that may not grow well on basic media? a) Differential media b) Enriched media c) Nutrient agar (media) d) Selective media 4. Which of the following metabolic characteristic is a distinguishing characteristic and identification of colonies of  E. coli ? a) Hydrogen sulfide formation b) Indole Formation c) Lactose fe...

Multiple Choice Questions (MCQs) on Diabetes Mellitus: Pathogenesis, Diagnosis and Treatment

                                        MCQs on Diabetes mellitus 1) Diabetes mellitus is a disorder characterized by hyperglycemia.  Which of the following is not the common characteristic features of type 2 diabetes mellitus ? a) Impaired insulin secretion b) Increased Insulin resistance  c) Diabetic ketoacidosis d) Excessive hepatic glucose production 2) Which of the following are the characteristic features of type 1 diabetes mellitus? a) Type 1 diabetes is caused by an absolute deficiency of insulin. b) Type 1 diabetes is associated with the autoimmune destruction of beta cells.  c) Patients with  uncontrolled type 1 diabetes present with diabetic ketoacidosis d) All of the above   3) Which of the following serum measurements are not used for the diagnosis of diabetes mellitus? a) Fasting blood glucose d) Postprandial blood glucose  c) Insulin ...