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Self-Assessment Questions

Gastroenterology

Jaundice: Review Questions

Douglas G. Adler, MD

Dr. Adler is an assistant professor of medicine and Director of Therapeutic Endoscopy, Division of Gastroenterology and Hepatology, Huntsman Cancer Center, University of Utah School of Medicine, Salt Lake City, UT.



Choose the single best answer for each question.


Figure 1

1. An 18-year-old male college freshman is referred to a gastroenterologist for evaluation of painless jaundice. He initially presented to a campus health center for evaluation of a flu-like illness with high fevers, where mild scleral icterus was noted. Initial laboratory studies revealed a normal complete blood count, normal alkaline phosphatase level, and normal alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels as well as a total serum bilirubin of 4 mg/dL and direct serum bilirubin of 0.4 mg/dL. Serologic testing for hepatitis was negative. At this visit, the flu-like illness has spontaneously resolved, and repeat laboratory testing reveals that total serum bilirubin has returned to normal. He has not taken any medications for his illness. What is the most likely cause of this patient’s elevated serum bilirubin level?

  1. Acute viral hepatitis
  2. Gilbert’s syndrome
  3. Primary biliary cirrhosis (PBC)
  4. Primary sclerosing cholangitis (PSC)
  5. Transient biliary obstruction caused by a gallstone
Click here to compare your answer.


2. A 29-year-old man is referred to a gastroenterologist for evaluation of progressive fatigue, intermittent fevers, and jaundice. He has a history of ulcerative colitis since age 18 years and underwent a proctocolectomy with an ileal pouch-anal anastomosis reconstruction. On physical examination, vital signs are stable and he is afebrile. He has a few spider angiomas on his chest and vague right upper quadrant pain with deep palpation. Laboratory testing reveals the following: AST, 120 U/L; ALT, 138 U/L; alkaline phosphatase, 800 U/L; and total serum bilirubin, 5.6 mg/dL. Complete blood count is normal. The patient undergoes endoscopic retrograde cholangiopancreatography (ERCP) and an occlusion cholangiogram is generated (Figure 1). What is this patient’s most likely diagnosis?

  1. Acute hepatitis A
  2. Choledocholithiasis
  3. PBC
  4. PSC
  5. Secondary sclerosing cholangitis (SSC)
Click here to compare your answer.


Questions 3 and 4 refer to the following case.

A 42-year-old female nurse is referred to a gastroenterologist for evaluation of jaundice. The patient was made aware that she looked jaundiced by her coworkers. She also complains of intense pruritus that has not been relieved by over-the-counter agents such as diphenhydramine. Her appetite and weight are stable, and she has no abdominal symptoms. Physical examination is remarkable for xanthomas on her upper eyelids near the bridge of her nose but is otherwise unremarkable except for jaundice. She takes no medications. Laboratory testing reveals normal ALT and AST levels, a total serum bilirubin level of 7 mg/dL, and an alkaline phosphatase level of 733 U/L. The patient is referred for ERCP due to concern for obstruction, but the cholangiogram is normal.



Figure 2

3. What is this patient’s most likely diagnosis?

  1. Acute hepatitis A
  2. Choledocholithiasis
  3. PBC
  4. PSC
  5. SSC
Click here to compare your answer.


4. Which additional blood test would be the most helpful to confirm this patient’s diagnosis?

  1. Antigliadin antibody
  2. Antimitochondrial antibody (AMA)
  3. Antinuclear antibody
  4. IgG subclass 4
  5. Serum amylase level
Click here to compare your answer.


5. A 62-year-old woman presents for evaluation of sudden-onset, severe, painless jaundice. The patient has developed anorexia with a 20-lb weight loss over a 3-month period and recently was diagnosed with diabetes mellitus. Complete blood count is normal, total serum bilirubin is 8.9 mg/dL, direct serum bilirubin is 8.3 mg/dL, alkaline phosphatase is 550 U/L, AST is 120 U/L, and ALT is 134 U/L. The patient undergoes magnetic resonance imaging of the abdomen, but she is unable to tolerate the examination due to claustrophobia. ERCP is performed, which reveals significant intra- and extrahepatic ductal dilation and a tight distal biliary stricture (Figure 2). What is this patient’s most likely diagnosis?

  1. Ampullary cancer
  2. Cholangiocarcinoma
  3. Cholecystitis
  4. Pancreatic adenocarcinoma
  5. Postoperative biliary stricture
Click here to compare your answer.

6. A 28-year-old woman is referred to a gastroenterologist for evaluation of jaundice. The patient has a history of recurrent urinary tract infections, kidney stones, and migraine headaches. She states that the jaundice came on suddenly over the last several days. She has vague right upper quadrant pain but also states she has large kidney stones on the right side, which cause similar pain. Medications include trimethoprim- sulfamethoxazole (TMP-SMX), which she takes 3 times per week to suppress urinary tract infections, as well as acetaminophen and sumatriptan for migraines. Laboratory testing reveals an AST of 59 U/L, ALT of 73 U/L, alkaline phosphatase of 630 U/L, a total serum bilirubin of 6.4 mg/dL, and a direct serum bilirubin of 5.9 mg/dL. A hepatobiliary iminodiacetic acid (HIDA) scan is normal. What is the most likely cause of this patient’s jaundice?

  1. Acetaminophen
  2. Cholecystitis
  3. Choledocholithiasis
  4. Sumatriptan
  5. TMP-SMX
Click here to compare your answer.
 

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