Introduction: body. Dubin-Johnson syndrome is associated with inability

Introduction:

In this case, the most likely
diagnosis of the patient has post-hepatic jaundice which might due to the
presence of gallstone blocking the bile duct known as extra-hepatic
obstruction. Another cause is carcinoma of the head of pancreas. The elevation
of bilirubin level which is 250 µmol/l will give rise to severe, painless
and deep jaundice. The post-hepatic jaundice is characterized by high alkaline
phosphatase (ALP) activity that is more than seven times the upper limit of the
reference range. In the given case, the aspartate and alanine aminotransferase
activities do not indicate severe hepatocellular damage.

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Discussion:

Elevated level of
bilirubin is ten times higher than the reference range, so it often indicates
that an obstruction of bile flow or a defect in the processing of bile by the
liver. Biliary obstruction signs and symptoms include light colour stool, dark
urine, nausea, vomiting and jaundice. Other possible causes elevation of
bilirubin are red blood cell breakdown destruction (anemia), liver scaring,
liver inflammation and cancer of pancreas or gall bladder. Several diseases are associated with hyperbilirubinemia.  Hemolytic jaundice is one
of the diseases because more
bilirubin is conjugated and excreted than normally, but the conjugation
mechanism is overwhelmed, and an abnormally large amount of unconjugated
bilirubin is found in the blood. Gilbert’s disease may
be caused by an inability of the hepatocytes to take up bilirubin from the
blood. As a result, unconjugated bilirubin accumulates. Physiological jaundice
and Crigler-Najjar syndrome are
conditions in which conjugation is impaired. Unconjugated bilirubin is retained
by the body. Dubin-Johnson syndrome is associated with inability of the hepatocytes to
secrete conjugated bilirubin after it has been formed. Conjugated bilirubin
returns to the blood. The given result
shown that the AST is exceeds the reference range value. AST
levels increase when there’s damage to the tissues and cells where the enzyme
is found. Elevated levels indicate that there is a certain amount of damage in
that area. AST is less specific for liver disease than ALT. It elevated in
other conditions such as myocardial infarction. The sensitive
indicator of liver cell injury is aminotransferase. They are most useful in helping to recognize the acute
hepatocellular diseases such as hepatitis and cirrhosis. ALT is more specific
for liver damage than AST. ALT usually increased more than AST in liver damage.
Usually, the aminotransferases are present in the serum with a low
concentration. When there is damage to the liver cell membrane resulting in
increased permeability, these enzymes will release into blood stream in a
greater amount. The activities of two enzymes include alkaline phosphatase
(ALP) and gamma-glutamyl transpeptidase (GGT) are normally increases in obstructive
liver disease which also known as cholestasis. The elevation of the alkaline phosphatase in serum is more
specific than GGT. GGT estimation is done to identify the patients with occult
alcohol use. The normal serum alkaline phosphatase consists of many distinct
isoenzymes found in the liver, bone, placenta and less commonly is small
intestine. There is not totally specific for cholestasis in the elevation of
liver derived alkaline phosphatase. A less threefold elevation can be seen in
almost any type of liver disease. An elevation greater than four times normal
of alkaline phosphatase occur in patients indicate that cholestatic liver
disorder, infiltrative liver disease such as cancer and bone conditions
characterized by rapid bone turnover (eg. Paget’s disease). This elevation is
due to increased amount of bone isoenzymes in bone disease whereas the
elevation is due to increased amount of liver isoenzymes in liver disease. In
intrahepatic obstruction, the values increased as in drug-induced hepatitis and
primary biliary cirrhosis. The values are found in extra-hepatic obstructive is
very high due to cancer, common duct stone or bile duct structure. The
increased of the level of serum alkaline phosphatase is not helpful to
differentiate between intrahepatic and extra-hepatic cholestasis. Values are
also greatly elevated in hepatobiliary disorders seen in patients with AIDS.

Other than biochemical testing, certain
parameters are need to be used to confirm it is post-hepatic jaundice.

 

Surgical
history:

The surgical history of the patients whether recent or past need to be understand
because it may be implicated in the cause of post-hepatic jaundice. It may be
due to a variety of problems within the first three post-operative weeks.
Levels of bilirubin increased related to hemolysis of transfused erythrocytes
(especially stored blood), resorption of hematomas or hemoperitoneum and rarely
to hemolysis of the patient’s erythrocytes due to G-6PD deficiency or malarial
parasites in transfused blood. Administration of halogenated anesthesia agents,
exposure to other hepatotoxic drugs, sepsis, or hepatic ischemia associated
with preoperative or intraoperative hypotension or hypoxia may cause the
impaired hepatocellular function. It is very important to examine the operative
record for transfusion, anesthesia, x-rays, drugs, and potential hypotension or
hypoxia, as well as the surgeon’s dictated note of intraoperative events and
his visual and palpation impression of the patient’s liver, biliary tree, and
pancreas when a case of jaundice potentially related to surgery needed to be
investigated.

Family history:

A family
history
of jaundice, liver disease, or anemia (especially when requiring splenectomy)
should be sought. A positive family history of liver disease may implicate the
genetically transmitted non-hemolytic hyperbilirubinemias (Crigler–Najjar,
Gilbert’s, Dubin–Johnson, or Rotor’s syndromes), benign recurrent intrahepatic
cholestasis, Wilson’s disease, hemochromatosis, alpha-1 antitrypsin deficiency
or hereditary spherocytosis in the differential diagnosis.

Imaging
evaluation:

To investigate jaundice, some advanced
techniques and equipment are really useful such as high-resolution ultrasound, computerized
tomography (CT), percutaneous transhepatic cholangiography (PTC), endoscopic
retrograde cholangiopancreatography (ERCP) and hepatobiliary scintigraphy
(HBS). A valuable screening test in the jaundiced patient is abdominal sonography. The
demonstration of biliary ductal dilation, gallstones, hepatic mass lesion, or
an enlarged or abnormally shaped pancreas directs further investigation or
therapy. Computerized tomography
has the advantage of surveying the entire abdomen as well as the hepatobiliary-pancreatic
axis. Furthermore to reliably detecting ductal dilation, CT is superior to
sonography in determining the level and cause of obstruction. The pancreas is
displayed more reliably and accurately by CT than by sonography.

Liver
biopsy:

Percutaneous needle liver biopsy is a
safe procedure in experienced hands provided that the patient’s coagulation
mechanism is normal. The individual factor deficiencies can be corrected by
needle biopsy even if the clotting process is abnormal. It is very helpful in
jaundiced patients to determine the cause of hepatomegaly, differentiate between
intrahepatic and extra-hepatic obstruction (patients with drug-induced
jaundice, primary biliary cirrhosis, and intrahepatic neoplasm may present with
jaundice and defy diagnosis until liver tissue is obtained), follow chronic
liver disease to determine progression of the natural process or the effects of
therapy and provide liver tissue for special investigations such as culture,
chemical analysis (hemochromatosis, Wilson’s disease), enzyme assay (glycogen
storage disease) or immunologic studies (hepatitis B virus, delta agent).

Treatment
for post-hepatic jaundice:

The
treatment for post-hepatic jaundice is entirely depends on the causes. Once a
diagnosis has been established, the appropriate course of treatment can then be
initiated. Patients can request for hospitalization or managed at home as
outpatients. Alcohol cessation
is necessary in patients with cirrhosis, alcoholic hepatitis, or acute
pancreatitis
secondary to alcohol use. Anti-viral medications may be used
for liver damage caused by infection such as viral hepatitis or glandular fever
to prevent further damage. In general ways, surgery to unblock the bile duct
system is recommended. During surgery, it may need to remove the gallbladder, a
section of bile duct system or pancreas to prevent further blockage. Liver
transplant is another possible option in severe cases of liver disease. Prevention
is better than cure in certain condition leading to post-hepatic jaundice. In fact, there are certain measures
that can be taken in order to decrease the risk of developing jaundice. To
decrease the risk of developing Hepatitis B or C, high-risk
behaviors such as unprotected intercourse or intravenous drug use, and
implement universal precautions when working with blood products and needles
must be avoided. Vaccination of Hepatitis A or B can be considered. When
travelling to areas where malaria is endemic, take the recommended precautions
and prophylactic medications in order to prevent the development of malaria.
Reduce alcohol consumption is also important to prevent the liver disease such
as alcoholic hepatitis, alcoholic cirrhosis and pancreatitis. Smoking behavior should
be avoided as well because it is the risk factor for the development of pancreatic
cancer and many other malignancies’.

Conclusion:

In
conclusion, the 65 years old man patient in this case study having post-hepatic
jaundice (obstructive jaundice) after diagnosis. The prognosis for patients
with post-hepatic jaundice is depends the underlying causes. Diagnostic test
and certain ways can be used to find out the best solutions to treat the
disease.  Appropriate treatment advised
by doctors must be taken in order to cure or prevent the conditions became worse.
However,
more serious causes of jaundice can sometimes be fatal despite medical or
surgical intervention.

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