Question:
Hi, I am an eighteen year old girl who has asthama. Since last Monday I have been having worsening stomach and lower back pain I went to my doctor and after testing for UTI he was alarmed to find my bilirubin levels were alarmingly high I was sent to the hospital for further test. All my test came back fine, so now they are sending me to a GI specialist. They said that they think I have spastic bowel syndrome and gave me medicine for that but it does nothing for the pain and doesnt make me feel any better. I am also being tested for Epstien Barr and have had mono in the past. This Wednesday I am being sent to a GI specialist who can hopefully find something that is causing my pain and high bili levels. Please tell me if you think my doctor is doing the right thing, I just dont think this pain has anything to do with my digestive tract because both sides hurt not the middle. Thank you very much any response or advice would be greatly appriciated.

Answer:
   

Cady- Have you had a HIDA scan or an abdominal ultrasound? It sounds like you are having gallbladder problems. Even at your age, the gallbladder can give you problems like this. If the HIDA or Abdominal US come back normal, then they should order a CT of your abdomen/pelvis. If spastic bowel was ruled out, then I don't know why you are being referred to a GI. You might need a surgical opinion and GI's are not surgeons. The only thing you're going to get from seeing a GI is a Gastroscopy or Colonoscopy and at this point, I don't see why you would need that this soon. Other things could be ruled out first.


Answer:
Hey Cady, how are you doing?

Once jaundice is recognized clinically or chemically, it is important to determine whether it is predominantly due to unconjugated or conjugated hyperbilirubinemia (a simple clue in this regard is to determine whether bilirubin is present in the urine). In its absence in the urine suggests unconjugated hyperbilirubinemia (since this pigment is not filtered by the glomerulus); its presence indicates conjugated hyperbilirubinemia.

The greater part of the bilirubin is deprived from the catabolism of hemoglobin present in senescent red blood cells, which normally accounts for about 80 to 85 percent of the daily bilirubin production. When an increased amount of hemoglobin is released from red blood cells into either the bloodstream or tissues, increased bilirubin production occurs.

Hyperbilirubinemia develops when the capacity of the liver to remove the pigment from the circulation is exceeded. If the direct bilirubin is elevated there may be some kind of blockage of the liver or bile duct, perhaps due to gallstones, hepatitis, trauma, a drug reaction, or long-term alcohol abuse.

Chronic overproduction of bilirubin may result in the formation of gallstones composed predominantly of bilirubin ("pigment stones"). In this situation, all the potential complications of calculus disease of the biliary tract may be superimposed on the chronic hemolytic state which produced it.

NOTE: In some people the presence of gallstones produce no symptoms at all. Common symptoms that suggest their presence are conciderable flatulence, belching, acid indigestion, mild jaundice, a fast pulse, and discomfort after meals.

However, when a gallbladder attack or biliary colic resulting from a stone in the bile duct occurs, the symptoms are agonizingly painful, with excruciating pain radiating from the upper abdomen to the back or right shoulder. Fried or greasy foods, pastries, and gas-forming vegetables (cabbage, Brussels sprouts, turnips, broccoli, cauliflower, and radishes) are forbidden.

While numerous drugs may theretically interfere with uptake of bilirubin by the liver, Flavaspidic acid, an active ingredient of male fern extract used in the treatment of tapeworm infestations, is the only one agent that has been definitely shown to influence this process, causing unconjugated hyperbilirubinemia, as well as Bromsulphalein (BSP) clearance, during its administration. The jaundice may occur with novobiocin and the iodinated agent bunamiodyl is also apparently due to an interference in bilirubin uptake.

Drugs/contrast agents: Rifampicin, Rifamycin, and Probenecid are associated with impaired hepatic bilirubin uptake (Unconjugated hyperbilirubinemia due to drugs/contrast agent resolves within 48 hours of discontinuing the drug). Metered-dose inhalers (MDIs) that use chlorofluorocarbons (CFCs) as the propellant most commonly used as an important part of asthma treatment, has been generally prohibited by the Montreal Protocol, because of effects on the ozone layer (see ozone depletion).

Once unconjugated or conjugated has been suggested, one can then proceed to the direct chemical measurement of the bilirubin pigments in the serum. In predominantly unconjugated hyperbilirubinemia, 80 to 85 percent of the total serum bilirubin is unconjugated (i.e., less than 15 to 20 percent is conjugated).

The patient is concidered to have predominantly conjugated hyperbilirubinemia when more than 50 percent of the serum bilirubin is of the conjugated type. Unconjugated bilirubin is water-insoluble and must be converted to a water soluble derivative in order to be excreted by the liver cell into the bile.

NOTE: A primary acid of human bile, chenodesoxycholic acid, when taken by mouth for a long time, can cause disappearance of gallstones. Surgery, however remains the only standard treatment. (...the services of a expert surgeon are required, since the gallbladder is not always easy to remove.)

Poison Control Centers offer a wide variety of toxicology resources, and Staff members are trained to resolve toxic situations in the home of the caller, though hospital referrals are given in some instances. Any Local Center can be reached by calling 800-222-1222.

REFERENCES
(1) Kurt J. Isselbacher,: Jaundice And Hepatomegaly;
Harrison's Principles of Internal Medicine, ed.8, chap. 43, p218

(2) Kurt J. Isselbacher,: Disturbances Of Bilirubin Metabolism
Harrison's Principles of Internal Medicine, ed.8, chap. 298, p1584

Charles E. Cherubin, M.D.,: The Liver and Gallblader
Funk & Wagnalls Family Medical Guide, Gallstones, p381-82

Wikipedia, the free encyclopedia: Chlorofluoro compounds (CFC, HCFC, HFC)

American Association for Clinical Chemistry: Bilirubin: The Test

Nuri Ozden, MD,: Hyperbilirubinemia, Unconjugated
Staff Physician, Department of Gastroenterology and Hepatology,
University of Nebraska Medical Center

National Inhalant Prevention Coalition: Poison Control Centers

David Tinkelman, MD: Device Deliver Inhaled Asthma Medication
National Jewish Medical and Research Center

Best wishes,





The Prison Hospital

Prisoner: Look here, doctor! You've already removed my spleen, tonsils, adenoids, and one of my kidneys. I only came to see if you could get me out of this place!

Doctor: I am, bit by bit.