Liver - Pt Presenting With Isolated, Fluctuating, Mixed Hyperbilirubinemia

[Celiza9]

Hi all,

I am looking for opinions on a 23-yo, seemingly healthy pt presenting with elevated levels of total and direct bilirubin, in the absence of elevated enzymes or hemolysis. Labs have been intermittently monitored since December of last year and include a peak total bili of 2.9 mg/dL (at which time the direct was 1 mg/dL), and a recent low of 1.9 and 0.7, respectively. Fe/ferritin, ceruloplasmin, Alpha-1, hep panel, etc. were all normal. Three ultrasounds (general, vascular, elastographic) were performed--all normal. Mild scleral icterus is present and the pt reports rapid gastric motility (floating stools 2x/day), accompanied with bloating.

So... the Hep has diagnosed Gilbert's, and I just cannot wrap my mind around this. I have reviewed not a single study indicating that Gilbert's would present with a consistently and overtly mixed bili fractionation. The literature is explicit: Gilbert's is a pre-hepatic, unconjugated hyperbilirubinemia. Conversely, I am concerned that the conjugated levels are too low to consider Rotor syndrome (not to mention the extreme rarity of that condition). Fecal analysis has not been performed, which I realize may be a limitation.

My question is, could this realistically be a Gilbert's variant, or is this an inaccurate diagnosis of exclusion? Does the presentation suggest early hepatobiliary disease or other as yet unidentified obstruction (malignancy, stone, etc.)?

Thoughts are very much appreciated!

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[gutonc]

My thought is "who cares?". You're obsessed with a lab abnormality with minimal symptomatology.

I recognize that you're pretending to be a resident and asking a personal medical question here, but you've not raised any red flags. If you're that worked up about it, just ask your doc for a pancreatic protocol CT A/P and get it over with.

 

[Gastrapathy]

But but but...gutonc...my poop floats. Don't you know how rare that is? Here, I took a picture with my smartphone (OP feel free to upload).

That's quite an ivory tower workup for Gilberts and IBS.

Fun fact, Rotor has a disease and an orchid named after him.

 

[Raryn]

The bilirubin is barely above the ULN and is wnl on recheck without treatment. What's the million dollar workup for?

 

[gutonc]

But but but...gutonc...my poop floats. Don't you know how rare that is?

My poop floats when I drink too much. So...not at all rare.

 

[Goro]

I once had an absolutely straight-faced conversionation with a clinician colleague of my on the nature of floating stools.

But but but...gutonc...my poop floats. Don't you know how rare that is? Here, I took a picture with my smartphone (OP feel free to upload).

That's quite an ivory tower workup for Gilberts and IBS.

Fun fact, Rotor has a disease and an orchid named after him.

 

[Celiza9]

The bilirubin is barely above the ULN and is wnl on recheck without treatment. What's the million dollar workup for?

Not quite wnl on recheck, but you're right--not terribly elevated and not progressive. Full workup was for the mixed presentation, which I understand to always warrant follow-through?