Question on urine bilirubin and urobilinogen

[lipofuscin232]

So I'm reviewing hepatobiliary disorders and came upon a discrepancy on hepatocellular (mixed aka viral) jaundice. In Goljan, it says that both urine bilirubin and urobilinogen are increased while in both first aid and BRS have urine bilirubin increased and urobilinogen decreased or normal. Goljan even gave a full explanation and it is one of his high yield blue notes on the side... anyone have any comments on this? I'm not really sure which one to trust

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[Proverbs31]

So I'm reviewing hepatobiliary disorders and came upon a discrepancy on hepatocellular (mixed aka viral) jaundice. In Goljan, it says that both urine bilirubin and urobilinogen are increased while in both first aid and BRS have urine bilirubin increased and urobilinogen decreased or normal. Goljan even gave a full explanation and it is one of his high yield blue notes on the side... anyone have any comments on this? I'm not really sure which one to trust

I guess it could always depend on how long the person has had the Dz...But...I always trust mechanisms and I dont know the last time BRS was revised or updates. Goljan constantly searches for new info to things..CONSTANTLY....and he updates info, esp when students email him discrepancies -he posts it on his Website with the errata for RR Path. (http://www.healthsciences.okstate.edu/college/biomedical/pathology/goljan.cfm)
We had him come to our school and in my notes of him talking--I basically wrote this:
So Conj Bilirubin (CB) is converted to urobilinogen (which is a porphoryn--has color) in the stool---thus why we get brown color to poop. Ahaha---Now seriously how many of you wondered when you were little why poop was brown... In any case, in the enterocirculaton (bowel circulation) some of that pigment gets reabsorbed out of the term illieum and goes back to the liver, while a small portion of it goes to the urine to be excreted---thus causing the COLOR we see in urine too! (urobilinogen). So if you think about it....A sick liver won't recycle the urobilinogen---so its going to get redirected to the kidney and thus will go to the urine. So a dipstick in urine in Hep. will show inc urobilinogen and be + for bilirubin.

I trust this mechanism so I go with Goljan. Hope that helps but thats my reasoning. Makes sense to me. Maybe when you first get sick...maybe its not so disfunctional of a liver and it can still partly recycle the urobilinogen...etc

 

[lipofuscin232]

ok thanks for the reply! it was very helpful

 

[LUBDUBB]

I trust Goljan on a his mechanisms in general. ALthough there are some things he's just confabulating because he's unsure.

I trust his hepatitis one. Although that section is good, he doesn't address the difference in presenation of viral vs. toxic. vs ischemic hepatitis.

 

[lipofuscin232]

Could you elaborate on the different presentations? Is it in first aid?

 

[LUBDUBB]

Could you elaborate on the different presentations? Is it in first aid?

Well, I'll try my best not to confuse myself nor others.

In general, there are two types of acute hepatitis
1. Immunological -
(viral, alcoholic, some drug-induced)
damage is gradual in onset and prolonged, therefore lab values change relatively little from day to day. 4-5wks of jaundice/elev enzymes

2. Direct Injury -
(Toxic - tylenol or amanita phalloides, and Ischemic -due to shock)damage occurs in a short period of time, and enzymes max out at 1-2 days and return to normal within ~12 days
*no prodrome of fever malaise, nausea, vomiting

Viral Hep:
% chronic - variable
AST/ALT ratio: <1 (ALT generally > AST)
Peak Enzymes (at Dx): 10-40x the normal
LDH: 1-2 the normal
Peak Bilirubin: 5-20 mg/dl
PT: usually normal

EtoH Hep:
% chronic - 5-10
AST/ALT ratio: >2 (remember mitochondrial AST has long halflife)
Peak Enzymes (at Dx): <10x the normal
LDH: 1-2 the normal
Peak Bilirubin: 3-20 mg/dl
PT: usually normal or slightly prolonged

Toxic/Ischemic Hep:
% chronic - None
AST/ALT ratio: >1 transiently (AST > ALT in first 2 days, then AST falls 8-10days, ALT takes longer)
Peak Enzymes (at Dx): >100x the normal
LDH: 10-40x the normal
Peak Bilirubin: <5 mg/dl
PT: markedly increased

Hope this helps