From the Guidelines
The initial workup for a 76-year-old female presenting with hyperbilirubinemia should include a comprehensive history, physical examination, and targeted laboratory and imaging studies, starting with a complete blood count, comprehensive metabolic panel, and coagulation studies to determine whether the hyperbilirubinemia is predominantly conjugated or unconjugated, as this helps narrow the differential diagnosis 1. The workup should prioritize the identification of the cause of hyperbilirubinemia, whether it is due to hemolysis, impaired conjugation, parenchymal liver disease, or obstruction of the biliary system. Key laboratory tests include:
- Complete blood count to evaluate for hemolysis or other hematological abnormalities
- Comprehensive metabolic panel, including fractionated bilirubin, liver enzymes, and alkaline phosphatase, to assess liver function and identify potential causes of hyperbilirubinemia
- Coagulation studies, such as prothrombin time and INR, to evaluate the synthetic function of the liver Ultrasound of the right upper quadrant should be performed promptly to evaluate for biliary obstruction, which is particularly important in elderly patients who are at higher risk for choledocholithiasis and malignancy 1. Additional tests may include:
- Hepatitis serologies to evaluate for viral hepatitis
- Autoimmune markers, such as ANA, anti-smooth muscle antibody, and anti-mitochondrial antibody, to evaluate for autoimmune liver disease
- Tumor markers, such as CA 19-9, if malignancy is suspected If ultrasound shows biliary dilation, further imaging with MRCP or ERCP may be necessary to evaluate for obstructive causes. The urgency of the workup should be guided by the severity of hyperbilirubinemia, presence of symptoms, and rate of elevation. In cases where the etiology remains unclear after initial testing, consider medication review for drug-induced liver injury and evaluate for less common causes such as hemolysis or Gilbert's syndrome.
From the Research
Initial Workup for Hyperbilirubinemia
The initial workup for a 76-year-old female presenting with hyperbilirubinemia includes:
- A comprehensive medical history, review of systems, and physical examination to differentiate potential causes such as alcoholic liver disease, biliary strictures, choledocholithiasis, drug-induced liver injury, hemolysis, or hepatitis 2
- Initial laboratory evaluation should include:
- Bilirubin (total and fractionated) to determine whether the hyperbilirubinemia is conjugated or unconjugated 3, 2
- Complete blood cell count 3, 2
- Aspartate transaminase (AST) and alanine transaminase (ALT) to evaluate hepatocellular injury 3, 2, 4
- Gamma-glutamyltransferase (GGT) and alkaline phosphatase to evaluate cholestatic injury 3, 2, 4
- Albumin and prothrombin time to evaluate hepatic function 5, 3, 2
- International normalized ratio (INR) 3, 2
Imaging Studies
Imaging studies such as ultrasonography of the abdomen, computed tomography with intravenous contrast media, and magnetic resonance cholangiopancreatography may be used to evaluate the biliary tree and liver, depending on the suspected underlying etiology 3, 2, 6
Further Evaluation
If the etiology of jaundice is unclear despite laboratory testing and imaging, liver biopsy may be required to establish the diagnosis, prognosis, and management of the disease 2, 4