In a patient who had 24 hours of vomiting, transient eye jaundice, dizziness, mild leukocytosis with neutrophilia and no eosinophils, normal liver function tests, borderline serum amylase and normal lipase, and who remains weak, dizzy, and has poor appetite two weeks later with improved jaundice, what diagnoses should be ruled out and what further work‑up and management are indicated?

Diagnostic Workup for Persistent Symptoms After Transient Jaundice with Vomiting

This patient requires urgent abdominal ultrasound to rule out common bile duct stones (choledocholithiasis), followed by MRCP or endoscopic ultrasound if ultrasound is non-diagnostic, given the clinical presentation of transient jaundice, vomiting, borderline amylase, and persistent symptoms suggesting possible biliary obstruction. 1

Key Diagnoses to Rule Out

Primary Concern: Biliary Obstruction

The combination of transient jaundice with vomiting and borderline amylase (92 U/L) raises significant concern for common bile duct stones, which account for 13-14% of jaundice cases and can present with these exact symptoms 1. The persistent weakness and poor appetite two weeks later suggest either:

• Incomplete resolution of biliary obstruction
• Passed stone with residual inflammation
• Ongoing intermittent obstruction

Critical point: Normal liver function tests do NOT exclude CBD stones—guidelines explicitly state that normal LFTs and ultrasound do not preclude further investigation when clinical suspicion remains high 2.

Secondary Considerations

Acute Hepatitis E deserves specific attention given your presentation. A recent 2025 case report describes a patient with hepatitis E presenting with nearly identical symptoms: recurrent vomiting, dizziness, jaundice, fatigue, poor appetite, and nausea lasting over one month 3. This viral hepatitis can cause prolonged symptoms and should be tested.

Post-pancreatitis syndrome: The borderline amylase with normal lipase is atypical for acute pancreatitis but could represent:

• Resolving mild pancreatitis (possibly gallstone-induced)
• Macroamylasemia (enzyme-antibody complexes causing falsely elevated levels without true disease) 4

Sepsis/cholangitis: The leukocytosis with neutrophilia and absence of eosinophils suggests bacterial infection. Sepsis accounts for 22% of new-onset jaundice cases 1. Even with improved jaundice, occult biliary infection can cause persistent constitutional symptoms.

Algorithmic Diagnostic Approach

Step 1: Immediate Laboratory Testing

• Fractionated bilirubin (conjugated vs unconjugated) to differentiate obstructive from hepatocellular causes 5
• Repeat comprehensive metabolic panel including AST, ALT, alkaline phosphatase, GGT
• Hepatitis panel including hepatitis A, B, C, and specifically hepatitis E IgM 3
• Blood cultures if fever or ongoing leukocytosis
• Lipase/amylase ratio: Ratio >2 suggests biliary pancreatitis; ratio <2 suggests alcoholic etiology 6

Step 2: Initial Imaging

Abdominal ultrasound is the mandatory first-line test 1. It should evaluate:

• CBD diameter (>6mm suggests obstruction)
• Presence of gallstones or CBD stones
• Liver parenchyma for cirrhosis or masses
• Gallbladder wall thickening

Step 3: Advanced Imaging Based on Ultrasound Results

If ultrasound shows dilated CBD or stones: Proceed directly to ERCP for therapeutic stone extraction, as patients with CBD stones should be offered removal to prevent unfavorable outcomes (25.3% complication rate if left untreated vs 12.7% with extraction) 2.

If ultrasound is normal but clinical suspicion remains high: Order MRCP or endoscopic ultrasound (EUS) 2, 1. Both have excellent sensitivity for CBD stones in intermediate-probability patients. MRCP is typically preferred for availability and non-invasiveness, but EUS can be performed if MRCP is contraindicated or unavailable.

Step 4: If All Imaging Negative

Consider:

• Periampullary duodenal diverticulum (Lemmel syndrome)—can cause transient obstructive jaundice without stones, diagnosed by upper endoscopy 7, 8
• Liver biopsy if etiology remains unclear after complete workup 5

Common Pitfalls to Avoid

1. Do not dismiss CBD stones based on normal LFTs alone—sensitivity of bilirubin for CBD stones is only 84%, and ultrasound sensitivity is only 73% 2

2. Do not assume borderline amylase with normal lipase excludes pancreaticobiliary disease—this pattern can occur with resolving pancreatitis or macroenzyme complexes 4

3. Do not overlook hepatitis E—it can cause prolonged vomiting and constitutional symptoms lasting weeks, and is often missed without specific testing 3

4. Do not delay MRCP/EUS if ultrasound is non-diagnostic—these are highly accurate for intermediate-probability patients and should be pursued when clinical suspicion persists 2, 1

Management Priorities

If CBD stones are identified: Stone extraction via ERCP is indicated regardless of stone size, as even stones <4mm have 15.9% unfavorable outcome rate without treatment 2.

If hepatitis E confirmed: Supportive care with antiemetics, rest, and monitoring for resolution (typically weeks to months) 3.

If no clear etiology found: Close outpatient follow-up with repeat LFTs in 1-2 weeks and consideration of gastroenterology referral for possible liver biopsy 5.

The persistent symptoms two weeks out are concerning and warrant aggressive diagnostic workup rather than watchful waiting, as untreated biliary obstruction or ongoing hepatitis can lead to serious complications including cholangitis, cirrhosis, or fulminant hepatic failure 1.