Post #248: Gee…EYE can see there is an issue here
Posted on: September 9, 2025, by : Brittany Fitzpatrick
Case by Chidimma Acholonu, CNH PEM Fellow
17 yo M with eczema presents to the emergency department with his mother for evaluation due to yellowing eyes over the past 3 days. Patient’s mother first noticed it. Denies any itching and no yellow to the skin, palms or feet. One month ago, he was evaluated for abdominal pain that eventually resolved with Miralax, but no other recent sick symptoms. He has not had any recent changes in his diet and does not take any medications regularly. Denies alcohol or drug use. There is no history of jaundice as an infant and no family history of liver or gallbladder disease or any hemolytic disease.
Physical Exam–
Vitals: T: 38.0 HR 105 RR 18 BP 116/72
Physical Exam
General: Alert
Skin: Mild eczema
EENT: Bilateral scleral icterus. PERRLA, EOMI. Moist mucous membranes.
CV: Regular rate and rhythm, no murmurs. Normal peripheral perfusion.
Resp: Non-labored, no wheeze, rales or rhonchi
GI: Obese abdomen. Soft, non-tender, non distended.
MSK: moves all extremities
Neuro: Alert, no focal deficits
Ordered CBC + Diff, BMP, LFTs and lipase. Also ordered Hepatitis panel, EBV and CMV with plans to discuss with GI pending results. Imaging also deferred pending lab results.
Labs:
CBC: 9.66/10.9/32.1/571 ab retic count 85.4
BMP: 134/3.6/100/29/4/0.46/99
AST 242 ALT 204 ALK 591
Total protein 9.1 Albumin 2.4
Total Bili 7.7 (Direct 6.3, Indirect 1.3)
Lipase 35
Added on GGT (elevated) and ordered RUQ ultrasound. After discussion with GI, also added coags (elevated).
RUQ Ultrasound
FINDINGS: AORTA GRAYSCALE: Visualized portions are normal
IVC GRAYSCALE: Visualized portions are normal
LIVER: Heterogenous echotexture. Right lobe length: 15.3 cm, within normal
limits
GALLBLADDER: Normal. Negative sonographic Murphy.
BILIARY TREE: Normal
CBD: 2 mm (porta hepatis), within normal limits
SPLEEN: Normal; length 10.4 cm, within normal limits
PANCREAS: Visualized portions are normal
RIGHT KIDNEY: Normal
URINARY BLADDER: Underdistended, incompletely assessed
ASCITES: None
Impression: Heterogenous liver echotexture, nonspecific finding. Gallbladder and common bile duct are within normal limits. Specifically no CBD enlargement.
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Conjugated hyperbilirubinemia is always pathologic and should be worked up. It is usually extrahepatic (obstruction) or intrahepatic cholestasis (viruses, alcohol, etc). With this child having a normal ultrasound it is probably something intrahepatic. Many of those tests won’t come back quickly but for me the push to inpatient vs discharge is the elevated coags and low albumin which is a true marker for liver function (not just the transaminases).