Part III – Something's Not Right

“It’s good to have you home, honey. I missed you. How was theflight?” Stacey had come to the airport to pick Frank up and sheleaned over to kiss him as he climbed into the car with hisluggage. “How were the meetings? You look tired,” she added.

“The past week was intense and I am exhausted. I thought I wouldmanage some R & R during the trip, but no such luck. John andDan were fired and we were told that there would be more layoffs inthe future if business doesn’t pick up. Everyone is feelingstressed. “

“You’re one of the hardest workers they have Frank, they can’tlet you go.”

“I hope you’re right. They gave us tomorrow off in lieu ofmaking us work for 7 days straight, but I can’t help but think Ishould go in and get a jump on the week.”

“I know you don’t want to hear this, but you have an appointmentfor that glucose tolerance test first thing in the morning. We’llneed to eat soon because the instructions say you are not allowedto eat for 8 hours before the test.”

Frank felt miserable. “I’m really not hungry. Maybe it was thechange in diet, but I’ve had a persistent stomach ache and I didn’teat much when I was away.

“Well, we need to take extra special care of you until we findout what’s wrong. I am sure everything’s going to be okay.”The nextmorning the alarm went off and Frank felt refreshed after a goodnight’s sleep.

“What’s the matter Stacey? You look like you’ve seen aghost.”

Stacey brought him her pocket mirror so that he could see forhimself. “Forget the glucose tolerance test. I think we need to goto the Emergency Room right now.”

* ************

Doctor Smithers looked into Frank’s eyes. “It’s a good thing youcame in because even a first year medical student could see thatyou are jaundiced.”

Stacey looked concerned. “What does that mean? Is he going to beokay?”
“Well it could mean a few different things,” replied the doctor,“so we are going to have to run some tests to be sure.”

Fill in Flow Chart 1 with the best choices from the providedword list.

Questions

5. Use Flow Chart 1 to suggest possible reasons for Frank’sjaundiced appearance.

6. Do you think that Frank’s jaundice is connected to the highblood glucose levels seen on the morning before his business trip?Why or why not?

7. Would you like to make a diagnosis to explain Frank’sjaundiced appearance?

8. What tests would you run to determine or confirm any of yourdiagnoses?

Part IV – The Test Results

“What does it mean to be jaundiced, doctor? Why did the whitesof my eyes turn yellow?” “It’s usually caused by a high level of amolecule called bilirubin in your blood, Frank.”
“I was a biology major in college, but I don’t remember wherebilirubin comes from.”

“Your blood has cells called erythrocytes or red blood cells;they contain hemoglobin which gives blood its red color. Cells inthe spleen break down red blood cells and the products are reusedby your body. The heme portion of hemoglobin is converted tobilirubin, which is the molecule that is responsible for youryellow color.”

“I remember now, isn’t bilirubin involved in digestion?”

“Yes. Bilirubin leaves the spleen in the blood and, because it’snot soluble in water, it binds with blood proteins called albumensto form unconjugated bilirubin. This bilirubin is taken up by thecells in the liver, where it combines with glucuronic acid to formconjugated bilirubin. It is one component of the bile, whichtravels down the bile duct to the gall bladder and the smallintestine. When you eat, the gall bladder contracts and pushes thestored bile into the small intestine to aid in the digestion offat.”

“So what do my tests show?”
“Your hematocrit and your liver enzymes are at normal levels.” “So,my liver’s okay?”

“These enzymes are normally confined to the liver cells andwould only be found in large amounts in the blood if your liver wasdamaged. So these results indicate that there is no liver damage;that’s good. But I am concerned that there is tenderness in theupper left quadrant of your abdomen ... sorry, around yourstomach,” the doctor smiled at Frank and Stacey.

“As I explained before, a jaundiced appearance is often producedby a buildup of bilirubin in the blood and your results confirmthis (Table 3).”

Table 3 – The Level of Bilirubin in Blood

Bilirubin Type	Frank’s Blood	Normal Blood
unconjugated	0.9 mg/dl	0.3 – 1.6 mg/dl
conjugated	0.6 mg/dl	0 – 0.3 mg/dl

“One more thing concerns me,” continued the doctor. “There isalmost no urobilinogen or urobilin in your urine.”

“What are they?” asked Frank.

“Bacteria in your intestines change bilirubin to urobilinogen.This urobilinogen can be reabsorbed back into your body and some isconverted to urobilin. These two molecules circulate in your bloodand are excreted in your urine; it is the urobilin that producesthe straw color of urine. The low level of these two molecules inyour urine plus the high level of bilirubin in your blood and thepale color of your stools indicates to me that, for some reason,bilirubin is staying in your body instead of going into yourintestines.”

Questions

1. Where is unconjugated bilirubin formed?
2. Is the level of unconjugated bilirubin in Frank’s blood withinthe normal range? 3. Where is conjugated bilirubin formed?
4. Is the level of conjugated bilirubin in Frank’s blood within thenormal range?

5. Using Flow Chart 1, outline some possible reasons for thehigh level of conjugated bilirubin; remember Frank’s liver enzymesare normal.

6. Frank experienced tenderness in the upper left quadrant ofhis abdomen. Use the word list in Figure 1 to label the majororgans in this area.

1. Consider your diagnosis for Frank’s high blood glucose levels.Which gland secretes insulin?

2. Which organs are involved in creating Frank’s jaundicedappearance?

3. Look at Figure 1 and determine whether this gland and theseorgans (answers to Questions 7 and 8) are connected in any way.

4. Can you think of a reason that would explain the high levels ofglucose and conjugated bilirubin in Frank’s blood?

5. Would you like to make any adjustments to your diagnoses?