Urine pH: 6.0
What is the most probable diagnosis?
Ans: The likely diagnosis is gouty arthritis. Gout classically afflicts the big toe,
but other joints may also sometimes be affected.
39.6 Case Studies of Liver Functions.......................
Q.1. A 48-year-old, fat female was admitted to hospital with complain of abdom-
inal pain, vomiting, nausea, and loss of appetite. She passed dark yellow
urine and clay-colored stool. The laboratory blood examination revealed:
Total bilirubin–12 mg/dl
Indirect (unconjugated) bilirubin–2.2 mg/dl
Direct (conjugated) bilirubin–9.8 mg/dl
ALT–105 U/L
AST–80 U/L
ALP–160 U/L
Urine was positive for bile salts and bile pigments. Urobilinogen was absent
in urine. Comment on report.Ans: The data shows that total bilirubin and conjugated bilirubin are very high as
compared to unconjugated bilirubin. Serum ALT and AST levels are highly
increased (ALT levels are higher than AST). This is a case of obstructive
jaundice. In this case, ALP is also increased significantly. Increase in serum
ALP activity is usually related to hepatobiliary obstruction. In hepatobiliary
disease, the concentration of ALP is increased due to defect in excretion of
ALP through bile. ALP mainly produced in the bone tissue reaches to the
liver and excreted through bile. The presence of conjugated bilirubin in the
urine and excretion of urobilinogen-free urine suggest the case of obstructive
jaundice. When complete obstruction of the bile duct occurs, urobilinogen is
absent in urine because bilirubin is not transported to the intestine. Nor-
mally, bilirubin is converted to urobilinogen by bacterial action in the
intestine, and a portion of it is absorbed by enterohepatic circulation.
Urobilinogen is also converted to urobilin in the kidneys and excreted.
The pale stools and dark urine also confirm obstructive or posthepatic
cause since feces color is contributed from bile pigments.
Q.2. A 45-year-old fat woman complained of recurrent pain in the abdomen
which often aggravated by fatty food intake. She had very high blood
bilirubin levels. The urine examination showed the presence of bile
pigments and bile salts, but urobilinogen was absent. What is the most likely
cause?
162 39 Some Important Case Studies