Hepatology: unconjugated hyperbilirubinaemia: practice question

A General Medicine question in the style of the NEET PG paper. Answer it first, then read why the right option is right and why each of the others is wrong.

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General Medicine · Hepatology: unconjugated hyperbilirubinaemia

Sample item

A 19-year-old man develops mild jaundice during a viral fever and a day of fasting. Total bilirubin is 3.0 mg/dL, almost entirely unconjugated. Liver enzymes, haemoglobin and reticulocyte count are normal, the smear is normal and there is no bilirubin in the urine. What is the most likely diagnosis and management?

Original practice item, not a recalled exam question. Nothing here is recorded.

The answer and the reasoning

C. Gilbert syndrome, with reassurance and no treatment

Gilbert syndrome results from reduced UGT1A1 activity, causing benign intermittent unconjugated hyperbilirubinaemia that increases with fasting, illness or stress. Diagnosis rests on normal liver tests and no haemolysis, and no treatment is needed. Crigler-Najjar presents in infancy with higher bilirubin, while Dubin-Johnson causes conjugated hyperbilirubinaemia with bilirubinuria.

Option by option

  • A. Dubin-Johnson syndrome, with liver biopsy

    Dubin-Johnson syndrome produces conjugated bilirubin, which appears in urine, so the pattern here does not fit.

  • B. Haemolytic anaemia, with splenectomy

    Normal haemoglobin, reticulocytes and smear exclude haemolysis, so splenectomy is not indicated.

  • C. Gilbert syndrome, with reassurance and no treatment (correct)

    Isolated mild unconjugated hyperbilirubinaemia precipitated by fasting with otherwise normal tests is typical of Gilbert syndrome, which is harmless.

  • D. Crigler-Najjar type II, with a phenobarbitone trial

    Crigler-Najjar type II is a rarer childhood-onset disorder with higher bilirubin levels, and is not suggested by a mild fasting rise.

Source note: Original NextPrep sample item — pending expert review. This item is original practice material awaiting independent expert review, so confirm important facts in a standard textbook.

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Questions about this General Medicine question

What is the answer to this General Medicine question?

The best answer is C, Gilbert syndrome, with reassurance and no treatment. Gilbert syndrome results from reduced UGT1A1 activity, causing benign intermittent unconjugated hyperbilirubinaemia that increases with fasting, illness or stress.

Why is "Dubin-Johnson syndrome, with liver biopsy" not the answer?

Dubin-Johnson syndrome produces conjugated bilirubin, which appears in urine, so the pattern here does not fit.

Why is "Haemolytic anaemia, with splenectomy" not the answer?

Normal haemoglobin, reticulocytes and smear exclude haemolysis, so splenectomy is not indicated.

Why is "Crigler-Najjar type II, with a phenobarbitone trial" not the answer?

Crigler-Najjar type II is a rarer childhood-onset disorder with higher bilirubin levels, and is not suggested by a mild fasting rise.

What concept does this question test?

It tests Hepatology: unconjugated hyperbilirubinaemia in General Medicine. Diagnosis rests on normal liver tests and no haemolysis, and no treatment is needed. Crigler-Najjar presents in infancy with higher bilirubin, while Dubin-Johnson causes conjugated hyperbilirubinaemia with bilirubinuria.

How hard is this question?

We tag it as a multi-step question: it asks you to combine more than one idea. The tag is our own editorial judgement, not an official difficulty rating, so read the reason for every option, not only the answer.

How should I study Hepatology: unconjugated hyperbilirubinaemia?

For each disease know the classic presentation, the best test, and the first-line treatment. Then use the flashcards and the other General Medicine questions on this site to test what stuck.

Is this a real NEET PG question?

No. It is an original practice item (editorial status: sample, version 1). NextPrep does not publish recalled or leaked questions, and independent faculty review of this item has not been completed yet, so confirm important facts in a standard textbook.