Previously Undiagnosed Gilbert Syndrome Causing Confusion in a Case of Hematemesis Secondary to Gastric Varices: 1255

Introduction: Gilbert syndrome is a relatively common condition affecting an estimated 4-16% of the population. It is mostly seen in males and diagnosed after adolescence. Gilbert syndrome is characterized by unconjugated hyperbilirubinemia without any pathologic abnormalities of the liver parenchyma. Patients with undiagnosed Gilbert syndrome can present with acute jaundice and may be subjected to needless interventions directed at the liver. We present a case of a 36-year old male with significant hematemesis with an associated hyperbilirubinemia. The clinical course illustrates how undiagnosed Gilbert syndrome can result in confusion leading to potentially needless invasive interventions. Case Report: A 36-year-old incarcerated male with a history prior heavy alcohol use (incarcerated 7 years ago) transferred to our institution for hematemesis and hypovolemic shock. At the outside hospital, the patient had 2 endoscopies demonstrating clot in the gastric fundus and findings suggestive of gastric varices. Given the history of alcohol use and findings of hyperbilirubinemia, the concern was that the patient’s variceal bleeding was secondary to chronic liver disease with decompensated portal hypertension and that the patient would require an emergent TIPS procedure. On arrival to our facility, lab work demonstrated an albumin 2.6 g/dL, total bilirubin 3.0 mg/dL, direct bilirubin 0.5 mg/dL, alkaline phosphatase 23 IU/L, AST 12 IU/L, ALT 10 IU/L, HGB 10.1 g/dL, INR 1.2, and a platelet count 69 th/mm3. The patient was started on medical therapy including continuous octreotide and pantoprazole infusions. Following a gastroenterology consult, a 4-phase CT scan of the abdomen was recommended. This demonstrated no focal or diffuse hepatic abnormalities or evidence of portal hypertension. It did demonstrate evidence of a main splenic vein thrombosis with significant large splenic varicosities and gastric mucosa varices. Following this finding, the patient was consulted by general surgery who performed a splenectomy. The patient’s unconjugated hyperbilirubinemia was attributed to a new diagnosis of Gilbert’s syndrome. Discussion: This case is an example as to how laboratory data in the right clinical setting can cause significant confusion among clinicians when dealing with a patient with Gilbert’s syndrome. The initial assumption was that the patient’s bleeding was secondary to portal hypertension and that TIPS would be necessary, when in fact, this would have provided no benefit to the patient. Given its high prevalence in the general population, it is important to always consider the possibility of Gilbert syndrome when dealing with a patient with hyperbilirubinemia without a clear etiology of cirrhosis.