In this case, the patient's most likely diagnosis is post-hepatic jaundice which could be due to the presence of gallstones blocking the bile duct known as extrahepatic obstruction. Another cause is carcinoma of the head of the pancreas. Raising the bilirubin level of 250 µmol/l causes severe, painless, deep jaundice. Posthepatic jaundice is characterized by elevated alkaline phosphatase (ALP) activity that is more than seven times the upper limit of the reference range. In the present case, aspartate and alanine aminotransferase activities do not indicate severe hepatocellular damage. Say no to plagiarism. Get a tailor-made essay on "Why Violent Video Games Shouldn't Be Banned"? Get an original essay An elevated bilirubin level is ten times higher than the reference range, so it often indicates obstruction of bile flow or a defect in the processing of bile by the liver. Signs and symptoms of biliary obstruction include light-colored stools, dark urine, nausea, vomiting, and jaundice. Other possible causes of increased bilirubin are destruction of red blood cells (anemia), liver scarring, liver inflammation, and cancer of the pancreas or gallbladder. Several diseases are associated with hyperbilirubinemia. Hemolytic jaundice is one of the diseases because more bilirubin than normal is conjugated and excreted, but the conjugation mechanism is overwhelmed and an abnormally large amount of unconjugated bilirubin is found in the blood. Gilbert's disease can be caused by the inability of hepatocytes to absorb bilirubin from the blood. As a result, unconjugated bilirubin accumulates. Physiological jaundice and Crigler-Najjar syndrome are conditions in which conjugation is impaired. Unconjugated bilirubin is retained by the body. Dubin-Johnson syndrome is associated with the inability of hepatocytes to secrete conjugated bilirubin after it is formed. The conjugated bilirubin returns to the blood. The result provided showed that the AST exceeded the reference range value. AST levels increase when damage occurs to the tissues and cells where the enzyme is found. High levels mean there is a certain amount of damage in that area. AST is less specific for liver disease than ALT. It is elevated in other conditions such as myocardial infarction. The sensitive indicator of liver cell damage is aminotransferase. They are very useful in helping recognize acute hepatocellular diseases such as hepatitis and cirrhosis. ALT is more specific for liver injury than AST. ALT usually increases more than AST in liver injury. Aminotransferases are usually present in serum at low concentrations. When damage occurs to the liver cell membrane resulting in increased permeability, these enzymes will be released into the bloodstream in greater quantities. The activities of two enzymes that include alkaline phosphatase (ALP) and gamma-glutamyl transpeptidase (GGT) are normally increased in obstructive liver disease also known as cholestasis. Elevated serum alkaline phosphatase is more specific than GGT. GGT estimation is performed to identify patients with occult alcohol consumption. Normal serum alkaline phosphatase consists of many distinct isoenzymes found in the liver, bone, placenta, and, less commonly, the small intestine. There is no increase in alkaline phosphatase of hepatic origin that is entirely specific for cholestasis. An increase of less than three times can be seen in almost any type of liver disease. A greater than four times normal increase in alkaline phosphatase seen in patients indicates that cholestatic liver disease, ainfiltrative such as cancer and bone conditions characterized by rapid bone turnover (e.g. Paget's disease). This increase is due to the increase in the amount of bone isoenzymes in bone diseases, while the increase is due to the increase in the amount of liver isoenzymes in liver diseases. In intrahepatic obstruction, values ​​increased as in drug-induced hepatitis and primary biliary cirrhosis. The values ​​found in extrahepatic obstruction are very high due to cancer, common duct stones or bile duct structure. Elevated serum alkaline phosphatase level is not useful in distinguishing between intrahepatic and extrahepatic cholestasis. The values ​​are also very high in hepatobiliary disorders observed in AIDS patients. In addition to biochemical tests, certain parameters must be used to confirm that it is posthepatic jaundice. Surgical history: It is necessary to understand patients' surgical history, recent or past, because it may be implicated in the cause of posthepatic jaundice. . It could be due to a variety of problems within the first three postoperative weeks. Increased bilirubin levels are related to hemolysis of transfused erythrocytes (especially stored blood), resorption of hematomas or hemoperitoneum, and rarely to hemolysis of the patient's erythrocytes due to G-6PD deficiency or malaria parasites in the transfused blood . Administration of halogenated anesthetic agents, exposure to other hepatotoxic drugs, sepsis, or hepatic ischemia associated with preoperative or intraoperative hypotension or hypoxia may result in impaired hepatocellular function. It is very important to review the medical record regarding transfusions, anesthesia, radiographs, medications, and potential hypotension or hypoxia, as well as the surgeon's dictated note on intraoperative events and his or her visual and palpatory impression of the patient's liver, biliary tree, and pancreas. when it was necessary to investigate a case of jaundice potentially related to surgery. Family history: A family history of jaundice, liver disease, or anemia should be sought (especially when splenectomy is necessary). A family history of liver disease may imply genetically transmitted nonhemolytic hyperbilirubinemia (Crigler-Najjar, Gilbert, Dubin-Johnson, or Rotor syndromes), benign recurrent intrahepatic cholestasis, Wilson disease, hemochromatosis, alpha-1 deficiency antitrypsin or hereditary disease spherocytosis in the differential diagnosis. Imaging evaluation: To investigate jaundice, some advanced techniques and equipment are really helpful such as high resolution ultrasound, computed tomography (CT), percutaneous transhepatic cholangiography (PTC), endoscopic retrograde cholangiopancreatography (ERCP) and hepatobiliary scintigraphy (HBS). A valid screening test in jaundiced patients is abdominal ultrasound. Demonstration of dilated bile ducts, gallstones, a hepatic mass lesion, or an enlarged or abnormally shaped pancreas directs further investigation or therapy. Computed tomography has the advantage of detecting the entire abdomen as well as the hepatobiliary-pancreatic axis. Furthermore, to reliably detect ductal dilatation, CT is superior to ultrasound in determining the level and cause of obstruction. The pancreas is visualized more reliably and accurately by CT than by ultrasound. Liver biopsy: Percutaneous needle liver biopsy is a safe procedure in experienced hands provided the patient's clotting mechanism is normal. Individual factor deficiencies can be corrected by needle biopsy even if the clotting process is abnormal. It is very useful in jaundiced patients to determine the cause of hepatomegaly, distinguish between obstruction.