Beyond the Hue: A Peculiar Case of Hyperbilirubinemia

Background: Hyperbilirubinemia can be caused by bile ducts obstruction or by several intrahepatic diseases including genetic disorders. Post-contrast hyperbilirubinemia has been reported in the literature, even though only few cases. Case Presentation: A 51-year-old woman presented with abdominal pain, jaundice, and generalized itching for seven days. Liver function tests revealed elevated total bilirubin (TBIL 6.7 mg/dL), AST (41 U/L), ALT (117 U/L), and GGT (322 U/L). Contrast enhanced-CT imaging indicated enlarged, fatty liver with common bile duct thickening. Despite initial management, bilirubin levels progressively increased following contrast exposure. MRCP confirmed choledocholithiasis, but ERCP-cholangiography showed no gallstones. Due to the worsening of jaundice a liver biopsy was performed indicating diffuse acute intrahepatic cholestasis. At this point alcoholic hepatitis, acute non-alcoholic hepatits or ischemic hepatitis had been also excluded. Genetic testing was performed revealing a homozygous polymorphism in the UGT1A1 gene, consistent with Gilbert Syndrome. Ursodeoxycholic acid (UDCA) was started (ex-juvantibus approach) and in the following days a reduction in bilirubin levels and symptom improvement was noticed. The patient was subsequently discharged with significant clinical and biochemical improvements. Conclusion: This case illustrated the diagnostic complexity of prolonged hyperbilirubinemia following contrast agent exposure and the importance of considering genetic predispositions when dealing with drug induced liver injury. Further research is needed in order to understand the mechanism and risk factors associated with contrast induced liver injury.