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Gastroenterologia Japonica Vol. 24, No.

3
Copyright (~ 1989 by The Japanese Society of Gastroenterology Printed in Japan

--Case Report--

A case of Gilbert's syndrome combined with macroamylasemia


Hiroshi INOUE, Yukihiko ADACHI, Masaki YAMASHITA, Tatsuo NANNO, Hiroko KATOH,
Masakazu ENOMOTO, Masao SUWA, and Toshio YAMAMOTO
Second Department of Internal Medicine, Kinki University School of Medicine, Osakasayama 589, Japan

Summary: A 30-year-old Japanese male, who had no remarkable family history, visited our hospital
with a complaint of abdominal pain, and unconjugated hyperbilirubinemia and hyperamylasemia were
observed. He showed negative hemolysis tests, positive nicotinic acid test, low hepatic bilirubin UDP-
glucuronyltransferase activity, decreased bilirubin diglucuronide and increased bilirubin mono-
glucuronide in bile, and a decrease in serum bilirubin after phenobarbital administration. He also
showed high serum amylase level, low urine amylase level, and low amylase-creatinine clearance ratio.
Gel filtration of serum with Sephadex G-200 revealed the existance of macroamylase. Countercurrent
immunoelectrophoresis proved binding of serum amylase to lambda type IgA. From these results, the
case was diagnosed as Gilbert's syndrome combined with macroamylasemia. Gastroenterol Jpn
1989;24:320-324

Key words: bilirubin; Gilbert's syndrome; immunoglobulin A; macroamylasemia; phenobarbital

History:
Introduction
He suffered from left ureterolithiasis at the
Gilbert's s y n d r o m e is m o s t f r e q u e n t l y f o u n d in age of 28; this w a s c u r e d by medical treatment.
constitutional u n c o n j u g a t e d h y p e r b i l i r u b i n - No operative history.
emia 1, in w h i c h slight h y p e r b i l i r u b i n e m i a of
less t h a n 5 m g / d l 2"3is observed. Macroamylase- Present History:
m i a w a s first reported by W i l d i n g et al. 4 in 1964. In March 1981, he visited a family doctor
The disease s h o w s a h i g h s e r u m amylase level because of a b d o m i n a l pain, was d i a g n o s e d as
b e c a u s e the s e r u m amylase is attached to h i g h - h a v i n g acute pancreatitis a n d received oral
m o l e c u l a r - w e i g h t molecules such as i m m u n o - medication. Jaundice w a s p o i n t e d o u t at that
globulin a n d forms molecules too large to pass time, b u t was n e g l e c t e d because the s y m p t o m s
t h r o u g h renal glomeruli. We recently e n c o u n - d i s a p p e a r e d . In O c t o b e r 1984, he c o n s u l t e d the
tered a case of Gilbert's s y n d r o m e c o m b i n e d s a m e doctor again for a b d o m i n a l pain, a n d
with macroamylasemia. jaundice, slight liver d y s f u n c t i o n a n d h y p e r -
a m y l a s e m i a w e r e o b s e r v e d as a result of blood
tests. He was i n t r o d u c e d to our h o s p i t a l for
Case Report
further e x a m i n a t i o n .
Patient: A 30-year-old b u s i n e s s m a n .
Chief complaint: Jaundice. Physical findings:
Family history: U n r e m a k a b l e . H e i g h t 166cm, w e i g h t 69kg, b l o o d pressure
130/60, heart rate 72/min. No a n e m i a or e d e m a

Received October 6, 1988. Accepted December 16, 1988.


Address for correspondence: Yukihiko Adachi, M.D., Second Department of Internal Medicine, Kinki University School of Medicine,
377-20hnohigashi, Osakasayama-shi, Osaka 589, Japan.
June 1989 Coexistance of Gilbert's syndrome and macroamylasemia 321

Table 1 Laboratory data on admission

GBC " Biochemical Examination ." Serological Examination :


R BC 5.36 x 10 s Glucose 83mg/d I CR P (-)
Hb 16.2 g / d l Cholesterol 17 l m g / d I ASLO (-)
Ht 48 % T.P. 7.3 g / d l RA (-)
P latlet 19.1 x 104 Albumin 5.76 g / d I Coombs' test (--)
Reticulocyte 19 %0 Oh-Globulin 0.41 g J d l antinuclear antibody (--)
WBC 5.6x103 Q'2-Globul in 0.77 g / d l anti - D N A (-)
Stab 1% #-Globulin 0.65 g / d l haptoglobin 241 m g / d I
Seg 40 % T-Globulin 1.06 g / d l I mmunogl obul ins "
Lymph 46 % T . B i l irubin 2.7 m g / d I I gG 970mg/d I
Mono 10 Yo D. Bilirubin 0.3 m g / d l I gA 28ling/all
Eos 3 % I .Bil irubin 2.4mg/dl IgM 79mg/d I
Bas 0 % GOT 29 U / L I gD 16.gmg/d I
Urinalysis : GPT 71 U / L Others
protein (-) AL P 87 U / L I C G (15") 10%
glucose (--) L DH 167 U / L PFD test 80.2 %
urobi I inogen normal BUN 16 m g / d l CPC pattern normal
sediment normal Great inine 1.0 m g / d l creatinine clearance 80.4m l / m i n .
Feces : Gh - E 1.15 -~pH s--Amylase 1030 I U / L
Occult blood (--) LAP 160 G.U. u--Amylase T87 I U / L
r -GTP 11 mU/ml s--Elastarse I 120 m g / d l
Na 143 m E q / L s - - Lipase 0.1 UJml
K 3.9 mEq/L Cam/Oct 0.6%
CI 108 m E q / L

Laboratory examinations:
As s h o w n in Table 1, slight unconjugated hy-
p e r b i l i r u b i n e m i a was observed with slightly
elevated GPT. No data suggestive of hemolysis
were obtained: negative C o o m b s ' test, normal
haptoglobin level, normal pattern of hemolysis
with a coil planet centrifuge, and normal reticu-
locyte count. Renal function test and pancreatic
Fig. 1 Electrophoretic mobility of patient's amylase on agarose
exocrine function test (PFD test) were normal.
gel film. Macroamylasemia was d i a g n o s e d by the
Serum amylase of the patient was stained diffusely be- high s e r u m amylase level, low urine amylase
tween bands S and P, with slight tailing of staining from level, and a low amylase-creatinine clearance
band S to anode.
V: The position where the samples were applied. ratio of 0.6%. Electrophoresis of the patient's
serum on agarose gel film 5 s h o w e d diffuse con-
tinuous staining from b a n d s P to S with slight
was found. Heart-lung observations w e r e un- tailing from b a n d S toward the anode (Fig. 1).
remarkable. The a b d o m e n was flat w i t h un- On thin layer gel filtration, control serum and
palpable liver and spleen. No abnormality was the patient's urine s h o w e d a single b a n d of
f o u n d on neurological examination. amylase activity at almost the same position,
while the patient's serum s h o w e d bands at the
low-molecular-weight area and near the IgG
322 H. Inoue et al. Vol. 24, No. 3

(mg/dl) : - T. Bil.
e.----e L Bil.
6.0- , - - - e D. Bil.
,~ 50mg of Nicotinic Acid.
- - ~,..,,,,.,,~
5.0-

Fig. 2 Thin layer gel chromatogram of serum and urinary amyl-


ase of the patient.
4.0-

3.0-

2.0"
/
/
Serum amylase of the patient was stained at the IgG
(and IgA) elution band and at the normal amylase band, 1.0"

with light staining between them. Urinary amylase of the


patient was stained at the normal amylase band.
(~ 610 1"~0 I~ 2~'0 (rain)

Fig. 4 Nicotinic acid test.


Serum total and indirect-reacting bilirubins increased after
intravenous nicotinic acid administration, and they
reached their peaks at more than twice the preadministra-
tion levels after 120 min. Serum direct-reacting bilirubin
did not change throughout the test.

(mgldl)

Fig. 3 Detection of immunoglobulin bonded to amylase by elec- 4.0. T. Bil.


troimmunosyneresis. e-...e I, Bil.
The amylase of the patient's serum was precipitated by 3.o-
anti-lgA antibody and anti-K chain antibody. On the right
side the precipitated bands are schematically drawn by 2.0-
pencil.
1.0.

area, with slight activity between them (Fig. 2). before after

Sorting by countercurrent immunoelectro- Fig. 5 Effect of phenobarbital administration on serum bilirubin


phoresis 6 proved that the amylase-binding im- level.
Serum total and indirect-reacting bilirubins fell to the up-
munoglobulin was lambda type IgA (Fig. 3). per limit of the normal values on the 8th day after oral
For the diagnosis of jaundice, nicotinic acid phenobarbital treatment (100 mg/day).
(50mg) was injected intravenously and serum Their decreased levels continued for at least 4 days after
discontinuation of the treatment.
bilirubin was monitored over time (nicotinic
acid test) (Fig. 4). Total and indirectreacting
bilirubin were 2.3 and 1.8 mg/dl, respectively,
before the nicotinic acid test. Bilirubin began to to the normal level a week later, remained low at
rise and reached a peak 120 min after loading, least for 4 days after the discontinuation of
with total bilirubin of 5.2 mg/dl and indirect- phenobarbital and then rose to the initial level
reacting bilirubin of 4.8 mg/dl: more than twice after a week. Bilirubin in the C bile obtained by
of the values before loading. Lowering of the the Meltzer-Lyon procedure was fractionated
serum bilirubin level was observed after oral by high performance liquid chromatography
phenobarbital administration (100 mg per day (HPLC) 7 to estimate in vivo hepatic bilirubin-
for 14 days) (Fig. 5). Serum bilirubin decreased conjugating ability (Table 2). Decreased biliru-
June 1989 Coexistance of Gilbert's syndrome and macroamylasemia 323

76.5+4.8% (mean+SD) for BDG, 9.8_+2.5% for


BMG and 0.2+0.2% for UB 8. Phenobarbital ad-
ministration increased the proportion of BDG
and decreased those of UB and BMG to the
normal levels in the C bile.
Laparoscopy revealed the normal appearance
and color of the surface of the liver. Histology of
the liver was compatible w i t h that of Gilbert's
s y n d r o m e : No fibrosis in lobules, no remark-
able inflammation, and slight fatty infiltration
(Fig. 6). Bilirubin-UDP-glucuronyltransferase
(BGT) activity of the liver h o m o g e n a t e 9 was 0.65
nmol/mg-protein/15 min, less than 1/4 of the
m e a n normal value of 4.10+0.30 (SD) n m o l / m g -
protein/15 m i n obtained in our department.

Discussion
Gilbert's s y n d r o m e is reported to be present in
2 to 5% of the population 2'3. Powell et al. l~ re-
ported that the s y n d r o m e was hereditary and
that the h o m o z y g o t e m i g h t develop Crigler-
Najjar s y n d r o m e type II. Patients with Gilbert's
s y n d r o m e are reported to have lower BGT ac-
tivity in the liver than normal subjects ii, and
this was true in the present case. Fractionation
of bilirubin in bile may allow estimation of the
Fig. 6 Histology of the biopsied liver specimen. Hematoxylin and in vivo conjugating ability of bilirubin in hep-
eosin staining. (x400) atocytes, since UB and BMG in bile are re-
ported to be clearly increased in Gilbert's syn-
d r o m e s. As illustrated in Table 2, the present
bin diglucuronide (BDG) and increased biliru- case s h o w e d higher levels of UB and BMG and
bin m o n o g l u c u r o n i d e (BMG) and unconju- lower level of BDG in d u o d e n a l aspirate than
gated bilirubin IXa (UB) were found in the C controls. In this case, phenobarbital increased
bile in comparison with the following percen- BDG and reduced UB and BMG to the normal
tages of the fractions in normal subjects: values. The increased BDG was thought to be

Table 2 Effect of phenobarbital administration on the bilirubin fractions in duodenal aspirates

Total bilirubin BDG GG GX BMG Bilirubin IX,8 UB


(mg/dl) &/or IXa
Before phenobarbital 9.6 66.2 9.1 4.5 16.7 2.5 1.0
After Phenobarbital 7.9 77.8 6.5 2.3 10.3 2.5 0.6
Normal controls
(mean+SD, n=7) 8 19.4+13.7 76.5+4.8 8.7_+2.0 3.7_+1.1 9.8_+2.5 1.1_+0.7 0.2_+0.2

Data of each fraction are expressed as the percentage of total bilirubin


GG: Bilirubin monoglucuronide monoglucoside diester
GX: Bilirubin monoglucuronide monoxyloside diester
324 H. Inoue et al. Vol. 24, No. 3

caused by BGT induction in hepatocytes after


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