Question:
(a) A patient presents with unconjugated hyperbilirubinemia and presence of urobilinogen in urine. Which amongst the following is the least likely diagnosis? (b) A related patient presents with unconjugated hyperbilirubinemia and elevated urobilinogen levels in urine, and the most likely diagnosis is asked. Choose the option that answers part (a), the least likely diagnosis.
(a) A patient presents with unconjugated hyperbilirubinemia and presence of urobilinogen in urine. Which amongst the following is the least likely diagnosis? (b) A related patient presents with unconjugated hyperbilirubinemia and elevated urobilinogen levels in urine, and the most likely diagnosis is asked. Choose the option that answers part (a), the least likely diagnosis.
Show Hint
In a list of unconjugated jaundice causes, the conjugated-defect outlier is the odd one out.
Updated On: Jun 24, 2026
- Hemolytic jaundice
- Crigler Najjar syndrome
- Gilbert's syndrome
- Dubin Johnson syndrome
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Verified By Collegedunia
The Correct Option is D
Solution and Explanation
Step 1: Understand the chemistry. Unconjugated bilirubin is fat-soluble and is not excreted in urine, so it never causes bilirubinuria. Urobilinogen, however, is formed in the gut from conjugated bilirubin and is reabsorbed, so increased urobilinogen in urine means plenty of bilirubin is reaching and being conjugated and excreted into the gut.
Step 2: Apply this to the unconjugated group. Hemolytic jaundice overproduces bilirubin, the liver conjugates and excretes a large load, gut urobilinogen rises, and urine urobilinogen goes up. Gilbert syndrome and Crigler Najjar are defects of conjugation that raise unconjugated bilirubin and can still allow urobilinogen formation. All three fit a picture of unconjugated hyperbilirubinemia.
Step 3: Examine Dubin Johnson. Dubin Johnson syndrome is a defect in canalicular excretion of conjugated bilirubin (MRP2 transporter). It causes conjugated (direct) hyperbilirubinemia, not unconjugated. So it does not belong in a list of unconjugated hyperbilirubinemia causes.
Step 4: Answer part (a). Since the patient has unconjugated hyperbilirubinemia, the least likely diagnosis is the one that is actually a conjugated hyperbilirubinemia, which is Dubin Johnson syndrome. (For reference, part b asks the most likely cause with raised urinary urobilinogen, which is hemolytic jaundice, since hemolysis produces the largest urobilinogen load.)
The answer to part (a) is option D, Dubin Johnson syndrome.
Step 2: Apply this to the unconjugated group. Hemolytic jaundice overproduces bilirubin, the liver conjugates and excretes a large load, gut urobilinogen rises, and urine urobilinogen goes up. Gilbert syndrome and Crigler Najjar are defects of conjugation that raise unconjugated bilirubin and can still allow urobilinogen formation. All three fit a picture of unconjugated hyperbilirubinemia.
Step 3: Examine Dubin Johnson. Dubin Johnson syndrome is a defect in canalicular excretion of conjugated bilirubin (MRP2 transporter). It causes conjugated (direct) hyperbilirubinemia, not unconjugated. So it does not belong in a list of unconjugated hyperbilirubinemia causes.
Step 4: Answer part (a). Since the patient has unconjugated hyperbilirubinemia, the least likely diagnosis is the one that is actually a conjugated hyperbilirubinemia, which is Dubin Johnson syndrome. (For reference, part b asks the most likely cause with raised urinary urobilinogen, which is hemolytic jaundice, since hemolysis produces the largest urobilinogen load.)
The answer to part (a) is option D, Dubin Johnson syndrome.
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