Elevated transaminases: a new tool for the diagnosis of choledocholithiasis. A case control study
DOI:
https://doi.org/10.22516/25007440.446Keywords:
Choledocholithiasis, Aminotransferases, Biliary colicAbstract
Introduction: Choledocolithiasis (CLD) affects 10% of patients with gallstones. Bile duct obstruction is associated with pancreatitis, cholangitis, and rupture of the common bile duct. This condition usually presents with increased alkaline phosphatase, GGTP and bilirubin levels. In the last decade, it has been found that up to 10% of patients with CLD have elevated aminotransferases levels. In Latin America, this alteration has not been studied. The aim of the present work was to determine the prevalence of transaminase elevation and its evolution.
Methodology: Case-control study. ALT was measured on admission, at 48 h and at 72 h. If ultrasound was normal, MRCP and/or echo-endoscopy and ERCP were performed, as appropriate.
Results: A total of 72 patients with choledocholithiasis (CLD) (cases) and 128 with cholecystitis without choledocholithiasis (controls) were included. Among the cases, 83% had increased ALT levels, which was 2-9 times higher in 56.9%, 10-20 times higher in 16%, and more than 20 times higher in 8.3%. At 48 hours, those levels decreased by 30% and at 72 hours by 56%. In turn, in 27.3% of the controls, ALT was 2-9 times higher in 15.6%, 10-20 times higher in 7.8% and more than 20 times higher in 2.9%. The combination of biliary colic and ALT elevation had a positive predictive value (PPV) for CLD of 72% and a negative predictive value (NPV) of 87.7%.
Conclusion: When biliary colic and ALT elevation are reported, it is imperative to rule out choledocholithiasis. If the ultrasound is normal, MRCP and/or biliopancreatic endoscopy should be performed.
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ASGE Standards of Practice Committee, Maple JT, Ben-Menachem T, Anderson MA, Appalaneni V, Banerjee S, Cash BD, Fisher L, Harrison ME, Fanelli RD, Fukami N, Ikenberry SO, Jain R, Khan K, Krinsky ML, Strohmeyer L, Dominitz JA. The role of endoscopy in the evaluation of suspected choledocholithiasis. Gastrointest Endosc. 2010;71(1):1-9.
http://doi.org/10.1016/j.gie.2009.09.041
Tozatti J, Mello AL, Frazon O. Predictor factors for choledocholithiasis. Arq Bras Cir Dig. 2015;28(2):109-112.
http://doi.org/10.1590/S0102-67202015000200006
Copelan A, Kapoor BS. Choledocholithiasis: Diagnosis and Management. Tech Vasc Interv Radiol. 2015;18(4):244-255.
http://doi.org/10.1053/j.tvir.2015.07.008
Gómez M, Pion J, Otero W. Predictores de coledocolitiasis en pacientes sometidos a colangiografía retrógrada endoscópica en el Hospital El Tunal de Bogotá. Rev Col Gastroenterol. 2011;26(4):243-252.
Frossard JL, Morel PM. Detection and management of bile duct stones. Gastrointest Endosc. 2010;72(4):808-816.
http://doi.org/10.1016/j.gie.2010.06.033
ASGE Standards of Practice Committee, Anderson MA, Fisher L, Jain R, Evans JA, Appalaneni V, Ben-Menachem T, Cash BD, Decker GA, Early DS, Fanelli RD, Fisher DA, Fukami N, Hwang JH, Ikenberry SO, Jue TL, Khan KM, Krinsky ML, Malpas PM, Maple JT, Sharaf RN, Shergill AK, Dominitz JA. Complications of ERCP. Gastrointest Endosc. 2012;75(3):467-73.
http://doi.org/10.1016/j.gie.2011.07.010
Suárez AL, LaBarre NT, Cotton PB, Payne KM, Coté GA, Elmunzer BJ. An assessment of existing risk stratification guidelines for the evaluation of patients with suspected choledocholithiasis. Surg Endosc. 2016;30(10):4613-8.
http://doi.org/10.1007/s00464-016-4799-8
Portincasa P, Wang DQ. Gallstones. En: Podolsky DK, Camilleri M, Fitz G, Kalloo AN, Shanahan F, Wang TC. Yamada’s Textbook of Gastroenterology. Chichester: John Wiley and Sons Ltda, 6a edición; 2016. p. 1808-1834.
https://doi.org/10.1002/9781118512074.ch89
Bangaru S, Thiele D, Sreenarasimhaiah J, Agrawal D. Severe Elevation of Liver Tests in Choledocholithiasis: An Uncommon Occurrence With Important Clinical Implications. J Clin Gastroenterol. 2017;51(8):728-733.
http://doi.org/10.1097/MCG.0000000000000608
Song SH, Kwon CI, Jin SM, Park HJ, Chung CW, Kwon SW, Ko KH, Hong SP. Clinical characteristics of acute cholecystitis with elevated liver enzymes not associated with choledocholithiasis. Eur J Gastroenterol Hepatol. 2014;26(4):452-7.
http://doi.org/10.1097/MEG.0000000000000053
Agahi A, McNair A. Choledocholithiasis presenting with very high transaminase level. BMJ Case Rep. 2012;2012:bcr2012007268.
http://doi.org/10.1136/bcr-2012-007268
Kim HC, Nam CM, Jee SH, Han KH, Oh DK, Suh I. Normal serum aminotransferase concentration and risk of mortality from liver diseases: prospective cohort study. BMJ. 2004;328(7446):983.
http://doi.org/10.1136/bmj.38050.593634.63
Williams E, Beckingham I, El Sayed G, Gurusamy K, Sturgess R, Webster G, Young T. Updated guideline on the management of common bile duct stones (CBDS). Gut. 2017;66(5):765-782.
http://doi.org/10.1136/gutjnl-2016-312317
Nathwani RA, Kumar SR, Reynolds TB, Kaplowitz N. Marked elevation in serum transaminases: an atypical presentation of choledocholithiasis. Am J Gastroenterol. 2005;100(2):295-298.
http://doi.org/10.1111/j.1572-0241.2005.40793.x
Adams MA, Hosmer AE, Wamsteker EJ, Anderson MA, Elta GH, Kubiliun NM, Kwon RS, Piraka CR, Scheiman JM, Waljee AK, Hussain HK, Elmunzer BJ. Predicting the likelihood of a persistent bile duct stone in patients with suspected choledocholithiasis: accuracy of existing guidelines and the impact of laboratory trends. Gastrointest Endosc. 2015;82(1):88-93.
http://doi.org/10.1016/j.gie.2014.12.023
Hu KC, Wang HY, Chang WH, Chu CH, Lin SC, Liu CJ, Wu MS, Shih SC. Clinical presentations of patients from different age cohorts with biliary tract stone diseases. J Gastroenterol Hepatol. 2014;29(8):1614-9.
http://doi.org/10.1111/jgh.12581
Huh CW, Jang SI, Lim BJ, Kim HW, Kim JK, Park JS, Kim JK, Lee SJ, Lee DK. Clinicopathological features of choledocholithiasis patients with high aminotransferase levels without cholangitis: Prospective comparative study. Medicine (Baltimore). 2016;95(42):e5176.
http://doi.org/10.1097/MD.0000000000005176
Bachar GN, Cohen M, Belenky A, Atar E, Gideon S. Effect of aging on the adult extrahepatic bile duct: a sonographic study. J Ultrasound Med. 2003;22(9):879-885.
http://doi.org/10.7863/jum.2003.22.9.879
Barthet M, Spinoza S, Affriat C, Berthezene P, Sahel J. Influence of age and biliary lithiasis on the diameter of the common bile duct. Gastroenterol Clin Biol. 1995;19(2):156-160.
Mossberg SM, Bloom A, Berkowitz J, Ross G. Serum enzyme activities following morphine. A study of transaminase and alkaline phosphatase levels in normal persons and those with gallbladder disease. Arch Intern Med. 1962;109:429-437.
http://doi.org/10.1001/archinte.1962.03620160055008
Rosser BG, Gores GJ. Liver cell necrosis: cellular mechanisms and clinical implications. Gastroenterology. 1995;108(1):252-275.
http://doi.org/10.1016/0016-5085(95)90032-2
Spivey JR, Bronk SF, Gores GJ. Glycochenodeoxycholate-induced lethal hepatocellular injury in rat hepatocytes. Role of ATP depletion and cytosolic free calcium. J Clin Invest. 1993;92(1):17-24.
http://doi.org/10.1172/JCI116546
Ginsberg AL. Very high levels of SGOT and LDH in patients with extrahepatic biliary tract obstruction. Am J Dig Dis. 1970;15(9):803-807.
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