Choledocholithiasis in patients with normal serum liver enzymes

Abstract

Retrospective chart review of 330 patients undergoing ERCP over a two-year period yielded five patients with choledocholithiasis whose serum liver enzyme and total bilirubin levels were repeatedly normal. All were female, three were elderly, and the gallbladder was in situ in three of the five, one of whom had a large gallbladder remnant. In four patients, the common bile duct was dilated (> 10 mm), whereas none had intrahepatic duct dilatation. Four patients had a prominent ampulla, and stone size varied widely. Each patient was managed with endoscopic sphincterotomy and stone extraction followed by cholecystectomy for the four patients with the gallbladder or its remnant in situ. This small series proves that common duct stones may exist in patients with repeatedly normal serum liver enzyme and total bilirubin levels. We hypothesize that marked dilatation of the common bile duct or gallbladder may serve as a pressure sump and blunt liver enzyme elevation. Normal liver enzymes should not dissuade one from performing cholangiography in patients with suspected choledocholithiasis.

Liver test patterns in patients with acute calculous cholecystitis and/or choledocholithiasis

“…Interestingly, four (0.5%) patients in the ACC/CDL group had no aminotransferase derangement even in the presence of a known CBD stone. This phenomenon has been observed in the past 30 . We do not know why a vast majority of patients have liver enzyme abnormalities, reflecting biliary obstruction, while a few do not.…”

The role of ERCP in choledocholithiasis

“…Therefore, a strict reliance on blood chemistry will lead to disappointments in predicting its presence. In fact, normal liver enzymes in the presence of CBDS are well reported [52].…”

Prevalence of Normal Liver Tests in Patients with Choledocholithiasis Undergoing Endoscopic Retrograde Cholangiopancreatography

“…Several older studies note the presence of normal liver tests in a small percentage of patients but did not characterize these patients further [6,7,8]. To our knowledge, there has been only one prior study specifically addressing normal liver chemistry tests in patients with choledocholithiasis [15]. This retrospective study of 330 patients undergoing ERCP identified 5 patients in whom these tests were repeatedly normal.…”

“…Indeed, abnormal liver chemistry tests are considered the hallmark of CBD stones. While CBD stones may be found in an asymptomatic patient, there is little information on the prevalence of normal liver chemistry tests in patients with CBD stones [15] and to our knowledge no data on associated risk factors. Such information could be useful for patients undergoing laparoscopic cholecystectomy as well as expanding the spectrum of clinical presentation of such patients.…”