Clinicopathological features of choledocholithiasis patients with high aminotransferase levels without cholangitis

Abstract

Common bile duct (CBD) stones are generally associated with greater elevations of alkaline phosphatase and gamma-glutamyl transpeptidase levels than aspartate aminotransferase and alanine aminotransferase levels. However, some patients with CBD stones show markedly increased aminotransferase levels, sometimes leading to the misdiagnosis of liver disease. Therefore, the aim of this study was to investigate the clinicopathologic features of patients with CBD stones and high aminotransferase levels.This prospective cohort study included 882 patients diagnosed with CBD stones using endoscopic retrograde cholangiopancreatography (ERCP). Among these patients, 38 (4.3%) exhibited aminotransferase levels above 400 IU/L without cholangitis (gallstone hepatitis [GSH] group), and 116 (13.2%) exhibited normal aminotransferase levels (control group). We compared groups in terms of clinical features, laboratory test results, radiologic images, and ERCP findings such as CBD diameter, CBD stone diameter and number, and periampullary diverticulum. Liver biopsy was performed for patients in the GSH group.GSH patients were younger and more likely to have gallbladder stones than control patients, implying a higher incidence of gallbladder stone migration. Also, GSH patients experienced more severe, short-lasting abdominal pain. ERCP showed narrower CBDs in GSH patients than in control patients. Histological analysis of liver tissue from GSH patients showed no abnormalities except for mild inflammation.Compared with control patients, GSH patients were younger and showed more severe, short-lasting abdominal pain, which could be due to a sudden increase of CBD pressure resulting from the migration of gallstones through narrower CBDs. These clinical features could be helpful not only for the differential diagnosis of liver disease but also for investigating the underlying mechanisms of liver damage in obstructive jaundice. Moreover, we propose a new definition of “gallstone hepatitis” based on the specific clinicopathologic characteristics observed in our patients.

Epidemiology and outcomes of marked elevations of alanine aminotransferase >1000 IU/L in an Australian cohort

“…Biliary obstruction is not traditionally considered to be a common cause of marked aminotransferase derangement but was the third most common cause in this study. Marked elevations of liver enzymes is an uncommon but increasingly recognized manifestation of choledocholithiasis, where up to 6% of patients develop ALT or AST over 1000 IU/L . Concentrations of aminotransferases above 400–500 IU/L are caused by biliary obstruction in 20–34% of cases in Western countries and in 12% of cases in China .…”

“…Marked elevations of liver enzymes is an uncommon but increasingly recognized manifestation of choledocholithiasis, where up to 6% of patients develop ALT or AST over 1000 IU/L. [20][21][22] Concentrations of aminotransferases above 400-500 IU/L are caused by biliary obstruction in 20-34% of cases in Western countries 11,17,23 and in 12% of cases in China. 24 However, biliary obstruction is rare at higher concentrations of aminotransferases, where choledocholithiasis causes only 4% of ALT greater than 1000 IU/L in Ireland 9 and only 1% of ALT or AST over 3000 IU/L in Singapore.…”

The Emergency Medicine−Focused Review of Cholangitis

“…Choledocholithiasis alone does not typically present with rigors or fevers, and the presence of these findings should prompt suspicion for cholangitis secondary to common bile duct stone obstruction and should be investigated and treated as such (36). Acute hepatitis, whether viral, drug-induced, or ischemic in etiology, may present with symptoms such as fever or right upper quadrant pain that overlap with the presentation of cholangitis (37). Differentiating factors include level of transaminases and imaging findings.…”

“…Differentiating factors include level of transaminases and imaging findings. Acute hepatitis typically results in much higher aspartate aminotransferase (AST) and alanine aminotransferase (ALT), with relatively normal alkaline phosphatase, while cholangitis is expected to demonstrate modestly elevated AST and ALT with concurrently elevated alkaline phosphatase to indicate an obstructive pattern (37). Imaging in acute hepatitis may demonstrate hepatomegaly, increased periportal echoes with decreased parenchymal echogenicity, or gallbladder wall abnormalities, or imaging may show no particular abnormalities (38).…”

Clinicopathological features of choledocholithiasis patients with high aminotransferase levels without cholangitis

“…In the article “Clinicopathological features of choledocholithiasis patients with high aminotransferase levels without cholangitis: Prospective comparative study”, [1] which appeared in Volume 95, Issue 42 of Medicine , Dr. Joon Seong Park's name was originally misspelled.…”