Choledocholithiasis in patients with normal serum liver enzymes

Area of Science:

• Gastroenterology
• Hepatology
• Endoscopic Retrograde Cholangiopancreatography (ERCP)

Background:

• Choledocholithiasis, or common bile duct stones, typically presents with elevated liver enzymes and bilirubin.
• Diagnostic challenges arise when biochemical markers are discordant with clinical suspicion.

Purpose of the Study:

• To investigate the occurrence of choledocholithiasis in patients with persistently normal serum liver enzyme and total bilirubin levels.
• To identify potential factors that may blunt biochemical evidence of common bile duct stones.

Main Methods:

• Retrospective chart review of 330 patients who underwent ERCP over a two-year period.
• Analysis of clinical characteristics, imaging findings, and biochemical markers in patients with choledocholithiasis and normal liver function tests.

Main Results:

• Five patients (1.5%) with choledocholithiasis had repeatedly normal liver enzymes and bilirubin.
• Common features included female gender, advanced age, and in three patients, the gallbladder or a remnant was present.
• Common bile duct dilatation (>10 mm) was observed in four patients, with prominent ampulla in four; intrahepatic duct dilatation was absent.

Conclusions:

• Common bile duct stones can exist despite normal serum liver enzyme and total bilirubin levels.
• Dilatation of the common bile duct or gallbladder may act as a pressure sump, masking enzyme elevations.
• Normal liver enzymes should not deter cholangiography in patients with suspected choledocholithiasis.