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Pancreatitis/CBD stricture/elevated liver enzymes
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Pancreatitis/CBD stricture/elevated liver enzymes

Any help in identifing what might be causing my husband to have the following problems would be greatly appreciated! He presented to the ER on Sept 15th with severe epigastric pain. Lipase was 11,000 & amylase was 5,331, liver enzymes normal, glucose normal, and triglycerides normal, Other abnormal labs included RBC 3.96(L), HGB 12.0(L), HCT 34.7(L), lymphs 15.1(L), ABS monocyte 0.6(H). He was admitted with acute pancreatis (pancreatitis). Put NPO/given IV's and pain meds and sent home in 4 days. ABD U/S & CT scan showed no evid of stone disease. Pancreas was unremarkable, question of fatty liver/hemangioma in liver. The abdominal pain persisted & he was admitted back into the hospital on Sept 24th. His lipase had gone down to 4119, but his liver enzymes were now elevated with alk phos 157, AST 130, and ALT 262, bilirubin normal, other abnormal labs this time included RBC 4.24(L), HGB 13.2(L), HCT 37.8(L), Lymphs 17.7(L), EOSIN 5.4(H). He was kept again 4 days (NPO/IV/pain meds) and sent home. The pain still persisted. He underwent ERCP on 09/26 which found a stricture in the distal common bile duct which was stented, brushing were negative. His labs were then followed:

09/27/03 glucose 138(H), alk phos 198(H), AST 296(H), ALT 498(H), Bilirubin normal, Lipase 832(H), RBC (4.15(L), HCT 38.2(L), GRAN/NEUT 76.4(H), LYMPHS 14.0(L), ABN GRN/NEUT 6.6(H)

09/29/03 glucose normal, anion gap 6(L), calcium 8.2(L), albumin 3.1(L), alk phos 179(H), AST 110(H), ALT 371(H), Lipase 632(H), RBC 3.49 (L), HGB 11.3(L), HCT 32.5(L), eosin 6.5(H), ABS monocyte 0.6(H)

epigastric pain (with some pain in back) persisted. Repeat abdominal CT 09/29 showed some indistinctness & edema in region of pancreatic head. EUS on 10/28 showed signs of chronic pancreatitis. Doctor said that area around pancreatic head showed alot of "fluid" which made it hard to visulize, recommended repeat CT 6 weeks (which has not been done at this time). Stent was removed on 10/31. Labs were again followed:
10/31 AST 237(H), ALT 155(H), ALk phos 127(H), anion gap 7(L), bilirun normal. lipase not done
11/05/03 Glucose 126(H), Alk phos 196(H), AST 64(H), ALT 338(H), SGGT 227(H)
11/07/03 Hep B, Hep C, Ferritin, FE/TIBC/%sat, ANA Alpha Feto protein, Ceruloplasmin & epstein barr were all done- per physician all were normal except Ferritin showed an elevation at 445(H). He stated his liver enzymes had come down some-however still not in normal range.
At this point gastroenterologist continues to monitor bloodwork. He has mentioned possible liver bx. My husband is currently taking percocet for pain and pancreatic enzymes 3 pills/3 times a day. He still has pain that comes and go's. He used to drink often about 10 years ago before we were married, since we've been married he only drinks approx 10 times/year parties etc... The last time he had alochol was Labor day Sept 1st. He has no significant past med hx. He is not overweight (175 lbs). No nausea or vomiting, no jaundice. Any advice appreciated!!
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Surgeon has kindly addressed you questions in his comments below and I agree with his assessment.

Followup with your personal physician is essential.

This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.

Thanks,
Kevin, M.D.
6 Comments
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I forgot to mention my husband is 44 years old. The only other symptoms he has besides the severe epigastric/rap around to the back pain is lots of burping and gas. Up to this point he has never had pain like this before and has been healthy with no medical issues.
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Sorry, but I have one more question that perhaps the surgeon could answer for me. My husbands gastroenterologist has been monitoring his liver enzymes since removeing the stent for("benign appearing" distal bile duct stricture)on 10/31. Since then as you can see above his alk phos, alt, and ast have still been quite elev. His doctor has mentioned the possibilty of surgical repair for the bile duct if it does not stay open; ie; cutting duct above stricture, and re-attaching it (by-passing the pancreas & connecting it directly to the small intestine. Whats perplexing the doc is that he has no elev of his bilirubin (which he says is usually elev with strictures) Could you comment on this for me and give me your thoughts on what would indicate this type of surgery? I understand that it is very extensive surgery. Would another ERCP be warrented to evaluate if the duct is staying open? or can they tell this just from the labs? Thank you for any assitance you can provide. I am very worried about him and would appreciate any insight.
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Avatar_n_tn
bile duct stricture can occur during or after pancreatitis. One question is why he developed pancreatitis in the first place: as you probably know, the most common causes by far are gallstones or alcohol intake. Some people get it for no known reason, or from medications. What might be done surgically -- or whether it should be done at all -- would depend in part on whether the cause becomes known. As to the stricture itself: first, it's not really rare to see the enzymes go up without the bilirubin. It depends in part on how narrow it is. If the stricture causes increased pressure in the biliary tree, the enzymes may go up; but unless the pressure is high enough the bile continues to flow and the bilirubin may not rise. Surgical correction depends on the exact anatomy. Usually if the stricture is due to the pancreatitis, there is easy access to the portion of the duct that's upstream from that which passes thru the pancreas, and the surgery can actually be quite simple: a procedure known as choledochoduondenostomy (sewing together in a side to side fashion the bile duct and the first portion of the duodenum -- the small intestine as it leaves the stomach -- is usually quite easy, safe, with low risk of complication. It's one of my "favorite" biliary procedures to do, when indicated, because it's so effective and straightforward. Sometimes it's better to create a Y-shaped limb of intestine and sew the end of it to the bile duct. More complex, but still common and not at all daunting.
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Thank you for your reply. As for the cause of the pancreatitis..I know they didn't see evid of gallstones in any of the tests CT, U/S, ERCP or EUS, but I was told by his doc that thats not to say he didn't pass one and it just was not to be seen. He was not on any meds prior. Alcohol has also been on their differential, but don't you see the AST being higher then the ALT with alcohol related elev liver enzymes? I think the theory his gastro doc was leaning toward was that for some reason he developed this acute pancreatitis, which led to the bile duct stricture, which led to the elev liver enzymes. Although the doc has been somewhat confused by his whole picture, saying that he "hasn't been following the rules" (I guess his labs are a bit puzzling to him and thats why he continues to follow them) I was hoping that by looking at his labs that one of you docs might have an idea of a test that hasn't been done yet that might lead us in a direction that could help us get some answers.

I am a cancer registrar...so of course working in that field, that is a big fear of mine. We have seen time and time again bile duct brushings come back negative, and the patient still go on to have cancer found on further testing. Should I feel pretty confident with the tests that have been performed thus far..and the findings that this is most likely not cancer, or could this still be a possibility?  

I apologize for being so full of questions! I am just a very worried and concerned wife. Thank you so much for explaining the bile duct surgery. I feel better about it now, if it does come to him having to undergo it.
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Avatar_n_tn
Hello,

Most likely, cancer isn't the cuase with all of the testing that has been done.  However, a spiral Cat Scan is particularly effective when trying to find biliary cancers.

Good luck!
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I don't think it's at all carved in stone that alcoholic liver disease always has a certain pattern of enzymes. As to cancer: it's not fully ruled out, of course. On the other hand, malignant strictures don't get better, they get steadily worse. Cancer is highly unlikely here. The after-effects of pancreatitis can linger for a long time. His course is more prolonged than average, but not startlingly so. It's likely that his stricture will improve further. Given the severity and length of his illness, one would consider removing the gallbladder even if stones aren't proven, if no other source becomes known. And it hopefully goes without saying that not a drop of alcohol should ever again pass his lips.
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