Gallstone passage?

I am a fit, thin female in my mid 30's.  4 years ago after my first child, I began having RUQ pain, nauseousness, and some vomiting.  I had clay-colored stools for a week.  My PCP ordered an abdominal ultrasound in which my gallbladder appeared normal.  No labs were done.  My symptoms resolved over time.  2 weeks ago I awoke at 12am with excruciating RUQ pain, nauseousness, and vomiting like textbook biliary colic.  I spent the night in the ER on pain and anti-emetic meds.  The pain lasted 7 hrs.  US showed mildly dilated intrahepatic duct, common bile duct of 7mm, but found no stones or sludge.  I was discharged with no dx other than mild transaminitis and hypokalemia.  The ER doc made me feel like a hypochondriac.  My ALT was 193, AST 183, neutrophils were at 94%, mildly elevated bilirubin, amylase normal, ALP 20 pts above my usual but in normal range, and my urine was light brown on this night.  A HIDA scan a week later showed ejection fraction of 25% and no other abnormalities.  I had nausea and cramping, but no acute pain with CCK injection.  My ALT peaked at 470/AST 100 48 hrs after attack and then a week later went down to ALT124/AST 21.  

Is it possible to pass stones when no stones show up on US?  I was also taking Plavix for a recent heart cath which gave me nausea, joint pain, flu-likes symptoms, fatigue and petechial rash.  PCP thinks I had drug-induced hepatitis rather than GB issue.  I had been taking Plavix for 6 wks and would get nauseous each time I took it, but never had extreme acute pain, although my enzymes dropped to ALT 124/AST 21 within 72 hrs after stopping.  I am off Plavix for good, but am concerned about the GB/liver issue.  I was constipated for a week after the episode and continue to have intermittent, but tolerable RUQ pain.  I have never had GI issues.  Can you explain if gallstones are actually formed in the liver and could then possibly travel down the intrahepatic duct or if they actually form in the GB?

Thanks for your help.

[Kevin Pho, MD]

Sorry for the delay in responding - I was on vacation.

Not all stones show up on US, so yes, it is possible to pass stones that may not have been detected on US.  

I agree with the tests you had done.  I would also consider an MRCP or ERCP to further evaluate the biliary tree.  Sometimes there can be biliary duct stones that may cause transient elevation of the liver enzymes.  Some cases require an ERCP, so the stone can be manually removed.

Repeating the liver enzymes is recommended.  If they continue to rise, discussing the aforementioned tests with your GI physician can be done.

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.

Kevin, M.D.
www.kevinmd.com