Gallstones With Elevated Bilirubin And Possible Blockage...What Are My Options?

[QuestionGuy]

On August 1st, I went to the hospital for some tests.  (Unrelated to the gallbladder)  In the process, it was discovered through ultrasound that I had some very small gallstones.  No blockages of the bile ducts showed up.  My bilary system wasn't dilated.  A liver enzyme test was done, and it revealed that my bilirubin was elevated (3.4 and 0.5), along with my ALK PHOS.  My doctor didn't seem too concerned about any of this, but I suspect that I have a blockage somewhere in the bile duct that's not showing up on ultrasound, as I'm having some of the classic symptoms of a blockage.  (Ocassional severe Itching, lighter than normal colored stools (medium brownish-orange) slight yellowing to eyes that comes and gos)  However, I am experiencing no pain.  These are my questions:

1. What steps do I need to take to determine whether or not my problem is due to a blockage?  What type of doctor would I have to see?

2. What are my options as far as clearing a blockage of the bile duct?  I know about ERCP, but are there any other alternatives?

3. I'm not planning on having my gallbladder removed, because I feel the stones are not big/numerous enough to warrent that type of surgery.  Plus, I am not having any painful gallbladder attacks.  What are my alternatives?  Are there any drugs that can be used to dissolve my small existing stones.

Thank you

[Kevin Pho, MD]

Your question was comprehensively answered in the comments below and I agree with the content.  I will repost it here as comments are not saved:

"It's possible you are passing stones, and that the elevation was due to transient blockage. However, in most cases of elevated bilirubin due to blockage, it's pretty obvious from the ultrasound that the ducts are dilated. There are pills that dissolve gallstones; however, people who form stones, form stones. So in almost all cases, the people whose stones dissolve (around 40% of those who try), the stones come back. Size and number of stones really isn't a reason to decide for or against surgery. In fact, small stones as you have are potentially the most dangerous; as they pass, they can do more than just cause transient jaundice. They can cause pancreatitis which is a potentially very serious illness, and repeated episodes are even more dangerous. To determine the significance of your elevated bilirubin, you might need more evaluation; including most simply repeating the test to see if it persists. If not, it suggest indeed you are passing stones, in which case surgery is to be very seriously considered (meaning removing the gallbladder, not just scoping the duct.) If chronically elevated, along with normal size ducts, it could indicate some form of liver disorder. I'd say you ought to consider seeing a gastroenterologist. And, in the long run, you need to give serious thought to having the gallbladder removed. As you probably know, nowadays it's usually an outpatient procedure, and the vast majority of people have no significant side effects. If it's judged that the stones indeed have nothing to do with your symptoms and/or lab tests, then waiting becomes a more reasonable option."

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.

Kevin, M.D.
Medical Weblog:
kevinmd_b

[surgeon]

It's possible you are passing stones, and that the elevation was due to transient blockage. However, in most cases of elevated bilirubin due to blockage, it's pretty obvious from the ultrasound that the ducts are dilated. There are pills that dissolve gallstones; however, people who form stones, form stones. So in almost all cases, the people whose stones dissolve (around 40% of those who try), the stones come back. Size and number of stones really isn't a reason to decide for or against surgery. In fact, small stones as you have are potentially the most dangerous; as they pass, they can do more than just cause transient jaundice. They can cause pancreatitis which is a potentially very serious illness, and repeated episodes are even more dangerous. To determine the significance of your elevated bilirubin, you might need more evaluation; including most simply repeating the test to see if it persists. If not, it suggest indeed you are passing stones, in which case surgery is to be very seriously considered (meaning removing the gallbladder, not just scoping the duct.) If chronically elevated, along with normal size ducts, it could indicate some form of liver disorder. I'd say you ought to consider seeing a gastroenterologist. And, in the long run, you need to give serious thought to having the gallbladder removed. As you probably know, nowadays it's usually an outpatient procedure, and the vast majority of people have no significant side effects. If it's judged that the stones indeed have nothing to do with your symptoms and/or lab tests, then waiting becomes a more reasonable option.