title: Severe Elevation of Liver Tests in Choledocholithiasis: An Uncommon Occurrence With Important Clinical Implications.
abstract: OBJECTIVE
  Choledocholithiasis is not commonly associated with dramatic elevations in aminotransferase or total serum bilirubin. Ours is the largest case series thus far studying the prevalence of dramatic elevations in liver tests associated with choledocholithiasis.
  
  
  METHODS
  We performed a retrospective chart review of all patients with choledocholithiasis diagnosed on endoscopic retrograde pancreatocholangiogram at a tertiary referral hospital over 7 years. We identified 740 patients with available liver tests and determined the prevalence of aspartate aminotransferase (AST)/alanine aminotransferase (ALT) >1000 IU/L and of total serum bilirubin >10 mg/dL. We compared clinical characteristics of these 2 nonoverlapping groups.
  
  
  RESULTS
  Of 740 patients, AST and/or ALT values >1000 IU/L were present in 45 (6.1%) patients. On average AST and ALT decreased 79% and 56%, respectively, at discharge 1 to 8 days later. Total serum bilirubin levels >10 mg/dL were present in 35 (4.7%) patients and decreased by an average of 64% at discharge 1 to 8 days later. When compared with the group with total serum bilirubin >10 mg/dL, the group with elevated aminotransferases had significantly more females (93% vs. 43%, P<0.001), had smaller common bile duct diameter (8.5 vs. 10.6 mm, P=0.04), and were more likely to have had a prior cholecystectomy (40% vs. 14%, P=0.01). These 80 patients had higher utilization of health resources: half had additional laboratory studies and one fourth had additional imaging studies performed.
  
  
  CONCLUSIONS
  In patients with high AST and/or ALT and serum total bilirubin levels with known choledocholithiasis, elaborate work up to look for another etiology is not required. As long as the values decrease significantly, they do not need to be followed until they normalize in the same hospitalization.
authors.affiliation: *Department of Internal Medicine †Division of Digestive and Liver Diseases, University Texas Southwestern Medical Center, Dallas, TX.
authors.forename: Saroja
authors.initials: S
authors.lastname: Bangaru
authors.forename: Dwain
authors.initials: D
authors.lastname: Thiele
authors.forename: Jayaprakash
authors.initials: J
authors.lastname: Sreenarasimhaiah
authors.forename: Deepak
authors.initials: D
authors.lastname: Agrawal
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000410:Alanine Transaminase / Q000097:blood; D000469:Alkaline Phosphatase / Q000097:blood; D001219:Aspartate Aminotransferases / Q000097:blood; D001663:Bilirubin / Q000097:blood; D042883:Choledocholithiasis / Q000097:blood / Q000175:diagnosis / Q000453:epidemiology*; D005260:Female; D006801:Humans; D008111:Liver Function Tests / Q000706:statistics & numerical data*; D008297:Male; D008499:Medical Records; D008875:Middle Aged; D012189:Retrospective Studies; D013781:Texas / Q000453:epidemiology; D055815:Young Adult
chemical_list: D001219:Aspartate Aminotransferases; D000410:Alanine Transaminase; D000469:Alkaline Phosphatase; D001663:Bilirubin