Stone or stricture as a cause of extrahepatic cholestasis – do liver function tests predict the diagnosis?
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Jukka Karvonen
Abstract
Background: Cholestasis, roughly divided into intrahepatic and extrahepatic forms, is a clinical challenge. Extrahepatic cholestasis, characterized by dilated bile ducts, is caused by either a bile duct stone or stricture, with stricture most often related to a malignancy. The aim of the present study was to analyze the value of common liver function tests in separating patients with malignant bile duct strictures from those with stones.
Methods: All consecutive patients admitted for endoscopic retrograde cholangiopancreatography (ERCP) were included in the study population if a bile duct stricture related to a malignancy was found by ERCP (n=103) or if a bile duct stone was successfully extracted during ERCP, thus confirming the diagnosis of a stone (n=109). Plasma alkaline phosphatase, γ-glutamyltransferase, alanine aminotransferase and bilirubin values were determined in the morning before ERCP.
Results: Plasma bilirubin (p<0.001), alkaline phosphatase (p<0.001) and alanine aminotransferase (p=0.040) levels were significantly higher in patients with malignant bile duct strictures than in those with bile duct stones. In addition, γ-glutamyltransferase levels seemed to be higher in patients with malignant strictures than in those with stones, although the difference did not reach statistical significance (p=0.053). In receiver operating characteristic analyses, bilirubin proved to be the best laboratory test in differentiating patients (p=0.001 vs. alkaline phosphatase, p<0.001 vs. alanine aminotransferase and p<0.001 vs. γ-glutamyltransferase). With a plasma bilirubin cutoff value of 145μmol/L, four out of five patients were categorized correctly.
Conclusions: Plasma bilirubin seems to be the best liver function test in distinguishing patients with malignant bile duct strictures from those with bile duct stones. This routine test should receive more attention in clinical decision-making than has previously been given.
Clin Chem Lab Med 2006;44:1453–6.
References
1. Green RM, Flamm S. AGA technical review on the evaluation of liver chemistry tests. Gastroenterology 2002; 123:1367–84.10.1053/gast.2002.36061Suche in Google Scholar
2. Reichling JJ, Kaplan MM. Clinical use of serum enzymes in liver disease. Dig Dis Sci 1988; 33:1601–14.10.1007/BF01535953Suche in Google Scholar
3. Becker CD, Grossholz M, Becker M, Mentha G, de Peyer R, Terrier F. Choledocholithiasis and bile duct stenosis: diagnostic accuracy of MR cholangiopancreatography. Radiology 1997; 205:523–30.10.1148/radiology.205.2.9356639Suche in Google Scholar
4. Magnuson TH, Bender JS, Duncan MD, Ahrendt SA, Harmon JW, Regan F. Utility of magnetic resonance cholangiography in the evaluation of biliary obstruction. J Am Coll Surg 1999; 189:63–71; discussion 71–2.10.1016/S1072-7515(99)00082-4Suche in Google Scholar
5. Scheiman JM, Carlos RC, Barnett JL, Elta GH, Nostrant TT, Chey WD, et al. Can endoscopic ultrasound or magnetic resonance cholangiopancreatography replace ERCP in patients with suspected biliary disease? A prospective trial and cost analysis. Am J Gastroenterol 2001; 96:2900–4.10.1111/j.1572-0241.2001.04245.xSuche in Google Scholar PubMed
6. Prat F, Meduri B, Ducot B, Chiche R, Salimbeni-Bartolini R, Pelletier G. Prediction of common bile duct stones by noninvasive tests. Ann Surg 1999; 229:362–8.10.1097/00000658-199903000-00009Suche in Google Scholar PubMed PubMed Central
7. Onken JE, Brazer SR, Eisen GM, Williams DM, Bouras EP, DeLong ER, et al. Predicting the presence of choledocholithiasis in patients with symptomatic cholelithiasis. Am J Gastroenterol 1996; 91:762–7.Suche in Google Scholar
8. Chang L, Lo SK, Stabile BE, Lewis RJ, de Virgilio C. Gallstone pancreatitis: a prospective study on the incidence of cholangitis and clinical predictors of retained common bile duct stones. Am J Gastroenterol 1998; 93:527–31.10.1111/j.1572-0241.1998.159_b.xSuche in Google Scholar PubMed
9. Pasanen P, Pikkarainen P, Alhava E, Partanen K, Penttila I. Value of serum alkaline phosphatase, aminotransferases, γ-glutamyltransferase, leucine aminopeptidase, and bilirubin in the distinction between benign and malignant diseases causing jaundice and cholestasis: results from a prospective study. Scand J Clin Lab Invest 1993; 53:35–9.10.3109/00365519309092529Suche in Google Scholar PubMed
10. Klauke R, Schmidt E, Lorentz K. Recommendations for carrying out standard ECCLS procedures (1988) for the catalytic concentrations of creatine kinase, aspartate aminotransferase, alanine aminotransferase and γ-glutamyltransferase at 37°C. Standardization Committee of the German Society for Clinical Chemistry, Enzyme Working Group of the German Society for Clinical Chemistry. Eur J Clin Chem Clin Biochem 1993; 31:901–9.Suche in Google Scholar
11. Jarvisalo J, Maatela J, Maki J, Marniemi J, Reunanen A. Health-based reference values of the Mini-Finland Health Survey: 1. Serum γ-glutamyltransferase, aspartate aminotransferase and alkaline phosphatase. Scand J Clin Lab Invest 1989; 49:623–32.10.1080/00365518909091537Suche in Google Scholar PubMed
12. Kairisto V, Poola A. Software for illustrative presentation of basic clinical characteristics of laboratory tests – GraphROC for Windows. Scand J Clin Lab Invest Suppl 1995; 222:43–60.10.3109/00365519509088450Suche in Google Scholar PubMed
13. Hanley JA, McNeil BJ. A method of comparing the areas under receiver operating characteristic curves derived from the same cases. Radiology 1983; 148:839–43.10.1148/radiology.148.3.6878708Suche in Google Scholar PubMed
©2006 by Walter de Gruyter Berlin New York
Artikel in diesem Heft
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- Improvement in HPLC separation of porphyrin isomers and application to biochemical diagnosis of porphyrias
- Measurement of late-night salivary cortisol with an automated immunoassay system
- Combining markers of nephrotoxicity and hepatotoxicity for improved monitoring and detection of chronic alcohol abuse
- Stone or stricture as a cause of extrahepatic cholestasis – do liver function tests predict the diagnosis?
- Insulin resistance and enhanced protein glycation in men with prehypertension
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- Variations in assay protocol for the Dako cystatin C method may change patient results by 50% without changing the results for controls
- Approved IFCC recommendation on reporting results for blood glucose: International Federation of Clinical Chemistry and Laboratory Medicine Scientific Division, Working Group on Selective Electrodes and Point-of-Care Testing (IFCC-SD-WG-SEPOCT)
- National survey on the pre-analytical variability in a representative cohort of Italian laboratories
- 10% CV concentration for the fourth generation Roche cardiac troponin T assay derived from Internal Quality Control data
- Biological variation of non-SI traceable biological quantities: example of proteins
- Effect of tibolone therapy on lipids and coagulation indices
- Acknowledgement
- Contents Volume 44, 2006
- Author Index
- Subject Index
Artikel in diesem Heft
- Initiation and progression of atherosclerosis – enzymatic or oxidative modification of low-density lipoprotein?
- Blood transfusions in athletes. Old dogmas, new tricks
- Molecular detection of tyrosinase transcripts in peripheral blood from patients with malignant melanoma: correlation of PCR sensitivity threshold with clinical and pathologic disease characteristics
- Increase in and clearance of cell-free plasma DNA in hemodialysis quantified by real-time PCR
- Lipoprotein lipase gene polymorphism at the PvuII locus and serum lipid levels in Guangxi Hei Yi Zhuang and Han populations
- Interpretation of cardiac troponin T behaviour in size-exclusion chromatography
- Point-of-care C-reactive protein testing in febrile children in general practice
- Improvement in HPLC separation of porphyrin isomers and application to biochemical diagnosis of porphyrias
- Measurement of late-night salivary cortisol with an automated immunoassay system
- Combining markers of nephrotoxicity and hepatotoxicity for improved monitoring and detection of chronic alcohol abuse
- Stone or stricture as a cause of extrahepatic cholestasis – do liver function tests predict the diagnosis?
- Insulin resistance and enhanced protein glycation in men with prehypertension
- Prevalence-dependent decision limits for the early detection of type 2 diabetes mellitus in venous blood, venous plasma and capillary blood during glucose challenge
- Analytical performance and clinical utility of the INNOTEST® PHOSPHO-TAU(181P) assay for discrimination between Alzheimer's disease and dementia with Lewy bodies
- Variations in assay protocol for the Dako cystatin C method may change patient results by 50% without changing the results for controls
- Approved IFCC recommendation on reporting results for blood glucose: International Federation of Clinical Chemistry and Laboratory Medicine Scientific Division, Working Group on Selective Electrodes and Point-of-Care Testing (IFCC-SD-WG-SEPOCT)
- National survey on the pre-analytical variability in a representative cohort of Italian laboratories
- 10% CV concentration for the fourth generation Roche cardiac troponin T assay derived from Internal Quality Control data
- Biological variation of non-SI traceable biological quantities: example of proteins
- Effect of tibolone therapy on lipids and coagulation indices
- Acknowledgement
- Contents Volume 44, 2006
- Author Index
- Subject Index
