Can Gallbladder Problems cause Elevated Liver Enzymes?
The pattern of cholestasis is characterized by an increase in phosphatase alkaline and gamma-glutamyl transpeptidase with or without an associated increase in bilirubin. The cause of the cholestasis pattern is the impediment to the arrival of bile from liver cells to the intestine, either by inability to form it or by obstruction to its flow.
The term cholestasis refers to disease determined by the presence of an obstacle, mechanical or functional, that prevents the arrival of bile to the duodenum.
Cholestasis is basically classified into 2 groups, intrahepatic and extrahepatic, depending on whether the obstacle is inside or outside the hepatic parenchyma, respectively. The most frequent causes in the case of intrahepatic are viral hepatitis, liver diseases caused by alcohol, primary biliary cirrhosis, and toxicity by drugs or other toxic and hormonal changes during pregnancy (cholestasis of pregnancy).
Among the causes of extrahepatic cholestasis are listed as the most common lithiasis in the bile duct, stenosis of the bile duct, either benign or malignant tumor, pancreatic cancer, and pancreatitis.
The consumption of alcohol, the presence of stigmas of liver disease and the time of establishment of cholestasis can guide on its etiology.
In general, the physical examination is of little help in the differential diagnosis. The finding of xanthomas or xanthelasmas (they are yellow plaques that occur most commonly near the inner canthus of the eyelid) may suggest chronic cholestasis. Likewise, the presence of signs that lead to an autoimmune process must be investigated. The presence of fever and chills force the carrying out diagnostic procedures with greater speed before the possible need for therapeutic measures.
Given the clinical suspicion of cholestasis, the first action is the biochemical confirmation of the process. General tests often help determine the origin of cholestasis.
The casual detection of elevation of cholestasis enzymes, such as alkaline phosphatase, gammaglutamyltranspeptidase and 5-nucleotidase, is sometimes the reason for starting the study in asymptomatic patients.
Alkaline Phosphatase: It has several origins (kidney, placenta, intestine, leukocytes, liver and bones) although the most important sources are the liver, bones and intestine. Thus, elevations may occur in the third trimester of pregnancy or during growth.
Gamma-glutamyltransferase: It is found in the kidney, pancreas, liver, spleen and lung. In addition, it increases in the majority of liver diseases, so it is not very specific. The most important increases appear in the presence of cholestasis, neoplastic infiltration or when enzymatic induction occurs by drugs or toxic agents such as alcohol.
The 5-Nucleotidase: It is an enzyme whose origin is mainly hepatic, so it is specific for cholestasis, but its routine determination in laboratories is not widespread.
Ultrasonography – In the study of a patient with cholestasis, abdominal ultrasound is the initial method to assess dilation of the bile duct. Although it is a simple and affordable method to distinguish between intrahepatic and extrahepatic cholestasis, it has certain limitations. The objective of the ultrasound is to show if there is dilation of the bile duct and, if possible, determine its cause.
Computed Tomography – Computed tomography is a radiological technique that allows a good hepatic and biliary study that has similar results to ultrasound in detecting the dilated biliary tract, but far exceeds it in its etiological diagnosis (94% versus 71%, respectively).
Computed tomography-cholangiography – It may be an alternative to endoscopic retrograde cholangiopancreatography (ERCP). The limitations of tomography-cholangiography are allergy to iodinated contrasts, the use of ionizing radiation, advanced liver disease and bilirubin values greater than 29.
Magnetic Resonance – Magnetic resonance cholangiopancreatography is an alternative technique to diagnostic ERCP, given its non-invasive nature and free of complications, although it does not allow for therapeutic procedures.
Endoscopic Retrograde Cholangiopancreatography – ERCP allows an etiological study and the performance of therapeutic procedures in patients with obstructive extrahepatic cholestasis, both in cases of choledocholithiasis through the practice of a sphincterotomy and extraction of the stones as well as in cases of benign stenoses or malignant tumors, by placing biliary prostheses.
It has a 95% sensitivity and specificity in the diagnosis of obstruction.
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