Introduction A 45-year-old man presented with a 2-day history of jaundice and severe epigastric pain radiating through to his back. He also complained of nausea and vomiting. He noted his urine to be dark and his stools pale but denied having pruritis. He drank 30 units of alcohol a week and had returned from mainland Spain 5 days prior to his illness. There was no previous history of jaundice or additional risk factors for chronic liver disease. He was on no regular medications. His only significant past medical history was a laparoscopic cholecystectomy performed 8 months previously due to an attack of cholecystitis.
Methods Initial blood tests demonstrated a mildly raised bilirubin and amylase but a marked transaminitis (ALT 2073 iu/l, normal range 0–35 iu/l). Twenty-four hours after admission he deterioratd with sepsis, renal failure, thrombocytopaenia and a microangiopathic anaemia. Imaging demonstrated common bile duct stones causing biliary obstruction and pancreatic inflammation. He was treated for his microangiopathic anaemia and as part the management of pancreatitis underwent an early therapeutic ERCP to provide biliary drainage.
Results The prevalence of common bile duct stones (CBDS) in patients with symptomatic gallstones is quoted to lie between 10 and 20%.1 In patients who are not jaundiced and have a normal trans-abdominal ultrasound the prevalence is said to be <5%.2 The natural history of CBDS is not well understood but if they do become symptomatic the consequences are often serious. He was assessed as low risk for CBDS and as suggested by current BSG guidelines did not have any additional biliary imaging.3
This patient had an atypical presentation of a relatively common condition and subsequently developed a very rare complication. He required a prolonged critical care admission to support the management of multi-organ failure, which involved the expertise of a closely coordinated multidisciplinary team.
Conclusion The traditional teaching that an ALT >1000 iu/is due to drugs, viral hepatitis or ischaemia is a good rule of thumb. However, it is not a “golden rule” and when the clinical picture does not fit, the differential diagnosis needs to be widened. This case highlights the difficulties, complexity and spectrum of clinical conditions which present with abnormal liver function tests.
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