Re: ERCP complications - question about liver numbers?

[Guest guest]

Hi,

I find the discussion on ERCP complications very interesting. I

posted earlier about 'first ERCP' because I have a 10-year old son

diagnosed with PSC for whom a leading gastroenterologist/hepatologist

in Finland recommended the ERCP procedure and colonoscopy after

reviewing his medical records over the past four years. That was last

August. Since then, our son's liver enzymes were rising (ALT till 106

and ALP 490) after which the treating pediatric gastroenterologists

prescribed metronidazole for four weeks (which caused stomach pains

especially in the evenings). The treatment got ALT back in normal

range (here below 40 is normal) but ALP only to 420 which is about

100 higher than the normal limit for his age group (in our scale).

OK, now it is 1.5 months since the metronidazole treatment ended and

ALT is back to 87 and ALP 505. GGT has been within the normal range

all this time. The hemoglobine is at the normal range just barely.

IBD has not been diagnosed but our son has had some symptoms for a

couple of years (rectal bleeding but not all the time). He has lost 8

kilograms since August without any diet -that is not a problem

because he has been overweight but I would like to know why? Also, he

is not growing like he used to, he has grown 9 cm in the last two

years altogether. Earlier he used to grow that much in one year. He

is mostly feeling well, just abnormally tired at times.

So what I wanted to ask is how much higher than the normal limit are

your liver enzymes when you (any of you) say they are elevated? And

is it possible to say an 'ok' level of elevation for PSC patients?

Should we be happy with our son 'just' having lab work every four

weeks as long as he is generally ok never mind the liver enzyme

numbers? I have a feeling this is not a normal situation (even for

PSC) and I hope I am wrong. In the last MRCP in late Oct this year

there seemed to be 'some' disease activity in the left lobe and

segments 7-8 of the right one. The bile ducts are dilatated, ball

bladder is way too large but there are no visible bile duct

strictures. However the hep last August said there are likely to be

strictures even if they do not show in the MRCP. Our son's other

internal organs are intact, there are no signs of the disease for

example in the pancreas. His IgG is normal although subtype IgG4 is

elevated (6) - and yes, I did read the study about this possibly

being an indication of the kind of PSC that reacts well to cortisone

treatment - our son's pediatric gastroenterologist does not seem to

be aware of this. Our son is on azathioprine 100 mg daily, urso 1200

mg daily and calcium+vitamin D.

I hope I worry about the liver numbers without any real cause - any

comments anyone?

Taru-Mari, mom of Eemeli (10) PSC July 2003

- In , wrote:

> My last ERCP was in 2001. My hep will not order one unless there

are indications (elevated LFTs, cholangitis episodes, etc.) -

[Guest guest]

Hi Taru-Mari;

Can I recommend reading this article?

Diagnosis and Monitoring of Hepatic Injury. I. Performance

Characteristics of Laboratory Tests

D. Dufour, A. Lott, Frederick S. Nolte, R. Gretch,

S. Koff and Leonard B. Seeff

Clinical Chemistry 46: 2027-2049 (2000)

http://www.clinchem.org/cgi/content/full/46/12/2027

I'd like you to focus on Fig. 3, which shows that in young children

(especially boys), alkaline phosphatase can normally be markedly

elevated during periods of rapid bone growth. I would say that if GGT

is " normal " then it's more likely that in your 10-year-old, his

elevated ALP may due to normal bone growth?

I've read elsewhere, that because of this, GGT is a prefered measure

of bile-duct blockage/cholestasis in children.

Looking at the graph in Fig. 3, ALP can peak at 5 x upper limit of

normal in young boys of 10 years of age! But please talk this over

with your son's doctor if you are still concerned.

Sorry it took me so long to reply to your message ... it took me a

while to track down this article.

Best regards,

Dave R.

[Guest guest]

Hi Dave,

Thank you very much for the link - I will gladly read more info on

the lab tests.

The ALP lab test reference numbers that I have been looking at are:

boys, 10 - 11 yrs 115 - 335 U/l

boys, 12 - 13 yrs 125 - 405 U/l

boys, 14 - 15 yrs 80 - 445 U/l

boys, 16 - 18 yrs 55 - 330 U/l

adults, yli 18 v 35 - 105 U/l

(our son is going to be 11 in February).

Our son's ALP is 505 which is about 5x the adult upper limit and

somewhat over the age-adjusted limit, too.

The ALT lab test upper limit here his 40 for kids 1-16 years of age,

and for males over 18 it is 70. Our son's is 87.

It is good the GGT is normal, I agree. And it is true the ALP and ALT

fluctuations may not mean anything. Thank you once again for the

comments, the article and the reassurance!

Taru-Mari