ALT / AST and SOD to

[Guest guest]

Hi ,

first of all I want to say that you sound exactly like me about a

year ago. I was having biliary colic attacks every couple of

months (which immediately before my ERCP / manometry

increased to every couple of weeks). Had an MRCP - CCK done

first to rule out CBD blockage then went to the ERCP -

manometry.

Fortunately I was in a position where I could monitor my liver

enzymes on my own and I can tell you that when blood was

drawn within 24 hours of an attack my AST / ALT and GGT were

all moderately to highly elevated (near 1,000 units for all).

However, if I waited over a week they were all normal (which is

why those that wait to have blood work done do not see these

elevations). When I was able to show these values to my doctor

(after about a year of having these attacks and collecting data) he

finally took my complaints seriously BUT, before I informed my GI

I asked my surgeon to look at them and give me his opinion.

Which was, " these are no big deal, don't worry about them " . So

from that experience and what you told me about your surgeon

makes me think that to a surgeon's point of view, if the Alkaline

phosphatase and bilirubin are all normal, it is not a surgical

problem (like gallbladder disease or stone in the CBD) so they

ignore the values. Also, if you just had a high GGT and slightly

high ALT or AST then this is a common abnormality and usually

isn't thought much of (not to excuse your surgeon though). The

problem with SOD and liver enzymes is that the rise to abnormal

values and the return to normals are relatively quick - days in

fact. Surgeons may not be that familiar with this concept as liver

enzyme abnormalities with surgical causes do not do this. They

go up quickly but they stay elevated and the person is always in

pain and may have jaundice too. So they see these lab values in

a totally different context as the GI. If you are able to get around

(although complaining of pain) they do not see this as

something urgent or surgical.

Basically what this can mean with a high ALT and AST and GGT

and Alk Phosphatase is that you are having intermittent

blockages of your common bile duct. This most likely occurs at

the level of your sphincter (of Oddi). This blockage can be

functional (as in the nerves / muscles don't send the right

message to the sphincter) or is mechanical (like having stones,

sludge or scarring at the level of the duct). Manometry can detect

high pressures - usually quite reliably if there is an mechanical

reason for the intermittent blockage, because the blockage is

there all the time. But not so reliable when it is a functional

problem (because functional problems come and go and there

is a chance that the day that you have the manometry done that

your sphincter is behaving). Also manometry as a science is

more dependent on the art of performing it than the science of

performing it - that is, it is VERY operator dependent. The more

experienced the endoscopist and the manometrist (who are

usually two different people) the more reliable and diagnostic the

procedure. That can be a reason why the ERCPs and testing

have to be done many times. In addition, once you eliminate the

blockage of the sphincter, sometimes it becomes apparent that

the pancreas ducts are also involved and they need to go in

again to do the pancreas study (unless the amylase and lipase

are elevated before the first ERCP they are usually reluctant to do

manometry on both the bile duct / sphincter and pancreas. The

protocal seems to be do the bile duct first, then if no or slight

improvement do the pancreatic ducts second). So if for some

reason you do not improve after the first sphincterotomy (if that is

what they end up doing) then tell them and suggest that they look

at the pancreas duct too. Because usually, although the docs

refer to this as an " ERCP " which indicates that the pancreas will

be looked at, they usually limit the study to just an ERC - which

means that only the biliary system is looked at. This is what

happened to me on the first ERCP. That is, for some reason,

they opted to NOT put the dye into the pancreas and therefore

they missed the pathology that was the obvious cause of most of

my problems since the summer of 2003 (and is the reason why I

had to go somewhere else to have the ERCP repeated three

weeks later). So, you may want to ask before you go under if they

actually intend to look at the pancreas or if they are going to just

limit it to the biliary system.

But...there is a good chance that the SO sphincterotomy will be

very effective. I have to say that since my first sphincterotomy I

have not had another biliary colic attack and this is almost a year

now since the first ERCP sphincterotomy. However, what did

happen is that after this was taken care of it became apparant

that I had pancreas problems that had nothing to do with the

SOD. And that is why I have had three more ERCPs and stents

and sphincterotomies. My case, while not rare, isn't that

common either, so I wouldn't suggest that this may happen to

you too. I bet that if they find SOD and treat it with a

sphincterotomy, that your chances for complete and dramatic

relief are very high!

Laurie

[Guest guest]

thank you SO MUCH for that info Laurie -- if you don't mind I'm

going to forward this message to my own email just so I'll have the

info and can get it to memory before the ERCP/w M is done. It seems

that this GI doc is heading in the right direction at least though.

I'm having an MRCP done next week at my local hospital and I'm

assuming that he's trying to rule out structural abnormalities

first???

Thank you very much Laurie, I appreciate any info I can get at this

point!

> Hi ,

>

> first of all I want to say that you sound exactly like me about a

> year ago. I was having biliary colic attacks every couple of

> months (which immediately before my ERCP / manometry

> increased to every couple of weeks). Had an MRCP - CCK done

> first to rule out CBD blockage then went to the ERCP -

> manometry.

>

> Fortunately I was in a position where I could monitor my liver

> enzymes on my own and I can tell you that when blood was

> drawn within 24 hours of an attack my AST / ALT and GGT were

> all moderately to highly elevated (near 1,000 units for all).

> However, if I waited over a week they were all normal (which is

> why those that wait to have blood work done do not see these

> elevations). When I was able to show these values to my doctor

> (after about a year of having these attacks and collecting data)

he

> finally took my complaints seriously BUT, before I informed my GI

> I asked my surgeon to look at them and give me his opinion.

> Which was, " these are no big deal, don't worry about them " . So

> from that experience and what you told me about your surgeon

> makes me think that to a surgeon's point of view, if the Alkaline

> phosphatase and bilirubin are all normal, it is not a surgical

> problem (like gallbladder disease or stone in the CBD) so they

> ignore the values. Also, if you just had a high GGT and slightly

> high ALT or AST then this is a common abnormality and usually

> isn't thought much of (not to excuse your surgeon though). The

> problem with SOD and liver enzymes is that the rise to abnormal

> values and the return to normals are relatively quick - days in

> fact. Surgeons may not be that familiar with this concept as

liver

> enzyme abnormalities with surgical causes do not do this. They

> go up quickly but they stay elevated and the person is always in

> pain and may have jaundice too. So they see these lab values in

> a totally different context as the GI. If you are able to get

around

> (although complaining of pain) they do not see this as

> something urgent or surgical.

>

> Basically what this can mean with a high ALT and AST and GGT

> and Alk Phosphatase is that you are having intermittent

> blockages of your common bile duct. This most likely occurs at

> the level of your sphincter (of Oddi). This blockage can be

> functional (as in the nerves / muscles don't send the right

> message to the sphincter) or is mechanical (like having stones,

> sludge or scarring at the level of the duct). Manometry can

detect

> high pressures - usually quite reliably if there is an mechanical

> reason for the intermittent blockage, because the blockage is

> there all the time. But not so reliable when it is a functional

> problem (because functional problems come and go and there

> is a chance that the day that you have the manometry done that

> your sphincter is behaving). Also manometry as a science is

> more dependent on the art of performing it than the science of

> performing it - that is, it is VERY operator dependent. The more

> experienced the endoscopist and the manometrist (who are

> usually two different people) the more reliable and diagnostic the

> procedure. That can be a reason why the ERCPs and testing

> have to be done many times. In addition, once you eliminate the

> blockage of the sphincter, sometimes it becomes apparent that

> the pancreas ducts are also involved and they need to go in

> again to do the pancreas study (unless the amylase and lipase

> are elevated before the first ERCP they are usually reluctant to

do

> manometry on both the bile duct / sphincter and pancreas. The

> protocal seems to be do the bile duct first, then if no or slight

> improvement do the pancreatic ducts second). So if for some

> reason you do not improve after the first sphincterotomy (if that

is

> what they end up doing) then tell them and suggest that they look

> at the pancreas duct too. Because usually, although the docs

> refer to this as an " ERCP " which indicates that the pancreas will

> be looked at, they usually limit the study to just an ERC - which

> means that only the biliary system is looked at. This is what

> happened to me on the first ERCP. That is, for some reason,

> they opted to NOT put the dye into the pancreas and therefore

> they missed the pathology that was the obvious cause of most of

> my problems since the summer of 2003 (and is the reason why I

> had to go somewhere else to have the ERCP repeated three

> weeks later). So, you may want to ask before you go under if they

> actually intend to look at the pancreas or if they are going to

just

> limit it to the biliary system.

>

>

> But...there is a good chance that the SO sphincterotomy will be

> very effective. I have to say that since my first sphincterotomy I

> have not had another biliary colic attack and this is almost a

year

> now since the first ERCP sphincterotomy. However, what did

> happen is that after this was taken care of it became apparant

> that I had pancreas problems that had nothing to do with the

> SOD. And that is why I have had three more ERCPs and stents

> and sphincterotomies. My case, while not rare, isn't that

> common either, so I wouldn't suggest that this may happen to

> you too. I bet that if they find SOD and treat it with a

> sphincterotomy, that your chances for complete and dramatic

> relief are very high!

>

> Laurie