CHOLEDOCHOLITHIASIS IN PATIENTS WITH NORMAL SERUM LIVER-ENZYMES

Retrospective chart review of 330 patients undergoing ERCP over a two- year period yielded five patients with choledocholithiasis whose serum liver enzyme and total bilirubin levels were repeatedly normal. All w ere female, three were elderly, and the gallbladder was in situ in thr ee of the five, one of whom had a large gallbladder remnant. In four p atients, the common bile duct was dilated (>10 mm), whereas none had i ntrahepatic duct dilatation. Four patients had a prominent ampulla, an d stone size varied widely. Each patient was managed with endoscopic s phincterotomy and stone extraction followed by cholecystectomy for the four patients with the gallbladder or its remnant in situ. This small series proves that common duct stones may exist in patients with repe atedly normal serum liver enzyme and total bilirubin levels. We hypoth esize that marked dilatation of the common bile duct or gallbladder ma y serve as a pressure sump and blunt liver enzyme elevation. Normal li ver enzymes should not dissuade one from performing cholangiography in patients with suspected choledocholithiasis.