Sometimes, extremely high transaminase elevations can occur with choledocholithiasis. Saroja Bangaru et al. reported on a case series of patients who all had transaminase values greater than 1,000 with symptomatic choledocholithiasis.4 All of the patients had normal or just mildly elevated alkaline phosphatase levels.
Rahul Nathwani, MD, and colleagues also reported on a series of 16 patients with choledocholithiasis and transaminase levels greater than 1,000.5 All patients were symptomatic, and the average alkaline phosphatase levels were 2.5 times the upper limit of normal.
Ala Sharara, MD, et al. looked at 40 patients in a retrospective study of patients found to have choledocholithiasis who presented within 12 hours of pain onset.6 Levels of AST and ALT both significantly correlated with duration of pain (P less than .001), whereas there was no significant correlation with alkaline phosphatase and bilirubin levels.
Dr. Douglas S. Paauw
Pearl: AST and ALT elevations in patients with acute abdominal pain could be due to choledocholithiasis, even if there are minimal or no abnormalities in alkaline phosphatase. Marked elevations (greater than 1,000) can occur.
Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at dpaauw@uw.edu.
References
1. Am J Emerg Med. 1985 Nov;3(6):556-60.
2. Surg Endosc. 2008 Jul;22(7):1620-4.
3. World J Surg. 2016 Aug;40(8):1925-31.
4. J Clin Gastroenterol. 2017 Sep;51(8):728-33.