Is bilirubin elevated in gallstone (gallbladder stone) pancreatitis?

From the Guidelines

Bilirubin is often elevated in gallstone pancreatitis, as indicated by a total serum bilirubin level > 1.8 mg/dl being considered a strong risk factor for common bile duct stones (CBDS) 1. This elevation occurs when gallstones migrate from the gallbladder and obstruct the common bile duct, which is the shared pathway for bile from the liver and digestive enzymes from the pancreas. When this duct becomes blocked, bile cannot flow properly into the intestine, causing bilirubin to back up and accumulate in the bloodstream. Some key points to consider in the diagnosis and treatment of acute calculus cholecystitis include:

• The presence of CBDS stone at the abdominal ultrasound or ascending cholangitis is considered a very strong risk factor 1
• A common bile duct diameter > 6 mm (with gallbladder in situ) or a total serum bilirubin level > 1.8 mg/dl is considered a strong risk factor 1
• Clinical gallstone pancreatitis is considered a moderate risk factor 1 The degree of bilirubin elevation varies depending on the location and completeness of the obstruction. Typically, total bilirubin levels may range from mildly elevated (2-3 mg/dL) to significantly increased (>10 mg/dL) in severe cases. Direct (conjugated) bilirubin is usually more prominently elevated than indirect bilirubin. Other liver enzymes like alkaline phosphatase (ALP) and gamma-glutamyl transferase (GGT) are also commonly elevated, along with pancreatic enzymes such as amylase and lipase. The presence of elevated bilirubin in a patient with acute pancreatitis strongly suggests a biliary etiology and may indicate the need for early endoscopic intervention to relieve the obstruction.

From the Research

Bilirubin Levels in Gallstone Pancreatitis

• Bilirubin levels are often elevated in patients with gallstone pancreatitis, particularly in those with persistent common bile duct (CBD) stones 2, 3, 4.
• Studies have shown that serum total bilirubin on hospital Day 2 is a useful predictor of persisting CBD stones in gallstone pancreatitis 2, 3.
• A serum total bilirubin level of 4 mg/dL or greater on hospital Day 2 has been found to predict persisting CBD stones with high specificity 2.
• Elevated liver function values, including bilirubin, have been found to be significant predictors of CBD stones in patients undergoing cholecystectomy 4.
• However, false positive and false negative values can occur, especially in patients with a history of cholecystitis or pancreatitis 4.

Predictors of Common Bile Duct Stones

• Clinical predictors of CBD stones in gallstone pancreatitis include serum total bilirubin, ALT, and alkaline phosphatase levels 3.
• A multivariate analysis found that serum total bilirubin on hospital Day 2 was the best predictor of CBD stones 3.
• Other predictors of CBD stones include clinical ascending cholangitis, CBD stones on ultrasonography, dilated CBD on US, abnormal liver function test, and age > 55 years 5.
• Gallstone pancreatitis has been found to be a significant predictor of CBD stones, although the association was not statistically significant in one study 5.

Clinical Implications

• The guidelines for endoscopic retrograde cholangiopancreatography (ERCP) in suspected choledocholithiasis should be considered to optimize patient selection for ERCP 5.
• A discriminant analysis procedure using age, bilirubin, ALAT, and gamma GT values has been found to be effective in predicting CBD stones and reducing the frequency of preoperative ERCP 6.