From the Guidelines
Gallbladder disease can indeed be present without elevation of liver enzymes, such as alanine transaminase (ALT) and aspartate transaminase (AST), as evidenced by the 2020 World Society of Emergency Surgery guidelines 1. The presence of normal liver function tests (LFTs) does not rule out gallbladder disease, as the gallbladder itself is not responsible for producing liver enzymes. Key points to consider include:
- Normal LFTs have a high negative predictive value (NPV) of 97%, but the positive predictive value (PPV) of abnormal LFTs is only 15% 1.
- The elevation of LFTs is a poor tool for predicting gallbladder disease, with literature ranging from 25 to 50% 1.
- In patients with acute calculus cholecystitis (ACC), LFTs may be altered due to the acute inflammatory process rather than direct biliary obstruction, with 15-50% of patients showing elevation in LFTs without common bile duct stones (CBDS) 1.
- Diagnosis of gallbladder disease often relies on imaging studies like ultrasound, HIDA scans, or CT scans rather than blood tests alone.
- Patients may experience typical symptoms like right upper quadrant pain, especially after fatty meals, nausea, or vomiting, despite having normal laboratory values.
- The 2020 guidelines recommend against using elevated LFTs or bilirubin as the only method to identify CBDS in patients with ACC, and instead suggest performing further diagnostic tests 1.
From the Research
Gallbladder Disease and Liver Enzymes
- Gallbladder disease can be present without elevation of liver enzymes, such as alanine transaminase (ALT) and aspartate transaminase (AST) 2.
- A study found that choledocholithiasis, a condition where gallstones are present in the common bile duct, can occur in patients with normal serum liver enzymes 2.
- The study suggested that marked dilatation of the common bile duct or gallbladder may serve as a pressure sump and blunt liver enzyme elevation 2.
- Another study found that nearly 80% of gallstones are found incidentally and remain asymptomatic, and that ultrasonography is the initial imaging choice for detecting gallstones and acute cholecystitis 3.
- A low ejection fraction (EF) on cholescintigraphy does not predict clinical outcome or histologic features of chronic cholecystitis without gallstones 4.
Asymptomatic Gallstones
- Asymptomatic gallstones are common, and only about 30% of patients with asymptomatic cholelithiasis will warrant surgery during their lifetime 5.
- Certain factors, such as large gallstones, congenital hemolytic anemia, or nonfunctioning gallbladders, may predict a more serious course in patients with asymptomatic gallstones and warrant a prophylactic cholecystectomy 5.
Diagnosis and Treatment
- Ultrasonography is the diagnostic test of choice for detecting gallstones and acute cholecystitis, with a sensitivity of 90-95% 5.
- Laparoscopic cholecystectomy is the treatment of choice for most patients with biliary colic or acute cholecystitis 3, 5.
- Endoscopic sphincterotomy and stone extraction may be used to manage choledocholithiasis, followed by cholecystectomy if the gallbladder is in situ 2.