From the Guidelines
An elevated alkaline phosphatase (ALP) of 700 in a patient with acute pancreatitis and previous cholecystectomy suggests biliary obstruction, likely due to choledocholithiasis (common bile duct stones) or less commonly, stricture or malignancy, and urgent ERCP (Endoscopic Retrograde Cholangiopancreatography) is recommended for diagnosis and therapeutic intervention. This procedure allows for direct visualization of the biliary tree, removal of any stones, and placement of stents if needed, as suggested by the American College of Radiology guidelines 1. While awaiting ERCP, supportive care should include IV hydration, pain management with opioid analgesics as needed, and NPO (nothing by mouth) status.
Some key points to consider in the management of this patient include:
- The high ALP level indicates cholestasis, and despite prior gallbladder removal, stones can still form in the bile ducts 1.
- Patients with prior cholecystectomy can develop recurrent biliary issues as stones may form in the common bile duct even after gallbladder removal 1.
- MRCP (Magnetic Resonance Cholangiopancreatography) is an alternative diagnostic option if ERCP is not immediately available, and can help identify the cause of biliary obstruction 1.
- Prompt intervention is necessary to prevent complications such as cholangitis or worsening pancreatitis, as recommended by the World Journal of Emergency Surgery guidelines 1.
In terms of specific management, the following steps can be taken:
- Urgent ERCP should be performed to diagnose and treat any biliary obstruction, as recommended by the Gut guidelines 1.
- Cholecystectomy may be considered during the initial admission to prevent recurrent episodes of acute pancreatitis, as recommended by the American Gastroenterological Association institute guideline 1.
- Supportive care, including IV hydration and pain management, should be provided to the patient while awaiting ERCP or other interventions.
Overall, the goal of management is to promptly diagnose and treat any biliary obstruction, prevent complications, and improve the patient's quality of life, as suggested by the most recent and highest quality studies 1.
From the Research
Alkaline Phosphatase Levels in Acute Pancreatitis
- An alkaline phosphatase (alk phos) level of 700 in the setting of acute pancreatitis and prior history of cholecystectomy is a significant finding that requires careful consideration of the underlying causes and potential complications.
- According to a study published in 2013 2, alkaline phosphatase levels can be elevated in patients with choledocholithiasis, but the sensitivity and specificity of this test are limited.
- The study found that the mean alkaline phosphatase level was 276 ± 25 IU/L in patients with choledocholithiasis, but there was no significant difference in alkaline phosphatase levels between patients with and without choledocholithiasis (p = 0.1154).
Diagnostic Approach
- The diagnosis of acute pancreatitis is typically based on characteristic symptoms, elevated serum pancreatic enzymes, and imaging studies 3, 4, 5.
- In patients with a prior history of cholecystectomy, it is essential to consider other potential causes of acute pancreatitis, such as bile duct stones or pancreatic duct disruption.
- Imaging studies, such as magnetic resonance cholangiopancreatography (MRCP) or endoscopic retrograde cholangiopancreatography (ERCP), may be necessary to evaluate the bile ducts and pancreatic duct for potential obstruction or damage 2, 6.
Management
- The management of acute pancreatitis involves supportive care with fluid replacement, pain control, and controlled initiation of regular food intake 3, 4, 5.
- In patients with severe acute pancreatitis, prophylactic antibiotics may be indicated to prevent pancreatic infection 4, 5.
- Early cholecystectomy and ERCP with sphincterotomy may be beneficial in patients with gallstone-associated pancreatitis to decrease the length of hospital stay and complication rates 4, 6.