What is the best course of action for a patient with elevated bilirubin, amylase, and lipase levels, a small hiatal hernia, and questionable distal esophageal wall prominence, who has a history of stable gastrohepatic and porta hepatic lymph nodes, and no radiopaque calculi or biliary ductal dilatation?

What This Means for You

Your CT scan shows no clear cause for your elevated blood tests in the pancreas or gallbladder, but there are some findings that need follow-up with a specialist.

Understanding Your Blood Test Results

Your blood work shows three elevated markers:

• Bilirubin (the substance that causes jaundice/yellowing) is elevated, which typically indicates either a blockage in your bile ducts or a problem with your liver processing bile 1, 2
• Amylase and lipase (enzymes from the pancreas) are elevated, which usually suggests pancreatic inflammation, though mild elevations (less than 3 times normal) often don't indicate serious pancreatic disease 3, 4

What the CT Scan Found

Good news:

• Your pancreas looks normal on the CT scan—no signs of inflammation or other problems that would explain your symptoms 1
• Your gallbladder is contracted (squeezed down) but shows no gallstones visible on CT and no blockage in the bile ducts 1, 5

Findings that need attention:

• Small hiatal hernia with possible swelling around the lower esophagus (where your esophagus meets your stomach) 1, 6
• Lymph nodes near your liver and stomach that are slightly enlarged, though they haven't changed from your previous CT scan 5

Why Your Doctors Recommend Additional Testing

The combination of elevated bilirubin with normal CT findings means you need an MRI/MRCP (a special MRI that looks at your bile ducts and pancreas in detail) because 5, 2:

• CT scans can miss small gallstones in the bile ducts—up to 80% of gallstones don't show up on regular CT 5
• MRCP detects bile duct stones with 85-100% accuracy, much better than CT 5
• MRCP can identify subtle blockages or narrowing in the bile ducts that CT cannot see 5

The hiatal hernia finding is important because in rare cases, a large hiatal hernia can cause both pancreatic inflammation and bile duct problems by kinking or compressing these structures 6. While your hernia is described as "small," the questionable esophageal swelling warrants evaluation by a gastroenterologist 1.

What Happens Next

Your doctors should order:

1. MRI with MRCP (without IV contrast is sufficient for looking at bile ducts) to comprehensively evaluate why your bilirubin is elevated despite normal-appearing bile ducts on CT 5, 2

2. Gastroenterology consultation to evaluate:

   • The hiatal hernia and esophageal findings 1
   • The stable but enlarged lymph nodes 5
   • Whether you need an upper endoscopy to directly visualize your esophagus and stomach 1
   • Whether the mild enzyme elevations warrant further investigation or can be monitored 3, 4

Important Context About Your Enzyme Elevations

Research shows that mild elevations of amylase and lipase (less than 3 times normal) with nonspecific abdominal symptoms rarely indicate serious pancreatic disease 3. In one study, 79% of patients with similar findings had completely normal pancreases after extensive testing 3. However, your elevated bilirubin suggests this isn't just isolated enzyme elevation—there may be a bile duct issue that needs identification 5, 2.

What This Means Practically

• You likely don't have acute pancreatitis since your CT scan is normal 1, 4
• You may have a small bile duct stone or narrowing that CT couldn't detect but MRCP will find 5
• The hiatal hernia may or may not be contributing to your symptoms and needs specialist evaluation 6
• The lymph nodes are probably not concerning since they're stable from your prior scan, but the gastroenterologist will assess them 5

Bottom line: Get the MRI/MRCP and see the gastroenterologist as recommended. These tests will determine whether you have a treatable bile duct problem causing your elevated bilirubin and guide management of your hiatal hernia and esophageal findings.