What is the concern regarding the patient's elevated bilirubin level from 16.6 to 19.1, with a history of previous Magnetic Resonance Cholangiopancreatography (MRCP) with strict Nil Per Os (NPO) and current lactose administration at 0600?

From the Guidelines

I strongly recommend keeping the patient NPO for the MRCP procedure, with no lactose at 0600, to ensure optimal imaging quality and prevent potential complications. The rising bilirubin level from 16.6 to 19.1 indicates worsening liver function or biliary obstruction, which makes the MRCP results even more important for diagnosis 1. According to the EASL clinical practice guidelines on sclerosing cholangitis, MRCP is the preferred diagnostic test for large duct PSC, and it requires high-quality imaging to accurately diagnose and assess the extent of the disease 1.

The guidelines emphasize the importance of excluding secondary causes of sclerosing cholangitis and considering a diagnosis of small duct PSC in patients with elevated serum markers of cholestasis of unknown cause, normal high-quality cholangiography, and compatible histology of PSC 1. In this case, the patient's rising bilirubin level and previous MRCP results suggest the need for a thorough evaluation, and any oral intake, including lactose, could compromise image quality by stimulating secretions or causing gastrointestinal movement.

Key considerations for the MRCP procedure include:

• Strict NPO status (typically 4-6 hours before the procedure) to prevent aspiration risks and ensure optimal imaging quality of the biliary and pancreatic ducts
• Avoiding any oral intake, including lactose, to prevent compromising image quality
• Closely monitoring the elevated bilirubin level after the procedure, as persistent increases may require additional interventions depending on the MRCP findings
• Considering the patient's previous MRCP was performed under strict NPO conditions, maintaining the same protocol would ensure consistency in imaging results for comparison 1.

From the Research

Patient Information

• The patient's bilirubin level has increased from 16.6 to 19.1.
• The patient is NPO (nothing by mouth) for an MRCP (magnetic resonance cholangiopancreatography) procedure, but has been given lactose at 0600.
• The patient has undergone an MRCP procedure before, during which they were on strict NPO.

Relevant Studies

• A study published in 2019 2 found that in patients with acute cholecystitis and a normal common bile duct diameter, normal or mildly elevated bilirubin levels may obviate the need for preoperative MRCP.
• A review published in 2017 3 discussed the diagnostic evaluation of hyperbilirubinemia, including the use of imaging assessments such as MRCP.
• A study published in 2025 4 outlined the evaluation of jaundice in adults, including the use of laboratory tests and imaging studies such as MRCP.
• A study published in 1994 5 found that ursodiol therapy can improve outcomes in patients with primary biliary cirrhosis, including reducing the risk of hyperbilirubinemia.
• A systematic review and meta-analysis published in 2025 6 compared the effectiveness of obeticholic acid and fibrates as second-line therapy for primary biliary cholangitis, including their effects on bilirubin levels.

Bilirubin Levels and MRCP

• The patient's increasing bilirubin level may be a concern, as high bilirubin levels can indicate underlying liver or biliary disease 3, 4.
• The use of MRCP to evaluate the patient's biliary system may be helpful in determining the cause of the elevated bilirubin level 2, 4.
• The patient's NPO status for the MRCP procedure is standard practice, but the administration of lactose at 0600 may affect the procedure or the patient's bilirubin level 2.