How should I manage a 64‑year‑old hypertensive man post‑cholecystectomy who develops epigastric pain with mildly elevated aspartate aminotransferase, alanine aminotransferase, and gamma‑glutamyl transferase, while bilirubin, amylase, lipase, C‑reactive protein, D‑dimer, and troponin are normal?

Management of Post-Cholecystectomy Epigastric Pain with Elevated Transaminases and GGT

Obtain urgent abdominal triphasic CT followed by contrast-enhanced MRCP to rule out bile duct injury, because this patient's elevated transaminases and GGT with normal bilirubin is the classic laboratory pattern of early bile leak, and delayed diagnosis can progress to secondary biliary cirrhosis and liver failure. 1, 2

Immediate Diagnostic Workup

Laboratory Assessment

• Complete the cholestatic panel immediately by adding alkaline phosphatase (ALP) and albumin to the existing AST, ALT, and GGT values, as this distinguishes hepatocellular from cholestatic injury patterns 1, 3
• Obtain a complete blood count to detect leukocytosis, which indicates peritoneal irritation from bile leak or early cholangitis 1
• The normal bilirubin is falsely reassuring and does not exclude bile duct injury—when bile leaks into the peritoneum, it decompresses the biliary tree and prevents the back-pressure needed to elevate bilirubin 1, 2
• The elevated AST (130), ALT (91), and GGT (200) with normal bilirubin is the pathognomonic laboratory signature of bile leak rather than obstruction 1, 2

First-Line Imaging

• Proceed directly to abdominal triphasic CT as the initial imaging study to detect intra-abdominal fluid collections, bilomas, and ductal dilation 1
• CT alone cannot differentiate bile from blood, pus, or serous fluid based on density, so any fluid collection requires further characterization 2, 4
• If CT shows fluid collections or if clinical suspicion remains high despite negative CT, immediately obtain contrast-enhanced MRCP for exact visualization and classification of bile duct injury 1, 3

Alternative Imaging When MRCP Unavailable

• Hepatobiliary scintigraphy (HIDA scan) is the most sensitive test for detecting active bile leakage and should be performed urgently if MRCP is not immediately available 2, 3
• HIDA scan identifies the active leak, maps bile flow routes, and shows the relationship to any fluid collections 2

Clinical Context and Risk Stratification

Alarm Symptoms Requiring Urgent Investigation

• Persistent epigastric pain after cholecystectomy is an alarm symptom that mandates prompt investigation for bile duct injury 1
• The two most frequent clinical scenarios are bile leakage (causing pain, distension, and biloma without jaundice) and bile duct obstruction (causing delayed jaundice and cholangitis) 1
• Epigastric pain radiating to the back is characteristic of biliary pathology including choledocholithiasis and bile duct injury 5

Why Normal Bilirubin Does Not Exclude Injury

• Bile leaking into the peritoneal cavity is absorbed and does not cause cholestasis, keeping bilirubin normal or only mildly elevated 1, 2
• Early bile leakage does not cause significant hepatocellular injury, so transaminases reflect surgical manipulation and pneumoperitoneum rather than true liver damage 1, 2
• Mild transaminase elevation (AST 130, ALT 91) is frequently observed after laparoscopic cholecystectomy due to CO2 pneumoperitoneum and has no pathological meaning in uncomplicated cases 1

Management Based on Imaging Findings

If Bile Duct Injury Confirmed

Minor Bile Leak (≤5 mm, extra-hepatic, no abscess)

• Perform ERCP with sphincterotomy and internal stent placement to achieve biliary decompression 2
• If biloma or fluid collection is present and accessible, perform percutaneous drainage under CT or ultrasound guidance 1, 2

Major Bile Duct Injury

• Urgent surgical consultation for Roux-en-Y hepaticojejunostomy is required because ERCP alone has low success rates in extensive injuries 2
• Complete healing of any fistula is an absolute prerequisite before delayed surgical repair 1

If Retained Choledocholithiasis Found

• Proceed directly to ERCP with sphincterotomy and stone extraction 3, 4
• Retained stones in the cystic duct remnant or common bile duct are a common cause of early post-cholecystectomy syndrome 4, 6

If No Leak Identified on Initial Imaging

• Consider alternative postoperative fluid collections such as seroma, hematoma, or lymphatic leakage 2
• Repeat imaging in 48–72 hours if symptoms persist, as progressive fluid accumulation is a red-flag indicator for bile leak 2

Critical Pitfalls to Avoid

• Do not be falsely reassured by normal bilirubin and lipase/amylase—these are typical in early bile leaks because bile drains into the peritoneum rather than causing back-pressure 1, 2
• Do not rely on CT alone to exclude bile duct injury—its sensitivity for small leaks is poor and it cannot distinguish bile from other postoperative fluids 2
• Do not postpone definitive imaging (MRCP or HIDA) while awaiting worsening symptoms, as unrecognized bile duct injury can progress within weeks to months to secondary biliary cirrhosis, portal hypertension, and liver failure 1
• Do not assume mild transaminase elevation is benign in the presence of persistent epigastric pain—this combination warrants urgent investigation 1

Monitoring and Follow-Up

• If bile duct injury is excluded and symptoms resolve, no specific follow-up imaging is required 2
• If bile leak is treated successfully, cholestatic markers (ALP, GGT) gradually improve over several weeks even when intervention is effective 7
• Persistent elevation of liver tests beyond the expected recovery window should prompt re-evaluation for anastomotic stenosis, recurrent leak, or other complications 7