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Clinical Review Interactive case report

Abnormal liver function found after an unplanned consultation: case outcome

BMJ 2004; 329 doi: (Published 26 August 2004) Cite this as: BMJ 2004;329:500
  1. James Heathcote, general practitioner (james.heathcote{at}
  1. 1 South View Lodge, South View, Bromley, Kent BR1 3DR

    Four weeks ago (31 July, p 273) we presented the case of Mrs Prior, a 40 year old woman with cystitis, itching, and rash. When her biochemical results showed raised liver enzyme concentrations, her general practitioner was advised to refer her for ultrasonography and an autoantibody test (7 August, p 342). The scan suggested the possibility of hepatic infiltration but the autoantibody screen gave negative results.

    Her general practitioner faxed an urgent letter (not a cancer referral) to the consultant, detailing the case history. Nine days later, Mrs Prior was seen in the hospital outpatient department. By then, the jaundice was already fading and her liver enzyme concentrations had improved (alkaline phosphatase 588 U/l, γ-gluatamyl transferase 686 U/l, and aspartate aminotransferase 74 U/l), although her total bilirubin concentration had risen (193 µmol/l).

    The specialist registrar made a presumptive diagnosis of symptomatic gall stone disease and requested urgent computed tomography of the abdomen and endoscopic retrograde cholangiopancreatography. The computed tomography showed a dilated biliary tree with stones in the gall bladder and multiple large stones packed into the lower common bile duct (figure). There was no evidence of neoplasm.

    Embedded Image

    Computed tomogram showing stones in the gall bladder

    At endoscopic retrograde cholangiopancreatography, a 12mm sphincterotomy was performed with a bow string papillotome. Biliary stones were partially extracted with a balloon catheter and a pigtail biliary stent was inserted.

    A large stone remained stuck in the lower end of the common bile duct, which did not move despite a second endoscopic retrograde cholangiopancreatography. Mrs Prior therefore later had an open cholecystectomy with exploration of the common bile duct, from which she has recovered well. One year after presentation, Mrs Prior remains well and itch free, with normal thyroid and liver function test results and full blood count.


    • This is the final part of a three part case report, which describes the outcome and summarises the comments made by readers during the case presentation

    • Competing interests None declared.

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