January 11, 2025

42-year-old woman presents with abdominal pain for the last 2 days

By Med-Challenger · 3 minute read

A 42-year-old woman presents with abdominal pain for the last 2 days. She describes the pain as crampy and intermittent in the epigastric area, and she tells you that it is particularly worse after meals. She has a history of Roux-en-Y gastric bypass surgery that occurred 2 years ago.

Upon physical examination, she is afebrile. Her abdomen is soft and nontender with no masses.

Laboratory studies are shown below in the Table.

Laboratory study	Value	Normal range
WBC count	7,700/µL	3,200-9,800/µL
Hemoglobin	13.2 g/dL	11-14 g/dL
Platelets	215,000/µL	150,000-450,00/µL
Albumin	4.3 g/dL	3.5-5.5 g/dL
AST	334 U/L	5-52 U/L
ALT	282 U/L	7-46 U/L
Alkaline phosphatase	115 U/L	40-100 U/L
Total bilirubin	1.7 mg/dL	0.2-1.5 mg/dL
Amylase	42 U/L	30-110 U/L
Lipase	24 U/L	13-141 U/L

ALT, alanine transaminase; AST aspartate aminotransferase; WBC, white blood cell.

Ultrasonography of the abdomen demonstrates a normal-appearing liver, mild distension of the gallbladder with several stones in the fundus of the gallbladder, and no apparent wall thickening or pericholecystic fluid. The common bile duct is dilated to 1.3 cm.

What is the next most appropriate step in the management of this patient's condition?

Magnetic resonance cholangiopancreatography (MRCP)
Upper endoscopy with balloon dilation
Manometry of the sphincter of Oddi
Modified endoscopic retrograde cholangiopancreatography (ERCP)
Surgical referral for cholecystectomy

The correct answer is:

Modified endoscopic retrograde cholangiopancreatography (ERCP)

Educational Objective:

Recognize clinical scenarios in which endoscopic retrograde cholangiopancreatography is appropriate.

Key Point:

In patients likely to be diagnosed with and require treatment for biliary obstruction, ERCP is the preferred method. However, the procedure needs to be modified in order to account for the modified stomach (the procedure is still referred to as an ERCP).

Explanation:

Gallstone formation is common after rapid weight loss, as seen after bariatric surgery. These stones are composed of cholesterol, and, although the exact mechanism is not fully understood, there may be increased biliary stasis due to reduced caloric intake, or saturation of bile with cholesterol due to increased cholesterol mobilization. This patient has elevated transaminases and common bile duct dilation consistent with stones, sludge, or an anatomic obstruction of the common bile duct. Thus, ERCP will aid in both the diagnosis and treatment of a biliary obstruction. Of note, given the patient’s history of prior Roux-en-Y gastric bypass, ERCP may require surgical consultation to endoscopically or laparoscopically access the biliopancreatic limb. Several methods exist to assess the biliary systems via a modified ERCP; if interested, follow this link to an excellent discussion.

https://www.gastroenterologyandhepatology.net/archives/november-2019/approaches-to-ercp-in-patients-with-roux-en-y-gastric-bypass-anatomy/

MRCP may also aid in diagnosis, but it does not offer a therapeutic option. Upper endoscopy may be useful to assess for peptic ulcer disease or evidence of an anastomotic stricture, but this patient does not demonstrate symptoms of obstruction or ulcer. Sphincter of Oddi dysfunction can also cause an elevation of transaminases and bile duct dilation, but the presence of a stone or sludge should be ruled out first. There is no gallbladder wall thickening or pericholecystic fluid to suggest acute cholecystitis, so immediate surgical referral for cholecystectomy is not the most appropriate next step.

References:

Khatri R, et al. Management of the gallbladder before and after bariatric surgery. ASMBS Textbook of Bariatric Surgery. 2015:365-372.

Baron T. Approaches to ERCP in Patients With Roux-en-Y Gastric Bypass Anatomy. Gastroenterology & Hepatology. November 2019 - Volume 15, Issue 11.

Bukhari M, Kowalski T, Nieto J, et al. An international, multicenter, comparative trial of EUS-guided gastrogastrostomy-assisted ERCP versus enteroscopy-assisted ERCP in patients with Roux-en-Y gastric bypass anatomy. Gastrointest Endosc. 2018;88(3):486-494.

James HJ, James TW, Wheeler SB, Spencer JC, Baron TH. Cost-effectiveness of endoscopic ultrasound-directed transgastric ERCP compared with device-assisted and laparoscopic-assisted ERCP in patients with Roux-en-Y anatomy [published online June 26, 2019]. Endoscopy. doi:10.1055/a-0938-3918.

Stokes C, Gluud LL, Casper M, Lammert F. Ursodeoxycholic acid and diets higher in fat prevent gallbladder stones during weight loss: a meta-analysis of randomized controlled trials. Clin Gastroenterol Hepatol. 2014;12(7):1090-1100.

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