Transabdominal ultrasound finding and acute hepatocellular injury in different cohorts of elderly adults with and without common bile duct stones
Journal
Journal of the American Geriatrics Society
Journal Volume
61
Journal Issue
7
Pages
1221-1224
Date Issued
2013
Author(s)
Abstract
Transabdominal ultrasound (US) scans and liver function tests (LFTs) were the most-convenient and least-invasive diagnostic methods for biliary–pancreatic diseases. The relationship between abnormal LFTs and common bile duct (CBD) stones in individuals with gallstones has been studied widely.1 In the general population, the sensitivity of USs for detection of CBD stones was approximately 0.38, and the specificity was 1.0,2 but there are no solid data for elderly people. Endoscopic retrograde cholangiopancreatography (ERCP) has been the criterion standard for preoperative diagnosis of CBD calculi and is also widely used in older adults.3, 4 The aim of the current study was to analyze the US findings and degree of hepatocellular injury in elderly adults with and without CBD stones when they underwent ERCP. Between July 2004 and June 2008, 273 individuals with naive papilla were included in this study and divided into cohorts according to age: young-old (YO, 65–74, n = 153), old-old (OO, 75–84, n = 88), and very old (VO, ≥85, n = 32). All participants underwent US examination before ERCP, and the aim was therapeutic (curative or palliative) rather than diagnostic in all cases. Biochemical liver tests, US findings, and ERCP results in these three groups were compared. Three hundred US and ERCP procedures were performed. Accuracy of US for CBD stones was 62.5% in YO, 70.1% in OO, and 71.4% in VO. YO and OO with CBD stones were more likely than those without to have abnormal aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels. YO with CBD stones had higher mean alkaline phosphatase (ALK-P) levels than those without and were more likely to have abnormal levels (abnormal levels: with CBD stone, 75.8%; without CBDE stone, 50.0%; P = .005, Table 1). Sensitivity and accuracy of US for detection of CBD stones was greater with older age. The incidence of abnormal LFTs was higher in YO and OO with CBD stones than in those without. Gallstones and CBD stones are frequently encountered in elderly adults. CBD stones develop in approximately 10–20% of individuals with gallbladder stones, which should be considered before planning surgical treatment.5 When intraoperative cholangiogram during laparoscopic cholecystectomy shows CBD stones, conversion to laparostomy is usually needed because of technical difficulties in performing laparoscopic CBD exploration.6 In the current study, YO with CBD stones were significantly more likely to have biliary colic and cholangitis than those without, but this difference was not found in OO and VO. Elderly adults with suspected biliary–pancreatic disease but without CBD stones were more likely to have biliary malignancy. This difference was significant in YO (with biliary malignancy, 3%; without biliary malignancy, 25%, P < .001) and OO (with biliary malignancy, 2%; without biliary malignancy 21%, P = .007) but not VO (biliary malignancy, 5%; without biliary malignancy, 23%, P = .15). US is always recommended as a preliminary investigation tool for screening for CBD stones.5 There was no significant difference in the diameter of the CBD in those with and without CBD stones in all groups of elderly adults. The reason for this finding might be related to the CBD diameter undergoing age-dependent changes. In elderly adults, a dilated CBD may not indicate the presence of CBD stones. Some participants had CBD stones according to US that did not appear in subsequent ERCP images (YO, 17%; OO, 6%; VO, 23%). Biliary malignancy was the cause of this discrepancy. The low sensitivity of US to detect CBD stones is partially due to abdominal fat or bowel gas accumulation obscuring the common bile duct, especially the distal end.7 In elderly adults it was found that the sensitivity of US was 0.45–0.68 to detect CBD stones and 0.73–0.82 to detect CBD dilatation. The sensitivity of US to detect CBD stones or dilatation was higher in elderly adults than in the general population. Difference in LFTs (especially ALK-P) between individuals with and without CBD stones was more often seen in YO and OO. Recently, in an animal model, high ALT was observed with biochemical or morphological evidence of cholestasis, and ALK-P had modest diagnostic value for peroxisome proliferation.8 It was thought that the contractility and tone of the CBD wall and the sphincter of Oddi might decrease in elderly adults, followed by an increase in CBD diameter,9 which increases the sensitivity of US in detecting CBD stones. In conclusion, combined evaluation with biochemical and US findings may help predict the presence of CBD stones in elderly adults. The classical clinical symptoms of CBD stones in elderly adults are variable, especially in OO and VO. In elderly people with suspected biliary–pancreatic diseases showing no CBD stones, biliary malignancy should be considered. The sensitivity and accuracy of US for CBD stone detection was greater with older age. In YO and OO with CBD stones, the probability of abnormal LFTs was higher than in those without CBD stones. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Shih S.-C., Wu M.-S.: study design, modification of manuscript draft, and statistical analysis of laboratory data. Hu K.-C., Lin S.-C., Liu C.-J., Wu M.-S.: preparation of manuscript draft. Chang W.-H., Chu C.-H.: performance of ERCP procedures. Wang H.-Y., Chang W.-H., Chu C.-H.: patient management and acquisition of subjects. Sponsor's Role: No sponsors.
SDGs
Other Subjects
alanine aminotransferase; alkaline phosphatase; aspartate aminotransferase; aged; biliary colic; biliary tract tumor; cholangitis; common bile duct stone; diagnostic accuracy; diagnostic test accuracy study; echography; endoscopic retrograde cholangiopancreatography; human; letter; liver cell damage; liver function test; major clinical study; sensitivity and specificity; Acute Disease; Aged; Aged, 80 and over; Bile Duct Diseases; Cholangiopancreatography, Endoscopic Retrograde; Cohort Studies; Common Bile Duct; Female; Gallstones; Humans; Liver Function Tests; Male; Sensitivity and Specificity
Type
letter