2 GI Case Quizzes: Fatigue/Poor LFTs; Pain post-Gastric Bypass

Case Quiz #1: Fatigue and Elevated LFTs in a 42-year-old Man

Patient history. This 42-year-old man wiht no significant past illnesses is referred to you complaining of fatigue; results of liver function tests show elevations in AST, ALT, total bilirubin and significant increase in alkaline phosphatiase. p-ANCA is positive; AMA, negative.

Imaging results, next steps? MRCP findings are notable for numerous fibrotic segments in both  intra- and extrahepatic bile ducts with saccular dilatation of normal areas between strictures. What is the next best step in management?
A. Colonoscopy
B. ERCP
C. Liver biopsy
D. Repeat MRCP in 6 months

Answer: A. Colonoscopy. The MRCP findings suggest primary sclerosing cholangitis, a progressive inflammatory condition that causes bile ducts to become fibrotic. From 30% to 50% of patients with PSC have comorbid inflammatory bowel disease, typcially ulcerative colitis. Thus full colonoscopy with biopsies is recommended on PSC diagnosis, regardless of presence of IBD symptoms. Annual surveillance is advised.

Case Quiz #2. Right Upper Quadrant Pain in a 35-year-old Woman s/o RNY Bypass

Patient history. A 35-year-old woman with medical history notable for obesity s/p Roux-en-Y gastric bypass and 2 C-sections presents with colicky right upper quadrant pain that she epxeriences approximately 30 minutes after meals.

Phyiscal exam, test results. Mild tenderness to palpation is noted in the right upper quadrant and there is redundant skin around the abdomen. Multiple mobile gallstones are seen on transabdominal ultrasound. No evidence is seen of gallbladder wall thickening or billiary ductal dilation.
 

Answer: D. Nulliparity. Pregnancy is a direct risk factor for gallstone formation. When estrogen levels rise, bile becomes supersaturated with cholesterol and gallbladder motility is reduced secondary to elevated progestin. Reduced motility creates an environment for sludge and stone formation.
 

Other risk factors for gallstones. Approximately 36% of patients who have had RNY gastric bypass will experience development of gallstones; ~5% of those will require intervention. Other risk factors include maternal family history, Hispanic or Native American ethnicity, obesity, rapid weight loss, and ileal disease.