P1121 - Abnormal Liver Function Tests: Navigating a Herd of Zebras

Sunday, October 22, 2023

3:30 PM – 7:00 PM PT

Location: Exhibit Hall

Has Audio

Presenting Author(s)

Matthew Reif, MD

Tulane University
New Orleans, LA

Matthew Reif, MD¹, Parker Ellison, MD², Stephen Wayne. Landreneau, MD², Peng-Sheng Ting, MD¹
¹Tulane University, New Orleans, LA; ²Louisiana State University, New Orleans, LA

Introduction: Evaluating deranged liver function tests (LFT’s) requires thorough history, exam, labs, imaging, and sometimes endoscopy. We present an unusual case requiring all of these elements for diagnosis.

Case Description/Methods: A 53 year old woman with self-reported Crohn's Disease, Roux-en-Y gastric bypass (ReY) for morbid obesity followed by cholecystectomy, was referred for abnormal LFTs that were normal pre-ReY (Table 1). Her ReY was complicated by an anastomotic ulcer, treated with proton pump inhibitors and sucralfate (Fig 1). Serologies for HIV, HBV, HCV, autoimmune hepatitis, and primary biliary cholangitis were negative, however IgG1, 2, and 4 were elevated. Contrast MRI and MRCP showed diffuse biliary ductal dilatation with abrupt cutoff at the ampulla without any masses, but excluded primary sclerosing or other cholangitis (Fig 2). Liver biopsy showed biliary obstruction with bile ductular proliferation and mild, non-granulomatous, mixed inflammation and moderate portal fibrosis, and no steatosis. Repeat colonoscopy/biopsy to exclude active Crohn’s was benign. She underwent endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE/ERCP), successfully deploying a lumen approximating metal stent across the gastrogastrostomy (Fig 3). ERCP via the latter showed prior cholecystectomy overlying a benign stenotic biliary orifice. After sphincterotomy and balloon sweeping, the biliary tree was thoroughly interrogated via SpyGlass^® cholangioscopy with only benign biliary mucosa (Fig 4). At follow-up, her LFTs improved (Table 1). The stent was later removed and gastrogastrostomy closed (Fig 5).

Discussion: ReY, irrespective of cholecystectomy, is associated with biliary dilatation, but not elevated LFTs^1-4. Several unusual diagnoses were considered, including IgG4-mediated sclerosing cholangitis, cholangiocarcinoma, small duct PSC, granulomatous hepatitis, and iatrogenic complication of ReY^1-5. EDGE permits ERCP in ReY anatomy, which was essential in our case^6-8. Given her normal pre-ReY LFTs, mostly unremarkable serologies, imaging ruling against inflammatory sclerosing cholangitis or malignancy, unremarkable EDGE-ERCP interrogation of the biliary tree, we are left with the interesting conclusion that her LFT derangements and ampullary stenosis are a complication of the ReY. While literature has described symptomatic ampullary dilatation, choledocholithiasis, and cholangitis following ReY, our case presented primarily with laboratory derangements^9-10.

Figure: Figure 1. Patient’s Roux-en-Y gastric bypass gastrojejunal anastomotic ulcer seen at 7 months post bypass (A), whereupon proton pump inhibitor and sucralfate therapy were instituted. Ulcer healing is present at 9 months (B), and nearly complete at 10 months (C) post-bypass.

Figure 2. MRI Contrast and MRCP showing diffuse intraductal dilatation with abrupt cutoff at the ampulla on T2 coronal (A), maximum-intensity 3D projection (B), and T2 3D reconstructional (C) views. Note the lack of multi-segment structuring with intervening normal duct segments that are typical of primary sclerosing cholangitis.

Figure 3. Endoscopic-ultrasound directed transgastric ERCP (EDGE) procedure, where the excluded gastric fundus is visualized (A), punctured (B), distended with saline (C), a lumen-apposing metal stent is deployed (D), and expanded successfully (E-F) to create a gastrogastrostomy between the remnant and excluded stomach.

Figure 4. ERCP showing benign common (A), Right (B), and Left (C) hepatic ducts after sphincterotomy of benign stricture, performed via lumen apposing metal stent placed during Endoscopic-Ultrasound Directed transgastric ERCP (EDGE/ERCP) in Figure 3.

Figure 5. EGD showing re-visualization of the stent placed via the fistula created in Figure 3, whereupon it is removed with rat-toothed forceps (A) to re-create said fistulae (B). Then, the associated defect is closed with a combination of argon plasma coagulation(B) and hemostatic clipping (C).

	Pre-ReY	3 mo Post-Rey	5 mo Post-ReY	1 mo Post-EDGE/ERCP
AST (U/L)	18	111	203	73
ALT (U/L)	12	55	89	38
ALP (U/L)	77	1662	2553	724
Albumin (g/dL)	4.2	3.7	3.4	3.9
Total Bilirubin (mg/dL)	0.4	0.8	1.2	0.5

Table: Table 1. Liver function testing relative to patient’s Roux-en-Y bypass (ReY), and post Endoscopic-Ultrasound-Directed Transgastric Endoscopic Retrograde Cholangiopancreatography (EDGE/ERCP).

Disclosures:

Matthew Reif indicated no relevant financial relationships.

Parker Ellison indicated no relevant financial relationships.

Stephen Landreneau indicated no relevant financial relationships.

Peng-Sheng Ting indicated no relevant financial relationships.

Matthew Reif, MD¹, Parker Ellison, MD², Stephen Wayne. Landreneau, MD², Peng-Sheng Ting, MD¹. P1121 - Abnormal Liver Function Tests: Navigating a Herd of Zebras, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.