Transaminases are better biochemical predictors of choledocholithiasis than bilirubin and alkaline phosphatase.
*Thomas Peponis, *Nikolaos Kokoroskos, *Jae Moo Lee, *April Mendoza, *Martin Rosenthal, *Noelle Saillant, Haytham Kaafarani, *David King, George Velmahos, *Peter Fagenholz
Massachusetts General Hospital, Boston, MA
Objective: We hypothesized that elevated transaminases (ALT and AST) are independent predictors of common bile duct (CBD) stones and have better sensitivity and specificity compared to the more commonly used bilirubin and alkaline phosphatase (ALP).
Design: Retrospective study.
Setting: Acute Care Surgery Service of an academic tertiary center.
Patients: All adult patients who underwent a laparoscopic cholecystectomy between 2010 and 2018.
Main Outcome Measures:
The sensitivity, specificity, and area under ROC curve for AST>120, ALT>165, ALP>230, and bilirubin>=4 to identify choledocholithiasis. Liver function tests were captured on admission. Choledocholithiasis was confirmed via either an intraoperative cholangiogram, ERCP, or MRCP. We used three times the upper limit of normal for the AST, ALT, and ALP, and bilirubin>=4, as is currently used in choledocholithiasis diagnostic guidelines. Multivariable logistic regression was performed to identify independent predictors of choledocholithiasis.
Results: A total of 1,036 patients, who underwent laparoscopic cholecystectomy, were included in the study. Of them, 210 (20.3%) were confirmed to have choledocholithiasis. Elevated bilirubin had a sensitivity of 23% and specificity of 95%, ALP was 28% sensitive and 93% specific, AST was 63% sensitive and 80% specific, and ALT was 52% sensitive and 82% specific. The area under ROC curve was highest for AST (0.71), followed by ALT (0.67), ALP (0.61), and bilirubin (0.59). In multivariate analysis, the only independent predictors for choledocholithiasis were AST>120 (OR 3.7, CI 1.4-8.2), age>60 (OR 1.8, CI 1.2-2.9), and bilirubin>4 (OR 2.4, CI 1.8-3.3).
Conclusions: Elevation of AST is a more accurate marker in the prediction of choledocholithiasis compared to the more traditionally used bilirubin and ALP. Transaminases should be featured in choledocholithiasis screening and detection algorithms.
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