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Clinical Chemistry and Laboratory Medicine (CCLM)

Published in Association with the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM)

Editor-in-Chief: Plebani, Mario

Ed. by Gillery, Philippe / Greaves, Ronda / Lackner, Karl J. / Lippi, Giuseppe / Melichar, Bohuslav / Payne, Deborah A. / Schlattmann, Peter

IMPACT FACTOR 2018: 3.638

CiteScore 2018: 2.44

SCImago Journal Rank (SJR) 2018: 1.191
Source Normalized Impact per Paper (SNIP) 2018: 1.205

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Volume 44, Issue 12


Stone or stricture as a cause of extrahepatic cholestasis – do liver function tests predict the diagnosis?

Jukka Karvonen / Veli Kairisto / Juha M. Grönroos
  • Department of Surgery, University of Turku, Turku, Finland and Department of Emergency, University of Turku, Turku, Finland
  • Other articles by this author:
  • De Gruyter OnlineGoogle Scholar
Published Online: 2006-12-13 | DOI: https://doi.org/10.1515/CCLM.2006.261


Background: Cholestasis, roughly divided into intrahepatic and extrahepatic forms, is a clinical challenge. Extrahepatic cholestasis, characterized by dilated bile ducts, is caused by either a bile duct stone or stricture, with stricture most often related to a malignancy. The aim of the present study was to analyze the value of common liver function tests in separating patients with malignant bile duct strictures from those with stones.

Methods: All consecutive patients admitted for endoscopic retrograde cholangiopancreatography (ERCP) were included in the study population if a bile duct stricture related to a malignancy was found by ERCP (n=103) or if a bile duct stone was successfully extracted during ERCP, thus confirming the diagnosis of a stone (n=109). Plasma alkaline phosphatase, γ-glutamyltransferase, alanine aminotransferase and bilirubin values were determined in the morning before ERCP.

Results: Plasma bilirubin (p<0.001), alkaline phosphatase (p<0.001) and alanine aminotransferase (p=0.040) levels were significantly higher in patients with malignant bile duct strictures than in those with bile duct stones. In addition, γ-glutamyltransferase levels seemed to be higher in patients with malignant strictures than in those with stones, although the difference did not reach statistical significance (p=0.053). In receiver operating characteristic analyses, bilirubin proved to be the best laboratory test in differentiating patients (p=0.001 vs. alkaline phosphatase, p<0.001 vs. alanine aminotransferase and p<0.001 vs. γ-glutamyltransferase). With a plasma bilirubin cutoff value of 145μmol/L, four out of five patients were categorized correctly.

Conclusions: Plasma bilirubin seems to be the best liver function test in distinguishing patients with malignant bile duct strictures from those with bile duct stones. This routine test should receive more attention in clinical decision-making than has previously been given.

Clin Chem Lab Med 2006;44:1453–6.

Keywords: bile duct stone; bile duct stricture; bilirubin; cholestasis; jaundice; liver function test


  • 1.

    Green RM, Flamm S. AGA technical review on the evaluation of liver chemistry tests. Gastroenterology 2002; 123:1367–84.Google Scholar

  • 2.

    Reichling JJ, Kaplan MM. Clinical use of serum enzymes in liver disease. Dig Dis Sci 1988; 33:1601–14.Google Scholar

  • 3.

    Becker CD, Grossholz M, Becker M, Mentha G, de Peyer R, Terrier F. Choledocholithiasis and bile duct stenosis: diagnostic accuracy of MR cholangiopancreatography. Radiology 1997; 205:523–30.Google Scholar

  • 4.

    Magnuson TH, Bender JS, Duncan MD, Ahrendt SA, Harmon JW, Regan F. Utility of magnetic resonance cholangiography in the evaluation of biliary obstruction. J Am Coll Surg 1999; 189:63–71; discussion 71–2.Google Scholar

  • 5.

    Scheiman JM, Carlos RC, Barnett JL, Elta GH, Nostrant TT, Chey WD, et al. Can endoscopic ultrasound or magnetic resonance cholangiopancreatography replace ERCP in patients with suspected biliary disease? A prospective trial and cost analysis. Am J Gastroenterol 2001; 96:2900–4.Google Scholar

  • 6.

    Prat F, Meduri B, Ducot B, Chiche R, Salimbeni-Bartolini R, Pelletier G. Prediction of common bile duct stones by noninvasive tests. Ann Surg 1999; 229:362–8.Google Scholar

  • 7.

    Onken JE, Brazer SR, Eisen GM, Williams DM, Bouras EP, DeLong ER, et al. Predicting the presence of choledocholithiasis in patients with symptomatic cholelithiasis. Am J Gastroenterol 1996; 91:762–7.Google Scholar

  • 8.

    Chang L, Lo SK, Stabile BE, Lewis RJ, de Virgilio C. Gallstone pancreatitis: a prospective study on the incidence of cholangitis and clinical predictors of retained common bile duct stones. Am J Gastroenterol 1998; 93:527–31.Google Scholar

  • 9.

    Pasanen P, Pikkarainen P, Alhava E, Partanen K, Penttila I. Value of serum alkaline phosphatase, aminotransferases, γ-glutamyltransferase, leucine aminopeptidase, and bilirubin in the distinction between benign and malignant diseases causing jaundice and cholestasis: results from a prospective study. Scand J Clin Lab Invest 1993; 53:35–9.Google Scholar

  • 10.

    Klauke R, Schmidt E, Lorentz K. Recommendations for carrying out standard ECCLS procedures (1988) for the catalytic concentrations of creatine kinase, aspartate aminotransferase, alanine aminotransferase and γ-glutamyltransferase at 37°C. Standardization Committee of the German Society for Clinical Chemistry, Enzyme Working Group of the German Society for Clinical Chemistry. Eur J Clin Chem Clin Biochem 1993; 31:901–9.Google Scholar

  • 11.

    Jarvisalo J, Maatela J, Maki J, Marniemi J, Reunanen A. Health-based reference values of the Mini-Finland Health Survey: 1. Serum γ-glutamyltransferase, aspartate aminotransferase and alkaline phosphatase. Scand J Clin Lab Invest 1989; 49:623–32.Google Scholar

  • 12.

    Kairisto V, Poola A. Software for illustrative presentation of basic clinical characteristics of laboratory tests – GraphROC for Windows. Scand J Clin Lab Invest Suppl 1995; 222:43–60.Google Scholar

  • 13.

    Hanley JA, McNeil BJ. A method of comparing the areas under receiver operating characteristic curves derived from the same cases. Radiology 1983; 148:839–43.Google Scholar

About the article

Corresponding author: Dr. Jukka Karvonen, Loimaa District Hospital, Seppälänkatu 15-17, P.O. Box 17, 32201 Loimaa, Finland Phone: +358-2-76130, Fax: +358-2-7613370,

Received: 2006-07-10

Accepted: 2006-09-10

Published Online: 2006-12-13

Published in Print: 2006-12-01

Citation Information: Clinical Chemistry and Laboratory Medicine (CCLM), Volume 44, Issue 12, Pages 1453–1456, ISSN (Online) 1437-4331, ISSN (Print) 1434-6621, DOI: https://doi.org/10.1515/CCLM.2006.261.

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