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Gammaglutamyl transaminase in biliary obstruction
European Journal of Internal Medicine 23 (2012) e76
Contents lists available at SciVerse ScienceDirect
European Journal of Internal Medicine journal homepage: www.elsevier.com/locate/ejim
Letter to the Editor Gammaglutamyl transaminase in biliary obstruction Keywords: Choledocholithiasis Endoscopic retrograde cholangiography Choledocholithiasis predictors Selection criteria Gammaglutamyl transaminase
potential biochemical marker for CDL [4]. On the other hand, excepting the obvious jaundice, a raised GGT level has been suggested to be the most sensitive and specific indicator of CBD stones, and a value of greater than 90 U/L has been proposed to indicate a high risk of CDL [5]. However, laboratory data may be normal in as many as a third of patients with CDL [6]. Conflict of interest statement for manuscript
Dear Editor, We read with interest the comments made by Jolobe OMP: “Limitations of gammaglutamyl transaminase as an indicator of biliary obstruction” [1]. The author raised some interesting points and I would like to address some of those. There is no doubt that the isolated elevation of serum gammaglutamyl transaminase (GGT) is not a firm predictive factor for choledocholithiasis (CDL) in itself [2], but what we learned was that the combination of an elevated GGT, common bile duct (CBD) diameter and the presence of a hyperechoic structure in CBD on ultrasound (US) could be used to construct a predictive model for the presence of CBD stones on ERCP [3]. That predictive model is a clinical decision tool which provides sufficient diagnostic accuracy to help us classify patients with high and low probabilities for the presence of CBD stones on ERCP. It was intended for this predictive model to be used as a quantitative measure of probability for the presence of CBD stones on ERCP. After the patients with a firm clinical and biochemical suspicion for CDL were classified into the group with a high probability for the presence of CBD stones, they are directed to ERCP in order to implement CBD clearance. It was not planned to wait and see if the spontaneous expulsion or disimpaction of retained CBD calculi will happen, even if the patients were calculated to belong into the low probability group for CBD stones on ERCP. Instead, they were directed to less invasive diagnostic modalities such as MRCP or EUS. Limitations of GGT as an idicator of biliary obstruction was mentioned, as for an example Bose et al. did not even take GGT as a
None of the authors have conflicts of interest relevant to publication to declare. References [1] Jolobe O. Limitations of gammaglutamyl transaminase as an indicator of biliary obstruction. Eur J Intern Med 2011 [doi:]. [2] Tekin O, Uraldi C, Isik B, et al. Clinical importance of gamma glutamyltransferase in the Ankara-Pursaklar region of Turkey. MedGenMed 2004;6:3. [3] Jovanovic P, Salkic N, Zerem E, Ljuca F. Biochemical and ultrasound parameters may help predict the need for therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in patients with a firm clinical and biochemical suspicion for choledocholithiasis. Eur J Intern Med 2011;22(6):e110–4. [4] Bose SM, Mazumdar A, Prakash VS, et al. Evaluation of the predictors of choledocholithiasis: comparative analysis of clinical, biochemical, radiological, radionuclear, and intraoperative parameters. Surg Today 2001;31:117–22. [5] Peng. Role of liver function tests in predicting common bile duct stones in acute calculous cholecystitis. Br J Surg 2005;92:1241–7. [6] Freitas ML, Bell RL, Duffy AJ. Choledocholithiasis: evolving standards for diagnosis and management. World J Gastroenterol 2006;12:3162–7.
Predrag Jovanovic⁎ Nermin Salkic Enver Zerem Farid Ljuca University Clinical Center Tuzla, Department of Gastroenterology, Tuzla, Bosnia and Herzegovina ⁎Corresponding author. Tel.: +387 61286514. E-mail address: [email protected] (P. Jovanovic).
0953-6205/$ – see front matter © 2011 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.ejim.2011.12.005
5 December 2011
Contents lists available at SciVerse ScienceDirect
European Journal of Internal Medicine journal homepage: www.elsevier.com/locate/ejim
Letter to the Editor Gammaglutamyl transaminase in biliary obstruction Keywords: Choledocholithiasis Endoscopic retrograde cholangiography Choledocholithiasis predictors Selection criteria Gammaglutamyl transaminase
potential biochemical marker for CDL [4]. On the other hand, excepting the obvious jaundice, a raised GGT level has been suggested to be the most sensitive and specific indicator of CBD stones, and a value of greater than 90 U/L has been proposed to indicate a high risk of CDL [5]. However, laboratory data may be normal in as many as a third of patients with CDL [6]. Conflict of interest statement for manuscript
Dear Editor, We read with interest the comments made by Jolobe OMP: “Limitations of gammaglutamyl transaminase as an indicator of biliary obstruction” [1]. The author raised some interesting points and I would like to address some of those. There is no doubt that the isolated elevation of serum gammaglutamyl transaminase (GGT) is not a firm predictive factor for choledocholithiasis (CDL) in itself [2], but what we learned was that the combination of an elevated GGT, common bile duct (CBD) diameter and the presence of a hyperechoic structure in CBD on ultrasound (US) could be used to construct a predictive model for the presence of CBD stones on ERCP [3]. That predictive model is a clinical decision tool which provides sufficient diagnostic accuracy to help us classify patients with high and low probabilities for the presence of CBD stones on ERCP. It was intended for this predictive model to be used as a quantitative measure of probability for the presence of CBD stones on ERCP. After the patients with a firm clinical and biochemical suspicion for CDL were classified into the group with a high probability for the presence of CBD stones, they are directed to ERCP in order to implement CBD clearance. It was not planned to wait and see if the spontaneous expulsion or disimpaction of retained CBD calculi will happen, even if the patients were calculated to belong into the low probability group for CBD stones on ERCP. Instead, they were directed to less invasive diagnostic modalities such as MRCP or EUS. Limitations of GGT as an idicator of biliary obstruction was mentioned, as for an example Bose et al. did not even take GGT as a
None of the authors have conflicts of interest relevant to publication to declare. References [1] Jolobe O. Limitations of gammaglutamyl transaminase as an indicator of biliary obstruction. Eur J Intern Med 2011 [doi:]. [2] Tekin O, Uraldi C, Isik B, et al. Clinical importance of gamma glutamyltransferase in the Ankara-Pursaklar region of Turkey. MedGenMed 2004;6:3. [3] Jovanovic P, Salkic N, Zerem E, Ljuca F. Biochemical and ultrasound parameters may help predict the need for therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in patients with a firm clinical and biochemical suspicion for choledocholithiasis. Eur J Intern Med 2011;22(6):e110–4. [4] Bose SM, Mazumdar A, Prakash VS, et al. Evaluation of the predictors of choledocholithiasis: comparative analysis of clinical, biochemical, radiological, radionuclear, and intraoperative parameters. Surg Today 2001;31:117–22. [5] Peng. Role of liver function tests in predicting common bile duct stones in acute calculous cholecystitis. Br J Surg 2005;92:1241–7. [6] Freitas ML, Bell RL, Duffy AJ. Choledocholithiasis: evolving standards for diagnosis and management. World J Gastroenterol 2006;12:3162–7.
Predrag Jovanovic⁎ Nermin Salkic Enver Zerem Farid Ljuca University Clinical Center Tuzla, Department of Gastroenterology, Tuzla, Bosnia and Herzegovina ⁎Corresponding author. Tel.: +387 61286514. E-mail address: [email protected] (P. Jovanovic).
0953-6205/$ – see front matter © 2011 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.ejim.2011.12.005
5 December 2011