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Postgrad Med J: first published as 10.1136/pgmj.58.676.85 on 1 February 1982. Downloaded from

Postgraduate Medical Journal (February 1982) 58, 85-86

Isolated elevation of and biliary disease in the elderly S. N. JONES G. P. J. BEYNON M.B. B.S. M.R.C.P. C. M. ASKEW J. R. CROKER B.M., B.Ch. M.R.C.P. The Middlesex Hospital, Department of Geriatric Medicine, Mortimer Street, London WIN 8AA

Summary Over the next 3 weeks she suffered recurrent Disease presentation is commonly non-specific in attacks of associated with elevation the geriatric age group. An isolated elevation of of the WBC and serum alkaline phosphatase and serum alkaline phosphatase concentration may be amylase concentrations. Endoscopic-retrograde- the only pointer to underlying biliary disease. cholangio-pancreatography (ERCP) revealed a Introduction normal pancreatic duct, but the common bile duct Although gall-stones occur in over 30 % of females was dilated and contained numerous small stones. above the age of 70 years (Bateson and Bouchier, Duodenoscopic sphincterotomy was performed and 1975), they are often overlooked as a cause of illness subsequently she has suffered no further attacks of in this age group. The pattern of clinical illness is pain. The WBC count, serum amylase and alkaline often atypical in the elderly and gall-stones do not phosphatase concentrations have returned to by copyright. always present classically with biliary colic, jaundice, normal. cholecystitis or cholangitis. Four patients are presented who had different in Case 2 forms of gall-stone disease, and whom the only A woman of 78 years was admitted with a 10-day abnormality of routine liver function was an isolated history of loss of mobility and of feeling unwell. elevation of serum alkaline phosphatase con- In the past, her health had been good, although she centration. had suffered a fractured, left neck of femur 2 years Case histories previously. On admission she was complaining of

Case 1 lower abdominal colicky pain. She was apyrexial http://pmj.bmj.com/ An 86-year-old woman was admitted with a left, and examination was unhelpful. Investigations fractured neck of femur. This was treated with a showed a normal haemoglobin, but the erythrocyte McKee pin and plate operation. Two years pre- sedimentation rate was 100 mm/hr. The WBC count viously she had suffered an attack of acute pan- was elevated to 19 x 109/l. Blood cultures were creatitis, which had been managed by surgical sterile, but a mid-stream specimen drainage and cholecystostomy. She drank only (MSU) grew a coliform organism. The serum alkaline occasionally and took a diuretic regularly for ankle phosphatase concentration was raised to 165 i.u./l, oedema. Three weeks after admission she suffered but the serum and aspartate on September 25, 2021 by guest. Protected an attack of acute, upper abdominal pain with concentrations were normal. The following day vomiting. She was pyrexial and her abdomen was her temperature rose to 38°C and she was given distended, and tender in the epigastrium. The bowel ampicillin with some improvement. One week later sounds were normal. Investigations revealed an she developed further abdominal pain now more elevation of the white blood cell (WBC) count and localized to the right hypochondrium and ultra- serum amylase concentration. The serum alkaline sound-examination showed an empyema of the phosphatase was 158 i.u./l (normal < 75 i.u./l), gall-bladder with abscess cavities in the gall-bladder but the serum bilirubin and bed. Metronidazole was also added and she was concentrations were normal. She was treated with a referred for surgical opinion. At operation the gall- naso-gastric tube and by intravenous fluids and bladder and abscess cavities were drained. Sub- antibiotics. An ultra-sound examination revealed sequently, she made a good recovery and both the stones in the gall-bladder without dilatation of the leucocytosis and serum alkaline phosphatase con- biliary tree; the was normal. centration returned to normal. 0032-5473/82/0200-0085 $02.00 (© 1982 The Fellowship of Postgraduate Medicine Postgrad Med J: first published as 10.1136/pgmj.58.676.85 on 1 February 1982. Downloaded from

86 S. N. Jones et al. Case 3 Discussion An 80-year-old woman was admitted from the Disease presentation is commonly non-specific in out-patients clinic. Over the previous month she had the geriatric age group and may lead to delay in suffered 4 episodes of rigors. On one occasion an diagnosis, particularly when a relevant history of MSU had shown growth of a coliform organism. previous biliary disease is overlooked. One of the She had not suffered any abdominal pain or urinary patients presented with acute , which symptoms. On examination she looked well and should always prompt a search for gall-stones was apyrexial but the liver was smoothly enlarged (Trapnell and Duncan, 1975). Two of the remaining 5 cm below the costal margin. Her blood count, patients were initially thought to be suffering from blood urea and were all normal. An urinary tract infection. MSU showed increased white cells but no growth on Physical signs and investigations may be con- culture. An intravenous pyelogram was normal. fusing. Three of the patients were apyrexial and in Liver function was normal except for a raised serum one the total WBC count was normal. Blood alkaline phosphatase concentration (765 i.u./l). cultures should always be performed in sick, elderly The serum gamma-glutamyl transpeptidase (y-GT) patients (Denham and Goodwin, 1977), but were was also elevated to 1442 i.u./l (normal < 33 i.u./l). unhelpful in the present cases. Ultra-sound examination of the biliary area showed In the 4 cases presented the only abnormality of stones in the gall-bladder but a normal biliary tree. routine liver function was an elevation of serum She remained well over the next 3 months, but the alkaline phosphatase concentration. In elderly serum alkaline phosphatase and y-GT concentration patients, as in younger cases, this elevation is always remained elevated and she was admitted for further due to disease (Hodkinson and McPherson, 1973). investigations. On examination she was anicteric Measurement of serum y-GT or 5-nucleotidase is but her gall-bladder was palpable. Repeat ultra- helpful in indicating a biliary cause (Whitfield sound examination showed a large gall-bladder with et al., 1972). Grey scale ultrasonography accurately a stone in the neck. At operation a large gall-bladder detects stones in the gall-bladder, but may fail to was removed. A peroperative cholangiogram demon- show those in the common bile duct (McKay et al.,by copyright. strated a stone in the common bile duct. Following 1979). Choledochal stones are readily demonstrated surgery her returned to normal. by ERCP (Cotton, 1977). The mortality rate for surgical removal of choledochal stones is highest in elderly patients (Vellacott and Powell, 1979) and Case 4 these are more appropriately removed by duodeno- A woman of 83 years was admitted having failed scopic sphincterotomy (Cotton, 1980). to cope at home. She had a long history of rheuma- Biliary stones are an important and treatable toid arthritis extending over 30 years and was now cause of illness in the elderly. Their presence may be wheel-chair bound. She had received a large number indicated by an isolated elevation of serum alkaline of anti-inflammatory drugs, most of which had been phosphatase concentration. http://pmj.bmj.com/ associated with iron deficiency anaemia. In 1969, she had suffered a single attack of abdominal pain References BATESON, M.C. & BOUCHIER, I.A.D. (1975) Prevalence of gall associated with signs of obstructive jaundice. stones in Dundee: a necropsy study. British Medical Since 1976, she had experienced intermittent dys- Journal, 4, 427. phagia. Investigations then had shown a benign COTTON, P.B. (1977) E.R.C.P. Gut, 18, 316. peptic stricture which had been dilated endo- COTTON, P.B. (1980) Non-operative removal of bile duct stones by duodenoscopic sphincterotomy. British Journal

time on September 25, 2021 by guest. Protected scopically on several occasions. At the present of Surgery, 67, 1. she was able to maintain normal body weight by DENHAM, M.J. & GOODWIN, G.S. (1977) The value of blood eating a semi-solid . The serum alkaline phos- cultures in geriatric practice. Age and Ageing, 6, 85. phatase concentration had been modestly elevated HODKINSON, H.M. & MCPHERSON, C.K. (1973) Alkaline she phosphatase in a geriatric in-patient population. Age and since 1976 (range 87 to 111 i.u./l). On admission Ageing, 2, 28. was apyrexial but the WBC count was raised to MCKAY, A.J., DUNCAN, J.G., LAM, P., HUNT, D.R. & 19 x 109/l, with a neutrophil leucocytosis. A chest BLUMGART, L.H. (1979) The role of grey scale ultrasono- X-ray, MSU and blood culture were all negative. graphy in the investigation of jaundice. British Journal of was Surgery, 66, 162. The serum alkaline phosphatase concentration TRAPNELL, J.E. & DUNCAN, E.H.L. (1975) Patterns of inci- elevated to 135 i.u./l. Ultra-sound examination dence in . British Medical Journal, 2, 179. showed a dilated gall-bladder and common bile VELLACOTT, K.D. & POWELL, P.H. (1979) Exploration of the duct containing stones. Following duodenoscopic common bile duct. A comparative study. British Journal of Surgery, 66, 389. sphincterotomy several small stones were removed WHITFIELD, J.B., POUNDER, R.E., NEALE, G. & Moss, D.W. and the serum alkaline phosphatase concentration (1972) Serum y-glutamyl transpeptidase activity in liver and WBC count have returned to normal. disease, Gut, 13, 702.