Patient: age 33 years old, female. Sudden acute abdominal pain without fever and diarrhea, nausea, shortness of breath, breath-holding and vomiting once at 8 pm on March 3. Hepatitis A, B, C, D, and E virus markers EBV, CMV were not seen abnormally. Anti-mitochondrial antibody, anti-smooth muscle antibody, anti-nuclear antibody, AFP 1.73ng/ml, CEA 0.33ng/ml, syphilis, prothrombin, etc., biochemistry, stool and urine routine were not abnormal. CA125, CA199, CA724, CA153 were normal. Anti-HDV.IGM was negative. Red blood cell information, RBC-P70Fsc, WBC-MFsc, conductivity were normal. Ultrasound suggested mild fatty liver and gallbladder stones, no other abnormalities were seen. After admission, hepatoprotection, anti-yellowness and symptomatic treatment with enzyme reduction. Questions: 1. The cause of acute abdominal pain was not found, and the cause of sudden abnormal liver function was not found. The transaminases rose sharply from 135 to 508 after a break of 7 hours, what could be the cause? 2. After 5 months of breastfeeding, can I continue breastfeeding after my liver function is normal and how long can I stop taking oral medication? When I was discharged from the hospital on March 16, my GGT was 200, but it is still abnormal, and my alkaline phosphatase is high. What other tests should be done and what should I pay attention to? Other liver tests are normal. Thanks! Description of treatment: I was hospitalized on March 5, during which I have been taking gardenia yellow granules, vitamin C, polyene-phosphatidylcholine injection, atomorelin powder injection, compound glycyrrhetinic acid for injection, pentaerythritol capsule, heparin sodium injection, potassium magnesium menthylate injection, diammonium glycyrrhetinate injection, and reduced glutathione. After being discharged from hospital on March 16, he has been taking pentosidine capsule and ezetimibe capsule. 2009.3.3 23:41 Abdominal pain 4 hours after examination Abnormal subjects in Civil Aviation General Hospital: Total bile acid TBA (0-10umol/L) 38.39 Glutathione transaminase ALT (0-40IU/L) 135.79 Glutathione transaminase AST (5-40IU/L) 273.27 Alkaline Alkaline phosphatase ALP (42-105 U/L) 117.02 Glutamyl transpeptidase GGT (10-40 U/L) 472.87 Glucose (3.9-6.1 mmol/L) 7.98 Creatinine Cr (44-97?mol/L) 40.37 WBC 13.1 Neutral 86.5 Total bilirubin TBIL (2-19?mol/L) in normal subjects 14.04 Direct bilirubin DBIL (0-6.84?mol/L) 5.37 Indirect bilirubin IBIL (0-18?mol/L) 8.67 Proalbumin PA (160.0-360.0 mg/L) 211.75 Total protein TP (60-80 g/L) 72.26 Albumin ALB (35-55 g/L) 45.03 Choline Lipase CHE(3.93-10.8KU/L) 9.04 Albumin/Globulin ratio (A/G)(1.0-2.5) 1.65 Globulin GLB(20-45g/L) 27.23 AST:ALT(0.8-3.0) 2.01 Potassium K(3.5-5.5mmol/L) 3.62 Sodium Na(135-150mmol/L ) 137.00 Chlorine Cl(94-110mmol/L) 101.70 Total carbon dioxide TC02(22-32mmol/L) 24.71 Calcium Ca(2.03-2.54mmol/L) 2.51 Phosphorus P(0.96-1.62mmol/L) 1.12 Urea nitrogen BUN(2.2-7.2mmol/L) 3.67 Uric acid Ua(149-387?mol/L) 250.33 Amylase AMY(0-220KU/L) 72.57 Urea nitrogen/creatinine(0.03-0.10) 0.09 Anion gap(7.0-16.0mmol/L) 10.59 2009.3.4 07:13 7 hours since last checkup Civil Aviation General Hospital Abnormal subjects: Total Bile acid TBA(0-10umol/L) 57.18 Glutathione ALT(0-40IU/L) 508.84 Total bilirubin TBIL(2-19?mol/L) 37.37 Direct bilirubin DBIL(0-6.84?mol/L) 18.54 Glutathione AST(5-40IU/L) 905.05 Alkaline phosphatase ALP (42-105U/L) 140.67 Glutamyl transpeptidase GGT (10-40U/L) 739.26 Indirect bilirubin IBIL (0-18?mol/L) 18.83 Normal section current albumin PA (160.0-360.0mg/L) 209.76 Total protein TP (60-80g/L) 72.13 Albumin ALB (35-55g/L) 44.35 Cholinesterase CHE (3.93-10.8KU/L) 9.36 Albumin/Globulin ratio (A/G) (1.0-2.5) 1.60 Globulin GLB (20-45g/L) 27.78 AST:ALT (0.8-3.0) 1.78 2009.3.5 xx General Hospital Inpatient Abnormalities Subject. Glutathione(0-40U/L) 793 Total bilirubin(4.3-22.5umol/L) 46.2 Direct bilirubin(0-8.84umol/L) 18.4 Glutathione(0-40U/L) ? Alkaline phosphatase (20-110U/L) 240 Glutamyl transpeptidase (8-50U/L) 862.0 Total protein in normal subjects (60-80g/L) 79 Albumin (35-55g/L) 49.6 Blood glucose (3.9-6.1mmol/L) 5.05 Urea nitrogen (2.2-7.2mmol/L) 4.40 Creatinine (44.2-115umol/L) 54 115umol/L) 54 Cholinesterase (5400-13200U/L) 9337 Alglucosidase (0-40U/L) 29 Uric acid (119-416umol/L) 257 2009.3.6 xx General Hospital inpatient abnormalities: Glutathione transaminase (0-40U/L) 627 Total bilirubin (4.3-22.5umol/L) 24.70 Direct bilirubin (0-8.84umol/L) 11.10 Glutathione aminotransferase (0-40U/L) 234 Alkaline phosphatase (20-110U/L) 252 Glutamyl transpeptidase (8-50U/L) 770.0 Normal subjects Total protein (60-80g/L) 74.8 Albumin (35-55g/L) 47.0 Blood glucose (3.9- 6.1mmol/L) 4.68 Urea nitrogen (2.2-7.2mmol/L) 3.50 Creatinine (44.2-115umol/L) 70 Cholinesterase (5400-13200U/L) 8528 Rockosidase (0-40U/L) 27 Uric acid (119-416umol/L) 246 Amylase 37 2009.3.10 abnormal subjects in xx general hospital: glutaminase (0-40U/L) 126 total bilirubin (4.3-22.5umol/L) 30.10 direct bilirubin (0-8.84umol/L) 22.80 glutamic oxaloacetic transaminase (0-40U/L) 65 alkaline phosphatase (20-110U/L) 143 glutamyl transpeptidase (8-50U/L) 391.0 Total protein of normal subjects (60-80g/L) 77.6 Albumin (35-55g/L) 46.6 Blood glucose (3.9-6.1mmol/L) 4.51 Urea nitrogen (2.2-7.2mmol/L) 3.50 Creatinine (44.2-115umol/L) 52.0 Cholinesterase (5400-13200U/L) 8090 laccase (0-40U/L) 26 uric acid (119-416umol/L) 194 2009.3.16 xx General Hospital inpatient, discharged this day Abnormal subjects: alkaline phosphatase (20-110U/L) 114 glutamyl transpeptidase (8-50U/L) 200.0 Normal subjects glutaminase (0-40U/L) 26 total bilirubin ( 4.3-22.5umol/L) 10.90 Direct bilirubin (0-8.84umol/L) 3.70 Glutathione aminotransferase (0-40U/L) 19 Total protein (60-80g/L) 68.7 Albumin (35-55g/L) 43.2 Blood glucose (3.9-6.1mmol/L) 4.01 Urea nitrogen (2.2-7.2mmol/ L) 4.60 Creatinine (44.2-115umol/L) 55.0 Cholinesterase (5400-13200U/L) 7578 Rockosidase (0-40U/L) 37 Uric acid (119-416umol/L) 265 Since discharge from the hospital on March 16, he has been taking pentosidine capsules and ezetimibe capsules. Chen Xueqing, Department of Gastroenterology, The First Affiliated Hospital of Guangzhou Medical College: If all the test results you reported are accurate, your patient’s is a typical common bile duct stone with obstructive jaundice. It is possible that your small stones were excreted, or some of them were not. In any case, I think you should have similar or more severe symptoms (e.g. high fever, pancreatitis, etc.) within the next year or so. At that time you should tell your doctor about your condition this time and let your local doctor give you an ERCP+EST procedure. Patient: Thank you very much Dr. Chen for your reply, if my condition is stable is there no need for surgery for now. Also, the largest stone I have is only 0.8 and I have 2 in total. Some doctors also think that obstructive jaundice would not lead to such serious liver damage, and some say it is not food poisoning. It is strange that the transaminases rise quickly and fall quickly after medication. Chen Xueqing, Department of Gastroenterology, The First Affiliated Hospital of Guangzhou Medical College: Basically, the diagnosis of common bile duct stones can be confirmed, but for the time being, surgery is not needed because you have had severe pain once and probably all the stones have been drained. Basically, this kind of problem will definitely appear again. But now it is not necessary to do an ERCP for a stone that you are not completely sure exists, and it would be helpful if you remember this experience and tell the doctor who will see you next time in time. If the gallbladder stones are large and the gallbladder wall is hairy, laparoscopic removal is recommended. Another point is that you can have regular follow-up examinations, such as ultrasound examination of the liver and gallbladder once every six months or once a year. If problems are found, they can be dealt with in time. If a common bile duct stone is found, ERCP endoscopic minimally invasive stone extraction can be performed at an elective stage, without waiting for the next attack. Good luck. Patient: Doctor, the gallstones were found at BC the morning after the abdominal pain. That is, about 10 hours after the pain ended. It is not clear whether there were stones before that. I think there are still 2 left. Another question, do I have to continue with the hepatoprotective treatment, the baby is only 5 months old and I want to continue breastfeeding. Thank you for your kind help, it’s my first consultation and I met a good doctor, I’m touched. Patient: If my stone is expelled, won’t the remaining stone stay quietly in the gallbladder and will it definitely go back to the common bile duct? After the stone is expelled, why is the GGT in the liver function still not normal? Is there still a blockage? How can I tell that the duct has been cleared and is no longer blocked, and do I need to have a BC review soon? Sorry, I have a lot of questions. I will reply when you are not busy. I am glad to meet such a responsible doctor like you, as I have been to several hospitals in Beijing without any conclusion. Chen Xueqing, Department of Gastroenterology, The First Affiliated Hospital of Guangzhou Medical College: If the stone is in the gallbladder, there is no need to do it for now. If the stone is in the common bile duct, it is better to do ERCP to remove the stone electively in the near future to avoid another attack. In addition, liver preservation therapy is not needed. Your liver damage was originally caused by the obstruction of the common bile duct stones and, strictly speaking, there are no real liver-protective drugs in this world. The best way to protect your liver and protect your liver is to remove the cause of the disease. I am trying to work hard to be a good doctor and not complain about some of the knowledge I have learned in vain. Patient: Thank you Dr. Chen, you will definitely be a successful doctor. I have a very unprofessional question, the stone will be expelled with the intestine even when it reaches the common bile duct, right? Also, how can I determine where the stone is currently located and is BC inaccurate? Patient: I used an enzyme-lowering drug and my transaminases came down a lot immediately. Is it possible that the enzymes will come down even without this medication? I don’t know what condition my body is in, but I feel basically the same as a normal person, and occasionally I feel heartburn after eating. What other tests can be done to test the gallbladder. I don’t know if the transaminases will continue to go up if I stop the liver-protecting and enzyme-lowering drugs. Thank you! Chen Xueqing, Department of Gastroenterology, The First Affiliated Hospital of Guangzhou Medical College, Guangzhou, China: Your attack is caused by the outward discharge of stones from the common bile duct. In general, 1/10 of patients with gallbladder stones have common bile duct stones, and the rate of spontaneous drainage of common bile duct stones below 0.8CM is about 20%, and most of them cannot drain spontaneously, so ERCP is needed for stone extraction. The diagnostic rate of ultrasound for gallstones is less than 60%, especially for microscopic stones, and the rate of ultrasound diagnosis is very low (of course, it depends on individual technique). In our jargon, ultrasound endoscopy and ERCP are the best way to diagnose choledocholithiasis. Not only can ultrasound endoscopy accurately diagnose choledocholithiasis, but it can also effectively avoid unnecessary ERCP because ERCP is a risky intervention after all. If you are interested, you can read my scientific articles (which are also considered as learning to serve patients). Chen Xueqing, Department of Gastroenterology, The First Affiliated Hospital of Guangzhou Medical College: Heh, the so-called liver-protective and enzyme-lowering drugs can all be stopped. Patient: Thank you, I’ve been bothering you all night. I saw a strong magnetic patch of bile clear sold online, I don’t know if I can trust it. Chen Xueqing, Department of Gastroenterology, The First Affiliated Hospital of Guangzhou Medical College: I won’t look at those things. As a doctor, I still believe in what we have proven to be effective in practice, or what is introduced in our professional magazines, because these contents are also tested. What I want to tell you is that so far, no drugs have really shown to dissolve gallstones. If they really have that ability, they don’t need to be advertised, we doctors will give them to use and promote them, because it is indeed something that merits no light. Patient: Dr. Chen, I had my liver function rechecked today. It’s been 10 days since I was last discharged from the hospital. It turns out that Glut C 39 (26 last time) and Glut Grass 47 (19 last time) are both elevated, but Glutamyl Transaminase has come down a bit from 200 to 105, but it hasn’t reached the normal value. What should I do? Can I breastfeed? Also, are the bile ducts still congested? What should I do if the enzyme continues to rise after stopping the hepatoprotective medication? I don’t feel any other discomfort. Thank you. Patient: Is there any medicine to unblock the bile ducts? I am very anxious, my child is still waiting for milk. There is a dietary treatment of lemon juice and apple juice with olive oil on the internet, is it possible to try it. Thank you! Chen Xueqing, Department of Gastroenterology, The First Affiliated Hospital of Guangzhou Medical College, Guangzhou, China: There is no discomfort, and neither glutathione nor glutamic acid has shown any major abnormality, and glutamyl transaminase has come down. Your enzymes are down not because of liver-protective drugs, but because your bile ducts are open. Stop taking all your medications due to breastfeeding. I would have recommended that you take Usfer, but you can also do without it. You should now do what you need to do in Beijing dialect. Patient: Thank you Dr. Chen, then I will go back in a few days to review my liver function. I’m always a little worried when I see enzyme rebound, thinking it’s blocked again or not completely clear or something. I don’t know how long it will take for the transaminases to completely drop to my previous level after the bile ducts are open, because the transaminases were in the mid-teens in previous physical exams, and it’s the first time I’ve had such a terrible disease, so I’m a little scared. In addition, if it is high for a long time, I am worried about the damage to my liver. Chen Xueqing, Department of Gastroenterology, The First Affiliated Hospital of Guangzhou Medical College: Actually, I hope you will donate this examination fee to Project Hope:-). Patient: Dr. Chen is so humorous, I just can’t stand any disease, I think about it all the time, and I ask the doctor a lot of questions, I always want to find out what’s going on before I get down to earth. It’s a pity I didn’t study medicine, huh? The last question is, if I have another attack, should I operate immediately, it won’t be too late to go into shock, right? I’m really afraid to go to the wrong hospital to delay, can the emergency room do surgery, or can temporary relief through the infusion, I’m afraid. The pain is vivid in my memory as my lips turn purple and I have difficulty breathing. Chen Xueqing, Department of Gastroenterology, The First Affiliated Hospital of Guangzhou Medical College: If similar morbidity occurs again, you have to do ERCP + EST for stone extraction, which is minimally invasive endoscopic stone extraction. The following paragraph is my copy of the answer I gave you above, which is already very comprehensive, so please read another one: Basically, you can be sure of the diagnosis of common bile duct stones, but for the time being, you don’t need surgery because you have had severe pain once and probably all the stones have been removed. Basically, this kind of problem will definitely reappear. But now it is not necessary to do an ERCP for a stone that you are not completely sure exists, and it would be helpful if you remember this experience and tell the doctor who will see you next time in time. If the gallbladder stones are large and the gallbladder wall is hairy, laparoscopic removal is recommended. Another point is that you can have regular follow-up examinations, such as ultrasound examination of the liver and gallbladder once every six months or once a year. If problems are found, they can be dealt with in time. If a common bile duct stone is found, ERCP endoscopic minimally invasive stone extraction can be performed at an elective stage, without waiting for the next attack. Good luck. Patient: Thank you Dr. Chen for your help in answering questions on the internet. Thank you very much! I wish you happy work and good health. Chen Xueqing, Department of Gastroenterology, The First Affiliated Hospital of Guangzhou Medical College: You are welcome.