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Liver & Pancreas Disorders Message Board


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In continuing question to find out the source of my epigastric and mid-back pain (after having my gallbladder out), I bought some urine test strips. These test for many different things, including bilirubin.

My bilirubin levels keep showing up on the test strips at the highest level on the strip (or, sometimes later in the day, at the 2d highest level). I also have measured very high urine density, and occasionally the strips show trace levels of protein and WBCs.

I mentioned the high bilirbuin level to my gastroenterologist, and he wasn't concerned.

I think this is evidence of an obstructed biliary tract -- I am going in for ERCP soon.

Past blood tests (several weeks ago) showed normal bilirubin levels.

Is it possible to have high bilirubin in the urine, but not the blood? And if so, is that OK?
From what I know, if the bile ducts are obstructed, direct bilirubin will build up to a high enough level that some of it will escape from the liver into the blood. If the levels are high enough, some of it will also appear in the urine. Only direct bilirubin appears in the urine. Increased direct bilirubin usually means that the biliary (liver secretion) ducts are obstructed. Also, some say that high doses of vitamin B can cause it but others say it may help get rid of excess bilirubin.
Thanks, actudan.

I finally read elsewhere that docs aren't too concerned about readings of high bilirubin in urine unless the blood test also shows high levels. Apparently, some things can cause "false positives" in urine bilirubin readings -- things as simple as vitamin C. So, I won't worry about it for now.

Of course, it's not like I'm asymptomatic... I've been having terrible mid-back and upper right quadrant pain since early April. Had my gallbladder out (no stones), and no relief. Am waiting to be scheduled for ERCP. So, when I discovered the high bilirubin levels, I thought it might confirm some kind of biliary obstruction that's causing my continued pain, but apparently my last blood work (3 weeks ago) was normal, and the same pain has continued...
Hi:

Clinical signs of bile duct obstruction include jaundice (yellow discoloration of the skin, easiest to detect in the whites of the eyes), and dark discoloration of urine. More worrisome symptoms include fever, that may be indicative of an obstructed, infected bile duct. Of course pain can also occur.

You should definitely have your blood checked in addition to urine in order to look for evidence of bile duct obstruction.

You need to be careful about ERCP. This procedure has a real chance of causing serious complications. Evaluation of right-upper quadrant abdominal pain usually requires additional work-up. If there is evidence of bile duct dilation on ultrasound, CT, or MRI, an ERCP might be justified.

Nowadays, diagnostic ERCP has been largely replaced by MRI/MRCP (a special magnetic resonance imaging protocol that allows reconstruction of images representative of bile and pancreas duct anatomy).

Endoscopic ultrasound (EUS) is another means for evaluation of the bile ducts and pancreas. EUS has a far more favorable complication profile than ERCP. We have descriptions of these procedures on our site at www.eus.ucla.edu.

From what I hear, your blood bilirubin levels were normal (though I don't know about your AST/SGOT, ALT/SGPT, ALP levels). You had no gallstones, and yor gallbladder surgery did not improve your symptoms. In short, I did not hear anything that would objectively necessitate an ERCP. The presence of WBC and protein in urine deserve further workup (e.g. urinary tract infection and other kidney problems).

HTH

Navid
Thanks, GIMDinLA.

My blood work (at least as of a few weeks ago) has been normal, but the pain that sent me in for gallbladder surgery continues. Mostly mid-back, and some epigastric pain. Occasionaly have RUQ twinges, but that is secondary to the pain I feel. It tends to follow eating, and woke me up last night (last night was a bad night).

My gastroenterologist thinks my symptoms suggest Sphincter of Oddi Dysfunction; hence, the recommendation for an ERCP. He said that Sphincter of Oddi dysfunction can cause the gallbladder to have a low ejection fraction (mine was 16%) in the absence of stones. I am also aware that this procedure may not be for me, since my liver enzymes aren't elevated (as far as I know).

I had a MRCP, and it did not reveal any abnormalities. My Dr. said, however, that an MRCP cannot definitively diagnose or rule out Sphincter of Oddi dysfunction.

I am frustrated, b/c my pain continues, yet the tests (so far) haven't diagnosed my problem... any other thoughts you may have are welcome.

Thanks.
Then they are suspecting type-III SOD

Type-I: pain, duct dilation and abnormal blood tests
Type-II: pain, either duct dilation of abnormal blood tests
Type-III: pain alone, without dilation of ducts or blood test abnormalities

Type III is the most controversial and commenting any further would not be appropriate for such a forum. In any case, you should make sure that your doc is experienced in ERCP with manometry and prophylactic pancreatic duct stenting - you fulfill a number of criteria that predicted a high risk of post-ERCP pancreatitis in some studies, namely, female gender, normal ducts (since your MRCP was normal) and suspected SOD.

Good luck ...
Thanks again, GIMDinLA... I've done a lot of reading, and your comments are completely consistent with what I've read.

The doctor I've been referred to is at Scott & White in Temple, and according to my doctor, he is supposed to be one of the best in the country, so I feel I am in good hands either way...





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