Expert: Ronald Levy, M.D. - 5/24/2008

Question
QUESTION: Dr. Levy,
My husband has been diagnosed with Cholestatic Jaundice.  Recent labwork still resulting in high levels of total bilirubin; direct bilirubin; alka phosphotase; and low levels of albumin.  He will be having a livery biopsy tomorrow.  Our GI Specialist believes the diagnosis stems from an adverse reaction to the Fentanyl (225 mcg) and Versed (9 mg) used for his colonoscopy procedure (which was done on April 14, 2008, with symptoms starting 1-2 days after the colonoscopy and progressively getting worse). Two abdominal ultrasounds and one MRI/MRPC were done.  We were assured on 2 occasions there is no detection of cancer.  My husband was also taking Verapamil  for about 10 days prior to the colonoscopy, to treat cluster headaches.  The liver biopsy is being performed because they are not comfortable with the very slow rate of the decrease in bilirubin levels.  Are you familiar with such a severe reaction to the anesthesias used?  Thank you in advance for your thoughts.

ANSWER: I don't know where he gets that idea. I don't know of any studies that have linked either drug to liver problems. It is true that both drugs should be used with caution in patients that have liver failure (that is how the drug is metabolized) but neither drug to my knowledge causes liver problems.

Ronald Levy, MD
Associate Professor of Anesthesiology
UTMB-Galveston

---------- FOLLOW-UP ----------

QUESTION: Dear Dr.Levy,
Thank you so much for your prompt response.  To update you, interestingly enough the radiologist who performed the biopsy yesterday, and took 6 pieces (and this was painfully done without any anesthesia due to the liver problems)suggested in a short comment to us prior to the procedure that his thoughts are this could be viral.  Viral was initially mentioned, but then basically disregarded as the cause.  The total bilirubin levels dropped to 8.0 the day prior to the liver biopsy. They initially were 12.4, then 11.4, then 10.9, then 9.3 then 8.0 as of 2 days ago.  He has been and still is taking Cholestyramine 3-4 (6 were too much)scoops daily to assist in reduction and to help ease the itching we're told.  I have found nothing in my "research", being a lay-person, that ties the 2 anesthesias to be the cause of this situation.  My husband was a healthy, strong man, had a complete annual physical about one month prior to the colonoscopy with all results being good.  He tested negative for Hep A and B 3-1/2 weeks ago.  In your opinion, could the cause by viral?  It seems likely it has something to do with the colonoscopy since all symptoms occurred after.  Other causes (i.e.; drug use, drinking, etc) have been asked to him and ruled out because it's not his history).  Thank you again should you have the time to give me your thoughts.

ANSWER: The most likely cause of liver problems (not related to drinking, etc) is viral so my guess is that it should be looked into. I don't think it is related to the colonoscopy because there is no relationship between the 2. It is probably coincidental.

Ronald Levy, MD
Associate Professor of Anesthesiology
UTMB-Galveston

---------- FOLLOW-UP ----------

QUESTION: Dear Dr. Levy,
In following-up again, we were told his gallbladder and common bile duct "contracted" due to the anesthesias.  The last ultrasound showed the bile duct had widened a very little bit, although still quite narrow, and the gallbladder still has sludge in it.  In your opinion, would removing the gallbladder be a safe option with his liver enzymes being what they are currently, if the the doctors do conclude at some point it's safe to use anesthesia again? This of course being if they conclude the gallbladder needs to be removed.  And would removing the gallbladder allow the bilirubins to get "back on track" for proper excretion and to ease the itching, jaundice, etc.  We have been told what is happening with him now will not do damage to any other organs, and no permanent damage to the liver. Your thoughts please?   Again, thank you in advance for your time and input.

Answer
Removing the gallbladder will have no effect on lowering the billirubin as the gall bladder is just a storage facility. The common duct is not removed with the gall bladder so that problem will still remain. As for whether they should remove the GB, that is up to you. The fact that it has sludge in it is an indication for removal but it's not mandatory.  There should be no problem with the anesthesia as I still don't believe the anesthesia was the problem. Once they rule out viral causes then anesthesia should not be a problem.

Ronald Levy, MD
Associate Professor of Anesthesiology
UTMB-Galveston