Common bile duct stenosis from chronic pancreatitis: a clinical and pathologic spectrum

The chronic pancreatitis population of Wadsworth VA Hospital over the past five years was screened for two-fold or greater alkaline phosphatase elevation at any time during their course, as a marker for either distal common bile duct stenosis or other hepatobiliary disease. Forty-seven of 207 patients screened met this criterion and are reviewed in detail. Of the 16 patients with persistent alkaline phosphatase elevation (group B), 15 had proven common bile duct stenosis, demonstrating a clear pathophysiologic role of partial bile duct obstruction in their liver disease. Three had developed secondary biliary cirrhosis, marking this entity the commonest cause of secondary biliary cirrhosis at our hospital. Of the remaining 31 patients with transient alkaline phosphatase elevation (group A), only 4 had proven duct abnormalities which may resolve during recovery. Alcoholic liver disease was demonstrated with normal extrahepatic ducts in the remainder in group A adequately studies. Persistent greater than two-fold alkaline phosphatase elevation in pancreatitis thus represents a reliable marker of distal common bile duct stenosis, whose sequelae may include cholangitis and secondary biliary cirrhosis and which requires operative intervention in these cases. When a persistent alkaline phosphatase elevation greater than two-fold is encountered in a chronic pancreatitis patient, adequate cholangiography and liver histology are both necessary to confirm and grade this frequent and treatable complication.     

Pressure measurements from biliary and pancreatic segments of sphincter of oddi

Using a minimally compliant infusion system and a triple-lumen pressure recording catheter, we obtained endoscopic manometric measurements from both the common bile duct and pancreatic duct segments of the sphincter of Oddi (SO) in 58 patients. Fifteen patients (ages 27–69) had the diagnosis of functional abdominal pain, 19 patients (ages 30–76) had partial biliary obstruction, and 24 patients (ages 15–80) had idiopathic acute recurrent pancreatitis. Resting ductal pressure was similar in the common bile duct and pancreatic duct in all patient groups. In the group with functional pain, basal SO pressure was similar, whether obtained from the common bile duct or pancreatic duct sphincteric segment. Eight of 19 patients with partial biliary obstruction had elevated basal SO pressure. Five of these eight patients had elevated basal SO pressure confined exclusively to the common bile duct segment of the sphincter, while three patients had elevated basal SO in both segments. Conversely seven of 24 patients with acute recurrent pancreatitis had an elevated basal SO pressure, with five patients having pressure elevation only in the pancreatic duct segment while two patients had abnormal basal SO pressure in both segments. We conclude that selective cannulation of the common bile duct and/or the pancreatic duct during manometric study of the SO is necessary in order to diagnose segmental SO dysfunction responsible for partial biliary obstruction or episodes of acute recurrent pancreatitis.     

Value of ultrasound and liver function tests in determining the need for endoscopic retrograde cholangiopancreatography in unexplained abdominal pain.

The value of serum liver function tests and abdominal ultrasound as screening tests of the need for endoscopic retrograde cholangiopancreatography (ERCP) was determined in patients with unexplained abdominal pain without associated jaundice. In 1989 and 1990 1005 ERCPs were undertaken, of which 138 (14%) were for this indication. The duct or ducts of interest were delineated by ERCP in 95% of patients. The lesions found were bile duct stones in 10 patients, chronic pancreatitis in five, pancreatic carcinoma in one, peptic ulcer or duodenitis in four. A satisfactory ultrasound examination had been performed in 94% of patients. For chronic pancreatitis, its sensitivity was 60% and specificity 95%. For choledocholithiasis, the ultrasonic detection of duct dilatation or stones had a sensitivity of 90% and specificity of 86%. Of the liver function tests, the alkaline phosphatase was more sensitive (67%) than the transaminases (44%) in indicating the presence of bile duct stones and had a high specificity (95%). None of the 10 patients with duct stones had normal ultrasound and normal alkaline phosphatase. Thus it was found that demonstration of a normal common bile duct by abdominal ultrasound and normal serum alkaline phosphatase together have 100% specificity in excluding bile duct stones. Using such knowledge over the two year period of this study would have spared 36 patients the need for ERCP.     

A case of carcinoma of the common bile duct, diagnosed at the non-icteric stage of the disease

It is rather seldom to detect a cancer of the common bile duct at the non-icteric stage of the disease. This report presents a non-icteric case of carcinoma of the choledochus. A 70-year-old woman complained of r-hypochondralgia with occasional fever. Laboratory examination revealed an increased serum alkaline phosphatase activity without any elevation of serum bilirubin content. The oral cholecystography failed to visualize the gallbladder. By endoscopic retrograde cholangiopancreatography (ERCP), a bilateral filling defect was demonstrated at the common bile duct. Pancreatoduodenectomy was performed and the resected specimen showed a 1 X 2 cm tumor (adenocarcinoma) at the choledochus. She is now in good health over 13 months after operation.     

Rapid diagnosis of choledocholithiasis using biochemical tests in patients undergoing laparoscopic cholecystectomy.

BACKGROUND/AIMS: The present study was designed to identify the biochemical tests which could detect the presence of common bile duct stones in patients with symptomatic gallstones, without other invasive investigations. The usefulness of biochemical tests may reduce the necessity of endoscopic retrograde cholangiopancreatography prior to laparoscopic cholecystectomy. METHODOLOGY: 3000 patients with symptomatic laparoscopic cholecystectomy scheduled for laparoscopic cholesystectomy were included in the study. 458 patients (201 men, 257 women; mean age, 57.7 +/- 14.6 yrs) were examined with endoscopic retrograde cholangiopancreatography for suspected common bile duct stones. The serum tests for liver function, including a measurement of aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, total bilirubin, direct bilirubin, gamma-glutamyltransferase and albumin were obtained on admission prior to the ultrasonography, and the endoscopic retrograde cholangiopancreatography. RESULTS: The six significant factors, including alkaline phosphatase, direct bilirubin, total bilirubin, aspartate aminotransferase, alanine aminotransferase and gamma-glutamyltransferase were identified by the univariate analysis and the multivariate logistic regression analysis which identified alkaline phosphatase and gamma-glutamyltransferase, as the two significant independent factors. A statistical model was developed with a formula of [formula: see text] A curve of receiver operating characteristics was constructed to identify an alkaline phosphatase level greater than 300 U/L or a gamma-glutamyltransferase level greater than 420 mU/mL which would have both higher sensitivity and specificity. CONCLUSIONS: Biochemical tests can be a significant aid to the clinician's decision-making when predicting the presence of common bile duct stones in patients with gallstones.     

Hepatobiliary complications in chronic pancreatitis.

Thirty nine patients undergoing surgery for chronic pancreatitis were investigated for evidence of hepatobiliary disease. In addition to pre-operative assessment by liver function tests, ultrasound, ERCP (in 33) and percutaneous transhepatic cholangiography (in five), all had peroperative liver biopsy. Common bile duct stenosis was diagnosed in 16 (62%) of the 26 patients with successful cholangiography. Features of extrahepatic biliary obstruction were found on biopsy in 11 patients, three of whom showed features of secondary sclerosing cholangitis. No patients had secondary biliary cirrhosis. Three had parenchymal liver disease (cirrhosis, resolving hepatitis and alcoholic hepatitis respectively) and two others had features suggestive of previous alcohol-induced injury. Five (83%) of the patients with clinical jaundice had biopsy features of extrahepatic biliary obstruction, as did eight (67%) with alkaline phosphatase above twice normal and seven (44%) with radiological common bile duct stenosis. Neither alkaline phosphatase rise, nor common bile duct stenosis alone or in combination, were a reliable indication of the need for biliary enteric bypass surgery. Pre-operative liver biopsy may be a valuable adjunct in the assessment of such patients.     

Hepatic fibrogenic activity in chronic alcoholic pancreatitis.

The prevalence and the mechanisms of hepatic fibrosis in chronic alcoholic pancreatitis remain uncertain. The aim of this study was to investigate the fibrogenic activity of the liver in patients with chronic pancreatitis and its relation with either the alcohol or cholestasis. Liver biopsies were obtained from 16 patients with chronic pancreatitis at the time of surgery and from 10 organ donors. Samples were processed for histologic examination to assess the presence and extent of fibrosis, inflammatory reactions, and cholestasis- and alcohol-related lesions. In other samples, the collagen content was measured by morphometry, and prolylhydroxylase activity was determined. Liver-function tests, ultrasonography, and endoscopic retrograde cholangiopancreatography were performed before surgery in all the patients. Of patients with chronic pancreatitis, 75% had significantly greater hepatic fibrosis and prolylhydroxylase activity than the control group. Moreover, prolylhydroxylase activity in patients with chronic pancreatitis was higher in those with cholestasis or partial obstruction of the common bile duct than in those without cholestasis or partial obstruction of the common bile duct. Both the fibrogenic activity and the collagen content in the livers of patients with chronic alcoholic pancreatitis are significantly increased, even in those without histologic lesions, and these alterations may be secondary to a partial occlusion of the common bile duct.     

Choledocholithiasis in patients with normal serum liver enzymes

Retrospective chart review of 330 patients undergoing ERCP over a two-year period yielded five patients with choledocholithiasis whose serum liver enzyme and total bilirubin levels were repeatedly normal. All were female, three were elderly, and the gallbladder wasin situ in three of the five, one of whom had a large gallbladder remnant. In four patients, the common bile duct was dilated (>10 mm), whereas none had intrahepatic duct dilatation. Four patients had a prominent ampulla, and stone size varied widely. Each patient was managed with endoscopic sphincterotomy and stone extraction followed by cholecystectomy for the four patients with the gallbladder or its remnantin situ. This small series proves that common duct stones may exist in patients with repeatedly normal serum liver enzyme and total bilirubin levels. We hypothesize that marked dilatation of the common bile duct or gallbladder may serve as a pressure sump and blunt liver enzyme elevation. Normal liver enzymes should not dissuade one from performing cholangiography in patients with suspected choledocholithiasis.     

Differential diagnostic evaluation of chronic pancreatitis in relation to pancreatic cancer based on clinical, laboratory chemical and diagnostic parameters. Studies of 174 patients in 10 years

174 patients with chronic pancreatic diseases, 30 patients with pancreatic carcinoma and 144 with chronic relapsing pancreatitis, 50 of them with calcifications, were observed in the Department of Internal Medicine of the University of Marburg/FRG between 1972 and 1982. In order to differentiate between carcinoma and relapsing pancreatitis the data of these patients were analysed retrospectively with regard to patient history, actual complaints, findings of laboratory, sonography, ERCP and X-ray investigations. The following results were obtained: Of discriminating value are steatorrhoe, local palpatory pain, alcohol ingestion, a history of earlier attacks and relapsing pain situations; however, general abdominal pain, nausea, vomiting and weight loss (if not exactly specified) are not. Within the laboratory findings bilirubin, GOT, alkaline phosphatase, gamma-GT, serum potassium, blood sugar and chymotrypsin content of the stool were significant while serum and urine amylase were similarly distributed within the groups of patients. Carcinoma and chronic relapsing pancreatitis can be identified by sonography in the majority of patients, but calcifications of the pancreas were rarely demonstrated during this observation period. The obstruction of the extrahepatic bile ducts--mostly due to a carcinoma of the pancreas head--was usually well documented by sonography. Intraabdominal air proofed to be the most disturbing factor. In carcinoma patients, the ERCP is important in demonstrating a complete obstruction of the pancreatic duct and stenosis and dilatation of the extrahepatic bile ducts. In patients with chronic relapsing pancreatitis the pancreatic duct alterations such as dilatations and partial stenosis are well documented by ERCP especially if calcifications occur. In patients without calcifications, dilatation of the branches of the main duct are less relevant in the diagnosis of pancreatic diseases. Radiological demonstration of calcification of the pancreatic area is important for the differential diagnosis. Longstanding characteristical complaints, symptoms and calcifications within the pancreatic area are the most relevant factors in discriminating carcinoma and chronic relapsing pancreatitis.     

Gallstone Pancreatitis: A Prospective Study on the Incidence of Cholangitis and Clinical Predictors of Retained Common Bile Duct Stones

Objective: The aim of this study was to define the incidence of cholangitis in gallstone pancreatitis, in the absence of cholangitis, to identify the clinical predictors of persistent common bile duct (CBD) stones at endoscopic retrograde cholangiography (ERCP) or at intraoperative cholangiography (IOC).
Methods: A total of 122 consecutive patients with acute gallstone pancreatitis were prospectively evaluated for the presence of CBD stones as determined by elective ERCP or IOC. Urgent ERCP was restricted to patients with concomitant cholangitis. APACHE II scores and serial laboratory data were obtained.
Results: Four (3%) patients had cholangitis and all underwent urgent ERCP successfully. Eighteen (15%) patients without cholangiogram were excluded. The remaining 100 patients underwent elective ERCP or IOC on a mean of hospital day 6.8. Twenty-one (21%) patients had persistent CBD stones. Univariate analysis detected significant differences in serum total bilirubin, ALT, and alkaline phosphatase levels between patients with and without persistent CBD stones. On multivariate analysis, serum total bilirubin on hospital day 2 was the best predictor of CBD stones. A serum total bilirubin level > 1.35 mg/dl had a sensitivity of 90.5% and specificity of 63%. Age, gender, mean APACHE II score, amylase, and presence of CBD dilation on ultrasound were not predictive of CBD stones.
Conclusions: In patients with gallstone pancreatitis, 1) cholangitis is uncommon, and 2) the best clinical predictor of persistent CBD stones is serum total bilirubin on hospital day 2.     

Studies in obstructive jaundice

Acute obstruction of the extrahepatic ducts causes gross proximal duct dilatation, and elevated levels of ornithine carbamyl transferase, bilirubin, and alkaline phosphatase.Slow progressive obstruction causes variable proximal duct dilatation and in these cases bilirubin, alkaline phosphatase, and ornithine carbamyl transferase return to normal, despite the presence of severe though incomplete obstruction of the common duct and microscopic findings of biliary cirrhosis. In the early phases, ornithine carbamyl transferase is a slightly more sensitive indicator of biliary obstruction than alkaline phosphatase or bilirubin, but the values still return to normal in the face of a persistent stricture.If a patient who has previously had common duct surgery develops recurrent episodes of fever which suggest cholangitis, it should be assumed that he has a recurrent stricture, even though a cholangiogram and liver function may be normal or only slightly altered. A delay until the liver function studies show consistently raised levels may result in severe biliary cirrhosis and decreased hepatic reserve.     

Marked increase in serum bilirubin in sickle cell anemia

Six patients with sickle cell anemia developed extremely high levels of serum bilirubin. In 4 instances, the elevated levels occurred during an episode of viral hepatitis. Two cases occurred at the time of common bile duct obstruction. The heavy burden of pigment resulting from increased red cell destruction was thought to lead to extreme hyperbilirubinemia, when combined with acute hepatic damage or common bile duct obstruction. Under similar circumstances, increased hemolysis from any cause may lead to markedly elevated levels of serum bilirubin.     

Utility of Endoscopic Retrograde Cholangiopancreatography in the Evaluation of Idiopathic Abdominal Pain

We investigated the role of endoscopic retrograde cholangiopancreatography in 86 consecutive patients with idiopathic chronic or recurrent abdominal pain. There were 18 males and 68 females with a mean age of 48 yr. Forty patients (47%) had previous cholecystectomy. Patients were divided into two groups: group I (normal serum alkaline phosphatase and total bilirubin) (n = 52), and group II (elevated serum alkaline phosphatase and/or total bilirubin) (n = 34). Panereatograms were normal in all patients, including five with pancreas divisum. Cholangiograms were abnormal in 10 of the 34 patients in group II (30%), and in only three of the 52 patients in group I (6%) ( p = 0.003). Bile duct stones were present in 18% of the patients in group II, and in none of the patients in group I ( p = 0.003). Of the 40 post-cholecystectomy patients, four patients had bile duct stones and five had common bile duct dilation without stones. However, no stones were found in any post-cholecystectomy patients with normal liver tests. Of the 46 patients with gallbladder in situ , two patients with abnormal liver tests had common bile duct stones and two patients had common bile duct dilation without stones. These results indicate that, among patients with idiopathic abdominal pain, cholangiography should be performed primarily in those with abnormal liver tests; however, further investigation with pancreatography is unnecessary.     

Unexpected metastasis of intraductal papillary neoplasm of the bile duct without an invasive component to the brain and lungs:A case report

BACKGROUND Despite an expanding number of studies on intraductal papillary neoplasm of the bile duct(IPNB),distant metastasis remains unexplained especially in cases of carcinoma in situ.In the present study,we report a rare and interesting case of IPNB without invasive components that later metastasized to lungs and brain.CASE SUMMARY A 69-year-old male was referred to our hospital due to suspected cholangiocarcinoma.Laboratory tests on admission reported a mild elevation of alkaline phosphatase,γ-glutamyl transpeptidase,and total bilirubin in serum.Endoscopic retrograde cholangiography revealed a filling defect in the common bile duct(CBD)extending to the left hepatic duct.Peroral cholangioscopy delineated a tumor in the CBD that had a papillary pattern.Multidetector computed tomography and magnetic resonance cholangiopancreatography detected partial blockage ot interlude in the CBD leading to cholestasis without evidence of metastasis.Therefore,a diagnosis of IPNB cT1N0M0 was established.Left hepatectomy with bile duct reconstruction was performed.Pathological examination confirmed an intraepithelial neoplasia pattern without an invasive component and an R0 resection achievement.The patient was monitored carefully by regular examinations.However,at 32 mo after the operation,a 26 mm tumor in the lungs and a 12 mm lesion in the brain were detected following a suspicious elevated CA 19-9 level.Video-assisted thoracoscopic surgery of left upper lobectomy and stereotactic radiotherapy are indicated.In addition to histopathological results,a genomic profiling analysis using whole exome sequencing subsequently confirmed lung metastasis originating from bile duct cancer.CONCLUSION This case highlights the important role of genomic profiling analysis using whole exome sequencing in identifying the origin of metastasis in patients with IPNB.     

Serum transaminase levels and cholescintigraphic abnormalities in acute biliary tract obstruction

Twenty-five patients presenting to the hospital with symptoms suggestive of acute biliary tract disease were noted to have a characteristic pattern of transaminase and cholescintigraphic abnormalities. There was marked variability in the initial serum transaminase levels; however, 16 patients had aspartate aminotransferase levels greater than 300 IU, and 19 patients had alanine aminotransferase values greater than 300 IU. Regardless of the initial values, there was a 76% (aspartate aminotransferase) and 58% (alanine aminotransferase) reduction in transaminase levels within 72 hours, prior to therapeutic relief of bile duct obstruction. In ten patients with common bile duct obstruction, cholescintigraphy revealed no excretion of technetium Tc-99m-labeled iminodiacetic acid, for up to two hours after injection, into the extrahepatic biliary tract or small bowel. Common bile duct stones were present in 16 patients, five patients had acute pancreatitis, and four patients were thought to have spontaneously passed common duct stones. We believe that high transaminase levels may be found in patients with obstructive biliary tract disease, sequential measurements of transaminase levels may provide an important diagnostic clue for biliary tract disease, and nonexcretion of radionuclide on cholescintigraphy may be a feature of acute bile duct obstruction.     

Endoscopic pancreatography in chronic pancreatitis of the tropics

The ERCP findings in 13 patients with chronic pancreatitis of the tropics are reported. 7 of the patients had pancreatic calculi on plain film of abdomen and 6 had no calcification. The changes observed in the pancreatograms were tortuosity, dilatation, stenosis, obstruction, cyst formation and presence of calculi in the main pancreatic ducts and their finer branches. The calcific variety showed a greater degree of ductal derangement compared to the non-calcific variety. The common bile duct was normal in all the patients. The pancreatographic changes observed are similar to those described in the alcoholic and other varieties of chronic pancreatitis.     

Newly developed autoimmune cholangitis without relapse of autoimmune pancreatitis after discontinuing prednisolone

A 57-year-old man presented with a 2-wk history of painless jaundice and weight loss. He had a large ill-defined enhancing mass-like lesion in the uncinate process of the pancreas with stricture of the distal common bile duct. Aspiration cytology of the pancreatic mass demonstrated inflammatory cells without evidence of malignancy. Total serum immunoglobulin G level was slightly elevated, but IgG4 level was normal. After the 2-wk 40 mg prednisolone trial, the patient’s symptoms and bilirubin level improved significantly. A follow-up computed tomography (CT) scan showed a dramatic resolution of the pancreatic lesion. A low dose steroid was continued. After six months he self-discontinued prednisolone for 3 wk, and was presented with jaundice again. A CT scan showed newly developed intrahepatic biliary dilatation and marked concentric wall thickening of the common hepatic duct and the proximal common bile duct without pancreatic aggravation. The patient’s IgG4 level was elevated to 2.51 g/L. Prednisolone was started again, after which his serum bilirubin level became normal and the thickening of the bile duct was resolved. This case suggests that autoimmune pancreatitis can progress to other organs that are not involved at the initial diagnosis, even with sustained pancreatic remission.     

Complete obstruction of the lower common bile duct caused by autoimmune pancreatitis: is biliary reconstruction really necessary?

Recent observations suggest that an immune response is involved in the development of chronic pancreatitis. We report a case of autoimmune pancreatitis in a patient who showed complete obstruction of the lower common bile duct. A 63‐year‐old man was admitted to a local hospital, complaining of appetite loss and back pain. The patient had obstructive jaundice, and percutaneous transhepatic gallbladder drainage was performed. Fluorography through the biliary drainage catheter showed complete obstruction of the lower common bile duct. The patient had no history of alcohol consumption and no family history of pancreatic disease. Physical examination revealed an elastic hard mass palpable in the upper abdomen. Abdominal ultrasound and abdominal computed tomography (CT) scans showed enlargement of the pancreas head. While autoimmune pancreatitis was highly likely, due to the patient's high serum immunoglobulin level, the possibility of carcinoma of the pancreas and/or lower common bile duct could not be ruled out. Laparotomy was performed, and wedge biopsy samples from the pancreas head and body revealed severe chronic pancreatitis with infiltration of reactive lymphocytes, a finding which was compatible with autoimmune pancreatitis. Cholecystectomy and biliary reconstruction, using choledochojejunostomy, were performed, because the complete bile duct obstruction was considered to be irreversible, due to severe fibrosis. After the operation, prednisolone (30 mg/day) was given orally for 1 month, and the entire pancreas regressed to a normal size. Complete obstruction of the common bile duct caused by autoimmune pancreatitis has not been reported previously; this phenomenon provides an insight into autoimmune pancreatitis and provokes a controversy regarding whether biliary reconstruction is needed for the treatment of complete biliary obstruction caused by autoimmune pancreatitis.     

超声诊断肝吸虫病性胆道梗阻患者临床研究*

目的 分析和总结肝吸虫病性胆道梗阻的超声检查表现及其对临床治疗的指导价值。方法 2012年1月~2018年11月我院消化内科和普外科收治的30例肝吸虫病性胆道梗阻患者,均接受超声检查。给予患者吡喹酮正规治疗,对驱虫治疗后仍存在胆道梗阻者,行内镜下胆总管切开手术治疗。结果 肝吸虫病性胆道梗阻患者胆管管壁增厚,肝内胆管扩张程度均严重,常合并胆总管病变;本组吡喹酮治疗成功率为63.3%,11例接受手术治疗,均获得成功;治疗前,本组患者血清总胆红素、天冬氨酸氨基转移酶和丙氨酸氨基转移酶水平分别为(56.1±13.9)μmol/L、(151.2±67.8)U/L和(74.3±30.7)U/L,治疗后恢复到【(13.3±1.3)μmol/L、(91.5±39.2)U/L和(32.7±14.3)U/L,P<0.05】;术后,4例患者发生急性胰腺炎,5例患者出现高淀粉酶血症。经2~10 d治疗,均治愈。结论 肝吸虫病性胆道梗阻的早期超声诊断以管壁增厚和肝内胆管扩张为特点,结合病史,可以帮助诊断。吡喹酮治疗肝吸虫病效果较好。对于胆道梗阻,采取内镜下介入治疗,效果肯定。     

Clinical value of biliary alkaline phosphatase in non-jaundiced cholangiocarcinoma

Purpose Measurement of the activities of alkaline phosphatase isoenzyme has been used for the identification and monitoring of diseases associated with the isoenzyme. Biliary alkaline phosphatase (BALP), an isoform of liver-ALP, has been found in the serum of patients with biliary obstruction and metastatic liver cancer. This study compared the BALP isoform in the serum of patients with cholangiocarcinoma (CCA) with that of non-jaundiced benign hepatobiliary disease, other cancers, and healthy persons.Methods ALP isoforms were separated using cellulose acetate electrophoresis and the activity was demonstrated using indolyl blue reagent.Results The BALP isoform was demonstrated in 65% of CCA patients independently of jaundice condition or histological grading of the tumor. The level of serum BALP in non-jaundiced CCA was significantly lower than that of jaundiced CCA, and not correlated with serum bilirubin. No BALP was detected in healthy persons. In the patients with high serum ALP (>147U/l), BALP can differentiate non-jaundiced CCA patients from other non-jaundiced carcinoma patients with 85% sensitivity, 79% specificity, and positive and negative predictive values of 81% and 83%, respectively.Conclusion The demonstration of serum BALP, in particular in non-jaundiced patients with high serum ALP, may indicate the presence of tumor in the bile duct.