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Taking mesalamine for mild ulcerative colitis and elevated ALT. What are the findings from liver ultrasound?
Question: Greetings from Florida, Dr. Kini - this is the same person - who had written to you about whether we should get repeat labs and MRCP prior to liver biopsy. If the liver ultrasound was fine and wants to rule out small duct PSC, could that still be diagnosed with the MRCP (to rule out small duct PSC)? 23 year old daughter - mild ulcerative colitis - unspecified (not sure what unspecified means); elevated ALPs around 600; on 4 tablets mesalamine (Apriso brand name) per day; otherwise very healthy; doc wants to do a biopsy - liver ultrasound was fine - need to rule small duct PSC.....proceeding with courage, faith, and all positive thoughts. Look forward to your feedback.
Brief Answer: Detailed answer given below. Detailed Answer: Hi, Nice to hear from you again. No, small duct PSC cannot be diagnosed with MRCP or even ERCP. Small duct PSC by definition itself is a condition in which cholangiogram (imaging of the ducts) is normal, but with clinical features, lab and histology findings of PSC. Ultrasound cannot diagnose small duct PSC. So to detect small duct PSC, biopsy may have to be done. But again as said earlier, the first step is repeat labs and MRCP ( or ERCP if the treating doctor prefers that). MRCP is non-inasive and ERCP is not. If MRCP/ERCP are normal and if clinical and lab picture still suggests PSC, then proceed for biopsy. I would like to add that small duct PSC is considered a precursor of large duct PSC. But only a small percentage of individuals with small duct PSC progress to classical /large duct PSC . And small duct PSC has got a better prognosis. Let me know if I can assist you further. Regards, Dr.Ratnakar Kini
Thanks for the prompt response and the thorough response, Dr. Kini. So let me try to sequence this: 1. Repeat labs 2. MRCP 3. if repeat labs and MRCP are normal - no biopsy? 4, if repeat labs sustain - MRCP? 5. if MRCP normal - Biopsy must follow? 6. if MRCP not normal - no biopsy? If the scenario of labs + MRCP normal - mean no need for liver biopsy? what is the scenario in which we may not have to do a biopsy? what is the scenario in which we MUST do a biopsy? by skipping repeat labs and MRCP, and if she gets the liver biopsy done, would that be final final? Is that the gold standard for small duct PSC? My daughter feels that liver biopsy will probably be most definitive - and that to skip all the rest of the steps. But I do not want to get into an invasive procedure if there are other options. look forward to hearing back from you. thank you.
Brief Answer: Detailed answer given below Detailed Answer: Hi, Yes what you have said is right. The scenario in which biopsy has to be done is - The clinical and lab picture points towards PSC, but MRCP/ERCP are normal. Yes liver biopsy is final. But since it is invasive, we generally start with non-invasive tests. Yes, biopsy is the gold standard for small duct PSC. Let me know if I can assist you further. Regards, Dr.Ratnakar Kini
Thanks again. At this stage, do you think I should go with an invasive procedure - all we have are 2 data points of high ALP levels - ulcerative colitis (unspecified) diagnosis? So - still at this point, repeat labs and MRCP OR go ahead and get the biopsy done since that would be the only modality needed at this time and we can skip everything else? is it only the invasive nature of it which makes people pause? Look forward to your guidance. Thanks for being very helpful.
Brief Answer: Detailed answer given below Detailed Answer: Hi, For my patients I would start with non-invasive tests only. Biopsy is invasive and has got complications like bleeding. She may have to get her coagulation profile checked first to ascertain that blood clotting mechanism is normal before going for biopsy. Let me know if I can assist your further. Regards, Dr.Ratnakar Kini
Dr. Kini - this makes total sense - absolutely. I tend to think of the current physician (IBD and Liver Specialist) as engaging in a bit of defensive medicine by immediately moving the modality to a biopsy- I could be totally wrong but cannot rule that out in a very litigious society in the U.S. I am not questioning the judgment at all - just trying to understand and make an informed decision. that is why we are going to an IBD / Liver Specialist attached to the University of Florida - they do tons of clinical trials also - plus it is a teaching hospital - I think of it as a plus. So - at this time - no invasive procedures - proceeding with patience, faith, courage and informed decision making. Things always always work out at the end. Your help has given me extraordinary peace of mind in many ways - with gratitude. Happy Deepavali in Chennai!
Brief Answer: Happy Deepavali to you and your family too. Detailed Answer: Regards, Dr.Ratnakar Kini
Greetings Dr. Kini.....so after much discussion with my daughter, she feels that she should just get the liver biopsy done. I have gently tried to persuade her but do not want to stress her out. I am staying very calm and taking my cues from her. Question: If clinical and lab picture point to small duct PSC, and coagulation profile is fine, will the biopsy clearly give the diagnosis? Is that definitive? Or will there be a reason to do another biopsy or some other modality? Look forward to your guidance. Thanks so much.
Brief Answer: Detailed answer given below Detailed Answer: Hi, Yes, biopsy is confirmative. Unless the biopsy procedure is not done properly, there is no reason why it should be repeated or another test be done. Let me know if I can assist you further. Regards, Dr.Ratnakar Kini
Thanks again. So at this time, the plan is to talk to the current doctor to find out if it would be percutaneous. The biopsy is scheduled for Friday, Nov. 8th. 2 days prior they will do the testing for the coagulation profile. And then, we will hope for the very best. In your practice, do you run into pediatric cases of small duct PSC? We are still wondering about even the UC since no one in my entire family - 5 siblings, cousins etc have it. Happy Deepavali to you and your family. BTW there is another physician here in Michigan who has exactly the same name as yours, and he has been in practice for many many years. We will remain hopeful and positive.
Brief Answer: Detailed answer given below Detailed Answer: Hi, Liver biopsy is usually done percutaneously. But if the coagulation profile is abnormal and the procedure can not be postponed, then it is done by transjugular route ( through a vein in the neck). Here we do not see too many cases of small duct PSC. Even with persons with UC, the association of PSC is just 5%. Also UC need not be always familial. Though many patients are diagnosed with UC, the exact cause of UC is still not known and it is multifactorial. Good to hear that there is another physician having the same name as mine. Happy Deepavali!
Above answer was peer-reviewed by : Dr. Vaishalee Punj
Smile, thanks so much for your continued thorough responses. This bit of statistic, am going to hold on to about the 5%.....but will remain practical and hopeful that the ALP level was some how an anomaly, aberration. I will keep you updated. Your feedback through this virtual world has helped our family tremendously. Wish you peace, XXXXXXX and success during the Deepavali season.
Above answer was peer-reviewed by : Dr. Yogesh D
Happy Saturday Dr. Kini. I talked to my daughter and to the gastroenterologist on Friday. Of course I tortured myself by reading more articles in different research publications. Is there any possibility that depending on where the tissue is drawn from, a confirmatory diagnosis may not be gathered? I just cannot imagine my daughter going through another biopsy. From your experience, there should be no need for another biopsy - right - in case it is inconclusive? Would the doc then go back to repeating LFTs / p-anca again? All of my effort is really to ensure that we are moving forward with informed decision making. again - look forward to hearing back from you. Your guidance has helped us tremendously. Faith, courage, and positive thoughts always. It must be a time of celebration in Chennai - miss all those days!
Brief Answer: Detailed answer given below Detailed Answer: Hi, Liver biopsy though invasive is a very simple procedure to do. If done properly, diagnosis will not be missed. A repeat biopsy may not be required. As said earlier MRCP is also diagnostic ( except for small duct PSC) Let me know if I can assist you further. Regards, Dr.Ratnakar Kini
Greetings Dr. Kini, As we prepare for the liver biopsy this upcoming Friday, it suddenly occurred to me if a liver biopsy can be done in the midst of a menstrual cycle. I did some basic searches on the web - just one article seems to suggest that it cannot be done. I thought our current GI physician would have said something if that was the case. So - wanted to run it by you - can the biopsy be done in the midst of a menstrual cycle? look forward to your feedback. thanks so much
Brief Answer: Biopsy can be done. Detailed Answer: Hi, Menstrual period is not a contraindication for liver biopsy procedure. She can have her liver biopsy done even if she would be having her menstrual period. Let me know if I can assist you further. Regards, Dr.Ratnakar Kini
Thanks so much, Dr. Kini. It seemed so and I also thought the GI Physician would have mentioned something. All good - biopsy on Friday, Nov. 8th. Moving forward with courage, faith, and positive thoughts. You have been an extraordinary help - am grateful.
Brief Answer: you are welcome Detailed Answer: Wish you good luck
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