IDEOPATHIC ANAPHYLAXIS WITH ELEVATED LIVER ENZYMES: A CASE STUDY

Background: Complications from a cholecystectomy are rare, especially with recurring episodes of anaphylaxis and urticaria. Anaphylaxis is an allergic reaction caused by an allergen, which may include: foods, venoms, medications, infections, among others. Idiopathic anaphylaxis (IA) is a severe allergic reaction with no know cause or etiology. This article describes a patient who presented with anaphylactic episodes following a laparoscopic cholecystectomy. We discuss the symptomology of the episodes and the eventual treatment, and we have also put forth a possible mechanism for why this patient was experiencing these episodes.

Case Presentation: A 48 year old female presented to her primary care physician with complaints of mid thoracic back pain. Therapy and other conservative treatments such as pain medications did not relieve her symptoms. An MRI was later performed that showed cholelithiasis (CL). She was referred to a general surgeon for a subsequent cholecystectomy in December 2013. This was performed laparoscopically. A few hours later developed itchy urticaria and anaphylactic symptoms. She was treated for the acute reaction and was discharged. Many years went by with these random episodes that presented as epigastric pain just below the xiphoid process that would radiate posteriorly with accompanying itchy urticaria and anaphylaxis. After one of her episodes an Magnetic Resonance Cholangiopancreatography (MRCP) was performed that showed a slightly torturous and dilated bile duct. In 2018 an ERCP demonstrated a sphincter of Oddi dysfunction that was released with surgery. She had one more episode after she awoke from anesthesia and has been symptom free for almost six years.

Discussion: The following is a proposed mechanism of symptomology based upon data and evidence showed elsewhere in literature. The LC or a gallstone moving through the sphincter of Oddi (SO) caused the SOD. The SOD was the causal factor in the elevation in liver transaminases, which in turn caused the radiating epigastric pain and might have also caused urticaria and anaphylaxis. It remains to be seen why the SO release has correlated with this patient not experiencing her anaphylactic episodes for the last five years (2018-2023). While it is inconclusive, it is suggestive that since the SO release has resolved the patient’s symptoms, lends credibility that the anaphylactic reactions were related to her SOD. More study is warranted to find a possible correlation between SOD, elevated transaminase levels, and anaphylaxis to determine whether these symptoms are associated in humans.