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Memis B, Saka B, Roa JC, Bandyopadhyay S, Reid M, Bagci P, Aktas BK, Armutlu A, Basturk O, Adsay NV. Eosinophilic Cholecystitis and Eosinophils in Gallbladder Injuries: A Clinicopathological Analysis of 1050 Cholecystectomies. Diagnostics (Basel) 2023; 13:2559. [PMID: 37568922 PMCID: PMC10417514 DOI: 10.3390/diagnostics13152559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/20/2023] [Accepted: 07/23/2023] [Indexed: 08/13/2023] Open
Abstract
"Eosinophilic cholecystitis" has been an elusive concept. Around 1050 consecutive cholecystectomies with chronic (CC, n = 895), subacute (SAC, n = 100), and acute cholecystitis (AC, n = 55) were reviewed for eosinophilic infiltration. Eosinophilic hot spots (>40 eosinophils/HPF) were seen in 63% of SAC and 35% of AC (vs. 6% of CC, p < 0.001). Eosinophils were mostly encountered in areas of wall thickening, revealing edema with early collagenization and young tissue-culture-type fibroblasts. However, in ten chronic cholecystitis patients (<1%), prominent eosinophilia with eosinophil-rich foci (>100 eosinophils/HPF) was noted. These ten cases, classified as "eosinophilic cholecystitis", were analyzed further: The patients were relatively young (mean age = 43 years), with a 9:1 female:male ratio. None had blood eosinophilia/eosinophilia syndromes. Although one had ulcerative colitis, others did not have any autoimmune diseases. The mean gallbladder wall thickness was 3.5 mm (vs. 4.2 mm in ordinary CC). In conclusion, eosinophils are a part of especially subacute injuries in the gallbladder. They are typically condensed in the areas of healing and appear to signify a distinctive state of injury in which there are erosions leading to slow/sustained exposure of the mural tissues to the bile contents that induce chemical injury/recruit eosinophils. Eosinophilic cholecystitis is a very uncommon occurrence and appears to be an exaggerated response in allergic patients who are prone to recruit eosinophils in reaction to injury.
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Affiliation(s)
- Bahar Memis
- Department of Pathology, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul 34396, Turkey
| | - Burcu Saka
- Department of Pathology, Koc University, Istanbul 34450, Turkey
| | - Juan Carlos Roa
- Department of Pathology, Pontificia Universidad Catolica de Chile, Center for Cancer Prevention and Control (CECAN), Millennium Institute on Immunology and Immunotherapy (IMII), Santiago 8331150, Chile
| | | | - Michelle Reid
- Department of Pathology, Emory University, Atlanta, GA 30322, USA
| | - Pelin Bagci
- Department of Pathology, Marmara University, Istanbul 34854, Turkey
| | - Berk Kaan Aktas
- Department of Pathology, Koc University, Istanbul 34450, Turkey
| | - Ayse Armutlu
- Department of Pathology, Koc University, Istanbul 34450, Turkey
| | - Olca Basturk
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - N. Volkan Adsay
- Department of Pathology, Koc University, Istanbul 34450, Turkey
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Tran S, Haque IU, Dhatrak D, Dolan P. Lymphoeosinophilic cholecystitis: A rare cause of acalculous cholecystitis in immunocompetent patients - A case report. Int J Surg Case Rep 2021; 80:105608. [PMID: 33592424 PMCID: PMC7893442 DOI: 10.1016/j.ijscr.2021.01.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 01/28/2021] [Accepted: 01/28/2021] [Indexed: 11/29/2022] Open
Abstract
Lymphoeosinophilic cholecystitis is an important cause of acalculous cholecystitis. Presentations can occur in otherwise well and immunocompetent patients. Cholecystectomy should be offered if the clinical picture fits cholecystitis.
Introduction Eosinophilic and lymphoeosinophilic cholecystitis are uncommonly encountered causes of acalculous cholecystitis characterised by a clinical presentation of acute cholecystitis with eosinophilic infiltration of the gallbladder. Acalculous cholecystitis is a disease that is traditionally associated with patients who are critically unwell and immunosuppressed. Presentation of case A fit and well 37-year-old man presented to the emergency department with a 12 -h history of constant upper abdominal pain radiating through to his back. Abdominal examination revealed tenderness in the right upper quadrant with a positive Murphy’s sign. An abdominal ultrasound was performed, revealing a thickened gallbladder wall with probe tenderness, but no gallstones. He proceeded to an uneventful emergency laparoscopic cholecystectomy. Histological examination of the gallbladder revealed mucosal and transmural inflammation comprising of lymphocytes and more than 50 % eosinophils. No gallstones were found. A diagnosis of lymphoeosinophilic cholecystitis was made. The patient had improvement in his symptoms and was discharged home. He was well at follow-up. Discussion There is a small subset of immunocompetent patients who are not critically unwell who present with acalculous cholecystitis. There is significant hesitancy in offering a cholecystectomy to these patients without radiological evidence of gallstones or sludge preoperatively. Cholecystectomy should be offered to these patients if the clinical picture fits acute cholecystitis. Conclusion Eosinophilic and lymphoeosinophilic cholecystitis are important causes of acalculous cholecystitis that can occur in immunocompetent patients. The decision to offer the patient a cholecystectomy should be based on clinical presentation and examination, rather than the absence or presence of gallstones.
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Affiliation(s)
- Steven Tran
- Royal Adelaide Hospital, Adelaide, South Australia, Australia.
| | - Izhar-Ul Haque
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Deepak Dhatrak
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Paul Dolan
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Eosinophilic cholecystitis: a retrospective study spanning a fourteen-year period. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2018. [DOI: 10.1016/j.rgmxen.2018.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2022] Open
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Gutiérrez-Moreno LI, Trejo-Avila ME, Díaz-Flores A, Dávila-Zenteno MR, Montoya-Fuentes IM, Cárdenas-Lailson LE. Eosinophilic cholecystitis: a retrospective study spanning a fourteen-year period. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2018; 83:405-409. [PMID: 29898861 DOI: 10.1016/j.rgmx.2018.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 12/13/2017] [Accepted: 01/04/2018] [Indexed: 12/07/2022]
Abstract
INTRODUCTION AND AIMS Eosinophilic cholecystitis is a rare entity that was first described in 1949 and is clinically indistinguishable from calculous cholecystitis. Histologically, there is transmural inflammatory infiltration of the gallbladder wall, more than 90% of which is composed of eosinophils. The aim of the present article was to review the prevalence of eosinophilic cholecystitis and analyze the clinical and surgical characteristics of patients diagnosed with the disease that were operated on at our hospital. MATERIALS AND METHODS A retrospective study was conducted on patients that underwent cholecystectomy and whose postoperative histopathologic diagnosis was eosinophilic cholecystitis, within the time frame of January 2000 and August 2014. The demographic, clinical, paraclinical, surgical, and histopathologic variables were described. RESULTS Over a period of 14 years, a total of 7,494 patients underwent cholecystectomy. Of those patients, 12 had a postoperative histologic diagnosis of eosinophilic cholecystitis. Mean patient age for disease presentation was 39 years (±11 years), and female sex was predominant, with 7 cases. All the patients had concomitant gallstones and 10 patients presented with acute cholecystitis that required urgent cholecystectomy. All the cases were considered idiopathic. We found a prevalence of 0.16%, corresponding to 1 case for every 625 cholecystectomies performed at our hospital. CONCLUSION We found a low prevalence of eosinophilic cholecystitis (0.16%) in our study population. The clinical manifestations were similar to those of calculous cholecystitis. Cholecystectomy is adequate treatment in patients with idiopathic disease.
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Affiliation(s)
- L I Gutiérrez-Moreno
- Departamento de Cirugía General y Endoscópica, Hospital General «Dr. Manuel Gea González», Ciudad de México, México
| | - M E Trejo-Avila
- Departamento de Cirugía General y Endoscópica, Hospital General «Dr. Manuel Gea González», Ciudad de México, México.
| | - A Díaz-Flores
- Departamento de Cirugía General y Endoscópica, Hospital General «Dr. Manuel Gea González», Ciudad de México, México
| | - M R Dávila-Zenteno
- Departamento de Cirugía General y Endoscópica, Hospital General «Dr. Manuel Gea González», Ciudad de México, México
| | - I M Montoya-Fuentes
- Departamento de Anatomía Patológica, Hospital General «Dr. Manuel Gea González», Ciudad de México, México
| | - L E Cárdenas-Lailson
- Departamento de Cirugía General y Endoscópica, Hospital General «Dr. Manuel Gea González», Ciudad de México, México
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Muta Y, Odaka A, Inoue S, Komagome M, Beck Y, Tamura M, Arai E. Acute acalculous cholecystitis with eosinophilic infiltration. Pediatr Int 2015; 57:788-91. [PMID: 26315204 DOI: 10.1111/ped.12650] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 12/10/2014] [Accepted: 01/08/2015] [Indexed: 12/21/2022]
Abstract
We report a case of acute acalculous cholecystitis with eosinophilic infiltration. A previously healthy 6-year-old boy was referred with right abdominal pain. Imaging demonstrated marked thickening of the gallbladder wall and peri-cholecystic effusion. Acute acalculous cholecystitis was diagnosed. Symptoms persisted despite conservative treatment, therefore cholecystectomy was performed. Pathology indicated infiltration of eosinophils into all layers of the gallbladder wall. The postoperative course was uneventful and the patient has had no further symptoms. Eosinophilic cholecystitis is acute acalculous cholecystitis with infiltration of eosinophils. The causes include parasites, gallstones, allergies, and medications. In addition, it may be seen in conjunction with eosinophilic gastroenteritis, eosinophilic pancreatitis, or both. An allergic reaction to abnormal bile is thought to be the underlying cause. The present case did not fulfill the diagnostic criteria of eosinophilic cholecystitis, but this may have been in the process of developing.
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Affiliation(s)
- Yuki Muta
- Departments of Hepato-Biliary-Pancreatic and Pediatric Surgery
| | - Akio Odaka
- Departments of Hepato-Biliary-Pancreatic and Pediatric Surgery
| | - Seiichiro Inoue
- Departments of Hepato-Biliary-Pancreatic and Pediatric Surgery
| | | | - Yoshifumi Beck
- Departments of Hepato-Biliary-Pancreatic and Pediatric Surgery
| | | | - Eiichi Arai
- Pathology, Saitama Medical Center, Saitama Medical University, Kawagoe City, Saitama, Japan
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Fernández Santiago R, Fontanillas Garmilla N, Gutiérrez Fernández G, Fernández Fernández F, Gómez Fleitas M. Colecistitis eosinofílica. Cir Esp 2013; 91:465-6. [DOI: 10.1016/j.ciresp.2012.02.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Accepted: 02/15/2012] [Indexed: 10/28/2022]
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Yeom SS, Kim HH, Kim JC, Hur YH, Koh YS, Cho CK, Kim HJ, Shin SS, Kim HS. Peripheral eosinophilia - is it a predictable factor associated with eosinophilic cholecystitis? KOREAN JOURNAL OF HEPATO-BILIARY-PANCREATIC SURGERY 2012; 16:65-9. [PMID: 26388909 PMCID: PMC4574993 DOI: 10.14701/kjhbps.2012.16.2.65] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/10/2012] [Revised: 05/14/2012] [Accepted: 05/16/2012] [Indexed: 11/17/2022]
Abstract
BACKGROUNDS/AIMS The purpose of this study was to evaluate the role of peripheral eosinophilia as a predictable factor associated with Eosinophilic cholecystitis (EC) compared with other forms of cholecystitis in patients who underwent a cholecystectomy. METHODS Between January 2001 and May 2011, the histopathologic features of 3,539 cholecystectomy specimens were reviewed retrospectively. EC was diagnosed in 30 specimens (0.84%). Data from 30 consecutive patients with EC (eosinophilic cholecystitis group [E-group]) were compared with a retrospective control group of 60 patients (other cholecystitis group [O-group]) during the same period. The two groups were matched for age, gender, and the presence of cholelithiasis. RESULTS The median absolute eosinophil count 1 day post-operatively was 144 cells/mm(3) (range: 9-801 cells/mm(3)) in the E-group and 93 cells/mm(3) (range: 0-490 cells/mm(3)) in the O-group (p=0.036). Pre-operative peripheral eosinophilia was more common in the E-group than the O-group (20% vs. 3.3%, p=0.015). Multivariate analysis revealed that pre-operative peripheral eosinophilia was an independent significant predictable factor associated with EC (odds ratio=7.250, 1.365 <95% confidence interval<38.494, p=0.020). CONCLUSIONS In the present study, pre-operative peripheral eosinophilia was shown to be an independent predictable factor associated with EC. Further researches seem to be necessary to confirm this finding.
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Affiliation(s)
- Seung-Seop Yeom
- Department of Surgery, Chonnam National University Medical School, Gwangju, Korea
| | - Ho-Hyun Kim
- Department of Surgery, Chonnam National University Medical School, Gwangju, Korea
| | - Jung-Chul Kim
- Department of Surgery, Chonnam National University Medical School, Gwangju, Korea
| | - Young-Hoe Hur
- Department of Surgery, Chonnam National University Medical School, Gwangju, Korea
| | - Yang-Seok Koh
- Department of Surgery, Chonnam National University Medical School, Gwangju, Korea
| | - Chol-Kyoon Cho
- Department of Surgery, Chonnam National University Medical School, Gwangju, Korea
| | - Hyun-Jong Kim
- Department of Surgery, Chonnam National University Medical School, Gwangju, Korea
| | - Sang-Soo Shin
- Department of Radiology, Chonnam National University Medical School, Gwangju, Korea
| | - Hyung-Seok Kim
- Department of Pathology, Chonnam National University Medical School, Gwangju, Korea
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Aihara Y, Yoshiji H, Yamazaki M, Ikenaka Y, Noguchi R, Morioka C, Kaji K, Tastumi H, Nakanishi K, Nakamura M, Yamao J, Toyohara M, Mitoro A, Sawai M, Yoshida M, Fujimoto M, Uemura M, Fukui H. A case of severe acalculous cholecystitis associated with sorafenib treatment for advanced hepatocellular carcinoma. World J Gastrointest Oncol 2012; 4:115-8. [PMID: 22645635 PMCID: PMC3360105 DOI: 10.4251/wjgo.v4.i5.115] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Revised: 02/14/2012] [Accepted: 02/20/2012] [Indexed: 02/05/2023] Open
Abstract
Sorafenib, a multikinase inhibitor, is the first and only drug, which improves significantly the overall survival in patients with advanced hepatocellular carcinoma (HCC). However, many patients experience diverse side effects, some of them severe and unexpected. To date, acute acalculous cholecystitis has not been documented in association with a HCC patient treated with sorafenib. Here, we report the case of a 43-year-old woman with hepatitis C virus-related advanced HCC. She received sorafenib, and later complained of a sudden onset of severe right hypocondrial pain with rebound tenderness and muscle defense. Laboratory examination showed mild elevation of transaminases, biliary enzymes, bilirubin, inflammation markers, and a marked peripheral eosinophilia. Abdominal computed tomography (CT) revealed a swollen gallbladder with exudate associated with severe inflammation without stones or debris. Consequently, sorafenib treatment was stopped immediately, and steroid-pulse therapy was performed. Steroid therapy drastically improved all clinical manifestations along with normalization of CT findings, eosinophilia, and liver functions. In summary, we herein report a rare case of acute severe acalculous cholecystitis associated with sorafenib in the patient with advanced HCC.
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Affiliation(s)
- Yosuke Aihara
- Yosuke Aihara, Hitoshi Yoshiji, Masaharu Yamazaki, Yasuhide Ikenaka, Ryuichi Noguchi, Chie Morioka, Kosuke Kaji, Haruki Tastumi, Keisuke Nakanishi, Maiko Nakamura, Junichi Yamao, Masahisa Toyohara, Akira Mitoro, Masayoshi Sawai, Motoyuki Yoshida, Masao Fujimoto, Masahito Uemura, Hiroshi Fukui, Third Department of Internal Medicine, Nara Medical University, Nara 634-8522, Japan
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Cerdán Santacruz C, Martín Antona E, Martín García-Almenta E, Díez Valladares L, Torres García AJ. [Eosinophilic cholecystitis after elective cholecystectomy for gallbladder stones]. Cir Esp 2012; 91:460-1. [PMID: 22565107 DOI: 10.1016/j.ciresp.2012.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2011] [Accepted: 02/14/2012] [Indexed: 10/28/2022]
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Kaji K, Yoshiji H, Yoshikawa M, Yamazaki M, Ikenaka Y, Noguchi R, Sawai M, Ishikawa M, Mashitani T, Kitade M, Kawaratani H, Uemura M, Yamao J, Fujimoto M, Mitoro A, Toyohara M, Yoshida M, Fukui H. Eosinophilic cholecystitis along with pericarditis caused by Ascaris lumbricoides: A case report. World J Gastroenterol 2007; 13:3760-2. [PMID: 17659742 PMCID: PMC4250654 DOI: 10.3748/wjg.v13.i27.3760] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Although the etiology of eosinophilic cholecystitis is still obscure, the postulated causes include allergies, parasites, hypereosinophilic syndrome, and eosinophilic gastroenteritis. It is sometimes accompanied by several complications, but a simultaneous onset with pericarditis is very rares. A 28-year-old woman complained of acute right hypocondrial pain and dyspnea associated with systemic eruption. Several imaging modalities revealed acute cholecystitis and pericarditis with massive pericardial effusion. A marked peripheral blood eosinophilia was observed, and the eruption was diagnosed as urticaria. Her serum had a high titer of antibody against Ascaris lumbricoides. Treatment with albendazole drastically improved all clinical manifestations along with normalization of the imaging features and eosinophilia. We report herein a rare case of simultaneous onset of acute cholecystitis and pericarditis associated with a marked eosinophilia caused by parasitic infection.
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Affiliation(s)
- Kosuke Kaji
- Third Department of Internal Medicine, Nara Medical University, Shijo-cho 840, Kashihara, Nara 634-8522, Japan
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Payne GS, Dzik-Jurasz ASK, Mancini L, Nutley B, Raynaud F, Leach MO. Identification of biliary metabolites of ifosfamide using 31P magnetic resonance spectroscopy and mass spectrometry. Cancer Chemother Pharmacol 2005; 56:409-14. [PMID: 15877229 DOI: 10.1007/s00280-005-1023-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2004] [Accepted: 01/25/2005] [Indexed: 12/01/2022]
Abstract
Biliary excretion is a significant component in the metabolism of many drugs, but remains difficult to detect and characterise non-invasively. A previous publication recently described the detection of metabolites of ifosfamide in gall bladder in a guinea pig model using in vivo 1H-decoupled 31P 3-D magnetic resonance spectroscopic imaging and a clinical 1.5 T MR scanner.. Here high-resolution 31P magnetic resonance spectroscopy (MRS) of extracted bile identifies peaks as parent ifosfamide (1.19+/-1.47 mM; mean+/-sd), carboxyifosfamide (2.04+/-1.04 mM) and a major contribution from a previously unreported peak at 16.0 ppm (4.05+/-2.38 mM). The unknown resonance was identified using liquid chromatography-mass spectrometry (LCMS) as the glutathione conjugate of ifosfamide (MW=531). This was confirmed by analysing products from the reaction of glutathione with ifosfamide using LCMS and MRS. These results demonstrate how combined in vivo and analytical MRS, together with mass spectrometry, can help identify visceral routes of drug metabolism, thereby aiding understanding of +/-drug disposition and mechanisms of action and toxicity. In particular, the distribution of ifosfamide and its metabolites into bile may be related to oxazophosphorine-related cholecystitis reported in patients.
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Affiliation(s)
- Geoffrey S Payne
- Cancer Research UK Clinical Magnetic Resonance Research Group, Royal Marsden NHS Trust and The Institute of Cancer Research, Downs Road, Sutton, Surrey, SM25PT, UK.
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Adusumilli PS, Ben-Porat L, Pereira M, Roesler D, Leitman IM. The prevalence and predictors of herbal medicine use in surgical patients. J Am Coll Surg 2004; 198:583-90. [PMID: 15051013 DOI: 10.1016/j.jamcollsurg.2003.11.019] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2003] [Revised: 10/27/2003] [Accepted: 11/19/2003] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite the rapid rise in herbal medicine consumption, explicitly eliciting and documenting herbal medicine usage among surgical patients is poor. STUDY DESIGN A survey by means of a self-administered questionnaire was conducted among patients undergoing elective surgery inquiring into the self-health perceptions, herbal medicine use, and communication of such usage to surgical health-care staff. RESULTS Sixty-five percent (n =2,186) of all the patients undergoing elective surgery completed the survey during a 10-week period. Fifty-seven percent of respondents admitted to using herbal medicine at some point in their life, 38% in the past 2 years (eg, echinacea [48%], aloe vera [30%], ginseng [28%], garlic [27%], and ginkgo biloba [22%] were the most common). One in six respondents continued the use of herbal medicine during the month of surgery. Herbal medicine usage was significantly higher among patients undergoing a gynecologic procedure (odds ratio [OR] 1.68; 95% confidence interval [CI] 1.29 to 2.18) and patients with a self-perception of good health (OR 1.32; 95% CI 1.04 to 1.69); it was lower among patients with a history of pulmonary symptoms (OR 0.77; 95% CI 0.62 to 0.94), African Americans (OR 0.69; 95% CI 0.51 to 0.95), in patients having a primary care physician (OR 0.71; 95% CI 0.52 to 0.98), in patients with a history of diabetes mellitus (OR 0.46; 95% CI 0.32 to 0.68), and in patients undergoing vascular surgery (OR 0.19; 95% CI 0.07 to 0.48). CONCLUSIONS Herbal medicine use is common among surgical patients and is consistent with the substantial increase in the use of alternative medical therapies. Awareness of this rising herbal medicine usage and documentation of the use of herbal medicines by surgical health-care staff is important to prevent, recognize, and treat potential problems that may arise from herbal medications taken alone or in conjunction with conventional medications during the perioperative period.
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