The mechanism of Yinchenhao decoction in treating obstructive-jaundice-induced liver injury based on Nrf2 signaling pathway

BACKGROUND

Obstructive jaundice (OJ) is caused by bile excretion disorder after partial or complete bile duct obstruction. It may cause liver injury through various mechanisms. Traditional Chinese medicine (TCM) has a lot of advantages in treating OJ. The recovery of liver function can be accelerated by combining Chinese medicine treatment with existing clinical practice. Yinchenhao decoction (YCHD), a TCM formula, has been used to treat jaundice. Although much progress has been made in recent years in understanding the mechanism of YCHD in treating OJ-induced liver injury, it is still not clear.

AIM

To investigate chemical components of YCHD that are effective in the treatment of OJ and predict the mechanism of YCHD.

METHODS

The active components and putative targets of YCHD were predicted using a network pharmacology approach. Gene Ontology biological process and Kyoto Encyclopedia of Genes and Genomes path enrichment analysis were carried out by cluster profile. We predicted the biological processes, possible targets, and associated signaling pathways that YCHD may involve in the treatment of OJ. Thirty male Sprague–Dawley rats were randomly divided into three groups, each consisting of 10 rats: the sham group (Group S), the OJ model group (Group M), and the YCHD-treated group (Group Y). The sham group only received laparotomy. The OJ model was established by ligating the common bile duct twice in Groups M and Y. For 1 wk, rats in Group Y were given a gavage of YCHD (3.6 mL/kg) twice daily, whereas rats in Groups S and M were given the same amount of physiological saline after intragastric administration daily. After 7 d, all rats were killed, and the liver and blood samples were collected for histopathological and biochemical examinations. Total bilirubin (TBIL), direct bilirubin (DBIL), alanine aminotransferase (ALT), and aspartate transaminase (AST) levels in the blood samples were detected. The gene expression levels of inducible nitric oxide synthase (iNOS) and endothelial nitric oxide synthase (eNOS), and the nucleus positive rate of NF-E2 related factor 2 (Nrf2) protein were measured. Western blot analyses were used to detect the protein and gene expression levels of Nrf2, Kelch-like ECH-associated protein 1, NAD(P)H quinone dehydrogenase 1 (NQO1), and glutathione-S-transferase (GST) in the liver tissues. One-way analysis of variance was used to evaluate the statistical differences using the statistical package for the social sciences 23.0 software. Intergroup comparisons were followed by the least significant difference test and Dunnett’s test.

RESULTS

The effects of YCHD on OJ involve biological processes such as DNA transcription factor binding, RNA polymerase II specific regulation, DNA binding transcriptional activator activity, and nuclear receptor activity. The protective effects of YCHD against OJ were closely related to 20 pathways, including the hepatitis-B, the mitogen-activated protein kinase, the phosphatidylinositol 3-kinase/protein kinase B, and tumor necrosis factor signaling pathways. YCHD alleviated the swelling and necrosis of hepatocytes. Following YCHD treatment, the serum levels of TBIL (176.39 ± 17.03 μmol/L vs 132.23 ± 13.88 μmol/L, P < 0.01), DBIL (141.41 ± 14.66 μmol/L vs 106.43 ± 10.88 μmol/L, P < 0.01), ALT (332.07 ± 34.34 U/L vs 269.97 ± 24.78 U/L, P < 0.05), and AST (411.44 ± 47.64 U/L vs 305.47 ± 29.36 U/L, P < 0.01) decreased. YCHD promoted the translocation of Nrf2 into the nucleus (12.78 ± 0.99 % vs 60.77 ± 1.90 %, P < 0.001). After YCHD treatment, we found a decrease in iNOS (0.30 ± 0.02 vs 0.20 ± 0.02, P < 0.001) and an increase in eNOS (0.18 ± 0.02 vs 0.32 ± 0.02, P < 0.001). Meanwhile, in OJ rats, YCHD increased the expressions of Nrf2 (0.57 ± 0.03 vs 1.18 ± 0.10, P < 0.001), NQO1 (0.13 ± 0.09 vs 1.19 ± 0.07, P < 0.001), and GST (0.12 ± 0.02 vs 0.50 ± 0.05, P < 0.001), implying that the potential mechanism of YCHD against OJ-induced liver injury was the upregulation of the Nrf2 signaling pathway.

CONCLUSION

OJ-induced liver injury is associated with the Nrf2 signaling pathway. YCHD can reduce liver injury and oxidative damage by upregulating the Nrf2 pathway.

Health-Related Quality of Life evaluation in "left" versus "right" access for percutaneous transhepatic biliary drainage using EORTC QLQBIL-21 questionnaire: a randomized controlled trial

PURPOSE

To investigate the impact of the different access for percutaneous transhepatic biliary drainage (PTBD) in terms of "Quality of Life" (QoL) in the management of malignant obstructive jaundice.

METHODS

In this IRB-approved study, 64 consecutive patients with malignant obstructive jaundice were prospectively randomized to the right (group A) or left access (group B) for PTBD between February 2017 and December 2018. In order to demonstrate differences in terms of QoL between these groups, patients were asked to complete the "EORTC QLQ-BIL21" questionnaire the week after the treatment. Continuous variables were summarized by mean ± SD and compared using a Mann-Whitney U test.

RESULTS

Percutaneous transhepatic biliary drainages were performed through right access in 31 cases and 33 cases through left access. Technical success was achieved in all cases (100%). During 1 week's follow-up, there was a significant difference between group A and B in terms of pain (p < 0.001). Group A showed higher intercostal pain and respiratory difficulties compared to group B. Moreover, patients of group A showed a higher level of tiredness, anxiety, and more difficult tubes drainage and bags management than group B patients.

CONCLUSION

In our experience, the use of the questionnaires showed the right access is associated with intercostal pain and respiratory difficulties. Left access for PTBD provides a better Quality of Life for patients who underwent PTBD as palliative treatment for the management of malignant obstructive jaundice and could be considered as the approach of choice in case of distal obstruction.

An electron microscopy study of liver and kidney damage in an experimental model of obstructive jaundice

With this experimental study we investigated the consequences of ligation of the common bile duct (CBD) on hepatic cells and on the renal ultrastructure by electron microscopy and also determine the effects after liberation of the ductus joint in order to clarify the mechanisms of renal failure commonly observed in cholestatic liver disease. The study was conducted on 53 Wistar albino rats divided into 4 subgroups. In the comparison group (sham) we proceeded to the simple laparotomy. After preparation of the common bile duct of all the rats of the four groups, and ligation of the duct at the level of the distal third, eight rats in each group were sacrificed on the 3rd, 7th, 10th and 14th day after surgery, taking blood samples to measure the serum levels of ALP and bilirubin, and liver and renal tissue samples for histological evaluation. In four rats of each group the common bile duct was unligated at the same deadlines to obtain free drainage of the bile for a week. At the end of this week, the rats were sacrificed by collecting blood and liver and kidney tissue samples.

RESULTS

after CBD ligation in both groups, the ALP value, total and direct bilurubin levels were proportionally increased. After duct release, bilurubin levels decreased significantly. In group II, while large lipid granules were observed to indicate oxidative damage, mitochondrial swelling and crystals were observed after duct liberation. Areas of glycogen and normal mitochondria were observed in group IV. After duct release in this group, increases in Ito granules, lipid granules and normal mitochondria were observed, which may reflect the evolution of hepatic regeneration. When renal tissue was examined in group II, fusion processes in the feet, thickening of the basement membrane and mesengium were observed, and mitochondrial crystals were observed in renal tissue as well as in the liver after duct release. Damage in group III and group IV was increased parallel to prolongation of jaundice and after loosening persistent damage with mitochondrial crystals.

CONCLUSION

Ultrastructural changes in rat liver tissue in conditions of obstructive jaundice may be reversible after restoration of drainage. On the other hand, ultrastructural changes in renal tissue in cases of prolonged jaundice are irreversible even if the internal drainage is restored.

KEY WORDS

Bile Duct, Liver, Kidney, Obstructive Jaundice.

Tumour stage and resection margin status are independent survival factors following partial pancreatoduodenectomy for duodenal adenocarcinoma

INTRODUCTION

There is limited published evidence on duodenal carcinoma due to its rarity. This study aimed to evaluate gastric outlet obstruction and obstructive jaundice along with pathological variables as survival factors in patients with duodenal adenocarcinoma following resection.

METHODS

Survival factor analysis was undertaken in patients undergoing duodenal cancer surgery from 1997 to 2015 in a single centre.

RESULTS

There were 57 patients of whom 18 had gastric outlet obstruction and 14 had obstructive jaundice. Fifty-three had a partial pancreatoduodenectomy and four had palliative bypass. Perioperative mortality and morbidity were 4% (2/53) and 47% (25/53) respectively in resected patients. With a median (95% confidence interval, CI) follow-up of 72 (57-86) months, median overall and recurrence-free survival was 38 months (95% CI 28-113) and 27 months (95% CI 18-83) respectively. The 1 and 3-year overall survival rates were 84% (95% CI 74-95) and 52% (95% CI 39-69) respectively. Median overall survival was 19 months in patients with gastric outlet obstruction vs 53 months in those without (p = 0.026) and 28 months in patients with obstructive jaundice vs 38 months in those without (p = 0.611). Univariate analysis revealed that tumour stage, resection margin status, pre-operative albumin status, gastric outlet obstruction and age were associated with poorer overall and recurrence-free survival but multivariate analysis confirmed only tumour stage and resection margin status to be significant.

CONCLUSION

Whereas gastric outlet obstruction in duodenal cancer appeared to be an important survival factor following partial pancreatoduodenectomy, multivariate analysis showed that only tumour stage and resection margin status were the key independent survival factors. Further multicentre studies are required to elucidate further characteristics of duodenal carcinoma and develop neoadjuvant/adjuvant management strategies.

Effects of different drainage methods on serum bile acid and hepatocyte apoptosis and regeneration after partial hepatectomy in rats with obstructive jaundice

The aim of this study was to investigate the mechanism of hepatocyte apoptosis and regeneration after partial hepatectomy in obstructive jaundice (OJ) rats under different drainage methods of bile acid intervention. Forty male Sprague Dawley rats were randomly divided into five groups. An OJ rat model was established by the following protocols. Seven days after obstruction, an SD rats model with 70% partial hepatectomy was established by different drainage methods of OJ. Blood and liver tissue samples were collected from rats 72 h after surgery; 72 h after partial hepatectomy (PH), the liver regeneration rate, the expression of proliferating cell nuclear antigen (PCNA) and the level of mitotic index (MI) in the internal biliary drainage (IBD) group were higher than those in external biliary drainage (EBD) group (P less than 0.05). Those in the EBD group were higher compared to the OJ group (P less than 0.05). There was no significant difference among the IBD group, EBD+CA group and (SO) sham operation group (P>0.05). Bax expressions had the same trend as AI in the five groups. The expression of Bcl-2 was increased in the IBD group and EBD+CA group, which was statistically higher compared to the SO group (P less than 0.05). In conclusion, both internal and external drainage can relieve biliary obstruction. The difference in liver regeneration caused by external drainage and internal drainage may be attributed to the destruction of bile acid enterohepatic circulation, which increases hepatocyte apoptosis and affects liver regeneration.

The pharmacokinetics of dexmedetomidine in patients with obstructive jaundice: A clinical trial

OBJECTIVES

Dexmedetomidine, a highly selective central α2-agonist, undergoes mainly biotransformation in the liver. The pharmacokinetics of dexmedetomidine were significantly affected by hepatic insufficiency. The clearance of dexmedetomidine in patients with severe hepatic failure decreased by 50% compared with controls. We tested the hypothesis that the pharmacokinetics of dexmedetomidine would be affected by obstructive jaundice. The prospective registration number of clinical trial is ChiCTR-IPR-15007572.

METHODS

18 patients with obstructive jaundice and 12 non-jaundiced patient controls received dexmedetomidine, 1 μg/kg, over 10 min. Arterial blood samples were drawn before, during, and up to 5 h after the infusion. Plasma dexmedetomidine concentrations were determined by 1290 infinity high performance liquid chromatography coupled with 6470 tandem mass spectrometry. The relevant pharmacokinetic parameters were calculated by non-compartmental analysis using Phoenix WinNonlin 7.0.

RESULTS

Plasma clearance of dexmedetomidine was decreased by 33.3% in the obstructive jaundice group as compared with the control group (0.0068±0.0017 vs. 0.0102±0.0033 L/kg/min; P = 0.002). Volume of distribution was decreased by 29.2% in the obstructive jaundice group as compared with the control group (1.43±0.58 vs. 2.02±0.84 L/kg; P = 0.041).

CONCLUSIONS

This study demonstrates that the clearance and distribution volume of dexmedetomidine were decreased in patients with obstructive jaundice. It may be advisable to adjust the dose of dexmedetomidine in those patients.

Gilbert syndrome combined with prolonged jaundice caused by contrast agent: Case report

This case highlights a patient with Gilbert syndrome who underwent endoscopic retrograde cholangiopancreatography (ERCP) with removal of bile duct stones, who then experienced an unexplained increase in bilirubin, with total bilirubin (TBIL) levels increasing from 159.5 μmol/L to 396.2 μmol/L and to a maximum of 502.8 μmol/L after 9 d. Following the decrease in the TBIL level, enhanced magnetic resonance cholangiopancreatography (MRCP) was performed to exclude any possible remaining choledocholithiasis. Nevertheless, the serum bilirubin level increased again, with TBIL levels rising from 455.7 μmol/L to 594.8 μmol/L and a maximum level of 660.3 μmol/L with no remaining bile duct stones. A liver biopsy showed severe bile duct cholestasis with no inflammation. Based on the exclusion of other potential causes of hyperbilirubinemia and the fact that both instances of increased bilirubin occurred after ERCP and MRCP, the contrast agents iopromide and gadoterate meglumine were suspected to be the causes of the hyperbilirubinemia. As of the writing of this report, the patient’s bilirubin levels have spontaneously returned to baseline levels. In summary, ERCP and MRCP utilizing the contrast agents iopromide and gadoterate meglumine may possibly induce prolonged hyperbilirubinemia.

A diffusely enlarged pancreas: the (un)usual suspect

An 81-years-old female presented with obstructive jaundice and a non-specific clinical picture of nausea and appetite loss. Labs demonstrated a conjugated hyperbilirrubinemia (7.7 mg/dL), increased aspartate aminotransferase and alanine aminotransferase (10xULN and 8xULN, respectively), increased lactate dehydrogenase (10xULN) and serum lipase (3xULN). CA 19.9 was 342 U/mL (Ref value < 37 U/mL). There was no evidence of peripheral lymphadenopathy or hepatosplenomegaly. Imaging (Figure 1A and 1B) revealed a marked homogeneous enlargement of the pancreas (without any well-defined mass), dilation of the extra and intra-hepatic bile ducts and ascites. Endoscopic ultrasound (Figure 1C and 1D) identified an enlarged homogeneous hypoechoic pancreas, without any well-defined lesion, no dilation of the main pancreatic duct, no peripancreatic or celiac enlarged lymph nodes. A fine-needle biopsy was performed yielding, on cytological examination and cell-block technique (Figure 2A and 2B), numerous medium/large sized atypical lymphoid cells that displayed a B-cell lineage immunophenotype (Figure 2A-2F). Even though, further characterization (by flow cytometric immunophenotyping) could not be obtained, a final diagnosis of primary pancreatic lymphoma (PPL) was assumed. Primary pancreatic lymphoma is a remarkably rare tumor of the pancreas, representing approximately 0.5% of all pancreatic neoplasms and <2% of all lymphomas (1,2). A correct diagnosis is crucial because therapeutic management differs from other pancreatic malignancies (pancreatic ductal adenocarcinoma, neuroendocrine tumor and metastases) (2,3). Two morphologic patterns of PPL are recognized: a focal form (occurring in the pancreatic head in 80% of cases) and a rarer diffuse/infiltrative pattern, as depicted herein, emulating an acute/autoimmune pancreatitis (1).

[Not Available]

Lethality, morbidity, survival indices and metabolic consequences of total pancreatec' tomy (TP), performed in patients, suffering pancreatic tumors, were analyzed. There were retrospectively analyzed 35 TP оperations, including 5— urgent, 30 — elective, performed in a single center. General lethality have constituted 20% (7 patients died), and after elective ТP — 6.7% (2 died). Complications rate after elective TP have consti' tuted 40%; survival mediana—18 mo; indices of a 3—year survival — 40%, and a 5— year one — 13.3%. Most frequently revealed metabolic changes after ТP — pancreatic exocrine insufficiency, pancreatogenic diabetes, changes in a lipid metabolism in hepatocytes. Our experience witnesses expediency of ТP introduction into surgical practice in specialized centers of Ukraine with results, which are matching a worldwide.

Amoxicillin-Clavulanate-Induced Liver Injury

BACKGROUND AND AIMS

Amoxicillin-clavulanate (AC) is the most frequent cause of idiosyncratic drug-induced injury (DILI) in the US DILI Network (DILIN) registry. Here, we examined a large cohort of AC-DILI cases and compared features of AC-DILI to those of other drugs.

METHODS

Subjects with suspected DILI were enrolled prospectively, and cases were adjudicated as previously described. Clinical variables and outcomes of patients with AC-DILI were compared to the overall DILIN cohort and to DILI caused by other antimicrobials.

RESULTS

One hundred and seventeen subjects with AC-DILI were identified from the cohort (n = 1038) representing 11 % of all cases and 24 % of those due to antimicrobial agents (n = 479). Those with AC-DILI were older (60 vs. 48 years, P < 0.001). AC-DILI was more frequent in men than women (62 vs. 39 %) compared to the overall cohort (40 vs. 60 %, P < 0.001). The mean time to symptom onset was 31 days. The Tb, ALT, and ALP were 7 mg/dL, 478, and 325 U/L at onset. Nearly all liver biopsies showed prominent cholestatic features. Resolution of AC-DILI, defined by return of Tb to <2.5 mg/dL, occurred on average 55 days after the peak value. Three female subjects required liver transplantation, and none died due to DILI.

CONCLUSION

AC-DILI causes a moderately severe, mixed hepatocellular-cholestatic injury, particularly in older men, unlike DILI in general, which predominates in women. Although often protracted, eventual apparent recovery is typical, particularly for men and usually in women, but three women required liver transplantation.

Murine model of long-term obstructive jaundice

BACKGROUND

With the recent emergence of conjugated bile acids as signaling molecules in cancer, a murine model of obstructive jaundice by cholestasis with long-term survival is in need. Here, we investigated the characteristics of three murine models of obstructive jaundice.

METHODS

C57BL/6J mice were used for total ligation of the common bile duct (tCL), partial common bile duct ligation (pCL), and ligation of left and median hepatic bile duct with gallbladder removal (LMHL) models. Survival was assessed by Kaplan-Meier method. Fibrotic change was determined by Masson-Trichrome staining and Collagen expression.

RESULTS

Overall, 70% (7 of 10) of tCL mice died by day 7, whereas majority 67% (10 of 15) of pCL mice survived with loss of jaundice. A total of 19% (3 of 16) of LMHL mice died; however, jaundice continued beyond day 14, with survival of more than a month. Compensatory enlargement of the right lobe was observed in both pCL and LMHL models. The pCL model demonstrated acute inflammation due to obstructive jaundice 3 d after ligation but jaundice rapidly decreased by day 7. The LHML group developed portal hypertension and severe fibrosis by day 14 in addition to prolonged jaundice.

CONCLUSIONS

The standard tCL model is too unstable with high mortality for long-term studies. pCL may be an appropriate model for acute inflammation with obstructive jaundice, but long-term survivors are no longer jaundiced. The LHML model was identified to be the most feasible model to study the effect of long-term obstructive jaundice.

[MORPHOLOGICAL CHANGES OF THE LIVER IN OBTURATION JAUNDICE, CAUSED BY CHOLEDOCHOLITHIASIS, DEPENDING ON ITS DURATION]

Abstract The results of surgical treatment of 184 patients for obturation jaundice, caused by choledocholithiasis, were analyzed. Morphological changes of the liver were studied in 20 patients. There were three groups of patients delineated, depending on the obturation jaundice duration: up to 7 days, from 8 to 14 days, more than 15 days, and also a group of patients after the bile outflow restoration. The obturation jaundice occurrence in choledocholithiasis is accompanied by significant morphological changes in the liver, severity of which is enhancing while the obturation jaundice persistence increasing. While persistence of obturation jaundice through 8 days and more the connective tissue volume is enhancing, a relative volume of hepatocytes is reducing and a stromal-parenchymatous index is increasing. The bile outflow restoration secures significant reduction of intensity of alterative and inflammatory changes in hepatic parenchyma, as well as activation of reparative processes in the tissue. In cholangitis, caused by P. aeruginosa and E. coli, according to morphological investigations data, in the liver a diffuse purulent cholangitis on background of chronic changes in accordance to duration of the obturation jaundice persists.

[IMPACT OF RONCOLEUKIN ON BALANCE OF CYTOKINS IN COMPLEX TREATMENT OF OBTURATION JAUNDICE OF NONTUMORAL GENESIS]

The results of surgical treatment of 137 patients, suffering obturation jaundice of non-tumoral etiology, were analyzed. In all the patients the cause of obturation jaundice was choledocholithiasis. Roncoleukin was infused intravenously additionally in a complex of therapy. A degree of hepatic dysfunction was determined, taking into account the cholestasis markers. In 23 patients purulent cholangitis have occurred on background of obturation jaundice. Concentration of cytokins TNF-α, IFN-γ, IL-1, IL-2, IL-4, IL-6, IL-10 in sera were determined, using immunoassay analysis. The cytokins dysbalance severity preoperatively and dynamics of its changes have depended upon the hepatic dysbalance degree and presence of purulent cholangitis; a dysbalance is deeper, when the hepatic dysfunction is higher. Application of pathogenetically substantiated purposeful cytokinotherapy, including roncoleukin, have promoted the cytokins dysbalance elimination and improvement of the patients treatment results.

The protective effects of pomegranate on liver and remote organs caused by experimental obstructive jaundice model

OBJECTIVE

We aimed to investigate the protective potential of pomegranate extract on the liver and remote organs in rats with obstructive jaundice.

MATERIALS AND METHODS

The rats were split into 4 groups. In Group 1 (G1) (sham group) rats, the common bile duct was mobilized without any ligation. Group 2 (G2) received a combination of the sham operation and synchronous treatment with pomegranate. Group 3 (G3) received common bile duct ligation (CBDL). Group 4 (G4) were subjected to CBDL and treatment with pomegranate. After 8 days, we measured total oxidative status (TOS) and antioxidant capacity in the rats' liver tissue and remote organs, and evaluated blood levels of malondialdehyde and total antioxidant capacity (TAC).

RESULTS

G3 rats showed significantly raised malondialdehyde level as compared to G1 rats (p < 0.001). Following the pomegranate therapy, a decrease in malondialdehyde was observed (p = 0.015). TAC levels were significantly raised in the G3 rats compared to the G1 rats (p = 0.004). TAC levels dropped after pomegranate therapy (p = 0.011). CBDL caused elevated TOS levels in the liver and remote organs, with a statistically significant increase in the lung tissue (p = 0.002). TOS levels in the CBDL groups decreased after pomegranate treatment (p < 0.001).

CONCLUSIONS

This study reveals the marked protective effect of pomegranate on the liver and remote organs in obstructive jaundice.

THE ANALYSIS OF REASONS OF FAILURES TRANSPAPILLARY METHODS OF TREATMENT OF OBSTRUCTIVE JAUNDICE OF CANCEROUS GENESIS

AIM OF THE STUDY

To analyze the reasons of failed transpapillary interventions in malignant obstructive jaundice.

MATERIAL AND METHODS

Single-center retrospective study of results of treatment of patients with malignant obstructive jaundice, in which an attempt of transpapillary endoscopic decompression (n=433) was done. We analyzed cases of clinical and technical failure (n=89) of endoscopic retrograde cholangiopancreatography (ERCP), demanded antegrade biliary drainage.

RESULTS

Analysis of cases of technical failure of endoscopic transpapillary decompression revealed following causes: inability to reach major duodenal papilla (MDP) due to stenosis of the gastric outlet - 10 (11.2%); inability to visualize MDP - 3 (3.4%); unsuccessful cannulation of the common bile duct - 26 (29.2%); high biliary stricture - 20 (22.5%); tumor proliferation in the area of MDP - 10 (11.2%); previously performed Billroth-2 gastrectomy - 5 (5.6%). Clinical failure of transpapillary stenting was detected in 15 (16.9%) patients.

CONCLUSION

Transpapillary intervention in malignant obstructive jaundice had technical success rate 82.9%, with clinical failure in 20.6% of patients. High biliary stricture was significantly more frequent in group of failed ERCP (X²=47.448, p<0.001) in comparison to the group of successful transpapillary decompression (n=8; 5.2%). Frequency of failed endoscopic biliary decompression in patients,with previous Billroth-2 gastrectomy was significantly greater than in successful ERCP group (n=1; 0.29%, p=0.002). Despite this, impaired gastroduodenal anatomy and high biliary strictures are not a contraindication for endoscopic transpapillary decompression. Failed ERCP was associated with higher mortality (X2=4.574; p=0.032). Unit providing treatment of patients with malignant obstructive jaundice should have alternative methods of biliary drainage.

[SURGICAL TREATMENT OF ACUTE CHOLANGITIS IN CHOLEDOCHOLITHIASIS]

The results of surgical treatment of 184 patients for obstructive jaundice and an acute cholangitis in choledocholithiasis were analyzed. Acute cholangitis was diagnosed in 62 (33.7%) patients. Sensitivity of a Tokyo Guidelines (2013)--TG 13 criteria for diagnosis and estimation of the course severity of an acute cholangitis was studied. Dynamics of postoperative laboratory parameters was studied. There was established, that occurrence of obturation jaundice and cholangitis coincides with pronounced hepatic function disorders, which are preserved after a bile outflow restoration also, and changes in peripheral blood. Severity of inflammatory reaction reflects hematological indices, the most informative of which is an intoxication index.

Identification of Pancreatic Cancer in Biliary Obstruction Patients by FRY Site-specific Methylation

BACKGROUND

Methylation at cg 16941656 of FRY is exclusively found in normal pancreatic tissue and has been proven to be specific for pancreatic-in-origin among several adenocarcinomas. Here, we investigated methylated DNA in the bile as a biomarker to differentiate the cause of obstruction between pancreatic cancer and benign causes.

MATERIALS AND METHODS

Bile samples of 45 patients with obstructive jaundice who underwent ERCP were collected and classified into pancreatic cancer (group 1) and benign causes (group 2) in 24 and 21 patients, respectively. DNA was extracted from bile and bisul te modification was performed. After, methylation in cg 16941656 of FRY was identified by real-time PCR, with beta-actin used as a positive control.

RESULTS

Methylated DNA was identified in 10/24 (41.67%) and 1/21 (4.8%) of cases in groups 1 and 2, respectively (P= 0.012). The sensitivity, specificity, positive predictive value and negative predictive value to differentiate pancreatic cancer from benign causes were 42%, 95%, 91%, and 59%, respectively.

CONCLUSIONS

Detecting a methylation at cg 16941656 of FRY in bile has high specificity, with an acceptable positive likelihood rate, and may therefore be helpful in distinguishing pancreatic cancer from benign strictures.

[ОPTIMIZATION OF PREOPERATIVE PREPARATION AND CONSERVATIVE TREATMENT OF OBTURATION JAUNDICE, OCCURRING ON BACKGROUND OF BILIARY CALCULOUS DISEASE]

Оbturation jaundice (ОJ) on background of biliary calculous disease (BCD) was diagnosed in 61 patients. There was studied the impact of L—lysine escinate and glutargin on the treatment results, which were included in complex of standard preoperative preparation, and what had transformed into conservative treatment and disappearing of ОJ without operative intervention. In accordance to the biochemical investigations results, which characterize a functional state of the liver, OJ had disappeared more rapidly while application of the treatment proposed. Positive results of treatment had witnessed actuality of the trend choosed and necessity of its further studying.

[CLINIC-EXPERIMENTAL SUBSTANTIATION OF OZONOTHERAPY APPLICATION IN THE TREATMENT OF PURULENT CHOLANGITIS AND OBTURATION JAUNDICE]

Efficacy of the ozonotherapy application as an important component of complex treatment in purulent cholangitis (PCH) was studied. In choledocholithiasis (without infectioning of bile) ozonotherapy may be prescribed as additional component at complex treatment. In PCH ozonotherapy application have promoted the improvement of laboratory indices in 6.6 times, comparing with such, occurring after basic therapy.

Recombinant human augmenter of liver regeneration protects hepatocyte mitochondrial DNA in rats with obstructive jaundice

BACKGROUND

Hepatocyte mitochondrial DNA (mtDNA) damage is an important cause of mitochondrial and hepatic function impairment in obstructive jaundice (OJ). This study investigated the protective effect of recombinant human augmenter of liver regeneration (rhALR) on hepatocyte mtDNA in rats with OJ.

MATERIALS AND METHODS

Wistar rats were randomly divided into three groups as follows: sham-operation, biliary obstruction and recanalization with rhALR treatment (BDO-RBF-rhALR), and BDO-RBF-Vehicle (n = 48 per group). After biliary obstruction, rats were intraperitoneally injected with 40 μg/kg rhALR in BDO-RBF-rhALR group and same volume of normal saline in other two groups once every 12 h, until sacrifice. Mitochondrial transcription factor A (mtTFA) and nuclear respiratory factor-1 (NRF-1) expression in hepatocytes were detected by real-time reverse transcription-polymerase chain reaction and Western blot. Hepatocyte mtDNA damage was evaluated by real-time-polymerase chain reaction. Mitochondrial and hepatic functions were also assessed.

RESULTS

After biliary obstruction, hepatic function was clearly impaired, as shown by the increases in serum alanine aminotransferase, aspartate aminotransferase, and total bilirubin levels, and the decrease in albumin level. Mitochondrial respiratory control ratio, phosphorus oxygen ratio, and ATP levels (all indicators of mitochondrial function) were decreased. The relative amount of total mtDNA, mtTFA, and NRF-1 expression in rat liver tissues were decreased, whereas the relative amount of deleted mtDNA was increased. However, the damage was significantly improved in the BDO-RBF-rhALR group. After recanalization, these changes were gradually restored, but the recovery was faster in the BDO-RBF-rhALR group than in BDO-RBF-Vehicle group.

CONCLUSIONS

rhALR may protect and improve mitochondrial and hepatic functions in rats with OJ by promoting the expression of mtTFA and NRF-1 and by protecting and repairing damaged mtDNA.

Glucagon-like peptide-2 protects impaired intestinal mucosal barriers in obstructive jaundice rats

AIM: To observe the protective effect of glucagon-like peptide-2 (GLP-2) on the intestinal barrier of rats with obstructive jaundice and determine the possible mechanisms of action involved in the protective effect.

METHODS: Thirty-six Sprague-Dawley rats were randomly divided into a sham operation group, an obstructive jaundice group, and a GLP-2 group; each group consisted of 12 rats. The GLP-2 group was treated with GLP-2 after the day of surgery, whereas the other two groups were treated with the same concentration of normal saline. Alanine aminotransferase (ALT), total bilirubin, and endotoxin levels were recorded at 1, 3, 7, 10 and 14 d. Furthermore, on the 14^th day, body weight, the wet weight of the small intestine, pathological changes of the small intestine and the immunoglobulin A (IgA) expressed by plasma cells located in the small intestinal lamina propria were recorded for each group.

RESULTS: In the rat model, jaundice was obvious, and the rats’ activity decreased 4-6 d post bile duct ligation. Compared with the sham operation group, the obstructive jaundice group displayed increased yellow staining of abdominal visceral serosa, decreased small intestine wet weight, thinning of the intestinal muscle layer and villi, villous atrophy, uneven height, fusion, partial villous epithelial cell shedding, substantial inflammatory cell infiltration and significantly reduced IgA expression. However, no significant gross changes were noted between the GLP-2 and sham groups. With time, the levels of ALT, endotoxin and bilirubin in the GLP-2 group were significantly increased compared with the sham group (P < 0.01). The increasing levels of the aforementioned markers were more significant in the obstructive jaundice group than in the GLP-2 group (P < 0.01).

CONCLUSION: GLP-2 reduces intestinal mucosal injuries in obstructive jaundice rats, which might be attributed to increased intestinal IgA and reduced bilirubin and endotoxin.

[DEVELOPMENT OF FUNCTIONAL AND MORPHOLOGICAL CHANGES OF A PANCREAS DEPENDING ON THE DURATION OF OBSTRUCTIVE CHOLESTASIS]

PURPOSE OF THE STUDY

To study the severity and timing of the development of functional (reversible) and morphological (irreversible) disturbances in the pancreas, depending on the duration of obstructive cholestasis.

MATERIALS AND METHODS

Obstructive jaundice in the experiment 18 dogs modeled by applying the loop stranglehold on the common bile duct, followed by observation for 30 days. We measured total bilirubin and fractions aspartate aminotransferase activity (AST) and alanine aminotransferase (ALT), the contents alpha-amylase, pancreatic lipase, glucose, histological examination of the pancreas (magnification of 100 times and 400).

RESULTS

On day 3 the common bile duct obstruction bilirubin increased from 7.1 to 286.8 μmol/l, ALT--from 0.17 to 4.18 μmol*h/l, alpha-amylase from 89 to 186 U/L and lipase--to 68 to 179 U/L. Then there was a slight decrease in the parameters studied with repeated their increase to 15 hours. Morphological changes in the first three days were characterized by reversible (swelling), impaired organ that 14-16 days passed in organic (irreversible) changes.

CONCLUSION

Dynamics of fluctuations in the level of liver enzymes in the pancreas and obstructive cholestasis correlates with morphological abnormalities in the pancreas and fit into the concept of general biological organism's reaction to injury.

The olive leaf extract attenuates bacterial translocation and liver damage in obstructive jaundice

OBJECTIVES

The olive leaf extract (OLext) is known to possess many biological properties including a powerful antioxidant. This study aimed to investigate the protective effects of postoperative nutrition with OLext and glutamine on bacterial translocation (BT) and liver damage in obstructive jaundice.

MATERIALS AND METHODS

Totally, 50 rats were randomly divided into the five groups of 10 each. The common bile duct was ligated in all animals, excepting in the group 1. Postoperative nutrition was given to all groups for ten days. The rats in the Group 1 and 2 were fed a normal diet, Group 3 rats were fed an additional glutamine (1 g/kg/day), and Group 4 and 5 rats were fed an additional OLext (1 ml of 1/2 diluted and pure form/kg/day). Biochemical, microbiological and liver histopathological changes were evaluated.

RESULTS

BT in the Groups 3, 4, and 5 was significantly lower than in the Group 2. The values of aspartate transaminase (AST), alanine transaminase (ALT), γ-glutamyl transferase (γ-GT) and alkalen phosphatase (ALP) in blood were increased in obstructive jaundice, but the levels of these tests were statistically lower in glutamine and OLext groups when compared to the Group 2. Histopathological changes were observed low in the liver in OLext and glutamine groups.

CONCLUSIONS

The present data has demonstrated that the supplementation of olive leaf extract and glutamine reduce the incidence of BT and liver damage in obstructive jaundiced rats (Tab. 4, Fig. 1, Ref. 23).

Hepatocyte apoptotic index and p53 expression in obstructive jaundice rats

OBJECTIVE

Obstructive jaundice is a serious disease. It can deteriorate critical functions in the liver.

MATERIAL AND METHOD

A total of 20 male Wistar-Albino rats were randomly allocated into two groups consisting of ten in each as follows: Group I (Control) was subjected to a sham operation isolating the bile duct. Group II(Study) was subjected to acute cholestasis induced by bile duct ligation with 4/0 silk suture from two different places and full fold cut between ligatures. On the 7th day, group II rats were re-operated for liver sampling and sacrification-aimed histological analysis through the old incision with anaesthesia. Hepatic tissues were histologically and immunohistochemically processed. The number of apoptotic and p53(+) cells were measured.

RESULTS

On the 7th day, the averages of direct and indirect bilirubin values in Group II rats were found to be 6.99 and 11.70 mg/dl, respectively. They were observed to be statistically significant. In the immunohistochemical evaluation p53 expression in hepatocytes was assessed, p53-positive hepatocytes were determined to exist quite widely in the tissue samples taken from the livers of rats in the study group. Nevertheless, no cells exhibiting p53 expression were found in the tissue samples of the control group.

CONCLUSION

Apoptosis is a closed box and it might make it possible to stop the many disease processes or accelerate the healing. If the principal effective mechanism in the liver under a certain stress factor is apoptosis, it is definite that it will make a difference in the treatment approach. Consequently, we can say that both apoptotic index and p53 expression increase in the rats' liver with biliary obstruction (Fig. 4, Ref. 51).

[The ways of prophylaxis of the pancreatic injuries occurring on background of cholangitis and choledocholithiasis complicated by obturation jaundice: algorithm for diagnosis and treatment]

The results of treatment of 45 patients, in whom obturation jaundice have occurred on background of purulent cholangitis and biliary calculous disease, were summarized. preoperatively conservative therapy was conducted to the patients, including ozonotherapy during 9 - 10 days (main group) and 2 - 4 days (control group). All the patients were operated on. Conservative therapy, conducted during 9 -- 10 days, have permitted to improve clinical and laboratory indices more rapidly postoperatively, to prognosticate possibilities of the pancreatic gland damage, pancreatitis occurrence, as well as its exacerbation in future.

Protective effects of intravenous anesthetics on kidney tissue in obstructive jaundice

AIM: To evaluate the protective effects on kidney tissue of frequently used intravenous anesthetics (ketamine, propofol, thiopental, and fentanyl) in rats with obstructive jaundice.

METHODS: There is an increased incidence of postoperative acute renal failure in patients with obstructive jaundice. Thirty-two Wistar-albino rats were randomly divided into four equal groups. Laparatomy was performed on each animal in the four groups and common bile ducts were ligated and severed on day 0. After 7 d, laparotomy was again performed using ketamine, propofol, thiopental, or fentanyl anesthesia whose antioxidative properties are well known in oxidative stress in a rat liver model of obstructive jaundice. After 2 h, the rats were sacrificed. Renal tissue specimens were analyzed for catalase, superoxide dismutase and malondialdehyde enzymes activities. All values are expressed as the mean ± SD. P values less than 0.05 were considered statistically significant.

RESULTS: All animals survived without complications until the end of the study. Enlargement in the bile duct and obstructive jaundice were observed in all rats. Catalase was found to be significantly lower in the fentanyl group than in the ketamine (P = 0.039), propofol (P = 0.012), and thiopental (P = 0.001) groups. Superoxide dismutase activities were similar in all groups (P > 0.05). Malondialdehyde was found to be significantly lower in the ketamine group than in the propofol (P = 0.028), thiopental (P = 0.002) and fentanyl (P = 0.005) groups. Malondialdehyde was also lower in the fentanyl group than in the thiopental group (P = 0.001). The results showed that obstructive jaundice sensitizes renal tissue to damage under the different anesthetics.

CONCLUSION: Among the agents tested, ketamine and propofol generated the least amount of oxidative stres on renal tissues in this rat model of obstructive jaundice created by common bile duct ligation. The importance of free radical injury in renal tissue in obstructive jaundice under different intravenous anesthetics during hepatobiliary and liver transplant surgery should be considered for prevention of postoperative acute renal failure.

Biopsy-driven diagnosis in infants with cholestatic jaundice in Iran

AIM: To determine the frequencies of diagnoses confirmed by liver biopsy in infants with cholestasis in an Iranian pediatric hospital.

METHODS: This was a retrospective study conducted in a tertiary referral children’s hospital in Iran. We retrieved all pathology reports of liver biopsies from children less than two years of age who had presented for evaluation of cholestatic jaundice from March 2001 to March 2011. Additional specimen samples obtained from archived pathology blocks were reviewed by a pathologist blinded to the final diagnosis. These results were compared with the pathology reports from chart records to ensure consensus and eliminate any inconsistencies in final diagnoses. A structured checklist was used to gather information on multiple variables including age, sex, gestational age at birth, birth weight, age at which hyperbilirubinemia manifested, presence and identification of associated anomalies, clinical manifestations, and histological findings from liver biopsies. The baseline data are reported using descriptive statistics, and differences between groups were assessed by Fisher’s exact test and Student’s t test when indicated.

RESULTS: Fifty-five cases (28 females; 27 males) of infantile cholestasis (IC) were included in this study. The mean serum total bilirubin and direct bilirubin at presentation were 13.6 ± 5.9 and 7.3 ± 3.4, respectively. Forty cases (72.7%) were the product of term pregnancies. Common associated clinical findings were acholic stool in 33 cases (60.0%), hepatomegaly in 30 cases (54.5%), and dark-colored urine in 21 cases (38.2%). Biliary atresia (BA) was the most frequent diagnosis, found in 32 cases (58.2%), followed by intrahepatic bile duct paucity found in 6 cases (10.9%), metabolic disease in 6 cases (10.9%), idiopathic neonatal hepatitis in 5 cases (9.1%), choledochal cyst in 2 cases (3.6%), liver cirrhosis in 2 cases (3.6%), and progressive familial intrahepatic cholestasis and portal fibrosis each in 1 case (1.8%). The mean times for jaundice onset and liver biopsy were 43.8 and 102.0 d, respectively. In BA, the mean age at jaundice presentation was 21 d and for liver biopsy was 87.5 d, representing a mean delay of 66.5 d.

CONCLUSION: A significant delay was found between IC presentation and liver biopsy, which is detrimental in conditions that can cause irreversible liver damage, such as BA.

Protective effects of ginseng total saponins against hepatic ischemia/reperfusion injury in experimental obstructive jaundice rats

CONTEXT

Ginseng, the root of Panax ginseng C.A. Meyer (Araliaceae), is one of the most extensively used herbs for stroke and chronic debilitating conditions in East Asian countries. Ginsenosides (GS) are the main bioactive compounds for ginseng's efficacy, but the mechanisms have not been fully clarified.

OBJECTIVE

To investigate hepatoprotective effects of GS against ischemia/reperfusion (IR) injury in the experimental obstructive jaundice rats.

MATERIALS AND METHODS

GS was fed to cholestatic rats with IR injury daily for 6 d at a dose of 1.10 g/kg. Levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), superoxide dismutase (SOD) and malondialdehyde (MDA) were determined by colorimetric method. Apoptosis was measured quantitatively by the terminal transferase UTP nick end-labeling method. Protein expression of Bax and Bcl-2 was detected by immunohistochemistry.

RESULTS AND DISCUSSION

After intervention of GS to cholestatic rats with IR injury, the levels of activating blood flow were significantly improved, and the levels of serum ALT were decreased 1.7-times, AST decreased 1.3-times, but SOD activities were increased 1.1-times compared with those of the model rats. It could also reverse histopathological changes and inhibit IR-induced apoptosis of hepatic tissues via decrease of Bax/Bcl-2 ratio (from 2.87 ± 0.57 to 1.65 ± 0.29). Oral administration of GS in a dosage of 26.4 g/kg did not lead to toxic effects in rats.

CONCLUSION

GS attenuated the IR injury in the presence of cholestasis and could be considered for the clinical treatment of cholestasis.

Lipid peroxidation and antioxidant enzymes activity in Plasmodium vivax malaria patients evolving with cholestatic jaundice

BACKGROUND

Plasmodium vivax infection has been considered a benign and self-limiting disease, however, recent studies highlight the association between vivax malaria and life-threatening manifestations. Increase in reactive oxygen species has already been described in vivax malaria, as a result of the increased metabolic rate triggered by the multiplying parasite, and large quantities of toxic redox-active byproducts generated. The present study aimed to study the oxidative stress responses in patients infected with P. vivax, who developed jaundice (hyperbilirubinaemia) in the course of the disease, a common clinical complication related to this species.

METHODS

An evaluation of the lipid peroxidation and antioxidant enzymes profile was performed in 28 healthy individuals and compared with P. vivax infected patients with jaundice, i.e., bilirubin < 51.3 μmol/L (8 patients) or without jaundice (34 patients), on day 1 (D1) and day 14 (D14) after anti-malarial therapy.

RESULTS

Hyperbilirubinaemia was more frequent among women and patients experiencing their first malarial infection, and lower haemoglobin and higher lactate dehydrogenase levels were observed in this group. Malondialdehyde levels and activity of celuroplasmin and glutathione reductase were increased in the plasma from patients with P. vivax with jaundice compared to the control group on D1. However, the activity of thioredoxin reductase was decreased. The enzymes glutathione reductase, thioredoxin reductase, thiols and malondialdehyde also differed between jaundiced versus non-jaundiced patients. On D14 jaundice and parasitaemia had resolved and oxidative stress biomarkers were very similar to the control group.

CONCLUSION

Cholestatic hyperbilirubinaemia in vivax malaria cannot be totally disassociated from malaria-related haemolysis. However, significant increase of lipid peroxidation markers and changes in antioxidant enzymes in patients with P. vivax-related jaundice was observed. These results suggest oxidative processes contributing to malaria pathogenesis, what may be useful information for future anti-oxidant therapeutical interventions in these patients.

[Application of a hepasol neo preparation in the treatment of obturation jaundice patients]

The results of treatment of 52 patients, suffering obturation jaundice (OJ), were analyzed. The causes of the OJ occurrence were studied up. A peculiar attention was drawn to the treatment of patients, suffering OJ on a hepatic cirrhosis background. On the first stage of surgical treatment various operative procedures were applied to eliminate OJ. The impact of the tactics proposed, consisting of detoxication and infusion therapy, on duration of postoperative rehabilitation of the patients was studied up. In postoperative period to all the patients Hepasol Neo was prescribed, what have promoted their general condition improvement, the bilirubin level normalization, as well as the cytolysis and cholestasis elimination.

[Peculiarities of performance of endoscopic transpapillary interventions in the early period after cholecystectomy]

The peculiarities of performance of endoscopic transpapillary interventions (ETI) during the early period after cholecystectomy were studied up. There were examined 1788 patients, aged from 18 to 90 yrs old, in whom postcholecystectomy syndrome was diagnosed. Emergent interventions were performed in 780 (43.6%) patients (main group). Into the comparison group 1008 (56.4%) patients were included, who were admitted to the hospital in 0.5-552 (Me 36) months after cholecystectomy conduction. The indications to perform the urgent endoscopic intervention were excessive transdrainage biliary output (more than 350 ml a day) from a subhepatic indignation (in 442 patients) and the obturation jaundice presence (in 338). Using ETI the cause of biliary obstruction in the early postoperative period was established in 93.5% of patients. Miniinvasive methods were applied in 82.2% patients of the main group and in 93.4%--of the comparison group.

[Criteria of diagnosis and principles of treatment of obturation jaundice and its complicated forms--an acute cholangitis and biliary sepsis]

Analysis of the examination and treatment results was conducted in 92 patients, suffering the obturation jaundice syndrome. There was elaborated a diagnostic program, in which the existing diagnostic standard for obturation jaundice and its complicated forms, an acute cholangitis and biliary sepsis, was added by determination of the blood procalcitonin level, microbiological investigation of the blood and bile, the bile microscopy, the analysis of the system inflammatory response syndrome signs and the organs dysfunction (according to SOFA scale). The program introduction have permitted to perform differential diagnosis of uncomplicated--in 30 (32.6%) patients, and complicated--in 42 (45.7%) obturation jaundice in an acute cholangitis and in 20 (21.7%)--in biliary sepsis. The treatment program is characterized by differentiated approach, depending on the disease kind, and includes the conduction of urgent decompression and sanation of biliary ducts. The method and volume of complex conservative therapy have differed essentially in patients, suffering obturation jaundice, an acute cholangitis and biliary sepsis.

[Unsolved issues of classification of mechanical jaundice]

Basing on analysis of results of examination and treatment of 160 patients, suffering mechanical jaundice, its practical classification was elaborated, containing the issues of pathogenesis and the main characteristics according to anatomo-topographic and clinical criteria.

[Portal hypertensive biliopathy--an unusual cause of obstructive jaundice]

Biliary symptoms may be an unusual presentation of portal hypertension, especiaLly in patients with portal vein thrombosis. This is a case report of a patient who developed acute and chronic portal vein thrombosis that presented as obstructive jaundice. The discussion will focus on diagnostic modalities and therapeutic options.

Endoscopic palliation of pancreatic cancer

Endoscopy has an increasingly important role in the palliation of patients with pancreatic ductal adenocarcinoma. Endoscopic biliary drainage is still requested in the majority of patients who present with obstructive jaundice, and the increased use of self-expandable metallic stents has reduced the incidence of premature stent occlusion. First-line use of metallic stents is expected to be utilized more frequently as neoadjuvant protocols are improved. The efficacy of endoscopy for palliating gastroduodenal obstruction has advanced with the development of through-the-scope, self-expandable gastroduodenal stents. There have been advances in pain management, with endoscopic ultrasound-guided celiac plexus neurolysis reducing opiate requirements and pain for patients with unresectable malignancy. Future applications of endoscopy in pancreatic cancer may include fine-needle injection of chemotherapeutic and other agents into the lesion itself. This review will summarize the evidence of endoscopy in the management of patients with pancreatic cancer.

[Effect of combined administration of bile duct decompression and lactulose in mechanical jaundice]

AIM

Study the state of intestine microecology in patients with obstructive jaundice after decompression of bile ducts and administration of lactulose.

MATERIALS AND METHODS

58 patients of different gender and age who were under treatment in the 13th surgical department of City Clinical Hospital No. 7 due to obstructive jaundice were examined. Evaluation of lactulose administration was carried out in a blinded randomized study. The patients were divided into 2 groups of 29 individuals each: (1) patients who had undergone surgery without administration oflactulose (control) and (2) patients who had received immediately after decompression of bile ducts 30 ml of lactulose for 1 week (comparison group). Feces samples were obtained with a weekly interval for bacteriological study for dysbacteriosis.

RESULTS

Based on the results of bacteriological analysis of feces in all the 58 patients with mechanical jaundice disorders of intestine microecology of various severity degrees were detected. In the patient group who had received lactulose for 7 days after the decompression ofbile ducts a tendency for an increase ofpopulation level of bifidobacteria and lactobacilli and a decrease of quantity of opportunistic microorganisms of various taxonomical groups was noted.

CONCLUSION

Administration of lactulose to patients at 30 ml dose per day for 7 days positively affected the state of microbiocenosis of colon towards its normalization.

[Intestine microbiocenosis in mechanical jaundice caused by obturation of biliary ducts]

AIM

Study the composition of bile and feces microflora in patients with mechanical jaundice of various geneses.

MATERIALS AND METHODS

66 feces and 25 bile samples during nasobiliary decompression were studied bacteriologically.

RESULTS

In all patients disorders of normal intestine microflora were detected. Patient bile in 84% of cases was infected by bacteria among which enterococci and urease positive enterobacteria predominated. In 30% of cases in patients identical species of bacteria were simultaneously detected in bile samples and in high titers (6.0 - 6.5 lg CFU/ml) in feces.

CONCLUSION

In mechanical jaundice caused by biliary duct obturation in all the patients dysbiotic events of digestive tract are registered, that defines the necessity to improve bacteriological examination of patients with mechanical jaundice and reasonability of disrupted normal intestine microflora correction.

Cytological sampling versus forceps biopsy during percutaneous transhepatic biliary drainage and analysis of factors predicting success

PURPOSE

To assess the accuracy of cytological sampling and forceps biopsy in obstructing biliary lesions and to identify factors predictive of success.

METHODS

Consecutive patients (n = 119) with suspected malignant inoperable obstructive jaundice treated with percutaneous transhepatic biliary drainage during 7 years were included (60 male; mean age 72.5 years). All patients underwent forceps biopsy plus cytological sampling by washing the forceps device in cytological solution. Patient history, procedural and pathological records, and clinical follow-up were reviewed. Statistical analysis included chi-square test and multivariate regression analysis.

RESULTS

Histological diagnosis after forceps biopsy was more successful than cytology: Sensitivity was 78 versus 61%, and negative predictive value was 30 versus 19%. Cytology results were never positive when the forceps biopsy was negative. The cytological sample was negative and forceps sample positive in 2 cases of cholangiocarcinoma, 16 cases of pancreatic carcinoma, and 1 case of benign disease. Diagnostic accuracy was predicted by low bilirubin (p < 0.001), aspartate transaminase (p < 0.05), and white cell count (p ≤ 0.05).

CONCLUSIONS

This technique is safe and effective and is recommended for histological diagnosis during PTBD in patients with inoperable malignant biliary strictures. Diagnostic yield is greater when bilirubin levels are low and there is no sepsis; histological diagnosis by way of forceps biopsy renders cytological sampling unnecessary.

Acquired perforating dermatosis: an innocuous lesion with possibly ominous implications

Acquired perforating dermatosis encompasses several specific disease entities occurring in adults that often have overlapping clinical and histologic features. Although chronic renal failure and diabetes mellitus are the most common underlying conditions, several other more rare associations have been noted, including internal malignancy. We describe a case of acquired perforating dermatosis presenting as the first symptom in a 64-year-old man who also was diagnosed to have mild obstructive jaundice due to a periampullary villous adenoma with high-grade dysplasia. In a patient with no other risk factors, the presence of an acquired perforating skin lesion may warrant further investigation to rule out an underlying malignancy.

Diagnosis of bile duct hepatocellular carcinoma thrombus without obvious intrahepatic mass

AIM

To study the diagnosis of hepatocellular carcinoma (HCC) presenting as bile duct tumor thrombus with no detectable intrahepatic mass.

METHODS

Six patients with pathologically proven bile duct HCC thrombi but no intrahepatic mass demonstrated on the preoperative imaging or palpated intrahepatic mass during operative exploration, were collected. Their clinical and imaging data were retrospectively analyzed. The major findings or signs on comprehensive imaging were correlated with the surgical and pathologic findings.

RESULTS

Jaundice was the major clinical symptom of the patients. The elevated serum total bilirubin, direct bilirubin and alanine aminotransferase levels were in concordance with obstructive jaundice and the underlying liver disease. Of the 6 patients showing evidence of viral hepatitis, 5 were positive for serum alpha fetoprotein and carbohydrate antigen 19-9, and 1 was positive for serum carcinoembryonic antigen. No patient was correctly diagnosed by ultrasound. The main features of patients on comprehensive imaging were filling defects with cup-shaped ends of the bile duct, with large filling defects presenting as casting moulds in the expanded bile duct, hypervascular intraluminal nodules, debris or blood clots in the bile duct. No obvious circular thickening of the bile duct walls was observed.

CONCLUSION

Even with no detectable intrahepatic tumor, bile duct HCC thrombus should be considered in patients predisposed to HCC, and some imaging signs are indicative of its diagnosis.