[Advancements and controversies in conversion therapy for biliary tract malignant tumors with insufficient future liver remnant]

Due to the unique location and aggressive tumor biology,hilar cholangiocarcinoma,intrahepatic cholangiocarcinoma,and gallbladder cancer often present with obstructive jaundice and require extensive liver resection,also exhibit high rates of recurrence and metastasis after radical excision. Therefore,surgeons should make treatment decisions based on the biliary anatomy of patients and the biological characteristics of tumors as it significantly affects patient's prognosis. Treatment strategy should be made to ensure the successful implementation of radical resection for biliary tract malignant tumors while maximizing the survival benefits of patients. Firstly,conversion of liver function by relieving jaundice technology and conversion of tumor biological characteristics through systematic therapy,followed by the conversion of future liver remnant. Currently,there are still controversies surrounding indications,methods,standards of relieving jaundice,and treatment plans,cycles,evaluation of therapeutic effects for systematic conversion therapy,and the standards and techniques of conversion therapy for future liver remnant.This article discusses these issues through literature analysis and the author's experience in the hope of resonating with colleagues.

Hepatic and renal lesions in sheep intoxicated with Urochloa hybrid Mulato II in Argentina

A flock of 48 sheep in Argentina grazing on a pasture of hybrid Urochloa (formerly Brachiaria) Mulato II (Urochloa ruziziensis × Urochloa decumbens × Urochloa brizantha) developed facial dermatitis, severe jaundice, and weakness after brief physical activity. Blood biochemistry of 3 animals revealed azotemia, elevated aspartate aminotransferase activity, and increased direct, indirect, and total bilirubin concentrations. The urine was markedly turbid and contained large concentrations of bile pigments and protein. At autopsy of 2 animals, there was severe jaundice and subcutaneous submandibular edema. The livers were enlarged, intensely yellow, and had a marked acinar pattern. Gallbladders were distended, and the kidneys were diffusely dark in one animal and yellow-green in the other. Microscopically, there was lymphoplasmacytic and histiocytic cholangiohepatitis with abundant crystals in the lumen of bile ducts and in the cytoplasm of macrophages. The proximal and distal convoluted renal tubules had protein casts in their lumens, and crystals were observed in the lumen and epithelial cells. Lectin histochemistry showed strong affinity for Arachis hypogaea agglutinin in hepatic macrophages. In the one sheep that was tested for heavy metals, copper concentrations in the liver and kidney were within the RIs. Despite the immediate change of pasture, morbidity and mortality were 100% within 3 mo. The association between the consumption of this pasture, and the clinical, biochemical, pathology, and lectin histochemistry findings confirmed intoxication with Urochloa hybrid Mulato II. To our knowledge, intoxication by this hybrid of Urochloa has not been reported previously.

Differentiation of malignant from benign ampullary strictures: A prediction nomogram based on MR imaging and clinical findings

PURPOSE

To construct a predictive nomogram based on contrast-enhanced magnetic resonance imaging (MRI) and clinical findings for differentiating malignant from benign ampullary strictures.

METHOD

In this retrospective study, 76 patients with ampullary strictures (51 benign and 25 malignant) who underwent contrast-enhanced MRI were enrolled. Imaging findings were evaluated independently by two abdominal radiologists who reached consensus. Clinical findings were also collected. Significant findings for malignant ampullary strictures were assessed by univariable and multivariable logistic regression analyses. Based on the results of multivariable analysis, a nomogram to differentiate malignant from benign ampullary strictures was developed and internally validated.

RESULTS

In multivariable analysis, presence of an ampullary mass (odds ratio [OR]: 8.42, p = 0.047), bulging ampulla (OR: 8.32, p = 0.033), diffusion restriction of the ampulla (OR: 42.76, p = 0.004) on MRI, and jaundice (OR: 12.41, p = 0.019) were significant predictors of malignant ampullary strictures. A predictive nomogram was constructed using these findings. Among them, diffusion restriction of the ampulla showed the highest OR and predictor score on the nomogram. The calibration plots for internal validation achieved strong agreement between the predicted probabilities and the actual rates of malignant ampullary strictures.

CONCLUSION

A combination of significant contrast-enhanced MRI and clinical findings of ampullary mass, bulging ampulla, diffusion restriction of the ampulla, and jaundice may be useful in the prediction of malignant ampullary stricture.

Impact of Preoperative Jaundice and Biliary Drainage on Short- and Long-term Outcomes among Patients with Gallbladder Cancer

OBJECTIVES

To characterize the prognostic implication of jaundice and preoperative biliary drainage on postoperative outcomes among patients with gallbladder cancer (GBC) undergoing surgical resection.

METHODS

Patients who underwent surgical resection of GBC identified from a multicenter database between January 2000 and December 2019 were retrospectively analyzed. Data on clinical and pathological details, as well as short- and long-term overall survival (OS), were obtained and compared among patients with and without preoperative jaundice and biliary drainage.

RESULTS

Among 449 patients with GBC, median and 1-, 3-, and 5-year OS were 17.4 months, 63.7%, 28.4%, and 22.1%, respectively. Patients who presented with preoperative jaundice (n = 100, 22.3%) were more likely to have advanced disease, a lower incidence of R0 resection (29.0% vs. 69.1%, p < 0.001), as well as a higher incidence of postoperative liver failure (4% vs. 0, p = 0.002), and worse long-term survival versus patients without jaundice (median OS, 10.4 vs. 27.1 months, p < 0.001). Preoperative biliary drainage was performed for the majority of jaundiced patients (77.0%) and was associated with decreased risk of postoperative liver failure (1.3% vs. 13.0%, p = 0.041); preoperative biliary drainage failed to improve long-term survival (median OS, 10.2 months vs. 12.0 months, p = 0.679). On multivariable analysis, R0 resection (17.5 vs. 7.6 months, p < 0.001) and adjuvant therapy (15.6 vs. 6.6 months, p = 0.027) were associated with improved long-term survival among jaundiced patients.

CONCLUSIONS

While preoperative biliary drainage of jaundiced GBC patients decreased the risk of postoperative liver failure, it did not impact long-term outcomes. Rather, preoperative jaundice was associated with a lower chance at R0 resection and worse long-term survival.

Vanishing Bile Duct Syndrome Secondary to Hodgkin Lymphoma in a Child

Vanishing bile duct syndrome (VBDS) is a condition resulting from progressive destruction and loss of intrahepatic bile ducts leading to cholestasis, biliary cirrhosis, and liver failure. It occurs secondary to various pathologic conditions like autoimmune diseases, graft versus host disease, drug reactions, and as a paraneoplastic syndrome in malignancies. We here described a 9-year-old girl who presented with cervical lymphadenopathy and jaundice. This child was diagnosed as a case of Hodgkin lymphoma. All other causes of cholestasis were ruled out by appropriate investigations (particularly autoimmune, metabolic, infections, and drug-induced possibilities). On liver biopsy, her diagnosis was established as VBDS. In view of hepatic dysfunction, alternative chemotherapy with dexamethasone, high-dose cytarabine, and cisplatin (DHAP) was given, and she was started on hepatoprotective measures with ursodeoxycholic acid. Hepatic function gradually improved after the initiation of chemotherapy. VBDS is considered a dismal paraneoplastic syndrome with a high-case fatality. This case report highlights the importance of early recognition and initiation of appropriate full-dose chemotherapy as the only way to achieve complete resolution of VBDS.

A case of true vocal fold jaundice

OBJECTIVES

While jaundice is frequently described in the sclera and skin, there are few reports of true vocal fold jaundice in patients with high bilirubin, and no reports by otolaryngologists in the literature. Here we describe a case of a patient with bilateral true vocal fold jaundice and discuss the potential pathogenesis and implications of this finding.

METHODS

A 29-year-old man with history of Dubin-Johnson Syndrome presented with cough and difficulty breathing and was incidentally found to have persistent yellow discoloration of the true vocal folds bilaterally.

RESULTS

Videolaryngoscopic exam demonstrated bilateral true vocal fold yellow discoloration with sparing of nearby laryngeal structures on initial presentation and follow-up exam. Direct and total bilirubin levels were found to be elevated.

CONCLUSION

A patient with benign Dubin-Johnson Syndrome and elevated total and direct bilirubin was incidentally found to have bilateral vocal fold jaundice. Jaundice and the presence of bilirubin do not appear to cause harm to the function or health of the true vocal folds and may be related to the high concentration of elastin present in the true vocal folds.

Rare cause of obstructive icterus in a young patient

In this case report is discussed the diagnosis of papillary carcinoma in the case of a patient in whose age the occurrence of the disease is very rare. The patient underwent a series of non-invasive and invasive examinations, the results of which eventually led to a surgical solution of the suspected lesion (Wipples procedure). Histological examination of the resection confirmed mixed type ampular adenocarcinoma. In the context of this finding, the results of the examination, their information value, interpretation and mutual interaction are discussed. In the postoperative period, the patient suffered from gastrointestinal bleeding, subileum and poor postoperative healing. After hospitalization, the patient was transferred to oncology care and indicated for genetic testing.

An outbreak of acute jaundice syndrome (AJS) among the Rohingya refugees in Cox's Bazar, Bangladesh: Findings from enhanced epidemiological surveillance

In the summer of 2017, an estimated 745,000 Rohingya fled to Bangladesh in what has been described as one of the largest and fastest growing refugee crises in the world. Among numerous health concerns, an outbreak of acute jaundice syndrome (AJS) was detected by the disease surveillance system in early 2018 among the refugee population. This paper describes the investigation into the increase in AJS cases, the process and results of the investigation, which were strongly suggestive of a large outbreak due to hepatitis A virus (HAV). An enhanced serological investigation was conducted between 28 February to 26 March 2018 to determine the etiologies and risk factors associated with the outbreak. A total of 275 samples were collected from 18 health facilities reporting AJS cases. Blood samples were collected from all patients fulfilling the study specific case definition and inclusion criteria, and tested for antibody responses using enzyme-linked immunosorbent assay (ELISA). Out of the 275 samples, 206 were positive for one of the agents tested. The laboratory results confirmed multiple etiologies including 154 (56%) samples tested positive for hepatitis A, 1 (0.4%) positive for hepatitis E, 36 (13%) positive for hepatitis B, 25 (9%) positive for hepatitis C, and 14 (5%) positive for leptospirosis. Among all specimens tested 24 (9%) showed evidence of co-infections with multiple etiologies. Hepatitis A and E are commonly found in refugee camps and have similar clinical presentations. In the absence of robust testing capacity when the epidemic was identified through syndromic reporting, a particular concern was that of a hepatitis E outbreak, for which immunity tends to be limited, and which may be particularly severe among pregnant women. This report highlights the challenges of identifying causative agents in such settings and the resources required to do so. Results from the month-long enhanced investigation did not point out widespread hepatitis E virus (HEV) transmission, but instead strongly suggested a large-scale hepatitis A outbreak of milder consequences, and highlighted a number of other concomitant causes of AJS (acute hepatitis B, hepatitis C, Leptospirosis), albeit most likely at sporadic level. Results strengthen the need for further water and sanitation interventions and are a stark reminder of the risk of other epidemics transmitted through similar routes in such settings, particularly dysentery and cholera. It also highlights the need to ensure clinical management capacity for potentially chronic conditions in this vulnerable population.

Etiological classification and treatment strategies for secondary bile duct dilatation

Secondary intra- and extrahepatic bile duct dilatation is a very common condition that can be caused by several diseases. However, it has been rarely discussed in the specialized literature. Moreover, no distinct etiology can be determined in some cases, which hampers the diagnosis and treatment. Here, we discuss the etiological classification and treatment strategies of secondary intra- and extrahepatic bile duct dilatation based on an extensive literature review, as well as our experimental research and clinical experience. The etiology of secondary intra- and extrahepatic bile duct dilatation can be classified in different ways. From a clinicopathological perspective, it can be classified into obstruction-, lesion-, and compression-induced dilatation. Treatment varies depending on the cause. For example, endoscopic dilation or stenting is used for biliary strictures, laparoscopic choledochectomy for stone removal, and resection for cholangiocarcinoma.

Aetiology of viral hepatitis among jaundiced patients presenting to a tertiary hospital in Ghana

BACKGROUND

Viral hepatitis continues to play significant role in causing morbidity and mortality in sub-Saharan Africa. Apart from the few population based studies available, not many have investigated the burden of these viruses in jaundiced patients. Among the few studies, hepatitis E is the least studied among jaundiced patients. This study was aimed at describing the frequency, distribution and risk of the different hepatitis viruses among jaundiced patients reporting to the second largest teaching hospital in Ghana.

METHODS

From November, 2015 to April, 2016, a cross-sectional study was conducted among jaundiced patients attending the Komfo Anokye Teaching Hospital. Between 3-5 ml of blood was collected from each patient and screened for viral hepatitis agents using both serologic and molecular-based assays.

RESULTS

In the 155 patients recruited, hepatitis B was the most prevalent [54.2% (95% CI = 46.0%-62.2%)] followed by hepatitis E [32.9% (95% CI = 25.6-40.9%)]. Most cases of hepatitis E occurred as co-infections with hepatitis B (18%), with the predominant clinical feature being hepatocellular carcinoma. Risk factor variable analysis showed middle and older aged individuals were more at risk of hepatitis B exposure whereas younger age groups (<18 years) were more at risk of hepatitis E virus infection.

CONCLUSION

Hepatitis viruses are still important in the viral aetiology of jaundice in Ghana. Hepatitis B and hepatitis E co-infections could play significant roles in causing severe disease. A more aggressive approach needs to be adopted in order to reduce the morbidity and mortality associated with hepatitis causing viruses in Ghana and other developing countries.

The Clinical Differences between Urgent Visits and Non-Urgent Visits in Emergency Department During the Neonatal Period

As neonates are brought to the emergency department (ED) for various complaints, it is challenging for emergency physicians to clinically determine the urgency of the visit. We sought to explore clinical characteristics associated with urgent visits to the ED. We conducted a retrospective study by reviewing medical records of neonatal visits to a tertiary pediatric regional emergency center for 5 years. Cases of patients who were discharged after checking only chest or abdominal X-ray or discharged without workup, were classified as non-urgent visits. Cases where more examinations were performed, or when the patient was hospitalized, were classified as urgent visits. Various clinical features and process in the ED were compared between the groups. Of the 1,008 cases enrolled in this study, 856 (84.9%) were urgent and 152 (15.1%) were non-urgent visits. After adjustment by multiple logistic regression analysis, non-urgent visits were associated with self-referrals rather than physician-referrals (odds ratio [OR], 5.96), visits in the evening rather than at night or daytime (OR, 2.51), patient visits from home rather than from medical facilities (OR, 2.19; 95). Fever and jaundice were the most common complaints (25.7% and 24.5%, respectively), and their OR of non-urgent visit was relatively low (adjusted OR 0.03 and 0.03, respectively). However, other common complaints, such as vomiting and cough (7.4% and 7.1%, respectively), were more likely to be non-urgent visits (adjusted OR 2.96 and 9.83, respectively). For suspected non-urgent visits, emergency physicians need to try to reduce unnecessary workup and shorten length of stay in ED.

Efficacy and safety assessment of ERCP in patients with malignant biliary obstruction

BACKGROUND

To assess the efficacy and safety of Endoscopic retrograde cholangiopancreatography (ERCP) for malignant biliary obstruction (MBO).

MATERIAL AND METHODS

A review of all ERCP-procedures performed at Akershus University Hospital during the six year period between 2009-2014 was analysed. Data for the period 2009- 2013 were obtained retrospectively and prospectively for 2014. Patients with jaundice due to MBO were selected for the present study.

RESULTS

A total of 210 patients (51% females), median age of 70 years (range 33-96) were included. The total number of procedures were 314, whereof 218 (69%) were successful and 96 (31%) were failures. 292 procedures were palliative and 22 procedures were intended as 'bridge to surgery' whereof 15 patients underwent surgery. Pancreatic carcinoma occurred in 105 (50%) patients and was the most common reason for MBO. Straight plastic stents (I-stents) were applied in 145 (74%), double-pigtail stents (JJ-stents) in 29 (15%), self-expanding metal stent (SEMS) in 18 (9%) procedures and in 3 procedures (1.5%) an I-stent was inserted through an indwelling SEMS. Median duration of stentpatency in months was 2 (range 0-74) for I-stent, 1 (range 0-29) for JJ-stent and 4 (range 0-29) for SEMS. The rates of complication and mortality due to complication were 8.9% and 1.3% per procedure.

CONCLUSION

Adequate drainage of MBO by ERCP was obtained in 69%. The rates of complication and procedure related mortality were at acceptable levels.

Development and external validation of a clinical prognostic score for death in visceral leishmaniasis patients in a high HIV co-infection burden area in Ethiopia

BACKGROUND

In Ethiopia, case fatality rates among subgroups of visceral leishmaniasis (VL) patients are high. A clinical prognostic score for death in VL patients could contribute to optimal management and reduction of these case fatality rates. We aimed to identify predictors of death from VL, and to develop and externally validate a clinical prognostic score for death in VL patients, in a high HIV co-infection burden area in Ethiopia.

METHODOLOGY/PRINCIPAL FINDINGS

We conducted a retrospective cohort study in north west Ethiopia. Predictors with an adjusted likelihood ratio ≥1.5 or ≤0.67 were retained to calculate the predictor score. The derivation cohort consisted of 1686 VL patients treated at an upgraded health center and the external validation cohort consisted of 404 VL patients treated in hospital. There were 99 deaths in the derivation cohort and 53 deaths in the external validation cohort. The predictors of death were: age >40 years (score +1); HIV seropositive (score +1); HIV seronegative (score -1); hemoglobin ≤6.5 g/dl (score +1); bleeding (score +1); jaundice (score +1); edema (score +1); ascites (score +2) and tuberculosis (score +1). The total predictor score per patient ranged from -1 to +5. A score of -1, indicated a low risk of death (1.0%), a score of 0 an intermediate risk of death (3.8%) and a score of +1 to +5, a high risk of death (10.4-85.7%). The area under the receiver operating characteristic curve was 0.83 (95% confidence interval: 0.79-0.87) in derivation, and 0.78 (95% confidence interval: 0.72-0.83) in external validation.

CONCLUSIONS/SIGNIFICANCE

The overall performance of the score was good. The score can enable the early detection of VL cases at high risk of death, which can inform operational, clinical management guidelines, and VL program management. Implementation of focused strategies could contribute to optimal management and reduction of the case fatality rates.

Fate of Neural Progenitor Cells Transplanted Into Jaundiced and Nonjaundiced Rat Brains

High levels of bilirubin in infants can cause kernicterus, which includes basal ganglia damage and dystonia. Stem cell transplantation may be an effective treatment for this disease. In this study, we transplanted human neural progenitor cells differentiated toward propriospinal interneurons into the striatum of 20-day-old spontaneously jaundiced (jj) Gunn rats and nonjaundiced (Nj) littermates. Using immunohistochemical methods, we found that grafted cells survived and grew fibers in jj and Nj brains 3 weeks after transplantation. Grafted cells had a higher survival rate in jj than in Nj brains, suggesting that slightly elevated bilirubin may protect graft survival due to its antioxidative and immunosuppressive effects. Despite their survival, only a small portion of grafted neurons expressed GAD-6 or ChAT, which mark GABAergic and cholinergic neurons, respectively, and are the cells that we are attempting to replace in kernicterus. Thus, NPCs containing large populations of GABAergic and cholinergic neurons should be used for further study in this field.

[Not Available]

Analyzed the results of surgical treatment of 132 patients, including 68 — for cancer of the pancreatic head (in 46 — with jaundice) and 64 — chronic pancreatitis (CP) with a primary lesion of the pancreatic head (16 — with jaundice). The distribution of patients into groups was carried out with a maximum value of classification functions calculated by special formulas. Next studied indicators of endothelial dysfunction for differential diagnosis. A certain threshold of VEGF = 346 pg / ml, in which the patients were divid' ed into groups: СP and cancer on the pancreatic head. It was even more accurate indi' cator threshold VEGF = 248 pg / ml. To predict the severity of the pathological process, along with the use of diagnostic data, using the method of classification trees. Pancreatoduodenal resection for Whipple was performed in 23 patients, for Traverso— Longmire — in 8, subtotal right sided pancreatectomy for Fortner — in 3, hepaticoje' junostomy by Roux — in 8, duodenopreserving resection for Beger — in 6, her Bernese option — in 7, operation Frey — in 51. In 26 (19.7%) patients, minimally invasive inter' vention for removal of bile were spread through the final primary pathological process and severe general state. Postoperative complications occurred in 18 (13.6%) patients, died 3 (2.3%).

The neuroprotective and anti-apoptotic effects of melatonin on hemolytic hyperbilirubinemia-induced oxidative brain damage

Melatonin exerts protection in several inflammatory and neurodegenerative disorders. To investigate the neuroprotective effects of melatonin in an experimental hemolysis-induced hyperbilirubinemia, newborn Sprague-Dawley rats (25-40 g, n = 72) were injected with phenylhydrazine hydrochloride (PHZ; 75 mg/kg) and the injections were repeated at the 24th hour. Rats were treated with saline or melatonin (10 mg/kg) 30 min before the first and second PHZ injections and 24 h after the 2nd PHZ injections. Control rats (n = 24) were injected with saline, but not PHZ. At sixth hours after the last injections of saline or melatonin, all rats were decapitated. Tumor necrosis factor (TNF)-α, IL-1β, IL-10 and brain-derived neurotrophic factor (BDNF) and S100B levels in the plasma were measured. Brain tissue malondialdehyde (MDA), glutathione (GSH) levels and myeloperoxidase (MPO) activities were measured, and brain tissues were evaluated for apoptosis by TUNEL method. In the saline-treated PHZ group, hemoglobin, hematocrit levels were reduced, and total/direct bilirubin levels were elevated when compared to control group. Increased plasma TNF-α, IL-1β levels, along with decreased BDNF, S100B and IL-10 values were observed in the saline-treated PHZ group, while these changes were all reversed in the melatonin-treated group. Increased MDA levels and MPO activities in the brain tissues of saline-treated hyperbilirubinemic rats, concomitant with depleted brain GSH stores, were also reversed in the melatonin-treated hyperbilirubinemic rats. Increased TUNEL(+) cells in the hippocampus of saline-treated PHZ group were reduced by melatonin treatment. Melatonin exerts neuroprotective and anti-apoptotic effects on the oxidative neuronal damage of the newborn rats with hemolysis and hyperbilirubinemia.

An outbreak of hepatitis E in an urban area of Bangladesh

We investigated an outbreak of jaundice in urban Bangladesh in 2010 to examine the cause and risk factors and assess the diagnostic utility of commercial assays. We classified municipal residents reporting jaundice during the preceding 4 weeks as probable hepatitis E cases and their neighbours without jaundice in the previous 6 months as probable controls. We tested the sera collected from probable cases and probable controls for IgM anti-hepatitis E virus (HEV), and the IgM-negative sera for IgG anti-HEV using a commercial assay locally. We retested the IgM-positive sera for both IgM and IgG anti-HEV using another assay at the Centre for Disease Control and Prevention (CDC), USA. Probable cases positive for IgM anti-HEV were confirmed cases; probable controls negative for both IgM and IgG anti-HEV were confirmed controls. We explored the local water supply and sanitation infrastructure and tested for bacterial concentration of water samples. Probable cases were more likely than probable controls to drink tap water (adjusted odds ratio: 3.4; 95% CI: 1.2-9.2). Fifty-eight percentage (36/62) of the case sera were IgM anti-HEV positive; and 75% of the IgM-positive samples were confirmed positive on retesting with another assay at CDC. Compared to confirmed controls, cases confirmed using either or both assays also identified drinking tap water as the risk factor. Two tap water samples had detectable thermotolerant coliforms. Research exploring decentralized water treatment technologies for sustainable safe water might prevent HEV transmission in resource-poor cities. Detection of serological markers in a majority of probable cases implied that available diagnostic assays could adequately identify HEV infection during outbreaks.

A Systematic Review of the Mortality from Untreated Leptospirosis

BACKGROUND

Leptospirosis occurs worldwide, but the global incidence of human disease and its mortality are not well understood. Many patients are undiagnosed and untreated due to its non-specific symptoms and a lack of access to diagnostics. This study systematically reviews the literature to clarify the mortality from untreated leptospirosis. Results will help quantify the global burden of disease and guide health policies.

METHODOLOGY/PRINCIPAL FINDINGS

A comprehensive literature search was performed to identify untreated patient series. Included patients were symptomatic, but asymptomatic patients and those who had received antibiotics, dialysis or who were treated on Intensive Care Units were excluded. Included patients had a confirmed laboratory diagnosis by culture, PCR, or serological tests. Data was extracted and individual patient series were assessed for bias. Thirty-five studies, comprising 41 patient series and 3,390 patients, were included in the study. A high degree of bias within studies was shown due to limitations in study design, diagnostic tests and missing data. Median series mortality was 2.2% (Range 0.0-39.7%), but mortality was high in jaundiced patients (19.1%) (Range 0.0-39.7%), those with renal failure 12.1% (Range 0-25.0%) and in patients aged over 60 (60%) (Range 33.3-60%), but low in anicteric patients (0%) (Range 0-1.7%).

CONCLUSIONS

This systematic review contributes to our understanding of the mortality of untreated leptospirosis and provides data for the estimation of DALYs attributable to this disease. We show that mortality is significantly higher in older patients with icteric disease or renal failure but is lower in younger, anicteric patients. Increased surveillance and accurate point-of-care diagnostics are required to better understand the incidence and improve diagnosis of disease. Empirical treatment strategies should prioritize early treatment to improve outcomes from leptospirosis.

Development and optimization of a noncontact optical device for online monitoring of jaundice in human subjects

Jaundice is one of the notable markers of liver malfunction in our body, revealing a significant rise in the concentration of an endogenous yellow pigment bilirubin. We have described a method for measuring the optical spectrum of our conjunctiva and derived pigment concentration by using diffused reflection measurement. The method uses no prior model and is expected to work across the races (skin color) encompassing a wide range of age groups. An optical fiber-based setup capable of measuring the conjunctival absorption spectrum from 400 to 800 nm is used to monitor the level of bilirubin and is calibrated with the value measured from blood serum of the same human subject. We have also developed software in the LabVIEW platform for use in online monitoring of bilirubin levels in human subjects by nonexperts. The results demonstrate that relative absorption at 460 and 600 nm has a distinct correlation with that of the bilirubin concentration measured from blood serum. Statistical analysis revealed that our proposed method is in agreement with the conventional biochemical method. The innovative noncontact, low-cost technique is expected to have importance in monitoring jaundice in developing/underdeveloped countries, where the inexpensive diagnosis of jaundice with minimally trained manpower is obligatory.

Mild to Moderate Symptoms Do Not Correlate with Lactate Levels in HIV-Positive Patients on Nucleoside Reverse Transcriptase Inhibitors

PURPOSE

Nucleoside reverse transcriptase inhibitors (NRTIs) are associated with mitochondrial toxicities ranging from asymptomatic hyperlactatemia to fatal lactic acidosis. It is uncertain whether mild clinical symptoms predict hyperlactatemia and the need to consider changes in antiretroviral therapy. This cross-sectional study evaluated whether an association exists between mild symptoms and lactate levels.

METHOD

HIV-positive patients on NRTIs attending routine clinic visits were surveyed about symptoms associated with hyperlactatemia. Symptom severity was quantified using Likert scales, and the sum was converted into a symptom score ranging from 0 to 30. Tourniquet-free blood specimens were collected simultaneously to measure serum lactate. Symptom scores were compared between patients with normal and elevated lactates.

RESULTS

284 individuals were included. The most common NRTIs used included lamivudine (79%), zidovudine (50%), abacavir (39%), and stavudine (24%). Twenty-two patients (8%) had increased lactates (mean = 2.7 mmol/L; range, 2.1-4.5 mmol/L), while 262 patients (92%) had normal lactates (mean = 1.2 mmol/L, range, 0.1-2.0 mmol/L). Median symptom scores were similar between groups (3 vs. 2, p = .23). Spearman's correlation coefficient for lactate and symptom score was 0.07 (p = .22).

CONCLUSIONS

Mild symptoms did not correlate with lactate levels, and symptoms alone should not trigger clinicians to measure serum lactates and stop NRTIs if the levels are elevated.

Profound jaundice in a patient with acute hepatitis C

A 52-year-old African-American woman with overall good health and medical history of asthma and depression presented with right lower quadrant abdominal pain, vomiting and icterus for 3 weeks. Her physical examination was remarkable for only sclera icterus and mild tenderness on palpation in the right lower quadrant. Investigations revealed marked hyperbilirubinemia and transaminitis, with other serological and radiological studies unremarkable and a hepatitis A, B and C panel negative 3 weeks before presentation. Repeat hepatitis panel showing hepatitis C antibody positive with viral load 20 739 524 IU/mL. Liver biopsy supported the diagnosis of acute hepatitis C infection.

Role of radical resection in patients with gallbladder carcinoma and jaundice

BACKGROUND

Gallbladder carcinoma (GBC) is a commonly-seen malignancy of the biliary tract characterized by difficult early diagnosis, rapid growth, early metastasis, and poor prognosis. Nearly half of GBC patients also have jaundice, which is a mark of the advanced stage of GBC. The role of radical resection in patients of gallbladder carcinoma with jaundice is still a matter of uncertainty, which we attempted to clarify in this study.

METHODS

Totally, 251 GBC patients who received treatment at the Eastern Hepatobiliary Surgery Hospital (EHBH) from December 2002 to January 2010 were recruited into this study. We divided them into group A (jaundice group, n=117) and group B (non-jaundice group, n=134). Clinical records and follow-up data were collected and retrospectively analyzed in both groups.

RESULTS

Compared with group A, patients in group B had a longer median survival time ((6.0±0.5) months vs. (15.0±2.6) months, P<0.01). Even in patients with stage III or stage IV GBC, the median survival time in patients without jaundice (n=111), was still longer than that in patients with jaundice (n=116) (P<0.01). The radical resection rate was lower in group A patients than in group B patients with stage III or stage IV GBC; 31.9% vs. 63.1%. However, the median survival time of patients undergoing radical resection did not show a statistical difference between jaundice patients and non-jaundice patients; (12.0±4.3) months vs. (18.0±3.0) months (P>0.05).

CONCLUSIONS

GBC with jaundice usually implies advanced stage disease and a poor prognosis for the patients. However, our findings indicate that as long as the patient's condition allows, radical resection is still feasible for GBC patients with jaundice, and may achieve a prognosis close to those GBC patients without jaundice.

Hepatocyte IKK2 protects Mdr2-/- mice from chronic liver failure

Mice lacking the Abc4 protein encoded by the multidrug resistance-2 gene (Mdr2(-/-)) develop chronic periductular inflammation and cholestatic liver disease resulting in the development of hepatocellular carcinoma (HCC). Inhibition of NF-κB by expression of an IκBα super-repressor (IκBαSR) transgene in hepatocytes was shown to prevent HCC development in Mdr2(-/-) mice, suggesting that NF-κB acts as a tumour promoter in this model of inflammation-associated carcinogenesis. On the other hand, inhibition of NF-κB by hepatocyte specific ablation of IKK2 resulted in increased liver tumour development induced by the chemical carcinogen DEN. To address the role of IKK2-mediated NF-κB activation in hepatocytes in the pathogenesis of liver disease and HCC in Mdr2(-/-) mice, we generated Mdr2-deficient animals lacking IKK2 specifically in hepatocytes using the Cre-loxP system. Mdr2(-/-) mice lacking IKK2 in hepatocytes developed spontaneously a severe liver disease characterized by cholestasis, major hyperbilirubinemia and severe to end-stage fibrosis, which caused muscle wasting, loss of body weight, lethargy and early spontaneous death. Cell culture experiments showed that primary hepatocytes lacking IKK2 were more sensitive to bile acid induced death, suggesting that hepatocyte-specific IKK2 deficiency sensitized hepatocytes to the toxicity of bile acids under conditions of cholestasis resulting in greatly exacerbated liver damage. Mdr2(-/-)IKK2(Hep-KO) mice remarkably recapitulate chronic liver failure in humans and might be of special importance for the study of the mechanisms contributing to the pathogenesis of end-stage chronic liver disease or its implications on other organs.

CONCLUSION

IKK2-mediated signaling in hepatocytes protects the liver from damage under conditions of chronic inflammatory cholestasis and prevents the development of severe fibrosis and liver failure.

Meropenem-induced vanishing bile duct syndrome

Vanishing bile duct syndrome (VBDS) is a rare and potentially life-threatening disorder in which progressive destruction and disappearance of small intrahepatic bile ducts occur, with resultant cholestasis. The mechanism by which biliary epithelial cells are damaged and intrahepatic bile ducts are lost has not been fully elucidated. However, many etiologies have been reported,and several drugs have been implicated. Meropenem is a widely used, well tolerated broad-spectrum carbapenem antibiotic indicated for the treatment of intraabdominal infections, complicated skin and skin structure infections, and pediatric bacterial meningitis. We describe what we believe is the first reported case of meropenem-induced VBDS. A 60-year-old woman was diagnosed with VBDS after being treated with meropenem for a left temporal lobe brain abscess. Three weeks after starting the drug, the patient developed mixed hepatocellular and cholestatic liver injury with jaundice and pruritus.Meropenem-induced liver injury was suspected, and the drug was discontinued. Diagnostic tests ruled out other causes of cholestasis, including infectious and immunologic conditions. A liver biopsy, performed due to persistent liver injury, demonstrated an absence of bile ducts, which, in conjunction with the patient's clinical course, was consistent with the diagnosis of VBDS. Several months after the cessation of meropenem, the patient's liver function test results improved. Use of the Naranjo adverse drug reaction probability scale indicated a probable relationship (score of 6)between the patient's development of VBDS and meropenem therapy. A high index of suspicion is necessary to diagnose VBDS and other types of drug induced liver injury. Clinicians should consider VBDS as a potential diagnosis in patients receiving meropenem who have prolonged cholestasis, especially after other more probable causes have been excluded.

[The palliative role of percutaneous endoscopic gastrostomy with jejunal extension (PEG-J) in an advanced pancreatic cancer patient with duodenal stenosis--a case report]

Although a 64-year-old man with pancreatic cancer was referred to our hospital due to difficulty in the bile drainage, he was initially planned to have an operation at another hospital after relief of obstructive jaundice. Laboratory tests on admission revealed obstructive jaundice, pancreatitis and malnutrition (T-Bil 12.1 mg/dL, AMY 1170 IU/L, Alb 2.0 g/dL). Abdominal computed tomography (CT) detected a pancreas tumor and multiple liver metastases. Then, we determined to carry out palliative therapy. Percutaneous transhepatic cholangiography (PTC) showed a common bile duct obstruction, and a biliary metallic stent was placed. Endoscopic examination revealed a tumorous duodenal stenosis. We performed percutaneous endoscopic gastrostomy with jejunal extension (PEG-J), which was used for both transintestinal nutrition and decompression gastrostomy. After these therapies, the patient's condition improved better in 2 weeks as such that he could have stayed away from our hospital for several days. PEG-J was useful to improve a quality of life in pancreatic cancer patient with duodenal stenosis.

Autoimmune lymphoproliferative syndrome (ALPS): a case with congenital onset

We describe a case of autoimmune lymphoproliferative syndrome (ALPS), which is very unusual with regard to a clinical onset soon after birth, and a clinical picture dominated by splenomegaly, jaundice, and consumptive peripheral blood cytopenias, with minimal lymphadenopathy. Our documented close follow up demonstrated initial involvement of the spleen, followed by involvement of the bone marrow and the peripheral blood. The patient underwent bone marrow transplant and is alive and well 20 months after diagnosis.

Atypical presentation of xanthogranulomatous pyelonephritis: a case report

Xanthogranulomatous pyelonephritis (XPN) is a rare form of chronic pyelonephritis, which is usually caused by calculous obstructive uropathy. We present a previously healthy 45-year-old housewife, who was admitted to The Dammam Central Hospital, Dammam, Saudi Arabia with left loin pain and increased frequency of micturition of four days duration. She also had icterus and features of disseminated intravascular coagulation. Abdominal ultrasound and computed tomography of the abdomen was suggestive of XPN. She responded well to treatment with antibiotics and nephrectomy. Histology of the resected kidney confirmed a diagnosis of XPN. Our case suggests that the diagnosis of XPN should be kept in mind when a middle-aged female patient presents with unilateral non-functioning hydronephrotic kidney, which is totally distorted, and has enhancing as well as non-enhancing regions on computed tomography.

Palliation of malignant hilar obstruction at a single centre--review of operative and non-operative techniques

INTRODUCTION

Jaundice secondary to a malignant hilar obstruction can be relieved by operative bypass or percutaneous stenting. Comparative trials involving these techniques are scarce. We reviewed our experience with these competing techniques in the palliation of malignant hilar obstruction.

PATIENTS AND METHODS

All patients with malignant hilar obstruction managed at our institution during the period 1992-2002 were identified for review.

RESULTS

A total of 36 deeply jaundiced patients with hilar obstruction were identified. Twenty-two patients underwent exploration with the intention of performing an operative bypass and 14 patients underwent percutaneous transhepatic cholangiography (PTC) with intention to stent. Procedure-related mortality was similar in both groups. Morbidity was much higher in the operative group. Effective symptom relief was achieved with both techniques. In the PTC group recurrent biliary obstruction in 2 patients necessitated salvage non-operative procedures. Although survival rates were slightly longer in the operative group, this was not significant. There were no long-term survivors.

CONCLUSION

Operative bypass provides better sustained relief of jaundice than PTC. However long-term survival in both groups is poor and operative bypass is best reserved for younger patients with no technical contraindications. Despite early and late procedural failures PTC is the method of choice for patients with advanced-stage disease and those with significant co-morbidities.

High serum nitric oxide levels in patients with severe leptospirosis

Leptospirosis is a globally distributed zoonosis of major public health importance and is associated with severe disease manifestations such as acute renal failure and pulmonary haemorrhage syndrome. However, the extent to which the pathogenesis of leptospirosis mimics sepsis caused by Gram-negative bacteria remains unknown. The aim of this study was to evaluate serum levels of nitric oxide (NO) in patients diagnosed with severe leptospirosis. Sera from 35 confirmed cases of severe leptospirosis and 13 healthy subjects were analysed. Patients with severe leptospirosis had significantly higher NO levels compared to healthy individuals (30.82+/-10.90 microM versus 3.86+/-1.34 microM, P < 0.001), indicating that this immune mediator plays a role in the underlying systemic inflammatory response.

Infectious haemolytic anaemia causes jaundice outbreaks in seawater-cultured coho salmon, Oncorhynchus kisutch (Walbaum), in Chile

In the last 9 years, epizootics of an icterus condition has affected coho salmon, Oncorhynchus kisutch (Walbaum), reared in seawater cages in southern regions of Chile. At necropsy, fish from field cases exhibited signs of jaundice accompanied by pale light-brown livers and dark spleens. Histopathological and haematological results indicated that these fish presented haemolytic anaemia. After microbiological examination no bacterial or viral agents could be identified as aetiological agents of this disease. In an infectivity trial, coho salmon, Atlantic salmon, Salmo salar L., and rainbow trout, Oncorhynchus mykiss (Walbaum), were inoculated intraperitoneally with a filtrate of an organ homogenate (0.45 microm) from a diseased coho salmon and held for 60 days in tanks supplied with fresh water. The disease was only reproduced in coho salmon in which mortalities, beginning at day 23 post-inoculation (p.i.), reached a cumulative value of 24% at day 27 p.i. This condition was transmitted to non-inoculated cohabiting coho salmon suggesting that it is a waterborne disease. Thus, this icteric condition is caused by an infectious form of haemolytic anaemia, probably of viral aetiology, and coho salmon are more susceptible than either Atlantic salmon or rainbow trout.

Carcinoid of the ampulla of Vater: Morphologic features and clinical implications

Carcinoids involving the ampulla of Vater are rare lesions that may produce painless jaundice. The published data indicate that these tumors, in contrast to their midgut counterparts, metastasize in approximately half of cases irrespective of primary tumor size. Therefore, radical excision in the form of pancreaticoduodenectomy is recommended regardless of tumor size. As with other gastrointestinal carcinoid tumors, biological treatment with octreotide analogues can be applied to symptomatic patients. Tumor-targeted radioactive therapy is a newly emerging treatment option. We here report case of a carcinoid tumor of the ampulla of Vater presenting as painless jaundice in a 65-year old man and review the relevant literature, giving special attention to the morphologic features, clinical characteristics, and treatment modalities associated with this disease process.

Clinical characteristics and prognostic markers in disulfiram-induced liver injury

BACKGROUND/AIMS

Limited systematic data exists on the incidence of drug-induced hepatotoxicity due to disulfiram and the most important prognostic markers. We aimed to determine the nature and frequency of suspected disulfiram hepatotoxicity in Sweden.

METHODS

All reports of suspected hepatic adverse drug reactions (ADR) associated with disulfiram received by the Swedish Adverse Drug Reactions Advisory Committee (SADRAC) 1966-2002 were reviewed. Causality assessment was based on the International Consensus Criteria.

RESULTS

A total of 82 reports of disulfiram suspected ADRs had at least a possible causal relationship. Eight patients died or underwent liver transplantation (Tx). Mortality or Tx was 16% in patients with jaundice. The median age of the patients (65% males) was 45 years with a median duration of treatment of 42 days. Bilirubin was higher (P<0.0001) in the deceased/transplanted patients compared to surviving patients. No difference was observed in age or duration of therapy between deceased and transplanted and those who recovered. Eosinophilic infiltration in liver biopsies was associated with a favourable outcome, hepatocyte drop-out with a poor outcome.

CONCLUSIONS

Disulfiram associated hepatitis has a considerable mortality risk. Histological signs of immunoallergy seem to be common. Bilirubin and hepatocyte drop-out were the only predictors for death or transplantation.

The pathology of jaundice-related renal insufficiency: cholemic nephrosis revisited

The spectrum of jaundice-related nephropathy can range from limited proximal tubulopathy to renal failure. The latter condition was known as cholemic nephrosis in the early literature on this subject. Elevated plasma concentrations of bile salts and bilirubin conjugated or not, putatively mediate the nephrotoxicity. A functional derangement of renal tubule cells is considered to underlie the nephropathy, but published data on renal histology are scarce. In this report, we describe the renal biopsies of two jaundiced patients with reduced creatinine clearance, and we critically review the literature on the pathogenesis of jaundice-related nephropathy. Normal renal architecture, indicating functional renal impairment, and extensive renal tubule necrosis were both observed in jaundice-related renal failure. The findings fit the original description of cholemic nephrosis. Both bilirubin and bile salts are potential nephrotoxins in animal models, but their precise role in the pathogenesis of jaundice-related nephropathy is not known. Patients with bilirubin plasma concentrations >20 mg/dL, a low serum albumin concentration or endo-toxemia, could be more prone to develop renal failure due to jaundice-related tubulopathy. In conclusion, jaundice-related nephropathy is essentially a tubulopathy, but the exact nature of the Pathogenesis is still uncertain.

Clinicopathologic features of ampullary carcinoma without jaundice

GOALS

To evaluate clinicopathological features of ampullary carcinoma without jaundice.

BACKGROUND

: Obstructive jaundice is the most common symptom of patients with ampullary carcinoma. However, some patients with ampullary carcinoma do not have jaundice at the time of diagnosis.

STUDY

Clinicopathologic findings of 23 patients with ampullary carcinoma showing no visible jaundice (serum total bilirubin <3.0 mg/dL) and 38 patients with ampullary carcinoma showing jaundice at the time of diagnosis were retrospectively compared.

RESULTS

Fifteen of 23 patients with nonjaundiced ampullary carcinoma complained of fever and/or abdominal pain. Five asymptomatic patients were found to have a dilated bile duct on screening ultrasound or to have a tumor-like swelling of the papilla of Vater during routine upper gastrointestinal endoscopy. There was no significant difference in age, sex, size, macroscopic type, histologic type, rates of duodenal invasion, pancreatic invasion, and lymph node metastasis, and prognosis between the two groups. The cumulative 5-year and 10-year survival rates of nonjaundiced patients were 70.2% and 49.0%, compared with 33.6% and 29.4% of jaundiced patients. Ten of the 23 nonjaundiced ampullary carcinomas (43%) were in Stage I, whereas 4 of the 38 jaundiced ampullary carcinomas (11%) were in Stage I (P < 0.01). Mechanisms of nonjaundice in ampullary carcinoma were suspected to be determinant by the infiltrating pattern of the carcinoma to the lower portion of the bile duct.

CONCLUSIONS

Mechanisms of nonjaundice in ampullary carcinoma might be determined by the infiltrating pattern of the carcinoma to the lower portion of the bile. As a greater number of nonjaundiced ampullary carcinomas were in an early stage, detection of them may provide an improved clinical outcome.

Bilirubin decreases nos2 expression via inhibition of NAD(P)H oxidase: implications for protection against endotoxic shock in rats

We investigated a possible beneficial role for bilirubin, one of the products of heme degradation by the cytoprotective enzyme heme oxygenase-1 in counteracting Escherichia coli endotoxin-mediated toxicity. Homozygous jaundice Gunn rats, which display high plasma bilirubin levels due to deficiency of glucuronyl transferase activity, and Sprague-Dawley rats subjected to sustained exogenous bilirubin administration were more resistant to endotoxin (LPS)-induced hypotension and death compared with nonhyperbilirubinemic rats. LPS-stimulated production of nitric oxide (NO) was significantly decreased in hyperbilirubinemic rats compared with normal animals; this effect was associated with reduction of inducible NO synthase (NOS2) expression in renal, myocardial, and aortic tissues. Furthermore, NOS2 protein expression and activity were reduced in murine macrophages stimulated with LPS and preincubated with bilirubin at concentrations similar to that found in the serum of hyperbilirubinemic animals. This effect was secondary to inhibition of NAD(P)H oxidase since 1) inhibition of NAD(P)H oxidase attenuated NOS2 induction by LPS, 2) bilirubin decreased NAD(P)H oxidase activity in vivo and in vitro, and 3) down-regulation of NOS2 by bilirubin was reversed by addition of NAD(P)H. These findings indicate that bilirubin can act as an effective agent to reduce mortality and counteract hypotension elicited by endotoxin through mechanisms involving a decreased NOS2 induction secondary to inhibition of NAD(P)H oxidase.

Jaundice at presentation heralds advanced disease and poor prognosis in patients with ampullary carcinoma

Jaundice is a common manifestation of ampullary carcinoma. The aim of this study was to evaluate the correlation between jaundice at initial presentation and the degree of tumor spread and to determine the prognostic significance of jaundice in patients with ampullary carcinoma. Fifty-nine patients who had undergone curative resection for ampullary carcinoma were analyzed retrospectively. Jaundice was defined as a total bilirubin serum concentration of > or = 3 mg/dl. The median follow-up time was 106 months. Jaundice was noted at the time of initial presentation in 43 (73%) patients. Jaundice at presentation correlated with lymph node metastasis (p < 0.0001), lymphatic vessel invasion (p < 0.0001), invasion into the pancreas (p = 0.0007), and vascular invasion (p = 0.0487). Pancreatic invasion was absent in patients without jaundice. Superior mesenteric nodal involvement was more frequent in patients with jaundice (15/43) than in those without (0/16) (p = 0.0062). The survival of patients with jaundice (median survival 48 months; cumulative 10-year survival rate 39%) was worse than for patients without jaundice (median survival time not available; cumulative 10-year survival rate 86%) (p = 0.0014). In conclusion, jaundice at presentation predicts advanced-stage ampullary carcinoma and a poor prognosis. Pancreatic invasion and superior mesenteric nodal involvement were not observed in nonjaundiced patients.