Retrospective analysis of early surgical treatment of acute calculous cholecystitis with elevated liver enzymes / 国际外科学杂志

Objective:To investigate the safety and feasibility of early operation for acute calculous cholecystitis with elevated liver enzymes.Methods:The clinical data concerned about 39 patients with acute calculous cholecystitis complicated with elevated liver enzymes in The First Department of General Surgery, The First Affiliated Hospital of Anhui University of Science and Technology between January 2018 to December 2018 were analyzed retrospectively.There were 14 males and 25 females, the age was(57.59±15.30) years(range 29 to 84 years). All patients were given hepatoprotective therapy and antibiotic therapy, A total of 18 patients received early surgical treatment within 7 days (surgical group), 21 patients who received only hepatoprotective therapy and antibiotic therapy(control group). Observation indicators: (1)Total bilirubin, white blood cells and pancreatin in both groups at admission; (2)Data of liver enzyme indexes (ALT, AST, GGT) of the two groups at admission and 3 days after admission; (3)The length of hospital stay in the two groups, and gallstone-related events after discharge(the incidence of gallstone-related emergency, the rehospitalization rate). Normally distributed measurement data were expressed as mean±standard deviation( ± s), and comparison between groups were analyzed using t test; Non-normal distribution measurement data were represented by M( Q1, Q3), and comparison between groups were analyzed using Mann-Whitney U test. Comparison between groups were analyzed using chi-square test or Fisher method of count data. Results:There was no statistical difference between the two groups in terms of total bilirubin, white blood cells and pancreatin( P>0.05). There was no significant difference in liver enzyme indexes (ALT, AST, GGT) between the two groups when they were admitted to the hospital ( P>0.05) and 3 days later ( P>0.05). Before treatment, ALT、AST、GGT in surgical group were 161.00(83.75, 237.75) U/L, 63.50(49.50, 257.75) U/L, 245.50(66.75, 549.75) μmol/L, ALT, AST, GGT in control group were 187.00(64.00, 335.50) U/L, 104.00(53.50, 355.00) U/L, 299.00(136.50, 455.00) μmol/L, after 3 days antibiotic therapy and hepatoprotective therapy, ALT, AST, GGT in surgical group were 77.50(52.00, 111.00) U/L, 41.50(33.00, 53.75) U/L, 190.50(65.00, 372.00) μmol/L, ALT, AST, GGT in control group were 67.00(23.50, 129.50) U/L, 37.00(26.00, 61.50) U/L, 187.00(90.50, 337.00) μmol/L, levels of the two groups decreased significantly( P<0.05). There was no statistically significant difference in the length of hospital stay between the surgical group and the control group[(12.89±3.41) d vs (11.05±4.57) d, P>0.05]. After 12 months of follow-up, Gallstone-related events after discharge, the incidence of gallstone-related emergency in the surgical group was lower than that in the control group (5.6% vs 33.3%), the rehospitalization rate in the surgical group was significantly lower than that in the control group (5.6% vs 42.9%), there was statistically significant difference between the two groups ( P<0.05). Conclusion:Hepatoprotective therapy and antibiotic therapy and can effectively reduce the liver enzyme indexes of such patients in a short period of time, early surgical treatment after liver enzymes has decreased is a complete and safe option.

Elevación de enzimas hepáticas inducida por COVID-19 en embarazada / Elevated liver enzimes induced by COVID-19 in pregnancy

INTRODUCCIÓN: Las alteraciones del perfil hepático durante el embarazo ocurren en 3-5% de las gestantes. Una nueva etiología que se ha presentado en el contexto de pandemia actual es el síndrome respiratorio agudo severo relacionado con el nuevo coronavirus (SARS-CoV-2). Éste es responsable de alteraciones hepáticas en 2 a 11% de la población general infectada por este virus, y de hasta un 30% en las embarazadas que se infectan con SARS-CoV-2. Con el objetivo de mostrar una presentación poco frecuente del SARS-CoV-2 se expone un caso clínico de elevación de transaminasas en embarazada inducida por este nuevo virus. CASO CLÍNICO: Paciente de 36 años, cursando embarazo de 20+6 semanas, consulta por dolor abdominal asociado a ictericia y coluria. Se solicita estudio donde destaca elevación de transaminasas. Ecografía abdominal con vía biliar fina. Se descartan diferentes etiologías de hepatitis aguda y crónica (dada la falta de antecedentes). Finalmente se solicita PCR para COVID-19 que resulta positiva. CONCLUSIÓN: Luego de un estudio exhaustivo de diferentes etiologías de elevación de transaminasas, se atribuye esta alteración enzimática a SARS-CoV-2. Se decide seguimiento ambulatorio estricto con pruebas hepáticas cada dos semanas. La paciente evoluciona estable con exámenes normales luego de un mes desde que se indica el alta hospitalaria. Después de descartar etiologías frecuentes de elevación de transaminasas durante el embarazo, sugerimos solicitar el estudio de este virus con PCR para COVID-19, ya que podría ser una presentación poco frecuente de SARS-CoV-2.

INTRODUCTION: Approximately 3-5% of women present alterations of hepatic enzymes during pregnancy. Under the new circumstances that the world is facing with the SARS-COV2 pandemic, a new etiology for hepatic enzyme alterations has risen. The severe acute respiratory syndrome that the novel coronavirus causes is responsible for hepatic enzyme alterations in 2 to 11% of the sick population that did not have a previous underlying hepatic condition. Furthermore, hepatic enzyme alterations in pregnant women infected with SARS-COV2 presents in up to 30% of the cases. An infrequent presentation of SARS-COV2 is presented as our clinical case. CLINICAL CASE: A 36-year-old patient with a 20+6 week pregnancy presents abdominal pain, jaundice and choluria. General blood workup shows elevated transaminases. The abdominal ultrasound revealed a thin bile duct. Acute and chronic hepatitis etiologies were discarded. Finally, a PCR of COVID-19 was solicited, which turned out to be positive. CONCLUSIÓN: After an exhaustive study to determine the etiology of the elevated transaminases, the hepatic alterations were attributed to SARS-COV2 infection. A conservative management was adopted, with outpatient follow-up with liver testing every two weeks. The patient progresses with a stable steady decline in hepatic enzyme levels, and one-month post hospital discharge, her transaminases had reached normal values. Based on this clinical case, after ruling out frequent etiologies for elevated transaminases during pregnancy, it seems reasonable to request a PCR for COVID-19, since it could be a rare presentation of SARS-CoV-2.

Fetomaternal outcome in women with hemolysis, elevated liver enzymes and low platelet count syndrome: a retrospective study

Background: HELLP (hemolysis, elevated liver enzymes and low platelet count) syndrome which is a variant form of severe preeclampsia is an important cause of maternal and fetal mortality and morbidity. The importance lies in the early diagnosis and timely intervention for better fetal and maternal outcome. The objective of this study was to assess the maternal and fetal outcome in pregnancies complicated with HELLP syndrome.Methods: This is a retrospective study analyzing fetomaternal outcome in 63 women diagnosed with HELLP syndrome in the department of obstetrics and gynecology, Government Medical College, Thrissur from 1st January 2014 to 31st December 2016. Details were collected from data records library.Results: Among 7,566 deliveries, 63 women (0.83%) had HELLP syndrome. Mean age was 29.5 years. 47.6% (n=30) women developed HELLP syndrome at gestational age less than 34 weeks. Maternal complications were abruption (27.78%), acute kidney injury (16.67%), DIC (16.67%), sepsis (11.11%) and postpartum hemorrhage (11.11%). In this study, HELLP syndrome lead to one maternal death (1.58%). The perinatal mortality was 25.75%.Conclusions: HELLP syndrome is an alarming complication, which brings high maternal and perinatal morbidity and mortality.

Fetomaternal outcome in pregnancy with HELLP syndrome

Background: HELLP Syndrome is a serious complication of pregnancy induced hypertensive disorders. It is defined as a triad of hemolysis, elevated liver enzymes, and low platelet count (HELLP). Objectives of this study was to find out incidence of HELLP syndrome in pre-eclampsia, eclampsia and its overall incidence. To analyse the clinical profile of HELLP syndrome. To study maternal and perinatal outcome including morbidity and mortality.Methods: A retrospective study was conducted from July 2017 to September 2019 at a tertiary care center with inclusion criteria of abnormal peripheral blood smear, elevated liver enzymes (LDH, aspartate aminotransferase), and low platelet count.Results: HELLP syndrome was more common in younger age group (45%) and in primigravida (52.5%). Most of the patients presented at >36 weeks of gestation (40%) and most of the patients delivered by caesarean section (67.5%). Maternal complications were acute renal failure (27.5%), DIC (22.5%), maternal mortality (7.5%). Neonatal complications associated were intrauterine death (27.5%), prematurity (25%) and intrauterine growth retardation (15%).Conclusions: Thus, HELLP syndrome requires an early diagnosis and early initiation of treatment at tertiary care center with all the medical facilities available.

Progressing haemolysis, elevated liver enzymes, low platelet count syndrome: near miss case

A 25 years old women presented in labour room with 30 weeks’ pregnancy in labour with breech with previous two caesarean section and scar tenderness with foetal bradycardia (FHR 90) and jaundice. After caesarean section in emergency hour she started bleeding in abdominal drain while uterus was well contracted. On investigation and examination diagnosed as HELLP syndrome, managed promptly by medical teams of three departments (obstetrician, anaesthesia and medicine).

Study of thrombocytopenia in pregnancy: clinical presentation and outcome at tertiary care rural institute

Background: Platelet count below 1.5 lakh/cumm is called as thrombocytopenia. After anaemia it is the second most common haematological disorder in pregnancy. It affects nearly 6 to 15%; on an average 10% of all pregnancies. Gestational thrombocytopenia is a clinically benign thrombocytopenic disorder usually occurring in late pregnancy. It resolves spontaneously after delivery.Methods: It is a hospital based prospective observational study over a period of 1 year. All pregnant women who attended OPD at the department of obstetrics and gynecology, UPUMS, Saifai for antenatal checkup were included for the study and blood sample was withdrawn.Results: Out of 263 cases enrolled for study, 90 women were found to have thrombocytopenia, and 173 had normal platelet count. Thus, incidence of thrombocytopenia was 34%. Gestational thrombocytopenia accounted for majority of cases of thrombocytopenia in pregnancy (50%) followed by hypertensive disorders (22.4%). It was further followed by ITP (11.11%) and dengue (5.5%).Conclusions: Gestational thrombocytopenia is the most common cause of thrombocytopenia during pregnancy (50%), but other underlying causes must be considered as well. A thorough history and physical examination will rule out most causes.

A study of thrombocytopenia in pregnancy

Background: Thrombocytopenia is defined as low platelet count and if it is present during pregnancy can jeopardize the maternal and fetal outcome. Thrombocytopenia occurs in 6-15% of pregnancies. Causes of thrombocytopenia include gestational, idiopathic thrombocytopenia, preeclampsia, HELLP, DIC, malignancy and marrow failure. Aim of this study was to find out the common causes of thrombocytopenia in this hospital and management being used.Methods: Data was collected form those women who came to the antenatal clinic (booked) and labour room (unbooked) in the department of obstetrics and gynecology, GMERS Medical College and Hospital, Sola, Ahmedabad. Data of a total of 75 pregnant women were collected during the period of July 2018 to June 2019.Results: There were 66.67% cases of gestational thrombocytopenia, 13.33% related to preeclampsia, 8% in Eclamptic patients, 2.67% in HELLP and DIC, 6.67 in ITP, and lastly 2.67% in dengue cases. There were number of associated complication whether directly related (PPH) or part of the disorder. PPH was observed in 22.67% which is maximum among all complications. Other complications were part of major associated illness i.e. liver failure (6.67%), renal failure (5.3%), DIC (5.3%) and HELLP (8%).Conclusions: Mode of delivery was not influenced by platelet count, but for obstetric indications. Management of patients was as per the diagnosis. Single donor plasma is preferable to random donor plasma. PPH was the commonest complication and we should be wary of that.

A study of clinical characteristics and outcome of obstetric patients in intensive care and high dependency unit of a tertiary centre of Jharkhand, India

Background: Few women during their pregnancy, labour and postnatal period require critical care related to the pregnancy itself, aggravation of a pre-existing illness and complications of the delivery. Pregnant patients account for a small number of ICU admission - 2-10% two main indications for admission are hypertensive disorders (17.2%-46%) and massive haemorrhage (10%-32.8%). The primary objective of the present study was to review the characteristics of the obstetric patients admitted to our ICU over a 2-year period.Methods: It was a prospective study conducted over 50 patients in high dependency and intensive care unit at Alam hospital over a period of 2 years (October 2014 to October 2016).Results: During the study period a total of 50 obstetric patients were transferred to the intensive care unit (ICU). Antenatal care played significant role in the obstetric outcome. 84% of patients transferred to the ICU during the study period had inadequate or no antenatal care, while 8% were booked in their pregnancy and had adequate antenatal care. ICU interventions included mechanical ventilation used in 20(40%) patients, blood and blood product transfusion in 35(70%) patients’ inotropes in 20 patients (40%) antihypertensive therapy in 20 patients (40%), arterial embolization in 2(4%) patients. Maternal mortality was seen in 10 patients (20%).Conclusions: There is a need for training in emergency obstetrics so that the complication can be managed right at the time of occurrence.

A Study On Etiology And Clinical Profile Of Patients With Thrombocytopenia

BACKGROUND: Thrombocytopenia refers to a reduction in platelet count below 1.5 lakh/microliter. The presence of thrombocytopenia in a hemogram should alert the physician to identify the underlying etiology for the prompt management of the patient. Timely identification and treatment prevent bleeding manifestations, requirement of platelet transfusions/steroids and overall impact on mortality of the patients. AIM OFSTUDY:Analysis to study the etiology, bleeding manifestation, percentage of patients requiring platelet transfusion, length of hospital stay in patients with thrombocytopenia. METHODOLOGY: 100 cases thrombocytopenia both male and female were included in the study. The diagnosis was made on peripheral smear and Hemogram. RESULTS: Dengue fever was the most common cause of thrombocytopenia with 43 cases. Sepsis with 23 cases was the second commonest. Bleeding manifestations were seen in 23% of the study population.100% of the patients with platelet count less than 10,000/microlitre had bleeding manifestations. 26 patients (26%) received platelet transfusion out of which 23 were therapeutic and 3 were prophylactic transfusions. Steroid therapy was given in 11% of patients. Mortality was highest in patients with sepsis induced thrombocytopenia. CONCLUSION:This study shows that Dengue fever is the commonest diagnosis made in patients who are detected to have thrombocytopenia. One fifth of patients with platelet count less than 1,00,000/microlitre tend to have bleeding manifestation, commonest being GI bleed, petechial rash and epistaxis. Majority of the bleeding occurs with platelet count less than 10,000. The proportion of patients receiving therapeutic platelet transfusion was higher compared to prophylactic transfusion.

Effects of the Mixture of ‎ Cynara cardunculus var scolymus and Cinnamomum zeylanicum on Hepatic Enzymes Activity and Lipid Profiles in Patients with Non-alcoholic Fatty Liver Disease

Objective:Nonalcoholic fatty liver disease (NAFLD) is rapidly going to be one of the most common metabolic diseases which can negatively affect the liver function and needs to be more explored within the context of new and efficient therapies. The aim of this study was to determine the benefit of Cynara cardunculus var scolymusand Cinnamomum zeylanicummixture infusion (1.5 and 0.25 g/100 mL and twice/day) on patients with NAFLD. Methods:The study was designed as a before-after clinical trial and performed on 20 patients having NAFLD. They were asked to use the mixture of extracts prepared in special bags twice a day for 30 days. Before and after using the mixture, Liver markers of NAFLD including alanin aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphates (ALP), cholesterol (chol), triglycerides (TG), high-density lipoprotein (HDL) and low-density lipoprotein (LDL) and also, fatty liver ultrasonograhic grading were measured. Results:Treatment with mixture of extracts in patients with NAFLD resulted in a significant decrease in ALT, AST, and ALP. Also there was a significant improvement in lipid profile of the patients given by decreased TG, Chol, and LDL and increased HDL in serum. Moreover, a significant decrease in grade of sonographic examination was showed. No significant linear correlation was found between age, BMI and gender one way side and biochemical parameters and liver enzymes.Conclusion:Taken together, it is concluded that the mixture of Cynara cardunculusvar scolymus, Cinnamomum zeylanicumcan have beneficial effects on hepatic function and lipid profiles of patients with NAFLD

Study of Acute Kidney Injury Associated with Pregnancy

Background: Pregnancy related acute kidney injury(PRAKI) is common in developing countries like India. The aim of the study was to identify the etiology, prognosis, management and to have preventable measures, to improve the maternal and fetal outcome. Methods: The study was conducted in S.P. Medical College& Hospital – Obstetrics and Gynecology Department from July 2017 to December 2017.A total of 22 cases has been studied. Results: The incidence of PRAKI was 1.3% in our hospital. Pregnancy induced hypertension, pre-eclampsia, eclampsia was found to be commonest cause. Incidence of PRAKI was high in third trimester. The outcome was favorable with complete recovery in 45.47% patients. Conclusion: The low incidence of PRAKI was probably due to improved obstetric practices. Future research is further needed, to decrease the incidence.

Transaminases elevadas em um paciente assintomático: o que fazer? / Elevated transaminases in an asymptomatic patient: what to do?

Objetivos: Enzimas hepáticas elevadas são um cenário comum encontrado pelos médicos na prática clínica. O objetivo desse estudo é auxiliar os profissionais de saúde na condução desses casos, revisando possíveis causas tanto hepáticas, quanto extra-hepáticas para este achado e como prosseguir com a avaliação diagnóstica frente ao mesmo. Métodos: As buscas foram realizadas nas bases de dados MEDLINE e LILACS. A estratégia de busca foi desenvolvida utilizando-se os seguintes termos de pesquisa: "transaminases" OR "alanina transaminase" OR "aspartato transaminase". Os critérios de elegibilidade foram: estudos realizados em humanos, adultos, maiores de 19 anos, estudos com texto disponível, publicados em português, espanhol ou inglês a partir de 2012. Resultados: De um total de 1219 artigos que foram encontrados nas bases de dados, 20 foram incluídos nessa revisão. Foram selecionados 11 artigos com base na relevância clínica e fator de impacto das revistas. Conclusões: A alteração dos níveis das enzimas hepáticas em um paciente assintomático é um problema comum encontrado no cenário médico. A anamnese, exame físico e avaliação laboratorial são fundamentais para o diagnóstico. Dessa forma, uma abordagem sistemática pode auxiliar na condução ao correto diagnóstico, sendo necessário, por vezes, o auxílio de um especialista.

Aims: Elevated liver enzymes are a common scenario found by doctors in clinical practice. The aim of this study is to assist health care professionals in the conduct of these cases, reviewing possible causes so much liver as liver extra for this found and how to proceed with the diagnostic evaluation it. Methods: The searches were performed in the MEDLINE and LILACS databases. The search strategy was developed using the following search terms: "transaminases" OR "alanine transaminase" OR "aspartate transaminase". The eligibility criteria were: studies in humans, adults over 19 years, studies with available text, published in Portuguese, Spanish or English from 2012 up. Results: Of a total of 1219 articles that were found in the databases, 20 were included in this review. Based on 11 articles based on the clinical relevance and impact factor of the journals. Conclusions: Changing liver enzyme levels in an asymptomatic patient is a common problem found in the medical setting. Anamnesis, physical examination and laboratory evaluation are fundamental for diagnosis. In this way, a systematic approach can help in conducting the correct diagnosis, sometimes requiring the assistance of a specialist.

Síndrome de encefalopatía reversible posterior (PRES) asociada a eclampsia y síndrome HELLP / Posterior reversible encephalopathy syndrome (PRES) associated with eclampsia and HELLP syndrome

Es un síndrome usualmente reversible consistente en cefalea, alteración del estado mental, convulsiones y pérdida de la visión, asociado a edema cerebral de localización predominantemente posterior en estudios de imagen (1). La falta de su reconocimiento y manejo temprano puede ocasionar daños neurológicos permanentes (2). Se presenta el caso de una paciente de 29 años con 36 semanas de edad gestacional que ingresa al servicio de urgencias en estado epiléptico por eclampsia, síndrome HELLP (Hemólisis, Enzimas hepáticas elevadas, Plaquetas bajas) e imágenes hipodensas en regiones occipital y frontal en Tomografía Axial Computarizada de cráneo.

This syndrome, usually reversible, consists in symptoms like headache, altered mental status, seizures and lost of sight, associated to brain edema predominantly in posterior cerebral regions. The lack of its recognition and early management can lead to permanent neurological damage. It is presented the case of a 29 - year - old patient with 36 weeks of gestational age who arrives to the emergency room in epileptic status. She was diagnosed with eclampsia, HELLP (Hemolysis, elevated liver enzymes, low platelets) syndrome and occipital hypodense images were determined by cerebral Computarized Tomography.

Management of early onset severe preeclampsia in a tertiary hospital in india: does expectant management alter perinatal outcome.

Objective: The aims of the study were to find out the maternal and perinatal outcome of early onset severe preeclampsia (PE) in a tertiary care center in a developing country like India and to determine whether expectant management in such a setup improves the perinatal outcome. Materials and Methods: It was a retrospective study. All women with early PE were admitted stabilized and evaluated. Expectant management was given whenever there was no indication for eminent delivery. The perinatal outcome of the expectant group was compared with that of the aggressive group, and appropriate statistical analysis was carried out. Results: A total of 106 women were admitted with severe PE, 61 were treated aggressively, and 45 were stable enough to receive expectant management. The total days gained on expectant management was 7 days. Perinatal mortality was 31.13%. Perinatal outcome of the expectant and aggressive management groups did not differ (P = 0.141); there was no increase in maternal complications on expectant management. There were 2 cases of maternal mortality in the aggressively managed group. Conclusion: Perinatal mortality in severe PE is high. There was no increase in maternal morbidity on expectant management; however, there was no difference in perinatal mortality on expectant management.