Fibrolamellar hepatocellular carcinoma presenting as cholestatic jaundice: An unusual presentation of a rare disease

Fibrolamellar hepatocellular carcinoma is a rare primary hepatic tumor that usually occurs in youth. The common presenting features are vague abdominal pain, nausea, vomiting and weight loss. We present a case report of a young male who presented with cholestatic jaundice and on evaluation was diagnosed to have fibrolamellar hepatocellular carcinoma. He underwent successful surgical resection of the tumor. In young individuals presenting with unexplained cholestasis, fibrolamellar hepatocellular carcinoma should be considered.

Influencing of preoperative biliary drainage on surgery-related complications after pancreatico-duodenectomy / 中华消化外科杂志

Objective:To investigate the influencing of preoperative biliary drainage on surgery-related complications after pancreaticoduodenectomy.Methods:The retrospective case-control study was conducted. The clinical data of 267 patients with periampullary space-occupying lesion who were admitted to Beijing Friendship Hospital of Capital Medical University from January 2016 to July 2020 were collected. There were 166 males and 101 females, aged 61 (range, 54?84)years. Observation indicators: (1) comparison of preoperative situations in patients with and without preoperative biliary drainage; (2) comparison of intraoperative and postoperative situations in patients with and without preoperative biliary drainage; (3) methods and efficacy of preoperative biliary drainage; (4) factors influencing surgery-related complications after pancreaticoduodenec-tomy. Measurement data with normal distribution were represented as Mean± SD, and comparison between groups was conducted using the t test. Measurement data with skewed distribution were represented as M(rang) or M( Q1, Q3), and comparison between groups was conducted using the Mann-Whitney U test. Count data were described as absolute numbers or percentages, and comparison between groups was conducted using the chi-square test. Univariate analysis was conducted using the corresponding statistical methods based on data type. Multivariate analysis was conducted using the Logistic stepwise regression model. Results:(1) Comparison of preoperative situations in patients with and without preoperative biliary drainage. Of the 267 patients, there were 104 cases with preoperative biliary drainage and 163 cases without preoperative biliary drainage. Cases with malignant tumor, cases with borderline tumor, cases with chronic pancreatitis were 89, 13, 2 in patients with preoperative biliary drainage, versus 111, 41, 11 in patients without preoperative biliary drainage, showing significant differences in pathology type between them ( χ2=10.652, P<0.05). (2) Comparison of intraoperative and postoperative situations in patients with and without preoperative biliary drainage. There was no significant difference in operation time, volume of intra-operative blood loss, postoperative complications, grade B pancreatic fistula, grade C pancreatic fistula, biliary leakage, abdominal or gastrointestinal bleeding, incidence of abdominal infection, white blood cell count at postoperative day 1, white blood cell count at postoperative day 3, neutrophil-to-lymphocyte ratio at postoperative day 1, neutrophil-to-lymphocyte ratio at postoperative day 3, C-reactive protein-albumin ratio at postoperative day 1, C-reactive protein-albumin ratio at post-operative day 3, duration of hospital stay between the 104 patients with preoperative biliary drainage and the 163 patients without preoperative biliary drainage ( P>0.05). (3) Methods and efficacy of preoperative biliary drainage. Of the 104 patients with preoperative biliary drainage, there were 40 cases receiving endoscopic nasobiliary drainage with drainage time as (12±2)days, there were 38 cases receiving percutaneous transhepatic cholangial drainage with drainage time as (7±1)days, and there were 26 cases receiving endoscopic retrograde biliary drainage with drainage time as (19±2)days. The total bilirubin, direct bilirubin, aspartate transaminase, alanine aminotrans-ferase in 104 patients were (223±18)μmol/L, (134±11)μmol/L, (112±10)U/L, (160±16)U/L before biliary drainage and (144±13)μmol/L, (84±8)μmol/L, (79±8)U/L, (109±12)U/L after biliary drainage, showing significant differences in the above indicators ( t=3.544, 3.608, 2.523, 2.509, P<0.05). (4) Factors influencing surgery-related complications after pancreatocoduodenectomy. Results of multi-variate analysis showed that operation time was an independent factor influencing surgery-related complications after pancreaticoduodenectomy ( odds ratio=1.005, 95% confidence interval as 1.002?1.008, P<0.05). Conclusions:Preoperative biliary drainage does not increase the incidence of complications related to pancreaticoduodenectomy in patients with periampullary space-occupying lesion. Operation time is an independent factor influencing postoperative surgery-related complications.

Effect of Photodynamic Therapy for Malignant Obstruction of Biliary Tract / 肿瘤防治研究

Objective To investigate the safety and efficacy of photodynamic therapy (PDT) for malignant obstruction of the biliary tract. Methods We retrospectively analyzed the clinical data of patients with malignant biliary obstruction treated by PDT in our medical center. On the basis of different treatment plans, the patients were categorized into the photodynamic only group and the combined treatment group, in which additional interventional operations, targeted therapy, or immunotherapy were arranged. The alterations in liver function, duration of biliary patency, and postoperative complications that occurred within one month were closely monitored in both groups. Results A total number of 19 patients were enrolled in this study. The technical success rate of PDT was 100%. The deterioration of liver function was not observed in any patients within one month after PDT. Within a maximum of 17.7 months follow-up, the patency rates of the biliary tract were 100.0%, 89.5%, 72%, and 64% at 1, 3, 6, and 12 months after the procedure, respectively. The mean biliary patency time was 6.9±0.8 months (95%CI: 5.2-8.7 months). Specifically, the biliary patency times for Bismuth type Ⅲ and Ⅳ were 7.5±1.1 and 6.1±1.3 months, respectively. The biliary patency time was around 3.3±0.7 months in the photodynamic only group and 7.9±0.9 months in the combined treatment group (P=0.017). Conclusion PDT for Bismuth Ⅲ-Ⅳ malignant biliary obstruction is safe and effective. Moreover, the period of biliary patency is greatly extended when PDT is combined with systemic therapy.

Ascariasis errática biliar como causa exótica de ictericia obstructiva / Erratic Biliary Ascariasis as an Exotic Cause of Obstructive Jaundice

Introducción: Áscaris lumbricoides es el helminto más frecuente en el tracto gastrointestinal humano; la mayor prevalencia se registra en países en desarrollo, tropicales y subtropicales. En Cuba constituye una causa exótica de ictericia obstructiva con pocos casos reportados. Objetivo: Describir el manejo terapéutico exitoso de un caso de un hombre con ictericia obstructiva secundaria a ascariasis coledociana. Caso clínico: Paciente de 74 años operado en el Hospital Clínico Quirúrgico "Lucía Íñiguez Landín" de la provincia Holguín por ictericia obstructiva por ascariasis coledociana, con evolución clínico-quirúrgica satisfactoria. Conclusiones: En países en desarrollo debe tomarse en cuenta la ascariasis como causa de enfermedad obstructiva biliar o pancreática. El conocimiento del cuadro clínico y sus complicaciones, además, de las diferentes opciones en el tratamiento, debe ser del dominio de todo médico. La ictericia obstructiva por áscaris lumbricoides constituye en Cuba una causa exótica de esta infestación por parásitos(AU)

Introduction: Ascaris lumbricoides is the most frequent helminthiasis in the human gastrointestinal tract; the highest prevalence is recorded in developing, tropical and subtropical countries. In Cuba, it constitutes an exotic cause of obstructive jaundice with few reported cases. Objective: To describe the successful therapeutic management of a case of a man with obstructive jaundice secondary to choledochal ascariasis. Clinical case report: We report the case of a 74-year-old patient operated on at Lucía Íñiguez Landín Surgical Clinical Hospital, in Holguín province, for obstructive jaundice due to choledochal ascariasis, with satisfactory clinical-surgical evolution. Conclusions: In developing countries, ascariasis should be taken into account as a cause of biliary or pancreatic obstructive disease. Knowledge of the clinical condition and its complications, in addition to the different treatment options, should be the domain of every physician. Obstructive jaundice due to ascaris lumbricoides constitutes an exotic cause of this parasite infestation in Cuba(AU)

Artichoke for biochemistry, histology, and gene expression in obstructive jaundice

SUMMARY OBJECTIVE: This study aimed to evaluate the hepatoprotective effect of artichoke leaf extract (Cynara scolymus) in experimental obstructive jaundice. METHODS: Rats were separated into three groups, namely, sham, control, and artichoke leaf extract. Ischemia was created for 60 min, and then liver tissue and blood samples were taken at the 90th minute of reperfusion. Artichoke leaf extract was given at a 300 mg/kg dose 2 h before the operation. Antioxidant enzyme activities and biochemical parameters were examined from the tissue and serum. Histopathological findings of the liver were scored semiquantitatively. RESULTS: Antioxidant enzyme activities in the artichoke leaf extract group were statistically significantly higher than that in the other two groups. Biochemical parameters, which show hepatocellular damage, were found to be similar in both sham and artichoke leaf extract groups. Although the values in the sham group were higher than the artichoke group in terms of protein and gene expressions, no statistically significant difference was found between these two groups. Regarding the hepatocellular effects of obstructive jaundice, the artichoke leaf extract group showed lower scores than the control group in all histopathological scores. CONCLUSION: The results of this study showed that artichoke leaf extract had a hepatoprotective effect that was associated with the antioxidant and anti-inflammatory effects of artichoke leaf extract.

Analysis of risk factors for bleeding in patients with malignant obstructive jaundice after endoscopic retrograde cholangiopancreatography / 国际外科学杂志

Objective:To investigate the risk factor analysis and model prediction of bleeding after endoscopic retrograde cholangiopancreatography in patients with malignant obstructive jaundice (MOJ).Methods:A retrospective analysis was performed on 302 patients with MOJ treated with ERCP who were treated in the No. 363 Hospital Affiliated to Southwest Medical University from January 2015 to June 2021. The general clinical data of the patients were collected, and the biochemical indicators of the pancreatic and bile ducts were detected. The patients were followed up after discharge, and the patients were divided into a bleeding group ( n=47) and a control group ( n=255) according to whether the follow-up patients were bleeding after ERCP. Compared the general and clinical data of the two groups of patients, including age, gender, platelet count, presence of bile duct stones, acute cholangitis, acute pancreatitis, number of stones, intraoperative bleeding, pancreatic cancer, cholangiocarcinoma, large stone diameter, stone incarceration, duodenal papillary diverticulum, and pre-surgical incision. The measurement data that obey the normal distribution were represented by the mean±standard deviation ( ± s), and the two independent sample t test was used for the comparison between groups; the data that do not conform to the normal distribution were represented by M ( Q1, Q3), and the comparison between groups was used Mann-Whitney U test. The comparison of enumeration data between groups adopted chi-square test. Logistic multivariate regression was used to analyze the independent risk factors of postoperative bleeding after ERCP, and a nomogram prediction model was established and verified according to the independent risk factors of postoperative bleeding. Results:The two groups of patients were compared in age, gender, platelet count, bile duct stones, acute cholangitis, acute pancreatitis, the number of stones, intraoperative bleeding and other aspects, the difference was not statistically significant ( P>0.05). The percentages of pancreatic cancer, cholangiocarcinoma, large stone diameter, stone incarceration, duodenal papillary diverticulum, and surgical pre-incision in the bleeding group were 12.77%, 17.02%, 19.15%, 51.06%, 59.57%, and 14.89%, respectively. , the percentages of the control group were 3.92%, 5.10%, 9.02%, 19.22%, 17.65%, and 5.88%, and the difference was statistically significant between the two groups ( P<0.05). Taking postoperative bleeding as the dependent variable, and using the indicators with statistical differences in univariate analysis as independent variables, multivariate Logistic regression analysis showed that the patient had pancreatic cancer ( OR=1.838, 95% CI: 1.524-4.613, P=0.041), cholangiocarcinoma ( OR=2.548, 95% CI: 1.870-5.116, P=0.015), stone incarceration ( OR=3.078, 95% CI: 2.374-6.012, P<0.001), duodenum Intestinal papillary diverticula ( OR=1.140, 95% CI: 1.045-1.628, P<0.001), surgical pre-incision ( OR=1.640, 95% CI: 1.321-1.928, P<0.001) were associated with postoperative bleeding in MOJ patients after ERCP independent risk factors. The predictive ability of duodenal papillary diverticulum was the highest; the predictive ability of stone incarceration and cholangiocarcinoma was the second, and there was no significant difference between them; the predictive ability of pancreatic cancer, stone diameter, and pre-incision on bleeding after ERCP in MOJ patients smaller. Pancreatic cancer, cholangiocarcinoma, large stone diameter, stone incarceration, duodenal papillary diverticulum, and pre-incision scores were 42, 63, 28, 65, 76, and 34 points respectively, and the total score was 308 points corresponding to the nomogram model. The predictive power of the nomogram was 61.6%, and overall, the nomogram had good predictive performance. Harrell concordance index analysis and ROC curve were used to evaluate the model discrimination, the C-index calculation result was 0.826 (95% CI: 0.771-0.847), the ROC curve AUC was 0.843 (95% CI: 0.801-0.884), and the ROC prediction The value and the calculation result of C-index are relatively close. The model discrimination is applied in this study and has a certain prediction effect. The nomogram model in the Calibration curve predicted the probability of postoperative bleeding after ERCP in MOJ patients with high consistency with the actual probability. Conclusion:ERCP is safe and feasible for most patients with MOJ, but for patients with pancreatic cancer, bile duct cancer, large stone diameter, stone incarceration, and duodenal papillary diverticulum, it should be performed with caution, and preoperative incision should be avoided, to reduce the risk of postoperative bleeding. In addition, the nomogram model has a strong predictive ability in predicting bleeding after ERCP in patients with MOJ, which is worthy of reference in clinical research.

Experiencia inicial con derivación biliar mediante coledocoduodenostomía guiada por ultrasonido endoscópico en la obstrucción biliar maligna en un hospital de referencia en Colombia / Initial experience with endoscopic ultrasound-guided biliary drainage via choledochoduodenostomy (EUS-CDS) in malignant biliary obstruction in a reference hospital in Colombia

Resumen Introducción: en pacientes con obstrucción biliar distal maligna en quienes la derivación biliar mediante colangiopancreatografía retrógrada endoscópica (CPRE) no sea factible o sea fallida, el drenaje biliar guiado por ultrasonido endoscópico mediante coledocoduodenostomía es una opción terapéutica viable, de la que se describen altas tasas de éxito técnico y clínico con una baja morbimortalidad. Adicionalmente, este método podría ser superior en la mejora de la calidad de vida en comparación con el manejo percutáneo o quirúrgico. Objetivo: describir la experiencia inicial con el drenaje biliar guiado por ultrasonido endoscópico en pacientes con obstrucción biliar maligna en un centro de referencia. Métodos: es una serie de casos retrospectiva de 6 pacientes con obstrucción biliar maligna a quienes se les realizó inicialmente una CPRE que fue fallida, por lo cual se procedió a realizar coledocoduodenostomía guiada por ultrasonografía endoscópica. Se describieron las tasas de éxito técnico, éxito clínico, eventos adversos, tasas de disfunción y tiempo de supervivencia de los pacientes. Resultados: se analizaron 6 casos, predominó el sexo femenino, con un promedio de edad de 71,8 ± 19,8 años; las indicaciones fueron adenocarcinoma de páncreas, tumor periampular y colangiocarcinoma distal. Se observó un éxito técnico en el 100 % de los casos y éxito clínico en 83,3 % de los casos. No se registraron eventos adversos graves. En el seguimiento de los casos se observó una supervivencia del 66,7 % a los 30 días. Conclusión: la coledocoduodenostomía es una alternativa terapéutica viable, segura y efectiva en pacientes con obstrucción biliar maligna en quienes la CPRE fue fallida, con una alta tasa de éxito técnico y clínico.

Abstract Introduction: Patients with malignant biliary distal obstruction who cannot be treated with endoscopic retrograde cholangiopancreatography (ERCP) or who had a failed ERCP, can find alternative treatment in endoscopic ultrasound-guided biliary drainage via choledochoduodenostomy. EUS-CDS performs with high rates of technical and clinical success and with low rates of morbimortality. Moreover, this method could have the potential to improve the patient's quality of life, compared with percutaneous or surgical means. Objective: This study aims to describe the initial experience with endoscopic ultrasound-guided biliary drainage in patients with malignant biliary distal obstruction in a reference center. Methods: Retrospective case review of six patients with malignant biliary obstruction and prior ERCP-placed and failed. Endoscopic ultrasound-guided biliary drainage via choledochoduodenostomy was performed as an alternative method. Technical and clinical success rates, adverse event rates, dysfunction rates, and patient survival time were described. Results: 6 cases were analyzed with a higher proportion of female patients, with a mean age of 71,8 ± 19,8 years. The symptoms were related to pancreas adenocarcinoma, periampullary tumor, and distal cholangiocarcinoma. The procedure was technically successful in 100% of cases and clinically successful in 83% of cases. Serious adverse events were nor reported. After 30 days, a survival rate of 66,7 % was observed. Conclusion: Choledochoduodenostomy is a viable, safe, and effective method in patients with malignant biliary obstruction who had a failed ERCP, and it has high rates of technical and clinical success.

Atresia biliar por citomegalovirus: un reporte de caso / Cytomegalovirus-associated biliary atresia: Case report

Resumen La atresia biliar asociada con inmunoglobulina M (IgM) positiva para citomegalovirus (CMV) es una entidad infrecuente que se caracteriza por la obliteración inflamatoria progresiva de los conductos intra- o extrahepáticos producida por una reacción autoinmune perinatal contra el CMV. El diagnóstico se realiza con IgM positiva para CMV y biopsia hepática con evidencia de atresia de las vías biliares. El conocimiento y la identificación temprana de esta patología conduce a un manejo quirúrgico temprano, mejorando considerablemente el pronóstico de estos pacientes. Se presenta un caso clínico de una paciente de 82 días de edad con un cuadro de acolia, coluria e ictericia de inicio tardío, asociado con hiperbilirrubinemia a expensas de la directa, elevación de perfil hepático e IgM positiva para CMV. La colangiorresonancia intraoperatoria confirmó el cuadro de atresia de las vías biliares. Se realizó una derivación biliodigestiva tipo Kasai y la toma de biopsia hepática que confirmó el cuadro clínico.

Abstract Biliary atresia associated with positive cytomegalovirus IgM results is a rare condition characterized by progressive inflammatory obliteration of the intra- or extrahepatic ducts. It is caused by a perinatal autoimmune reaction against cytomegalovirus (CMV). Diagnosis is made based on positive IgM for CMV and liver biopsy with evidence of bile duct atresia. Knowledge and timely identification of this disease leads to early surgical management, considerably improving the prognosis of these patients. This is the clinical case of an 82-day-old female patient with late-onset acholia, choluria, and jaundice, associated with conjugated hyperbilirubinemia, elevated liver function tests and positive CMV IgM results. Intraoperative cholangioresonance confirmed bile duct atresia. The Kasai procedure was performed, and a liver biopsy was taken, confirming the diagnosis.

Effect of obstructive jaundice on pharmacokinetics of dexmedetomidine in vivo / 药学实践杂志

Objective To establish a UPLC-MS/MS method for the determination of dexmedetomidine in human plasma and investigate the effect of obstructive jaundice on pharmacokinetics of dexmedetomidine in vivo. Methods Samples were obtained by liquid-liquid extraction. Agilent Eclipse Plus C18 column was used for chromatograph with methanol and 0.1% formic acid-water solution as mobile phase. Flow rate was 0.2 ml/min. The column temperature was 35 ℃, and the MS detection was selected in MRM mode. Results The calibration curves of dexmedetomidine showed good linearity in the ranges of 0.01−10.00 ng/ml. The results of intra and inter-day precisions were both within 15%. The recovery rate was 85.5%−93.1%. Matrix effect was 91.2%−95.6%. Samples remained stable during analysis. Compared with the control group, cmax、AUC(0−t)、AUC(0−∞) and Vz of dexmedetomidine in the patients with obstructive jaundice were increased by 63.4%, 78.9, 66.4%, 82.5%, respectively (P<0.01). CLz was decreased by 42.1%. Conclusion This method is accurate, sensitive and reproducible. It is suitable for dexmedetomidine assay in human plasma. The elimination rate of dexmedetomidine is slower in obstructive jaundice.

Ultrasonografía endoscópica para el diagnóstico de áscaris biliar: reporte de caso y revisión de la literatura / Endoscopic ultrasound for the diagnosis of biliary ascariasis: case report and literature review

Resumen Se presenta un caso de áscaris de la vía biliar (AB), cuya manifestación clínica fue ictericia obstructiva, acompañada de dolor abdominal causado por un cuadro de pancreatitis aguda. Inicialmente, se sospechó de etiología litiásica, por lo cual se realizaron estudios de imágenes diagnósticas y se evidenció la presencia de AB como hallazgo incidental, diagnosticado por ultrasonografía endoscópica biliopancreática (UEB), que fue confirmado y tratado mediante colangiopancreatografía retrógrada endoscópica (CPRE).

Abstract The following is a case of biliary ascariasis (BA), whose clinical presentation was obstructive jaundice, accompanied by abdominal pain due to acute pancreatitis. At first, clinical suspicion led to consider a stone etiology, for which diagnostic imaging studies were performed, evidencing BA as an incidental finding diagnosed by endoscopic biliopancreatic ultrasonography (EBU), which was confirmed and treated using endoscopic retrograde cholangiopancreatography (ERCP).

Comparison of pre-operative ultrasonography and magnetic resonance cholangiopancreatography with intra-operative surgical findings among patients suspicious to choledocholithiasis

Background: Choledocholithiasis with cholelithiasis is a common problem in the middle and older age group people. Aim of this study is to assess the usefulness of ultrasonography in the diagnosis of choledocholithiasis in resource poor set up.Methods: After matching the inclusion and exclusion criteria, all cases of diagnosed choledocholithiasis were taken for this prospective, single center, observational study.Results: Out of total 130 subjects, 41 were male and 89 were female. Increased incidence of choledocholithiasis was found in females (M:F=1:2.08). The mean age of presentation was 49.27±10.60 years. Ultrasonography was able to diagnose common bile duct (CBD) stones in 57 patients (43.84%) and ductal dilatation in 89 (68.46%). Whereas, magnetic resonance cholangiopancreatography (MRCP) detected CBD stones in 112 (86.15%). Cholelithiasis was associated with choledocholithiasis in 108 patients (83.07%).Conclusions: In the evaluation of choledocholithiasis, in our study particularly trans-abdominal ultrasonography (USG) seemed to have a lower yield than expected for accuracy in determining choledocholithiasis when compared to MRCP and Intra-operative findings. So, a negative USG in a particular may not exclude choledocholithiasis. So, MRCP is the ‘investigation of choice’ among the suspicious patients for CBD stone disease. That is why prior to cholecystectomy in symptomatic patients with deranged liver function test, MRCP always to be done, to detect the missed stone in CBD.

Liver function trends after biliary decompression in obstructive jaundice: a clinico-pathological-biochemical study

Background: Liver functions tests suggest the underlying cause, estimate the severity, assess prognosis and monitor efficacy of therapy. Severity of liver dysfunction when performed serially may predict prognosis and may be helpful in assessing response to medical therapy or a surgical intervention.Methods: The data was collected in thirty cases of surgical obstructive jaundice in terms of age, sex, etiology, clinical presentation, surgical intervention for biliary drainage and the laboratory liver biochemical and coagulation profiles on a day prior to surgical intervention and post-operatively on 1st week and 4th week were recorded.Results: Of total 30 patients 56.66% were females. Patients with 73.68% of benign disease and 100% of malignant disease were of age more than 40 years. 63.33% of patients had benign cause for biliary obstruction. Choledochoithiasis and periampullary carcinoma were two most common causes of obstructive jaundice. The commonest complaints were; yellowish discolouration of sclera and skin, high colored urine (100%) and acholic stool (70%). Hepatomegaly, palpable gallbladder and ascites were observed in only malignant conditions. Serum bilirubin and transaminases were significantly higher in patients with malignant lesions on pre-operative and postoperative assessment. After decompression the rate of fall of serum bilirubin, serum glutamic-oxaloacetic transaminase and SGPT were almost identical in both benign and malignant biliary obstructions. However, a better biochemical recovery profile was observed in patients with benign lesions, as they returned to normal by 4 weeks but remained at 2 to 3 times of the normal in malignant lesions.Conclusions: Sequential biochemical assessment of liver functions has diagnostic as well as prognostic value in surgical obstructive jaundice.

Síndrome de Mirizzi que simulaba una neoplasia biliar maligna / Mirizzi syndrome simulating a biliary malignant neoplasm

El síndrome de Mirizzi puede cursar con manifestaciones clínicas y hallazgos imagenológicos y de laboratorio, similares a los encontrados en las neoplasias biliares malignas. Se describe el caso de un paciente cuyo enfoque clínico inicial y estudios de imágenes aportaron datos sugerentes de neoplasia de las vías biliares. Los marcadores tumorales (CA 19-9, CEA) resultaron elevados. Una nueva evaluación clínica, la laparoscopia exploradora y la exploración endoscópica de las vías biliares, permitieron establecer el diagnóstico de síndrome de Mirizzi. Después de la extracción del cálculo biliar y de la anastomosis entre el conducto hepático y el yeyuno, el paciente permaneció asintomático. En este caso, la reevaluación clínica y el uso del protocolo adecuado de estudio, contribuyeron a orientar y confirmar el diagnóstico de síndrome de Mirizzi, lo cual determinó la conducta terapéutica más acertada

Mirizzi syndrome can occur with clinical manifestations and imaging and laboratory findings, similar to those found in malignant biliary neoplasms. We describe the case of a patient whose initial clinical approach and imaging studies provided data suggestive of bile duct neoplasia. Tumor markers (CA 19-9, CEA) were high. A new clinical evaluation, an explorative laparoscopy and endoscopic bile duct exploration allowed establish the diagnosis of Mirizzi syndrome. After removal the bile duct stone and to perform an hepatico jejunostomy the patient remained asymptomatic. In this case the clinical reevaluation and the use of the appropriate study proto-col contributed to guide and confirm the diagnosis of Mirizzi syndrome, which determined the most successful therapeutic approach

Influencing factors for poor jaundice resolution after radical pancreaticoduodenectomy in patients with malignant obstructive jaundice / 中华消化外科杂志

Objective To investigate the influencing factors for poor jaundice resolution after radical pancreaticoduodenectomy in patients with malignant obstructive jaundice.Methods The retrospective case-control study was conducted.The clinicopathological data of 121 patients with malignant obstructive jaundice who were admitted to the Affiliated Changzhou No.2 People's Hospital of Nanjing Medical University between March 2013 and June 2018 were collected.There were 70 males and 51 females,aged (69±9)years,with a range from 39 to 85 years.Of 121 patients,112 underwent open radical pancreaticoduodenectomy,and 9 underwent totally laparoscopic radical pancreaticoduodenectomy.Observation indicators:(1) situations of jaundice resolution after pancreaticoduodenectomy;(2) influencing factors for poor jaundice resolution after pancreaticoduodenectomy.Measurement data with normal distribution were represented as Mean ± SD.Measurement data with skewed distribution were represented as M (range).Count data were described as absolute numbers.Univariate analysis was performed using the chi-square test,t test,Fisher exact probability or Mann-Whitney U test.Multivariate analysis was performed by the Logistic regression model using P＜0.10 as an inclusion criteria in the univariate analysis.Results (1) Situations of jaundice resolution after pancreaticoduodenectomy:of 121 patients,97 had good jaundice resolution after pancreaticoduodenectomy,and 24 had poor jaundice resolution after pancreaticoduodenectomy.(2) Influencing factors for poor jaundice resolution after pancreaticoduodenectomy:results of univariate analysis showd that preoperative level of serum total bilirubin,comorbidity with diabetes mellitus were influencing factors for poor jaundice resolution after pancreaticoduodenectomy (t =-2.073,x2 =10.201,P＜0.05).Postoperative pancreatic fistula was also an influencing factor for poor jaundice resolution after pancreaticoduodenectomy (P ＜ 0.05).Results of multivariate analysis showed that comorbidity with diabetes mellitus and postoperative pancreatic fistula were independent risk factors for poor jaundice resolution after pancreaticoduodenectomy (odds ratio=0.258,0.129,95％ confidence interval:0.087-0.769,0.023-0.726,P＜0.05).Conclusions Preoperative level of serum total bilirubin,diabetes mellitus,and postoperative pancreatic fistula are influencing factors for poor jaundice resolution after pancreaticoduodenectomy.Comorbidity with diabetes mellitus and postoperative pancreatic fistula are independent risk factors for poor jaundice resolution after pancreaticoduodenectomy.

Characteristics of Choledocal Cyst Patients in Bandung, Indonesia : Single Centre Experience

@#Introduction: Choledochal cyst (CC) is a congenital cystic dilation of bile duct. Although considered a benign disorder, but CC has various complications like cholangitis, cholelithiasis, pancreatitis and malignant degeneration. The characteristic of this malformation are still not well documented in our region. We aimed to describe the characteristic of CC patients in Hasan Sadikin Hospital Bandung, Indonesia. Method: The medical records of patients that were diagnosed with CC between 2014 and 2017 were reviewed. We retrospectively collected demographic data, clinical symptoms, diagnostic imaging and surgical data. Results: Fifteen patients were diagnosed as CC, predominantly were girls (12 patients). The mean age was 63,47 months old (range from 7 to 144 months). Jaundic was found in all patients, followed by abdominal pain in 12 patients (80%) and abdominal mass in 9 patients (60%). The laboratory results showed signs of bile obstruction in 5 patients (33,3%). Diagnostic imaging using ultrasonography revealed 5 patients (33,3%) with CC type IV, whereas type I in 6 patients (40%). MRI was performed in 8 patients (53,3%) and CT Scan was performed in 5 patient (33,3%). Eleven patients (73,3%) underwent cyst excision and Roux-en-Y hepaticojejunostomy with liver biopsy. Conclusion: Our data suggested that CC predominantly found in girls, and abdominal pain was the most common symptom. Ultrasonography, MRI, and CT are imaging modalities use to diagnose CC. Surgical treatment should be done includes total cyst excision dan biliodigestive reconstruction.

Aerobic exercise combined with huwentoxin-I upregulates phase-Ⅱ detoxification enzymes to alleviate obstructive jaundice-induced central nervous system injury in mice / 南方医科大学学报

OBJECTIVE@#To explore the effects of aerobic exercise combined with huwentoxin-I (HWTX-I)-mediated Keap1-Nrf2-ARE pathway on phase II detoxification enzymes HO-1 and NQO1 and their protective effects against obstructive jaundice (OJ)-induced central nervous system injury in mice.@*METHODS@#50 male KM mice were randomly divided into blank group (GO), model group (M), aerobic exercise group (T), HWTX-I group (H), and aerobic exercise combined with HWTX-I group (TH). Mouse models of OJ were established with surgical suture for 72 h in the mice in all the groups except for the blank control group. The mice received interventions by aerobic exercise and tail vein injection of HWTX-I (0.05 μg/g) and were assessed by behavioral observation, Clark's neurological function scores, enzyme-linked immunosorbent assay (ELISA), brain tissue Nissl staining, hippocampal tissue Western blotting, and liver tissue mRNA expression profiling and sequencing.@*RESULTS@#The mice in group M had obvious jaundice symptoms after the operation with significantly increased Clark's neurological score ( < 0.01). Compared with those in group M, the mice in group T, group H, and group TH showed significantly decreased serum levels of ALT, AST, TBIL, and TBA ( < 0.01) with increased contents of 5-HT and BDNF and decreased contents of S100B and NSE in the hippocampus ( < 0.01). Synergistic effects between aerobic exercise and HWTX-I were noted on the above parameters except for the liver function indicators. Interventions with aerobic exercise and HWTX-I, alone or in combination, obviously lessened pathologies in the brain tissue induced by OJ, and the combined treatment produced the strongest effect. The treatment also increased the expression levels of Nrf2, HO-1, and NQO1 mRNA and protein in brain tissues ( < 0.01 or 0.05) with a synergistic effect between aerobic exercise and HWTX-I. Illumina high-throughput sequencing showed that the differentially expressed factors participated mainly in such neural regulatory pathways as neuroactive ligand-receptor interaction, GABAergic synapses, dopaminergic synapses, synaptic vesicle circulation, and axon guidance, involving tissue cell neuronal signal transduction, apoptosis inhibition, immune response, and toxicity. Aerobic exercise and HWTX-I synergistically increased the accumulation of the signal pathways related with neuron damage repair and proliferation.@*CONCLUSIONS@#Aerobic exercise combined with HWTX-I can up-regulate the expression of phase Ⅱ detoxification enzymes HO-1 and NQO1 through the Keap1-Nrf2-ARE pathway to protect the central nervous system against OJ-induced damage in mice.

Influencing factors for poor jaundice resolution after radical pancreaticoduodenectomy in patients with malignant obstructive jaundice / 中华消化外科杂志

Objective@#To investigate the influencing factors for poor jaundice resolution after radical pancreaticoduodenectomy in patients with malignant obstructive jaundice.@*Methods@#The retrospective case-control study was conducted. The clinicopathological data of 121 patients with malignant obstructive jaundice who were admitted to the Affiliated Changzhou No.2 People′s Hospital of Nanjing Medical University between March 2013 and June 2018 were collected. There were 70 males and 51 females, aged (69±9)years, with a range from 39 to 85 years. Of 121 patients, 112 underwent open radical pancreaticoduodenectomy, and 9 underwent totally laparoscopic radical pancreaticoduodenectomy. Observation indicators: (1) situations of jaundice resolution after pancreaticoduodenectomy; (2) influencing factors for poor jaundice resolution after pancreaticoduodenectomy. Measurement data with normal distribution were represented as Mean±SD. Measurement data with skewed distribution were represented as M (range). Count data were described as absolute numbers. Univariate analysis was performed using the chi-square test, t test, Fisher exact probability or Mann-Whitney U test. Multivariate analysis was performed by the Logistic regression model using P<0.10 as an inclusion criteria in the univariate analysis .@*Results@#(1) Situations of jaundice resolution after pancreaticoduodenectomy: of 121 patients, 97 had good jaundice resolution after pancreaticoduodenectomy, and 24 had poor jaundice resolution after pancreaticoduodenectomy. (2) Influencing factors for poor jaundice resolution after pancreaticoduodenectomy: results of univariate analysis showd that preoperative level of serum total bilirubin, comorbidity with diabetes mellitus were influencing factors for poor jaundice resolution after pancreaticoduodenectomy (t=-2.073, χ2=10.201, P<0.05). Postoperative pancreatic fistula was also an influencing factor for poor jaundice resolution after pancreaticoduodenectomy (P<0.05). Results of multivariate analysis showed that comorbidity with diabetes mellitus and postoperative pancreatic fistula were independent risk factors for poor jaundice resolution after pancreaticoduodenectomy (odds ratio=0.258, 0.129, 95% confidence interval: 0.087-0.769, 0.023-0.726, P<0.05).@*Conclusions@#Preoperative level of serum total bilirubin, diabetes mellitus, and postoperative pancreatic fistula are influencing factors for poor jaundice resolution after pancreaticoduodenectomy. Comorbidity with diabetes mellitus and postoperative pancreatic fistula are independent risk factors for poor jaundice resolution after pancreaticoduodenectomy.

Myeloid sarcoma of bile ducts presenting as obstructive jaundice – A case report

Myeloid sarcoma is an extra medullary manifestation of acute myeloid leukemia (AML). Primary involvement of the biliary tract with myeloid sarcoma presenting as obstructive jaundice without evidence of leukemia is very rare. Here we present a case of 72 year old lady, who initially presented with features of biliary obstruction and was clinically considered as cholangiocarcinoma. She was diagnosed as myeloid sarcoma involving right and left hepatic duct, common bile duct (CBD) on histopathological and immunohistochemistry (IHC) examination after surgical resection. Since she did not show evidence of leukemia on peripheral blood and bone marrow examination treatment was deferred. However, she developed full blown picture of AML within two months and succumbed to her disease. We conclude that obstructive jaundice can be the presenting symptom in myeloid sarcoma without evidence of AML in peripheral blood and bone marrow. However, these cases have to be treated aggressively to obtain remission.

Epidemiological profile, referral routes and diagnostic accuracy of cases of acute cholangitis among individuals with obstructive jaundice admitted to a tertiary-level university hospital: a cross-sectional study

ABSTRACT BACKGROUND: Obstructive jaundice may lead to ominous complications and requires complex diagnostic evaluations and therapies that are not widely available. OBJECTIVE: To analyze the epidemiological profile, referral routes and diagnostic accuracy at admittance of cases of acute cholangitis among patients with obstructive jaundice treated at a referral unit. DESIGN AND SETTING: Cross-sectional study at a tertiary-level university hospital. METHODS: Patients with obstructive jaundice who were treated by means of endoscopic retrograde cholangiopancreatography, resection and/or surgical biliary drainage were evaluated. The main variables analyzed were epidemiological data, referral route, bilirubin levels and time elapsed between symptom onset and admittance and diagnosing of acute cholangitis at the referral unit. The accuracy of the clinical diagnosis of acute cholangitis was compared with a retrospective analysis on the medical records in accordance with the Tokyo criteria. RESULTS: Female patients predominated (58%), with an average age of 56 years. Acute cholangitis was detected in 9.9% of the individuals; application of the Tokyo criteria showed that the real prevalence was approximately 43%. The main referral route was direct contact (31.8%) and emergency care (29.7%); routing via official referral through the public healthcare system accounted for 17.6%, and internal referral from other specialties, 20%. The direct route with unofficial referral was the most important route for cases of neoplastic etiology (P < 0.01) and was the fastest route (P < 0.01). CONCLUSIONS: There is a deficiency in the official referral routes for patients with obstructive jaundice. The accuracy of the clinical diagnosis of acute cholangitis was poor. Wider dissemination of the Tokyo criteria is essential.

Role of Magnetic Resonance Cholangiopancreatography (MRCP) in the Evaluation of Patients with Obstructive Jaundice

Introduction: Obstructive jaundice is a common clinicalproblem and most common presentation in patients withbiliary ductal obstruction. The role of imaging is crucialfor detection of site and cause of obstruction and also todifferentiation of benign and malignant pathology. MRCP isused in patients with history of obstructive jaundice to identifyand confirm the presence of obstruction, its location, extent,probable cause and also to obtain a map of the biliary treethat will help the surgeon or the interventionist to determinethe best approach to each individual case. The main aim andobjective of the study was to determine the accuracy of MRCPin the evaluation of patients with obstructive jaundice.Method and Materials: In the evaluation of patientswith obstructive jaundice, MRCP was conducted in theDepartment of Radio Diagnosis, Sree Balaji Medical collegeand Hospital. A total number of twenty five patients sufferingfrom obstructive jaundice of all age groups and either sexwere included in this study. Total of Twenty five patients withclinical diagnosis of obstructive jaundice were included in thestudy. MRCP was done in all the patients and results werecompiled and compared with Operative/ ERCP findings andhistopathological reports.Results: A total of twenty five patients suffering fromobstructive jaundice underwent MRCP. Out of the twentyfive patients, ten patients had benign causes of obstructivejaundice, while fifteen patients had malignant causes ofobstructive jaundice. MRCP had an accuracy of 97% indetecting the cause of obstructive jaundice. In diagnosing thesite of obstruction MRCP had an accuracy of 100%.Conclusion: In the diagnosis of obstructive jaundice and toknow the cause, site and extent of the lesion MRCP being anon invasive, non ionizing procedure seems to be a accurateand better choice.