Differential diagnoses in 83 dogs with icterus / Diagnósticos diferenciais em 83 cães com icterícia

Icterus (jaundice) is a yellowish pigmentation resulting from the depositing of bilirubin in tissues due to its high plasmatic concentration. The pathogenesis of icterus includes metabolic changes or obstructed bilirubin excretion and it is classified as pre-hepatic, hepatic and post-hepatic. This study aimed to evaluate and classify different causes of icterus in dogs during post mortem examination. These dogs were examined from 2014 to 2017, using macroscopic and histologic exams as well as ancillary tests. Eighty-three dogs were examined macroscopically and microscopically. They were separated into groups of icterus types: 24 (28.9%) dogs had pre-hepatic icterus, 45 (54.2%) had hepatic, 13 (15.7%) pre-hepatic and hepatic and one (1.2%) had post-hepatic icterus. Many factors were identified as a cause of icterus, including infectious agents (51/83), neoplasms (13/83), hepatic degeneration (11/83), chronic hepatic diseases (6/83), and obstructive causes (1/87). Among the infectious causes, leptospirosis, ehrlichiosis and disorders suggestive of septicemia were diagnosed. Neoplasms associated with icterus were cholangiocarcinoma, hemangiosarcoma and lymphoma. Other causes of icterus included degenerative diseases, such as lipidosis and glycogen degeneration. Hepatic fibrosis (cirrhosis) as a chronic disease and cholelithiasis also produced icterus. PCR was performed to confirm leptospirosis and ehrlichiosis. Samples of total DNA were used to amplify a fragment of a gene from Leptospira interrogans and Ehrlichia canis. In some dogs, co-infection of these agents was detected. The classification and identification of icterus etiologies in dogs is very important due to the number of diseases with this alteration, where ante mortem diagnosis is not always easily performed when some of these conditions are present.(AU)

Icterícia é a pigmentação amarelada decorrente da deposição de bilirrubina em tecidos devido à elevada concentração plasmática. A patogênese da icterícia inclui alterações no metabolismo ou na excreção de bilirrubina, sendo classificada em pré-hepática, hepática ou pós-hepática. O objetivo desse estudo foi identificar, avaliar e classificar as causas de icterícia em cães necropsiados de 2014 a 2017, associando as lesões macroscópicas, histológicas e exames complementares. Foram avaliados macro- e microscopicamente 83 cães com diferentes intensidades de icterícia. Os cães foram separados em grupos de acordo com o tipo de icterícia: 24 (28,9%) cães com icterícia pré-hepática, 45 (54,2%) cães com icterícia hepática, 13 (15,7%) com icterícia pré-hepática e hepática e um (1,2%) com icterícia pós-hepática. Foram identificadas várias etiologias associadas à icterícia, dentre elas pode-se destacar, agentes infecciosos (51/83), neoplasmas (13/83), processos degenerativos (11/83), crônicos (6/83) e obstrutivos (1/83). Dentre as causas infecciosas, destacam-se a leptospirose, a erliquiose e as lesões sugestivas de septicemia. Entre os neoplasmas associados com icterícia destacaram-se o colangiocarcinoma, hemangiossarcoma e linfoma. Outras causas de icterícia incluiriam os processos degenerativos como as degenerações gordurosa e glicogênica. Fibrose hepática (cirrose) e colelitíase foram também diagnosticados como causa de icterícia. A PCR foi utilizada para o diagnóstico confirmatório de leptospirose e erliquiose. Amostras de DNA total foram utilizadas para amplificar um fragmento dos genes de Leptospira interrogans e de Ehrlichia canis. Em alguns cães foi detectada co-infecção por estes agentes. A classificação e a identificação das causas de icterícia em cães são relevantes devido ao grande número de doenças que apresentam essa alteração, muitas vezes sem diagnóstico ante mortem.(AU)

Malaria grave en mujeres gestantes hospitalizadas entre el 2010 y el 2014 en el departamento de Antioquia, Colombia / Severe malaria in pregnant women hospitalized between 2010 and 2014 in the Department of Antioquia (Colombia)

Resumen Introducción. La malaria (o paludismo) durante la gestación impacta negativamente la salud de la madre y del neonato, con alto riesgo de complicaciones clínicas y mortalidad. En las regiones de alta endemia se han caracterizado, especialmente, la anemia materna y el bajo peso al nacer, pero es poco conocido el espectro clínico en las zonas de baja endemia. Objetivo. Caracterizar clínica y epidemiológicamente los episodios de malaria en mujeres gestantes hospitalizadas en el departamento de Antioquia entre el 2010 y el 2014. Materiales y métodos. Se hizo un estudio descriptivo, transversal y retrospectivo, con historias clínicas de mujeres gestantes con malaria por Plasmodium falciparum y P. vivax. Se utilizaron los criterios diagnósticos de malaria complicada de la Organización Mundial de la Salud (OMS) y de la Guía para la atención clínica integral del paciente con malaria vigente en Colombia. Resultados. Se analizaron 111 casos; el 13,5 % se clasificó como complicación grave según los criterios de la OMS, porcentaje que ascendió a 23,4 % según los criterios de la guía colombiana. Las complicaciones detectadas fueron disfunción hepática, anemia, acidosis y trombocitopenia grave. No se observó diferencia en la frecuencia de las complicaciones según la especie de plasmodio. El 39,4 % de los casos presentó signos generales de peligro; la palidez y la ictericia fueron los más frecuentes. El 40,5 % presentó signos de peligro para la gestación como la cefalea persistente, el dolor abdominal y el sangrado vaginal. Conclusiones. La malaria grave se presenta con gran frecuencia en las mujeres gestantes, sin diferencia según la especie de plasmodio, y se manifiesta con signos de peligro precozmente reconocibles. Se encontró un subregistro hospitalario del 88 % de los casos graves y falta de exámenes de laboratorio para un diagnóstico más completo. Se requiere un protocolo para el diagnóstico clínico de las mujeres gestantes con malaria.

Abstract Introduction: Malaria during pregnancy has a negative impact on maternal-neonatal health, with a high risk of clinic complications and mortality. High endemic areas are specially characterized by maternal anaemia and low birth weight. The clinical spectrum is little known in low endemic areas. Objective: To clinically and epidemiologically characterize malaria episodes in hospitalized pregnant women in the Department of Antioquia (Colombia) in the period 2010-2014. Materials and methods: Retrospective, cross-sectional, descriptive study with medical records of pregnant women with P. falciparum and P. vivax malaria. The WHO severe malaria diagnostic criteria and the Colombian Guía para la atención clínica integral del paciente con malaria (guidelines for comprehensive malaria treatment) were used. Results: We analyzed 111 cases, out of which 13.5% were classified as severe malaria according to the WHO criteria. Following the Colombian Guidelines, the proportion increased to 23.4%. Identified complications included hepatic dysfunction, anaemia, acidosis, and severe thrombocytopenia. No difference in the frequency of complications by Plasmodium species was observed; 39.4% of the cases presented general danger signs, pallor and jaundice being the most frequent; 40.5% showed danger signs for pregnancy, such as persistent headache, abdominal pain, and vaginal bleeding. Conclusions: Severe malaria is a highly frequent event in pregnant women, without differences by Plasmodium species. It shows early recognizable dangers signs. Hospital under-reporting was identified in 88% of severe cases as well as a lack of laboratory tests for a more comprehensive diagnosis. A protocol for the clinical diagnosis of pregnant women with malaria is required.

Colestasis por deficiencia de 3β-Δ5-C27-hidroxiesteroide deshidrogenasa en un paciente con alteración en la síntesis de ácidos biliares / Cholestasis due to deficiency of 3β-Δ5-C27-hydroxysteroid dehydrogenase in a patient with altered bile acid synthesis

Resumen: Introducción: Los errores innatos en la síntesis de ácidos biliares son un grupo de defectos genéticos que representan del 1 al 2% de las enfermedades colestásicas crónicas en lactantes, niños y adolescentes. La deficiencia de 3β-Δ5-C27-hidroxiesteroide oxidoreductasa (3β-HSDH) es el defecto más comúnmente reportado. El cuadro clínico característico consiste en hepatitis neonatal, hepatomegalia, esplenomegalia, malabsorción, desnutrición y enfermedad hepática de aparición tardía. Caso clínico: Lactante masculino con antecedente de ictericia en escleras a los 4 meses que se resolvió espontáneamente; posteriormente, a los 18 meses, presentó enfermedad colestásica. Durante su abordaje se documentó gamma-glutamil transpeptidasa normal, hallazgo que es altamente sugestivo de alteración en la síntesis de ácidos biliares. El diagnóstico se realizó con espectrometría de masas en orina. Se inició tratamiento con ácido cólico oral, y presentó mejoría inmediata. Conclusiones: El resultado en los ácidos biliares urinarios es definitivo para el defecto genético y consistente con mutaciones homocigotas en el gen HSD3B7. Este padecimiento constituye un diagnóstico de exclusión en las enfermedades colestásicas de la infancia, particularmente el hallazgo de gamma-glutamil transpeptidasa normal o levemente aumentada, y responde adecuadamente al tratamiento oral, por lo que debe identificarse de forma temprana.

Abstract: Background: Inborn errors in bile acid synthesis are a group of genetic defects accounting for 1 to 2% of chronic cholestatic diseases in infants, children and adolescents. Deficiency of 3β-Δ5-C27-hydroxysteroid dehydrogenase (3β-HSDH) is the most common defect in this disease. Clinical features consist of neonatal hepatitis, hepatomegaly, splenomegaly, malabsorption, malnutrition, and late-onset liver disease. Case report: A male infant who presented jaundice in sclera at 4 months that resolved spontaneously, later presented cholestatic disease at 18 months. During his approach, normal gamma-glutamyl transpeptidase was documented, a finding that is highly suggestive of alteration in the synthesis of bile acids. The diagnosis was made using urine mass spectrometry. Oral colic acid treatment was started, presenting immediate improvement. Conclusions: The result in urinary bile acids is definitive for the genetic defect and consistent with homozygous mutations in the HSD3B7 gene. This condition is a diagnosis of exclusion in childhood cholestatic diseases, particularly in the presence of normal or mildly enlarged gamma-glutamyl transpeptidase, and responds adequately to oral treatment; it should be identified early.

Liver transplantation for acute liver failure due to antitubercular drugs - a single-center experience

OBJECTIVES: Patients receiving treatment for tuberculosis are at risk of developing acute liver failure due to the hepatotoxicity of antitubercular drugs. We aimed to describe our experience with liver transplantation from deceased donors in this situation. METHODS: We identified patients undergoing transplantation for acute liver failure due to antitubercular drugs in our prospectively maintained database. RESULTS: Of 81 patients undergoing transplantation for acute liver failure, 8 cases were attributed to antitubercular drugs during the period of 2006-2016. Regarding the time of tuberculosis treatment until the onset of jaundice, patients were on antitubercular drugs for a mean of 64.7 days (21-155 days). The model for end-stage liver disease (MELD) score of patients ranged from 32 to 47 (median 38), and seven patients underwent transplantation under vasopressors. The 1-year survival was 50%. Three patients died during the week following transplantation due to septic shock (including a patient with acute liver failure due to hepatic/disseminated tuberculosis), and the remaining patient died 2 months after transplantation due to pulmonary infection. There were 2 cases of mild rejection and 1 case of moderate rejection. Of the surviving patients, all were considered cured of tuberculosis after alternative drugs were given. CONCLUSION: Patients arrived very sick and displayed poor survival after deceased donor transplantation.

Twelve years of experience using cholecystojejunal by-pass for palliative treatment of advanced pancreatic cancer / Derivação colecistojejunal para o tratamento paliativo do câncer de pâncreas avançado

ABSTRACT Background: The cholecistojejunal bypass is an important resource to treat obstructive jaundice due to advanced pancreatic cancer. Aim: To assess the early morbidity and mortality of patients with pancreatic cancer who underwent cholecystojejunal derivation, and to assess the success of this procedure in relieving jaundice. Method: This retrospective study examined the medical records of patients who underwent surgery. They were categorized into early death and non-early death groups according to case outcome. Results: 51.8% of the patients were male and 48.2% were female. The mean age was 62.3 years. Early mortality was 14.5%, and 10.9% of them experienced surgical complications. The cholecystojejunostomy procedure was effective in 97% of cases. There was a tendency of increased survival in women and patients with preoperative serum total bilirubin levels below 15 mg/dl. Conclusion: Cholecystojejunal derivation is a good therapeutic option for relieving jaundice in patients with advanced pancreatic cancer, with acceptable rates of morbidity and mortality.

RESUMO Racional: A derivação colecistojejunal é um importante recurso para o tratamento de pacientes com icterícia obstrutiva secundária ao câncer de pâncreas avançado. Objetivo: Avaliar a morbimortalidade precoce dos doentes com câncer de pâncreas submetidos à derivação colecistojejunal, assim como avaliar o alivio da icterícia. Método: Estudo retrospectivo de prontuários de pacientes que foram operados. Eles foram categorizados de acordo com a resolução dos casos em: morte precoce e sem morte precoce. Resultados: 51,8% dos pacientes eram homens e 48,2% mulheres. A média etária foi de 62,3 anos. A mortalidade precoce foi de 14,5%. 10,9% evoluíram com complicações cirúrgicas. A colecistojejunostomia foi efetiva em 97% dos casos. Houve tendência à maior sobrevida em mulheres e pacientes com níveis séricos de bilirrubina total pré-operatório menor do que 15mg/dl. Conclusão: A derivação colecistojejunal constitui boa opção terapêutica para alívio da icterícia em pacientes com câncer de pâncreas avançado, apresentando morbimortalidade aceitável.

Lesión de vía biliar en trauma cerrado: nuevas tendencias en lesiones infrecuentes / Biliar injury in closed trauma: new trends in unusual injury

Objetivo: Reportar un caso clínico de lesión de la vía biliar intrapancreática tras traumatismo abdominal cerrado. Caso clínico: Paciente que acude a urgencias por intenso dolor abdominal, tras sufrir traumatismo toraco-abdominal cerrado al caer de una bicicleta. Posteriormente a su ingreso desarrolló fiebre, ictericia y patrón analítico de colestasis. Se solicitó colangiorresonancia magnética donde no se pudo valorar correctamente la vía biliar, pero se evidenció abundante líquido intraabdominal que no correspondía a sangre. Se indicó cirugía urgente ante la sospecha de lesión biliar. Se objetivó lesión de la vía biliar intrapancreática mediante colangiografía intra-operatoria y se decidió colocación de prótesis intrabiliar mediante colangiopancreatografía retrógrada endoscópica (CPRE) intraoperatoria. Conclusión: La cirugía ha sido el tratamiento convencional para la lesión de la vía biliar, pero en la actualidad la CPRE con esfinterotomía y colocación de prótesis intrabiliar es un tratamiento adecuado y resolutivo de este tipo de lesiones pudiéndose considerar como tratamiento de primera línea.

Aim: To report a clinical case of biliar injury intrapancreatic in closed abdominal trauma. Clinical case: Patient who comes to the emergency room by severe abdominal pain after suffering thoraco-abdominal blunt trauma after falling from a bicycle. After his admission he developed fever, jaundice and analytical standards of cholestasis. Magnetic resonance which failed to correctly assess the bile duct was requested but showed plenty of intra-abdominal fluid blood that did not match. Emergency surgery for suspected biliary injury was reported. Intrapancreatic injury bile duct was observed by intraoperative cholangiography and prosthesis was decided intrabiliary by intraoperative endoscopic retrograde cholangiopancreatography (ERCP). Conclusions: Surgery has been the standard treatment for bile duct injury, but now ERCP with sphincterotomy and placement of intrabiliary prosthesis is adequate and operative treatment of these injuries and can be considered as first-line treatment.

Características sociodemográficas y clínicas de pacientes con infección por Leptospira spp. atendidos en cuatro centros hospitalarios de Medellín, Colombia, 2008-2013 / Sociodemographic and clinical characteristics of patients infected with Leptospira spp. treated at four hospitals in Medellín, Colombia, 2008-2013

Resumen Introducción: La leptospirosis continúa siendo un problema significativo de salud en regiones tropicales, incluidos los países de Latinoamérica, donde es 100 veces más frecuente que en otras regiones del mundo. En los cuadros graves de la enfermedad, su mortalidad alcanza el 10 %. Su diagnóstico es un reto debido a que las manifestaciones clínicas en la fase inicial son inespecíficas y a la poca disponibilidad de pruebas diagnósticas. Objetivo: Describir las características sociodemográficas y clínicas, y el desenlace de la enfermedad en pacientes hospitalizados con leptospirosis. Materiales y métodos: Es un estudio retrospectivo que incluyó pacientes atendidos en cuatro instituciones de Medellín, entre enero de 2009 y diciembre de 2013, con un cuadro clínico sugestivo e IgM positiva para Leptospira spp. Resultados: Se incluyeron 119 pacientes, 80 % hombres y 58 % de procedencia rural. La duración promedio de los síntomas fue de 9,6 días (DE=9,6). El 89 % de los pacientes presentó fiebre; el 62 %, ictericia; el 74 %, mialgias; el 46 %, diarrea; el 41 %, hepatomegalia; el 13 %, esplenomegalia, y 13 %, enrojecimiento de los ojos. En 54 % de los pacientes hubo deterioro de la función renal, en 32 %, compromiso pulmonar y, en 13 %, falla hepática. El 16 % de los pacientes requirió atención en la unidad de cuidados intensivos, el 12 %, asistencia respiratoria mecánica, y el 11 %, administración de vasopresores. En 38,6 % de ellos la enfermedad cursó con síndrome de Weil y el 5 % falleció. La duración promedio de la hospitalización fue de 11 días (DE=9,6). Conclusiones:. La leptospirosis en esta población tuvo manifestaciones clínicas y complicaciones similares a las reportadas en la literatura científica. Se observó una mortalidad general relativamente baja comparada con las estadísticas mundiales.

Abstract Introduction: Leptospirosis remains a significant health problem in tropical regions including Latin America, where its presentation is 100 times higher than that observed in other regions of the world. Mortality reaches 10% in severe cases. Its diagnosis is challenging because clinical manifestations during the initial phase are non-specific and because of limited availability of diagnostic tests Objective: To describe the demographic and clinical characteristics and the outcomes in hospitalized patients with leptospirosis. Materials and methods: This retrospective study included patients treated at four institutions in Medellín between January, 2009, and December, 2013, with a compatible clinical picture and a positive IgM for Leptospira spp. Results: We included 119 patients, 80% male, and 58% of rural origin. The mean duration of symptoms was 9.6 days (SD=9.6). Eighty nine per cent of patients had fever; 62%, jaundice; 74%, myalgia; 46%, diarrhea; 41%, hepatomegaly; 13%, splenomegaly, and 13%, conjunctival injection. Fifty four per cent of patients had impaired renal function; 32%, pulmonary compromise, and 13%, liver failure. Sixteen per cent required admission to the ICU; 12%, mechanical ventilation, and 11%, vasopressor therapy. Weil's syndrome occurred in 38.6% and 5% died. The average hospital stay was 11 days (SD=9.6). Conclusions: In this population, the clinical manifestations and complications of leptospirosis were similar to those reported in the literature. We observed a relatively low overall mortality in relation to global statistics.

Quistes de colédoco, una causa inusual de ictericia en pediatría: presentación de serie de casos / Bile duct cysts; an unusual cause of jaundice in paediatrics: presentation of a case series

Introducción Los quistes de la vía biliar o quistes de colédoco (QC) son una patología rara en nuestro medio. La etiología es desconocida, siendo la hipótesis más aceptada las anomalías en la unión biliopancreática. Objetivo Analizar los datos clínicos, diagnóstico y tratamiento de una serie de pacientes diagnosticados de QC y realizar una actualización sobre el tema. Metodo Se revisaron retrospectivamente los diagnósticos de QC en 20 años en un hospital terciario. Casos clínicos Se identificaron 4 casos, con predominio del sexo femenino. Rango de edad 16 meses a 4 años. Los signos y síntomas fueron ictericia y coluria (100%), vómitos (75%), dolor abdominal y acolia (50%). Ninguno tuvo masa palpable. La ecografía abdominal orientó el diagnóstico que se confirmó con colangio-resonancia magnética (colangio-RM). Se clasificaron como QC tipo I tres de los casos y uno como tipo IVa. El tratamiento fue quirúrgico, ningún paciente presentó complicaciones hasta la fecha. Conclusiones Los quistes de las vías biliares son de baja prevalencia. El tratamiento de elección es quirúrgico, requiriendo seguimiento estrecho, dado el riesgo de colangiocarcinoma.

Introduction Cysts of the bile duct or choledochal cysts are rare diseases in our area. The aetiology is unknown, with the most accepted hypothesis being a pancreatobiliary maljunction anomaly. Objective To analyse the clinical data, diagnosis and treatment of a number of patients with choledochal cyst, as well as presenting an update on this condition. Method A retrospective descriptive study was performed on paediatric patients diagnosed with choledochal cyst in the last 20 years in a tertiary hospital. Case reports A total of 4 choledochal cyst cases in childhood, predominantly female, are pre- sented. The most frequent reason for consultation was vomiting, and presenting with jaundice and choluria in all cases. Patients with choledochal cyst were classified as type I in 3 cases, and one case of type IVa. In all cases surgical treatment was performed; any patient had complications to date. Conclusions Cysts of the bile ducts have a low prevalence. The treatment of choice is surgical, requiring close monitoring due to the risk of cholangiocarcinoma.

A case of levocetirizine-induced liver injury

Levocetirizine is a second-generation nonsedative antihistaminic agent that has been demonstrated to be safe and effective for treating allergic disease. There was only one case report of levocetirizine-induced liver toxicity, but a liver biopsy was not performed. In this article, we present the first case of levocetirizine-induced liver injury with histologic findings. A 48-year-old man was hospitalized with jaundice and generalized pruritus that had developed after 2 months of therapy with levocetirizine for prurigo nodularis. Laboratory findings revealed acute hepatitis with cholestasis. A liver biopsy demonstrated portal inflammation and hepatitis with apoptotic hepatocytes. The patient fully recovered 3 weeks after withdrawing levocetirizine. Although levocetirizine is safe and effective, physicians should be aware of its potential hepatotoxicity.

FLUCTUATING JAUNDICE IN THE ADENOCARCINOMA OF THE AMPULLA OF VATER: a classic sign or an exception? / Icterícia flutuante em adenocarcinoma de ampola de Vater: um sinal clássico ou uma exceção?

Background Some authors consider the fluctuating jaundice as a classic sign of the adenocarcinoma of the ampulla of Vater. Objetive Assessing the frequency of fluctuating jaundice in their forms of its depiction in the patients with adenocarcinoma of the ampulla of Vater. Methods Observational and retrospective study, conducted through analyses of medical records from patients subjected to pancreatic cephalic resections between February 2008 and July 2013. The pathological examination of the surgical specimen was positive to adenocarcinoma of the ampulla of Vater. Concepts and differences on clinical and laboratory fluctuating jaundice were standardized. It was subdivided into type A and type B laboratory fluctuating jaundice. Results Twenty patients were selected. One of them always remained anicteric, 11 patients developed progressive jaundice, 2 of them developed clinical and laboratory fluctuating jaundice, 5 presented only laboratory fluctuating jaundice and one did not present significant variations on total serum bilirubin levels. Among the seven patients with fluctuating jaundice, two were classified as type A, one as type B and four were not classified due to lack information. Finally, progressive jaundice was the prevailing presentation form in these patients (11 cases). Conclusion This series of cases suggested that clinical fluctuating jaundice is a uncommon signal in adenocarcinoma of the ampulla of Vater. .

Contexto Alguns autores consideram a icterícia flutuante como um sinal clássico do adenocarcinoma da ampola de Vater. Objetivo Determinar a frequência de icterícia flutuante em suas formas de apresentação nos pacientes portadores de adenocarcinoma de ampola de Vater. Métodos Estudo observacional e restrospectivo, realizado a partir de análise de prontuários médicos de pacientes submetidos à ressecção cefálica pancreática entre fevereiro de 2008 e julho de 2013, cujo anatomopatológico confirmou o diagnóstico de adenocarcinoma de ampola de Vater. Conceituação e diferenciação entre icterícia flutuante clínica e laboratorial foram padronizadas. Icterícia flutuante laboratorial foi dividida em tipo A e B. Resultados Vinte pacientes foram selecionados. Um deles permaneceu sempre anictérico, 11 pacientes desenvolveram icterícia progressiva, 2 desenvolveram icterícia flutuante clínica e laboratorial, 5 apresentaram apenas icterícia flutuante laboratorial e 1 não apresentou significativa variação nos níveis séricos de bilirrubina total. Entre os sete pacientes com icterícia flutuante, dois foram classificados como tipo A, um como tipo B e quatro não foram classificados devido à falta de informações. Finalmente, icterícia progressiva foi a apresentação mais prevalente nos pacientes selecionados (11 casos). Conclusão Este artigo sugere que a icterícia flutuante clínica é um sinal incomum em pacientes portadores de adenocarcinoma de ampola de Vater. .

Amoxycillin Clavulanic Acid Induced Hepatotoxicity.

Drug-related hepatotoxicity is a serious health problem, with broad implications for patients, healthcare providers, the pharmaceutical industry and governmental regulatory agencies. Herein we report a rare case of amoxycillinclavulanic acid combination induced liver injury of cholestatic pattern in 40 years old, well educated male patient. Patient gave history that though other drugs were given to him by his physician for fever with chills & rigors, malaise, bodyache, except amoxycillin-clavulanic acid combination all other drugs were well tolerated previously by the patient, without appearance of jaundice. So jaundice in this patient was most probably due to amoxycillinclavulanic acid combination. Though severe liver injury is rare, proper history should be taken while prescribing amoxycillin-clavulanic acid combination. Attention must be paid to potential side-effects of the drugs and close follow-up with patients is a medical necessity to evaluate adverse reactions, especially in case of amoxycillinclavulanic acid combination.

Ictericia post-operatoria / Post-operative jaundice

The occurrence of postoperative jaundice should encourage the surgeon to review the wide spectrum of possible causes of jaundice and perform detailed history, physical examination and laboratory tests to define the causes, and take the measures to treat the patient properly. We also emphasize the need to prevent the presence of residual stones in the bile duct and bile duct iatrogenic injuries. This paper describe the possible causes of postoperative jaundice and current recommendations for adequate treatment.

La aparición de ictericia en el postoperatorio debe alertar al cirujano y llevarlo a revisar el gran espectro de causas posibles del cuadro. Se debe realizar una anamnesis y examen físico detallado y complementarlo con exámenes de laboratorio e imágenes según el caso. Además, se insiste en la necesidad de prevenir la presencia de cálculos residuales en colédoco y lesiones iatrogénicas de vía biliar. Se revisan las causas posibles de ictericia postoperatoria y las recomendaciones actuales de manejo.

Disappearance of Intrahepatic Bile Duct Hepatocellular Carcinoma after Endoscopic Retrograde Cholangiopancreatography and Transarterial Chemoinfusion: A Case Report / 대한소화기학회지

Invasion of the bile duct by hepatocellular carcinoma (HCC), which is called intrahepatic bile duct HCC, is rare and has a poor prognosis. Early diagnosis and surgical resection is important for treatment. A 58-year-old man who underwent hepatic resection for HCC 4 years ago and received transarterial chemoembolization (TACE) 2 years after the operation for recurred HCC presented with jaundice. CT scan revealed a tumor in the common bile duct without intrahepatic lesion. Therefore, ERCP was done to perform biopsy and biliary drainage. Histological examination was compatible with hepatocellular carcinoma. However, the tumor could not be visualized at angiography and thus, only transarterial chemoinfusion was performed without embolization. The tumor had disappeared on follow-up CT scan, and the patient has been disease free for 23 months without evidence of recurrence. Herein, we report a case of intrahepatic bile duct HCC which disappeared after ERCP.

Hepatitis alcohólica severa no respondedor a a glucocorticoides: reporte de un caso / Alcoholic hepatitis not responding to corticosteroids: a case report

INTRODUCCIÓN: La hepatitis alcohólica corresponde a un daño inflamatorio agudo sobre un hígado progresivamente dañado por la ingesta excesiva y prolongada de alcohol. Puede presentar ictericia, manifestaciones de alcoholismo crónico e insuficiencia hepática progresiva. PRESENTACIÓN DEL CASO: Varón de 60años con antecedentes de daño hepático crónico secundario a alcoholismo activo, que presentó cuadro de dos semanas de ictericia progresiva, prurito y bradipsiquia, asociado a leucocitosis, hiperbilirrubinemia, y elevación discreta de transaminasas, con predominio de GOT sobre GPT. Hemocultivos, urocultivo y serologías para virus hepatotropos fueron negativos. La ecografía abdominal mostró signos de hepatopatía crónica, sin dilatación de vía biliar. Con una función discriminante de Maddrey de 106 puntos se inició pentoxifilina, evolucionando tórpidamente. Se agregó prednisona durante siete días; se obtiene una puntuación de Lille de 0,99 (no respondedor), suspendiendo los corticoides. Progresó la insuficiencia hepática, con posterior insuficiencia renal aguda, acidosis metabólica, trastornos hidroelectrolíticos y fallecimiento al mes de evolución. DISCUSIÓN: La hepatitis alcohólica posee alta mortalidad. Existen múltiples escalas pronósticas. Los corticoides están indicados en casos severos, sin embargo hasta un 40 por ciento se catalogan como no respondedores. Se requieren nuevos tratamientos para mejorar la supervivencia de estos pacientes.

INTRODUCTION: Alcoholic hepatitis constitutes an acute inflammatory episode due to prolonged alcohol abuse on a previously damaged liver. Clinical features include jaundice, signs of chronic alcoholism and progressive liver failure. CASE REPORT: A 60-yearold male with a history of cirrhosis due to ongoing excessive intake of alcohol presented a two week history of progressive jaundice, pruritus, and bradypsychia. Laboratory tests showed leukocytosis, hyperbilirubinemia and a mild elevation of liver enzymes (GOT over GPT). Blood and urine cultures as well as serological markers for viral hepatitis were negative. Abdominal ultrasound showed signs of chronic liver disease, with no bile duct dilatation. A modified Maddrey’s discriminant function of 106 was determinant on starting therapy with pentoxifyline. However, patient’s status deteriorated. Prednisone was added to the treatment but seven days later, the patient was categorized as a non-responder (Lille score of 0.99), so the glucocorticoids were suspended. The patient’s liver failure progressed, after which renal failure, metabolic acidosis and electrolytic abnormalities developed; that led to his death after one month from admission. DISCUSSION: Alcoholic hepatitis requires prompt diagnosis and treatment, due to its high death rate. There are various prognostic scales available, one of which is the modified Maddrey’s discriminant function. The fundamental therapeutic measure is the use of intravenous glucocorticoids; yet up to 40 percent of patients qualify as non-responders.

Reingreso para fototerapia en recién nacidos con ictericia sin hemólisis / Readmission for phototherapy in jaundiced newborns without hemolysis

La presencia de elevados niveles de bilirrubina indirectaen el período neonatal se convirtió en un problema desalud pública en los últimos años asociados al alta antesde las 72 h de vida y la alimentación exclusiva a pecho.Con los objetivos de determinar la incidencia dereingreso para fototerapia de recién nacidos de edadgestacional igual o mayor a 35 semanas aparentementesanos sin hemólisis en el departamento de Florida,analizar qué factores se asociaron a la necesidad defototerapia y describir el tratamiento realizado en lainternación se realizó un estudio descriptivo y analítico decarácter retrospectivo. El período de estudio fue de dosaños desde el 1 de enero de 2008 al 31 de diciembre de2009.Resultados: se incluyeron 18 recién nacidos en elperíodo de estudio lo que representa el 16,2 por mil dereingresos. Trece fueron del sexo masculino (72.2%) y 5de sexo femenino (27,8%). Primigestas correspondieron a83,3% y fueron producto de segunda gestación o más un16,7%. La vía de parto fue en un 77,7% parto vaginal y enun 22.3% por cesárea. Tenían 37 semanas de edadgestacional o menor tiempo de gestación 9 (50%). Elporcentaje de pérdida de peso al momento del reingresovarió entre 10% y 14,8% del peso al nacer.Conclusiones: la ictericia es una causa importante dereingreso hospitalario, correspondiendo a 16,2 por milrecién nacidos vivos en el departamento de Florida. Lapresencia de ictericia se asoció a alta antes de las 72 h,sexo masculino, edad gestacional menor a 38 semanas,alimentación a pecho exclusivo y pérdida de peso mayoral 10% del peso al nacer. Es importante evaluaradecuadamente el riesgo de ictericia y la calidad de laalimentación para evitar el reingreso debido a esta causa.

Neonatal polycythemia: risk factors, clinical manifestation and treatment applied

Polycythemia is defined as a venous hematocrit above 65%. Polycythemia is sometimes associated with hyper viscosity of blood. The etiology of polycythemia is related either to intra-uterine hypoxia or secondary to fetal transfusion. Increased viscosity of blood is associated with symptoms of hypoperfusion. Clinical features related to hyper viscosity may affect all organ systems. To evaluate the prevalence of polycythemia among neonates who were admitted to the nursery care unit, to evaluate the difference between peripheral and central hematocrit [PCV] and to have an idea about the main presentation and modes of treatment of polycythemia. A case - control study was done in the nursery care unit of AL - Kadhyimia Teaching Hospital, one hundred neonates [50 polycythemic and 50 control healthy neonates] were taken, for each neonates, information regarding [name, age, sex, gestational age, mode of delivery, body weight, length, head circumference, clinical presentation and risk factors] were taken, investigations including hematocrite [PCV], random blood sugar and total serum bilirubin were done for all neonates. The prevalence of neonatal polycythemia was [2.2%], male was affected more than female with male: female ratio equal to [1.5:1]. The difference between peripheral and central PCV was [4 - 15%] with a mean and standard deviation of [7 +/- 0.33%]. The main signs and symptoms were jaundice [58%], lethargy [30%], respiratory distress [26%] and hypoglycemia [26%]. Risk factors were preterm [36%], neonates of diabetic mother [20%], small for gestational age [18%], twin pregnancy [12%] and down's syndrome [10%]. Partial exchange transfusion was done to 28 cases [56%]. Males were affected more than females. Jaundice was the main presentation followed by lethargy, respiratory distress and hypoglycemia. Higher risk in twin pregnancy, neonates of diabetic mother, small for gestational age, preterm and down's syndrome while delivery by caesarian section reduce the risk of polycythemia.

Massive Bleeding Hemobilia Occurred in Patient with Hepatocellular Carcinoma / 대한소화기학회지

Massive bleeding hemobilia occurs rarely in patients with hepatocellular carcinoma (HCC) without any invasive procedure. Upper gastrointestinal bleeding in patient with cirrhosis and abdominal pain with progressive jaundice in patient with HCC were usually thought as variceal bleeding and HCC progression respectively. We experienced recently massive bleeding hemobilia in patient with HCC who was a 73-year old man and showed sudden abdominal pain, jaundice and hematochezia. He had alcoholic cirrhosis and history of variceal bleeding. One year ago, he was diagnosed as HCC and treated with transarterial chemoembolization periodically. Sudden right upper abdominal pain occurred then subsided with onset of hemotochezia. Computed tomography showed bile duct thrombosis spreading in the intrahepatic and extrahepatic ducts, while an ampulla of vater bleeding was observed during duodenoscopy. Hemobilia could be one of the causes of massive bleeding in patients with cirrhosis and HCC especially when they had sudden abdominal pain and abrupt elevation of bilirubin.

Icterícia grave e miocardiopatia tireotóxica com trombo atrial / Serious jaundice and thyrotoxic myocardiopathy with atrial thrombus

Icterícia relacionada à tireotoxicose, e não como efeito das drogas antitireoidianas, é uma complicação rara que, em geral, ocorre na presença de insuficiência cardíaca (IC) ou hepatite. Apresentamos o caso de mulher de 54 anos de idade, branca, diagnóstico de hipertireoidismo por doença de Graves com icterícia associada a despeito da suspensão prévia de metimazol. A bilirrubina oscilava em valores elevados entre 30,0 e 52,3 mg/dL, as transaminases eram pouco elevadas com valores de ALT, na admissão, de 46 U/I e AST de 87 U/I; coagulograma e proteínas encontravam-se no limite inferior da normalidade, sendo TAP 68% e albumina = 2,5 g/dL. Sorologias para hepatites foram negativas. Após a primeira dose de radioiodoterapia (RT), a bilirrubina atingiu seu valor máximo, que coincidiu com período de pior exacerbação da IC. A bilirrubina normalizou-se após quatro semanas da segunda dose de RT com a estabilização da IC e a normalização dos hormônios tireoidianos. Discutimos as possíveis etiologias de icterícia severa em pacientes hipertireoideos, assim como a difícil terapia anticoagulante com varfarina.

Jaundice related to thyrotoxicosis and not as an effect of antithyroid drugs is a rare complication that usually occurs in the presence of heart failure (HF) or hepatitis. We report a case of a 54-year-old white woman with hyperthyroidism caused by Graves's disease and jaundice despite methimazole suspension. Bilirubin fluctuated at high values, between 30.0 and 52.3 mg/dL, transaminases were slightly increased, on admission ALT = 46 U/L and AST = 87 U/L; coagulation indices and serum proteins were on the lower limit of the normal range with PT 68% and albumin = 2.5 g/dL. Serology for hepatitis was negative. After the first radioiodine therapy (RT), bilirubin reached its maximum, which coincided with the worst period of HF exacerbation. Bilirubin normalized 4 weeks after the second RT, with the stabilization of HF and normalization of thyroid hormones. We discuss the possible etiologies of severe jaundice in hyperthyroid patients, as well as the difficult anticoagulant therapy with warfarin.

Síntese e metabolismo da bilirrubina e fisiopatologia da hiperbilirrubinemia associados à Síndrome de Gilbert: revisão de literatura / Bilirubin synthesis and metabolism, and hyperbilirubinemia associated with Gilbert’s Syndrome: A review of the literature

A icterícia é sinal clínico comum a várias condições patológicas, podendo ser evidenciada em vários locais do organismo devido à grande capacidade de impregnação do pigmento biliar. A icterícia torna-se evidente quando a concentração plasmática encontra-se acima de 2,5 a 3,0 mg/dL. O presente trabalho retrata o metabolismo fisiológico dos pigmentos biliares concomitantemente com a síntese e metabolismo de bilirrubina, assim como processos fisiopatológicos causados pelo aumento da bilirrubina plasmática (hiperbilirrubinemia), como ocorre na síndrome de Gilbert, caracterizada pela deficiência enzimática, que se manifesta clinicamente como icterícia. Compreender os passos da formação e excreção da bilirrubina é fundamental para a compreensão das manifestações clínicas e que ocorrem na icterícia, facilitando o entendimento dos mecanismos fisiopatológicos da hiperbilirrubinemia, como ocorrem na síndrome de Gilbert.

Jaundice is a common clinical manifestation of several pathological conditions. It can be found in several parts of the body because of the high impregnation capacity of the bile pigment. Jaundice is evident when plasmatic concentration is higher than 2.5 ? 3.0 mg/dL. This paper describes the physiological metabolism of bile pigments concomitantly with bilirubin synthesis and metabolism, as well as the pathophysiological processes derived from increased plasmatic bilirubin (hyperbilirubinemia). This is a circumstance typical of the Gilbert?s syndrome, which causes enzymatic deficiency that is clinically manifested as jaundice. Knowledge of the steps of bilirubin formation and excretion is crucial to shed light into the clinical manifestations of jaundice and thus gain more understanding of the physiological mechanisms of hyperbilirubinema associated with Gilbert?s syndrome.

Prolonged jaundice attributed to super infection of hepatitis E virus in a case of resolving leptospirosis.

India is endemic for both Leptospira and hepatitis E virus (HEV). The clinical presentations of these diseases have overlapping features. We report a case of superinfection of HEV in a patient with resolving leptospirosis with underlying Hodgkin lymphoma. The diagnosis of HEV in our case was established by HEV-RNA PCR as our patient was immunosuppressed. The present study highlights the need for molecular diagnosis in the case of HEV infection with strong clinical suspicion and negative serological results.