A New Paradigm in Gallstones Diseases and Marked Elevation of Transaminases: An Observational Study

ABSTRACT Background. In clinical practice, it is assumed that a severe rise in transaminases is caused by ischemic, viral or toxic hepatitis. Nevertheless, cases of biliary obstruction have increasingly been associated with significant hypertransaminemia. With this study, we sought to determine the true etiology of marked rise in transaminases levels, in the context of an emergency department. Material and methods. We retrospectively identified all patients admitted to the emergency unit at Centro Hospitalar e Universitário de Coimbra between 1st January 2010 and 31st December 2010, displaying an increase of at least one of the transaminases by more than 15 times. All patient records were analyzed in order to determine the cause of hypertransaminemia. Results. We analyzed 273 patients - 146 males, mean age 65.1 ± 19.4 years. The most frequently etiology found for marked hypertransaminemia was pancreaticobiliary acute disease (n = 142;39.4%), mostly lithiasic (n = 113;79.6%), followed by malignancy (n = 74;20.6%), ischemic hepatitis (n = 61;17.0%), acute primary hepatocellular disease (n = 50;13.9%) and muscle damage (n = 23;6.4%). We were not able to determine a diagnosis for 10 cases. There were 27 cases of recurrence in the lithiasic pancreaticobiliary pathology group. Recurrence was more frequent in the group of patients who had not been submitted to early cholecystectomy after the first episode of biliary obstruction (p = 0.014). The etiology of hypertransaminemia varied according to age, cholestasis and glutamic-pyruvic transaminase values. Conclusion. Pancreaticobiliary lithiasis is the main cause of marked hypertransaminemia. Hence, it must be considered when dealing with such situations. Not performing cholecystectomy early on, after the first episode of biliary obstruction, may lead to recurrence.

Total oxidant status, total antioxidant status, and paraoxonase and arylesterase activities during laparoscopic cholecystectomy

INTRODUCTION: Laparoscopic cholecystectomy is the gold standard for the treatment of gallstone disease; however, adverse hemodynamic changes induced by increased intraabdominal pressure due to pneumoperitoneum are known to occur. Herein, we investigated the effects of pneumoperitoneum on oxidative stress markers, including paraoxonase, arylesterase, total oxidant status, and total antioxidant status, during laparoscopic cholecystectomy. PATIENTS AND METHODS: Patients that underwent a laparoscopic cholecystectomy were classified as Group I, whereas patients that underwent surgical procedures for an abdominal wall hernia under general anesthesia were classified as Group II. Blood samples were obtained during the preoperative period, the perioperative period, and 24 hours after surgery (postoperative day 1). Leukocyte counts, neutrophil rates, paraoxonase activities, arylesterase activities, and total oxidant and antioxidant status levels were measured. RESULTS: The differences in leukocyte counts and neutrophil rates were not significant between the two groups. In Group I, no significant differences in the total oxidant and antioxidant status levels were identified; however, paraoxonase and arylesterase levels were lower on postoperative day 1. No significant changes were observed in the total oxidant status, total antioxidant status, and paraoxonase or arylesterase activities in Group II. The perioperative total antioxidant status and arylesterase level were higher in Group I in comparison to Group II. CONCLUSION: Paraoxonase and arylesterase levels are useful markers in the evaluation of oxidative stress caused by intraabdominal pressure due to pneumoperitoneum.

A comparative study of serum lipid profile and gallstone disease.

The diseased gallbladder is one of the commonest specimens submitted to the surgical pathology laboratory in North India. Obesity is associated with a linear increase in gallstone formation. It has been observed that the plasma lipoprotein profile of patients with gallstones differs markedly from that of healthy subjects. Serum lipid profile was done by enzyme kit method. All the gallstones received were categorized morphologically and examined biochemically. The age range of 200 cases was 13 to 77 years with a mean of43.75 +/- 13.39 years. There were 171 females (85.5%) and 29 males (14.5%) with male to female ratio of 1: 5.8. The stones containing both cholesterol and bile pigments were the most common (129 cases, 84.87%); while pure cholesterol stones were seen in 23 cases (11.50%) and pigment stones were infrequent (1 case, 0.65%). On lipidogram of patients in the study group, mean serum total cholesterol was 155.50 +/- 43.03 mg/dL, mean serum triglycerides was 100.49 +/- 45.23 mg/dL, mean HDL cholesterol was 46.71 +/- 15.20 mg/dL, mean LDL cholesterol was 87.94 +/- 36.85 mg/dL and mean VLDL cholesterol was 20.84 +/- 11.97 mg/dL. Serum total cholesterol values were significantly higher in patients older than 39 years as compared to patients < or =39 years (161.44 +/- 42.32 mg/dL vs. 145.79 +/- 32.96 mg/dL, p < 0.05). But the observed mean values in both of these subgroups were within the normal range i.e. <200 mg/dL. No significant difference was observed in the mean serum triglyceride values between male and female patients. The findings of this study did not indicate any role of serum lipid profile in the formation of gallstones. However the higher mean values of serum total cholesterol and serum triglycerides in patients older than 39 years of age may be explained by increasing age.

El papel de la leptina en el desarrollo de esteatosis hepática y litiasis biliar / Leptine participation in the development of liver steatosis and biliar lithiasis

La obesidad incrementa el riesgo para varios padecimientos gastro intestinales como litiasis biliar (LB), esteatosis hepática (EH) y este-atohepatitis no alcohólica. Recientemente observamos una relación entre colesterol HDL, índice de saturación de colesterol en la bilis y leptina en pacientes obesos en reducción de peso. De igual manera la leptina tiene un papel importante en el desarrollo de la EH y probablemente en los mecanismos inflamatorios. El objetivo de este trabajo fue investigar la relación entre la LB y la EH. Se estudiaron a sujetos de la Unidad de Diagnóstico Clínico que acudieron a la realización de una revisión clínica preventiva. Aquellos que presentaron LB o EH por ultrasonido fueron considerados como casos, se compararon con controles sanos. Se tomaron medidas antropométricas, índice de masa corporal (IMC) y concentraciones de leptina, insulina, lípidos séricos, y lipoproteínas por métodos convencionales. Se estudiaron 317 sujetos, quienes fueron divididos en cuatro grupos: LB (n = 100), EH (n = 84), LB + EH (n = 33) y control (n = 100). La edad del grupo control fue significativamente mayor (LB, 52.6 ± 11.6; EH, 49.8 ± 11.1; LB +EH, 51.6 ± 10,5; controles 57.1 ± 7.4), p< 0.05. ElIMC fue mayor en los grupos de EH (28.7 ± 2.8) y LB +EH (29.0 ± 3.8) que en los grupos de LB (27.4 ± 4.3) y control (27.0 ± 3.0), p< 0.05. El grupo de LB (13.7 ± 8.1) presentó las concentraciones más elevadas de leptina comparado con los otros grupos, P < 0.05. Mientras que las concentraciones de insulina fueron similares en los cuatro grupos de sujetos. Los resultados del presente estudio muestran que los sujetos con LB y EH presentan concentraciones elevadas de leptina, comparados con controles. Esto sugiere que la leptina juega un papel importante en la fisiopatología de la LB y EH.

Obesity increases significantly the risk of developing several common gastrointestinal diseases such as gallstone disease (GD) and hepatic steatosis (HS). Elsewhere we have shown a relationship between HDL cholesterol, cholesterol saturation index, and leptin in obese patients loosing weight. Furthermore, leptin plays an important role facilitating HS and possibly in the associated inflammatory process. The aim of this study was to investigate the relationship between GD and HS. The sample was comprised by patients attending the unit for check up. Subjects with visible stones or HS by ultrasound (cases) were compared with healthy controls. Demographic and body mass index (BMI) were recorded. Plasma leptin, insulin and serum lipids and lipoproteins levels were measured by standard methods. A total of 317 subjects were included in this study. They were divided in four groups as follows: GD (n=100), HS (n=84), GD + HS (n=33) and controls (n=100). The control group was significantly older (GD, 52.6 ± 11.6; HS, 49.8 ±11.1; GD +HS, 51.6 ±10.5; 57.1 ± 7.4), p< 0.05. BMI was higher in the HS groups (28.7 ± 2.8) and GD +EH (29.0 ± 3.8) than in the GD (27.4 ± 4.3) and control (27.0 ± 3.1) group, p< 0.05. The GD group displayed the highest leptin levels (13.7 241 8.1), P < 0.05, whereas insulin levels were similar in all groups. Since GD and HS subjects have high plasma leptin levels compared with controls, our results suggest that leptin plays an important role in the pathophysiology of GD and HS.

Interleukin-6 (IL-6) and tumour necrosis factor-alpha in open and laparoscopic cholecystectomy.

Injury to the human body alters normal physiology across several systems and these alterations are proportional to the extent of the injury. Physiological response to minimally invasive surgery appears to be different than those of traditional open surgery. Acute phase protein response appears to be one example. The important cytokines that are known as major mediators of acute phase response are interleukin-6 and TNF-alpha. Thirty patients were studied in which 14 underwent open cholecystectomy and 16 laparoscopic cholecystectomy. Three blood samples were taken from each patient, one pre-operatively and 2 post operatively at 4 and 24 hours. Interleukin-6 and Tumour Necrosis Factor-alpha (TNF-alpha) were raised significantly in post operative blood sample in both groups but the rise was much more in open group than laparoscopic group. This suggest less stress response in laparoscopic group which also showed a direct effect on patient convalescence in terms of less pain, less analgesic requirement and shorter hospital stay