Prognostic Value of Preoperative Neutrophil-to-lymphocyte Ratio for Prediction of Severe Cholecystitis.

BACKGROUND: The predictive value of preoperative neutrophil-to-lymphocyte ratio (NLR) in patients with cholecystitis has not been established. The aim of this study was to investigate preoperative NLR in patients with cholecystitis and to identify a relevant NLR value that discriminates between simple and severe cholecystitis. METHODS: This study included 136 patients who under went laparoscopic cholecystectomy due to cholecystitis. The Receiver Operating Characteristic (ROC) analysis was performed to identify the most useful NLR cut-off value in relation to the severity of cholecystitis. The patients were di vided into two groups according to the cut-off NLR value: high NLR group (≥4.18, n=23) and low NLR group (<4.18, n=113). Severe cholecystitis was defined as a state which includes inflammation, empyema, gangrene, perforation of gallbladder, adhesions or difficulty in dissecting Calot's triangle. RESULTS: In the high NLR group, severe cholecystitis (p<0.0001) and higher C-reactive protein level (CRP) and white blood cells count (WBC) (p<0.0001) were significantly more frequent. There was no difference in homeostatic model assessment-insulin resistance index (HOMA-IR) between both groups before the operation (p<0.634). The incidence of severe cholecystitis was 16.9%. The NLR of 4.18 could predict severe cholecystitis with 78.3% sensitivity and 74.3% specificity. Spearman's correlation revealed significant association between the preoperative NLR and HOMA-IR on day 1, (r=0.254, p=0.030) and between preoperative NLR and CRP on day 1 (ρ=0.355; p<0.0001). CONCLUSIONS: NLR ≥4.18 was significantly associated with severe cholecystitis. The preoperative NLR in patients under going cholecystectomy due to cholecystitis could be a useful surrogate marker of severe cholecystitis.

Spontaneous gastrojejunal fistula is a complication of gastric ulcer.

Spontaneous gastrojejunal fistula formation is an extremely rare complication of gastric ulcer disease. We report a 77-year old woman who presented with diffuse abdominal pain, weight loss, malaise, nausea, and occasional dark stools. Laboratory tests showed extreme hyposideremic anemia with inflammatory syndrome. In addition, biochemical parameters of malnourishment were presented. Upper endoscopy revealed the patent esophagus along the full length without any pathological changes. Large and deep ulceration with perforation in the small intestine was detected in the posterior gastric wall. The small intestine loop was reached by endoscope through spontaneously developed gastrojejunal fistula. Polytopic biopsies of described ulcerative change were carried out. Histopathologically reepithelialized ulcerous zone was seen in the gastric mucosa. Also, gastrojejunal fistula was visualized after wide opening of hepatogastric and gastrocolic ligament. Jejunal loop 25 cm from ligament of Treitz was attached to mesocolon and posterior gastric wall because of ulcer penetration. Postoperative course was uneventful. Per oral intake started on the 4(th) postoperative day, and the patient was discharged on the 8(th) postoperative day. In summary, this case indicates that persistent symptoms of peptic ulcer disease associated with nutritional disturbances may be caused by gastrojejunal fistula.

Drospirenone in the treatment of severe premenstrual cerebral edema in a woman with antiphospholipid syndrome, lateral sinus thrombosis, situs inversus and epileptic seizures.

We report herein the case of 32-year-old woman with situs inversus, thrombophilia, antiphospholipid syndrome and severe premenstrual syndrome (PMS) with cerebral edema and epileptic seizures prior to menstruation. Seven days prior to regular menstruation she developed severe PMS, including headache, blurred vision, epileptic seizures, urinary incontinence, craving for food, depression and irritability. Papilledema was detected. Daily hormone analyses prior to and during menstruation confirmed an ovulatory cycle with extremely high progesterone, prolactin and insulin levels in the late luteal phase. From day 29 to day 31, progesterone and insulin decreased sharply and the estradiol/progesterone ratio changed, leading to epileptic seizures and the peak of her symptoms. Diuretic treatment was administered. All symptoms disappeared during the first few days of menstruation. A novel oral contraceptive, containing ethinyl estradiol and drospirenone, an antimineralocorticoid progestogen, was given during the next cycle and hormone analyses were repeated. All symptoms were reduced significantly and no cerebral edema and epileptic seizures occurred. This is the first report of a woman with severe PMS and cerebral edema being treated successfully with an oral contraceptive containing drospirenone.

[Relation of pathoanatomic substrate and incidence of bacterial infection in the acute biliary tract disease].

Acute biliary diseases have become the most common indication for major abdominal surgery. We investigated 60 patients who underwent surgery for the acute biliary diseases, within 48 hours from the onset of the illness (group I), and over longer preoperative interval (48 h up to 5 days) (group II). Surgical specimen (gallbladder) was histologically examined. Samples for microbiological exams were obtained from gallbladder, common bile duct, Lund's node, gallbladder bed and peritoneal cavity. Positive bile cultures were found in 43% of group I, and in 70% of group II (p<0.05). Microbiological analysis revealed 13 different species, mostly Gram negative aerobic rods (69%). The incidence of bacteriobilia was in correlation with HP of lesions (79% in the acute and 18% in chronic lesions; p<0.01), what testified the importance of time interval and role of bacterial factor in the acute biliary pathology. Septic complications strictly occurred in patients with positive biliary findings. Early surgical treatment eliminates focus, and stops further development of intraabdominal and systemic septic complications. Correlation between bacteriobilia and septic sequelae calls for prophylactic use of antibiotics.