Marked elevation in serum transaminases: an atypical presentation of choledocholithiasis.

BACKGROUND: Choledocholithiasis causes elevations in levels of alkaline phosphatase out of proportion to aspartate aminotransferase (AST) and alanine aminotransferase (ALT). Isolated marked elevation in AST and ALT levels over 1,000 IU/L has been reported infrequently in patients with choledocholithiasis. METHODS: The charts of 18 patients who presented between 1971 and 2002 with documented choledocholithiasis and AST or ALT levels greater than 1,000 IU/L were retrospectively reviewed. An extensive work-up for coexisting disease processes to account for the abnormal AST and ALT levels was negative. RESULTS: Eighteen patients (16 women, 16 Hispanics, age 38 +/- 3 yr) presented with symptoms of choledocholithiasis and marked transaminase elevation. Peak levels of AST and ALT were 1,062 +/- 129 and 1,119 +/- 90, respectively. Following successful management of gallstone disease, AST and ALT levels fell rapidly to 129 +/- 22 and 268 +/- 61, respectively, within 3-14 days. There was also a concomitant improvement in the levels of bilirubin and alkaline phosphatase. CONCLUSIONS: In the absence of other hepatobiliary or pancreatic disease, choledocholithiasis can result in elevations in AST and/or ALT greater than 1,000 IU/L. These levels fall markedly once the gallstone disease is appropriately managed.

Serum alanine aminotransferase in skeletal muscle diseases.

Although elevation of the levels of serum alanine aminotransferase (ALT) following liver injury is well known, confusion exists concerning skeletal muscle injury as the cause of this rise. We reviewed the records of 16 patients who had muscle necrosis without evidence of liver disease. The patients were divided into three groups: extreme exercise, polymyositis, and seizures. All patients exhibited markedly elevated creatine kinase and lactate dehydrogenase levels consistent with muscle injury. In acute cases, aspartate aminotransferase (AST) and ALT were both elevated, and the AST/ALT ratio was greater than 3, but this ratio approached 1 after a few days because of a faster decline in AST. In conclusion, this difference in half-life accounts for the comparable AST and ALT levels in our cases with chronic muscle injury.

Effect of misoprostol on ibuprofen-induced renal dysfunction in patients with decompensated cirrhosis: results of a double-blind placebo-controlled parallel group study.

OBJECTIVES: Patients with cirrhosis are prone to develop renal failure upon administration of nonsteroidal anti-inflammatory drugs. The aim of the present study was to determine the safety and efficacy of misoprostol (400 microg) in two repeated doses for the prevention of ibuprofen-induced decrements in renal function in decompensated cirrhotics. METHODS: Patients were given ibuprofen (800 mg) with either misoprostol (n = 9) or a placebo (n = 10). Sixty minutes later another dose of misoprostol or the placebo was administered. Renal function tests were assessed by clearance techniques. RESULTS: Administration of ibuprofen with a placebo caused significant decreases in urinary output, inulin clearance, sodium excretion, osmolar clearance, free water clearance, and urinary prostaglandin E2 excretion. Coadministration of ibuprofen and the first misoprostol dose maintained urinary output and sodium excretion, and caused an increase in free water clearance. These changes were maintained only for 1 h. Administration of the second dose of misoprostol temporarily improved inulin and creatinine clearances. Half the patients who received misoprostol suffered from episodes of chills, fever, and diarrhea. CONCLUSION: Ibuprofen causes renal dysfunction in decompensated cirrhotics, whereas misoprostol may have some protective renal effects, which are, however, short lived and clinically insignificant. Because of side effects, misoprostol should be used with caution in these patients.

Duplex Doppler ultrasound of the hepatic artery in patients with acute alcoholic hepatitis.

BACKGROUND: Acute alcoholic hepatitis (AAH) is a clinical diagnosis associated with increased hepatic artery diameter and flow. Duplex Doppler ultrasound (DDU) has been shown to accurately measure arterial flow in both liver and kidney transplant patients. The authors conducted a blinded, controlled study to evaluate the accuracy of measuring hepatic artery parameters with DDU in diagnosing AAH. STUDY: Duplex Doppler ultrasound was performed by an investigator, blinded to group makeup, on 22 consecutive hospital inpatients with the clinical diagnosis of AAH. The diagnosis of AAH was based on specific criteria, including the following: recent alcohol abuse, hyperbilirubinemia, prolonged prothrombin time, leukocytosis, hepatomegaly, hepatic bruit, and marked redistribution of isotope on 99mTc-sulfur colloid liver-spleen scan. Controls were 12 cirrhotic patients without AAH and 17 healthy volunteers. Duplex Doppler ultrasound measurements were obtained most consistently from the proximal right hepatic artery. Measured parameters included the following: peak systolic velocity (PSV); resistive index = (PSV - end diastolic velocity [EDV])/PSV; pulsatility index = (PSV - EDV)/mean velocity; and hepatic artery diameter. RESULTS: The mean hepatic artery diameter was significantly larger in patients with AAH (3.55 +/- 0.72 mm) than in patients with cirrhosis (2.75 +/- 0.69 mm; p = 0.003) and healthy controls (2.68 +/- 0.69 mm; p = 0.001). The mean PSV was significantly higher in patients with AAH (187 +/- 52 cm/s) compared with cirrhotic (67 +/- 51 cm/s) and healthy (66 +/- 51 cm/s) controls (p = 0.0001). The mean resistive index was lower in AAH patients (0.60 +/- 0.11) compared with cirrhotic (0.69 +/- 0.10; p value was not significant) and healthy controls (0.72 +/- 0.11; p = 0.004). The mean pulsatility index was lower in AAH patients (1.04 +/- 0.47) compared with cirrhotic (1.36 +/- 0.45; p value was not significant) and healthy controls (1.53 +/- 0.45; p = 0.01). CONCLUSIONS: In the appropriate clinical setting, an elevated hepatic artery diameter or PSV measurement is suggestive of AAH. Duplex Doppler ultrasound offers a noninvasive test to assist in the diagnosis of AAH.

Lepromatous leprosy in reaction

Biopsies of the skin and liver were obtained from a patient with Lucio´s type of leprosy and from one with erythema nodosum leprosum. Vasculitis, a dense inflammatory exudate, and necrosis of the skin characyerized the Lucio type of leprosy; in erythema nodosum leprosum the vasculitis was not so severe and necrosis didi not occur. Large numbers of organisms in the endothelial cells of the vessels in the skin could have given rise to bacteremia and development of the disease in the liver. The liver in the patient with Lucio´s phenomenon contained tuberculoid lesions, whereas necrosis of sinusoidal walls and many Virchow´s cells were noted in the other patient. Leprosy becilli in Kupffer cells were easily demonstrated with electron microscopy. The presence of the bacteria within membrane-bound phagocytic vacuoles and the fusion of lysosomes with the vacuoles were seen...