Hepatobiliary diseases in women

Aetiological Spectrum of Pancreaticobiliary Diseases in Adult Nigerians on Magnetic Resonance Cholangiopancreatography

BACKGROUND

Imaging is vital for assessing pancreaticobiliary diseases.

AIM

The aim of the study was to investigate the spectrum and pattern of pancreaticobiliary diseases in adult Nigerians using magnetic resonance cholangiopancreatography (MRCP).

METHODS

This was a retrospective, descriptive cross-sectional study. The electronic radiological records of 110 adult Nigerians who had undergone MRCP were reviewed. The MRCP images were evaluated for bile duct dilatation, intraluminal filling defects, strictures, calculi, and other abnormalities.

RESULTS

There were 45 males (40.9%) and 65 females (59.1%) aged 18-83 years, with a mean age of 51.93 ± 15.22 years. Jaundice (59.1%) and right hypochondrial pain (31.8%) were the most common presenting complaints. Gallstones (32.7%), common bile duct strictures (15.5%), choledocholithiasis (11.8%), pancreatic head carcinoma (10.9%), and gallbladder carcinoma (2.7%) were the most frequent abnormalities. There was biliary obstruction in 56.4% of participants, mostly at the distal and proximal common bile duct. Other findings include hepatomegaly (23.6%), hepatic cysts (6.4%), hepatic steatosis (0.9%), duodenal wall thickening (1.8%), and ascites (5.5%). MRCP was normal in 25 (22.7%) participants.

CONCLUSION

Gallstones were the predominant pathology of the various pancreaticobiliary diseases, while Pancreatic head and gallbladder carcinoma were the most common malignant diseases.

The effect of therapeutic plasma exchange on management of HELLP Syndrome: The report of 47 patients

BACKGROUND AND OBJECTIVES

HELLP syndrome is a life-threatening condition that may potentially cause complications during pregnancy. If not diagnosed and treated quickly, HELLP syndrome may lead to serious complications both for the mother and the baby. The aim of this study was to determin the effectiveness of therapeutic plasma exchange (TPE) for treatment of Class-I HELLP syndrome.

MATERIALS AND METHODS

Laboratory results from 47 patients with Class-I HELLP syndrome patients who underwent TPE between 2011 and 2020 were recorded before and after the procedure. A central venous catheter was inserted, and TPE was performed in patients who had not responded to delivery, steroid, and supportive therapy (blood products, anti-hypertensive therapy, intravenous fluid administration, and antibiotics) within 24 hours after the diagnosis of Class I HELLP syndrome according to the Mississippi Criteria.

RESULTS

The average age of patients was 33 ± 4.7 years (range; 21-39 years). A mean of 5 (range; 4 to 6) TPE sessions were performed. There was a statistically significant decrease in total bilirubin, lactic dehydrogenase, aspartate aminotransferase, and alanine aminotransferase levels in all patients, whereas a significant increase in platelet count was observed (p < 0.05). Furthermore, clinical and laboratory improvement was achieved.

CONCLUSION

In all patients with HELLP syndrome, a dramatically clinical and laboratory improvement occurred after TPE. Our study suggests that postpartum use of TPE within 24 hours is an efficient treatment option for Class-I HELLP syndrome.

Preclinical Evidence of Curcuma longa and Its Noncurcuminoid Constituents against Hepatobiliary Diseases: A Review

Hepatobiliary disease currently serves as an important public health issue due to the fact that it is one of the major causes of death among economically active individuals and can easily progress to chronic diseases. Despite the development of vaccines and numerous drugs, a definite treatment remains lacking owing to different stages of the disease itself, its intricate pathogenesis, an effect uncertainty for long-term use, resistance, and side effects. Curcuma longa (C. longa), which belongs to the family Zingiberaceae and the genus Curcuma, has long been used not only as spice for curry or dye but also as a constituent of herbal formula for the treatment of different diseases due to its bioactive activities. Recently, many studies on the experimental results of C. longa have been published relative to hepatobiliary diseases such as fatty liver, hepatitis, cirrhosis, and tumors. Therefore, in this review, we aimed to summarize the pharmacological effects and underlying molecular mechanisms of C. longa and its four compounds, β-elemene, germacrone, ar-turmerone, and bisacurone, against hepatobiliary diseases. C. longa exhibited antioxidant, hepatoprotective, antisteatotic, anti-inflammatory, antifibrotic, antitumor, and cholagogic effects by regulating apoptosis, CYP2E1, Nrf, lipid metabolism-related factors, TGF-β, NF-κB, CYP7A1, and so on. In particular, β-elemene could be an attractive compound owing to its remarkable hepatoprotective, anti-inflammatory, antifibrotic, and antitumor activities. Altogether, the present review provides a preclinical basis for the efficacy of C. longa as an effective therapeutic agent for the prevention and treatment of hepatobiliary diseases, despite the need for further studies to establish the extraction conditions and separation of active constituents with high bioavailability, and warrants further evaluation in clinical trials.

Androgens and esophageal cancer: What do we know?

Significant disparities exist between genders for the development and progression of several gastro-intestinal (GI) diseases including cancer. Differences in incidence between men vs women for colon, gastric and hepatocellular cancers suggest a role for steroid sex hormones in regulation of GI carcinogenesis. Involvement of intrinsic gender-linked mechanisms is also possible for esophageal adenocarcinoma as its incidence is disproportionally high among men. However, the cause of the observed gender differences and the potential role of androgens in esophageal carcinogenesis remains unclear, even though the cancer-promoting role of androgen receptors (AR) shown in other cancers such as prostate and bladder suggests this aspect warrants exploration. Several studies have demonstrated expression of ARs in esophageal cancer. However, only one study has suggested a potential link between AR signaling and outcome - poorer prognosis. Two groups have analyzed data from cohorts with prostate cancer and one of these found a decreased incidence of esophageal squamous and adenocarcinoma after androgen deprivation therapy. However, very limited information is available about the effects of androgen and AR-initiated signaling on esophageal cancer cell growth in vitro and in vivo. Possible mechanisms for androgens/AR involvement in the regulation of esophageal cancer growth are considered, and the potential use of AR as a prognostic factor and clinical target is highlighted, although insufficient evidence is available to support clinical trials of novel therapies. As esophageal adenocarcinoma is a gender linked cancer with a large male predominance further studies are warranted to clarify the role of androgens and ARs in shaping intracellular signaling and genomic responses in esophageal cancer.

Influence of cholestatic jaundice on the weight variance in an experimental model

OBJECTIVE

To evaluate the influence of cholestatic jaundice in weight variation.

METHODS

We used 64 adult rats divided into six groups: F1 (n = 6): normal females; F2 (n = 6): laparotomy females; F3 (n = 20): jaundiced females; M1 (n = 6): normal males; M2 (n = 6): laparotomy males; M3 (n = 20): jaundiced males. Jaundice was obtained by ligation and section of the biliopancreatic duct. The animal weights were recorded weekly for seven weeks. On the 14th day of the experiment, bilirubin and gonadal hormones were assessed. After the seventh week a histological study of the liver was performed.

RESULTS

The animals in groups F3 and M3 showed elevated bilirubin and decreased body mass when compared to the other groups. The weight differences were significant from the fourth week on amongst females and from the fifth in males. In Jaundiced animals there was increased estradiol and decreased progesterone and testosterone. Perivenular septa and periportal fibrosis, cholangitis and bile duct hyperplasia occurred in the liver of jaundiced rats. No animal showed cirrhosis.

CONCLUSION

There was decrease in murine body weight in the presence of cholestatic jaundice in both genders.

There may be a link between intrahepatic cholestasis of pregnancy and familial combined hyperlipidaemia: a case report

A 26-year-old gravida 3 para 1+1 was referred for antenatal care. In her last pregnancy she had a early spontaneous preterm delivery at 32 weeks and 2 days complicated by intra hepatic cholestasis of pregnancy. She had a strong family history of ischemic heart and combined hyperlipidaemia. In view of her past obstetric history a baseline liver function test and fasting bile acid assay was carried out. Upto 21 week her Bile acids were normal but at 22 weeks her fasting bile acid assay increased to the upper limit of normal (9 micromol/L).Ursodeoxycholic acid was started from 28 weeks gestation on a dosage of 500 mg b.i.d., which was subsequently increased to 500 mg t.d.s. at 32 weeks.At 34 weeks she gave a history of occasional right upper quadrant abdominal pain and her biochemistry revealed raised serum aspartate transaminase ,alanine transaminase, fasting serum triglyceride and cholesterol levels 58 IU,79 IU/L,18.37 mmol/L and 25.7 mmol/L respectively. The triglyceride level was too high to calculate the low density lipoprotein cholesterol. A diagnosis of severe intrahepatic cholestasis of pregnancy in a patient with background familial combined hyperlipidaemia was made. Ultrasound abdomen and cardiotocography was normal. She had normal delivery. In cases of early onset cholestasis of pregnancy we suggest that lipid profiles are checked in these patients to rule out hyperlipidaemia and its attendant short term and long-term risks. More research will be required to ascertain if there is a link between these 2 disorders.

There may be a link between intrahepatic cholestasis of pregnancy and familial combined hyperlipidaemia: a case report

A 26-year-old gravida 3 para 1+1 was referred for antenatal care. In her last pregnancy she had a early spontaneous preterm delivery at 32 weeks and 2 days complicated by intra hepatic cholestasis of pregnancy. She had a strong family history of ischemic heart and combined hyperlipidaemia. In view of her past obstetric history a baseline liver function test and fasting bile acid assay was carried out. Upto 21 week her Bile acids were normal but at 22 weeks her fasting bile acid assay increased to the upper limit of normal (9 µmol/L).

Ursodeoxycholic acid was started from 28 weeks gestation on a dosage of 500 mg b.i.d., which was subsequently increased to 500 mg t.d.s. at 32 weeks.

At 34 weeks she gave a history of occasional right upper quadrant abdominal pain and her biochemistry revealed raised serum aspartate transaminase ,alanine transaminase, fasting serum triglyceride and cholesterol levels 58 IU,79 IU/L,18.37 mmol/L and 25.7 mmol/L respectively. The triglyceride level was too high to calculate the low density lipoprotein cholesterol. A diagnosis of severe intrahepatic cholestasis of pregnancy in a patient with background familial combined hyperlipidaemia was made. Ultrasound abdomen and cardiotocography was normal. She had normal delivery. In cases of early onset cholestasis of pregnancy we suggest that lipid profiles are checked in these patients to rule out hyperlipidaemia and its attendant short term and long-term risks. More research will be required to ascertain if there is a link between these 2 disorders.

Diagnosis and laparoscopic treatment of surgical diseases during pregnancy: an evidence-based review

Treatment of surgical disease in the gravid patient requires a unique and careful approach where safety of the mother and fetus are both considered. Approaches to diagnosis and therapy of surgical disease in the gravid patient are increasingly clarified and defined in the literature. Laparoscopy, once described as contraindicated in pregnancy, has been steadily accepted and applied as data supporting its safety and use have accumulated. An extensive review of the literature was performed to define the use of laparoscopy in pregnancy. Diagnoses for independent surgical diseases as well as imaging modalities and techniques during pregnancy are reviewed. Preoperative, intraoperative, and postoperative management of the pregnant patient are described and evaluated with focus on use of laparoscopy. Literature supporting safety and efficacy of laparoscopy in cholecystectomy, appendectomy, solid organ resection, and oophorectomy in the gravid patient is outlined. Based on level of evidence, this review includes recommendations specific to surgical approach, trimester of pregnancy, patient positioning, port placement, insufflation pressure, monitoring, venous thromboembolic prophylaxis, obstetric consultation, and use of tocolytics in the pregnant patient.

Intrahepatic cholestasis of pregnancy: review of the literature and evaluation of current evidence

OBJECTIVE

To provide an overview of the epidemiology, etiology, pathogenesis, diagnosis, and management of intrahepatic cholestasis of pregnancy.

METHODS

We searched the Medline and PubMed database using the key words intrahepatic cholestasis of pregnancy, obstetric cholestasis, diagnosis, management, and complications.

RESULTS

Intrahepatic cholestasis of pregnancy, or obstetric cholestasis, is a liver condition that develops during pregnancy. It is associated with increased perinatal morbidity and mortality. Pruritus and risk of postpartum hemorrhage are the main causes of maternal morbidity. Intrahepatic cholestasis of pregnancy is a diagnosis of exclusion. The current management policies depend on regular fetal and maternal monitoring and delivery at fetal maturity. The analysis of the quality of previous studies provided in this review highlights the areas of deficiency in evidence-based knowledge of this subject.

CONCLUSIONS

More research is required into the etiology, pathogenesis, and monitoring modalities that can specifically predict fetal outcome in intrahepatic cholestasis of pregnancy. Clinical trials are required to identify the most suitable drugs for treatment.

The role of plasma exchange in HELLP syndrome

Plasma exchange therapy has been successfully used in selected patients with hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome who have organ failure or refractory to treatment. There is no prospective study regarding plasma exchange and its effect in HELLP syndrome. The aim of this study was to investigate the effects of early postpartum use of plasma exchange in patients with HELLP syndrome on outcomes. The mortality rate and the recovery times were compared in patients with HELLP syndrome treated with plasma exchange and historic control group of patients treated conservatively. During a 3-year period (between April 2000 and December 2003), 29 consecutive patients with HELLP syndrome were treated with single or multiple plasma exchange by using fresh-frozen plasma at post-partum period. The control group consist of 26 patients with HELLP syndrome treated between 1993 and 1999. Maternal mortality rate was 23.1% in the control group; there was no death in plasma exchange group; and the mortality rate was significantly higher in the control group (p=0.006). The length of stay at the intensive care unit was shorter in the plasma exchange group (p<0.0001). Rapid improvement of the platelet, aspartate aminotransferase, alanine aminotransferase, and lactic dehydrogenase levels were observed in the plasma exchange group. This study showed that postpartum early plasma exchange therapy improves treatment outcomes in patients with severe HELLP syndrome.

The mystery of primary biliary cirrhosis in British Columbia's First Nations people

OBJECTIVES

Primary biliary cirrhosis (PBC) is a rare chronic, progressive liver disorder leading to transplantation or death, with a known autoimmune basis. Although it has been estimated to have a prevalence of between 2-5 cases per 100,000 worldwide, it is not rare in British Columbia's (BC) First Nations (FN) peoples, where it is the leading indication for liver transplant in that population. A study of indications for liver transplant from 1989 to 1998 demonstrated that although just 3.9% of the population of BC is of FN descent, 25% of those requiring transplantation for PBC were of FN descent. From this, it can be calculated that PBC is about 8 times more common than in the non-native population.

METHODS

We studied the prevalence of PCB on Vancouver Island, where about 50% of the cases on the transplant Society List are reported.

RESULTS AND DISCUSSION

As with many autoimmune diseases, PBC affects women predominantly. Genetic predisposition and environmental factors are thought to contribute to the development of PBC. A strong genetic component is postulated in the BC population where 6 affected individuals are all related through common great grandparents. Nonetheless, both genetic and environmental components are being explored in this unique population.

Pregnancy and liver disease

Liver disease has an impact on women's health during pregnancy because of the complex interactions between the physiologic changes induced by pregnancy and the pathophysiologic changes of liver disease. In particular, liver diseases that predominantly afflict females, such as primary biliary cirrhosis and autoimmune hepatitis, pose a special problem for conception and management of pregnancy. Pregnancy, moreover, specifically is associated with several potentially life-threatening liver diseases. This article reviews comprehensively the impact of liver diseases on pregnancy and of pregnancy on liver function and liver disease.

Intrahepatic cholestasis of pregnancy: review of the literature

Intrahepatic cholestasis of pregnancy (ICP) is a rare disorder of unknown etiology with a symptomatically distressing maternal course with pruritus as the chief complaint. ICP poses little medical risk to the mother, but poses significant risk to the fetus of perinatal mortality, preterm delivery, fetal distress, and meconium staining. ICP has a geographically variable prevalence and appears to have a heritable component. Current evidence suggests a susceptibility to derangements in the sulfation of steroid compounds, affecting the metabolism of progesterone and bile acids in the fetal/placental compartment. This impairs transport of bile acids across the placenta from the fetal to the maternal circulation. Exactly how this leads to fetal compromise is unknown. The most efficacious current medical management that improves both maternal symptoms and laboratory abnormalities is ursodeoxycholic acid (UDCA), a hydrophilic bile acid that alters the composition of the bile acid pool in maternal blood. When ICP is diagnosed, UDCA coupled with close maternal-fetal surveillance is indicated. Delivery should be effected near term, with confirmation of fetal lung maturity or earlier if fetal compromise is identified.

Nonsurgical management of gallstone disease

Cholelithiasis is a common disease in the United States associated with significant morbidity. Surgical treatment with cholecystectomy has been increasing with a significant cost to the health care system. Surgical management is not without risk. Cholecystectomy has also been associated with a significant morbidity and mortality in elderly patients. Cholecystectomies are often performed unnecessarily in gallstone patients for nonspecific symptoms. Many patients with nonspecific pain, which may have a psychogenic component, continue to experience similar pain after cholecystectomy. There are problems in determining the symptom status of patients. Patients who believe surgery will relieve symptoms may maximize their symptoms, whereas patients who are reluctant to undergo surgery may minimize their symptoms. Although cholecystectomy is the mainstay of gallstone treatment, bile acid therapy and, if available, ESWL and topical dissolution are nonsurgical treatment alternatives in selected patients. In selected cases, in particular in the elderly and in other patients at increased risk from surgery, nonsurgical management offers lower morbidity and mortality than does operative treatment. The decision for surgical versus nonsurgical management should be based on both objective selection criteria and patient choice.