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Papafragkakis H, Ona MA, Changela K, Sadanandan S, Jelin A, Anand S, Duddempudi S. Acute liver function decompensation in a patient with sickle cell disease managed with exchange transfusion and endoscopic retrograde cholangiography. Therap Adv Gastroenterol 2014; 7:217-23. [PMID: 25177368 PMCID: PMC4107698 DOI: 10.1177/1756283x14530781] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Sickle cell intrahepatic cholestasis is a relatively uncommon complication of homozygous sickle cell anemia, which may lead to acute hepatic failure and death. Treatment is mainly supportive, but exchange transfusion is used as salvage therapy in life threatening situations. We describe a case of a 16-year-old female with homozygous sickle cell anemia who presented to the emergency room with fatigue, malaise, dark urine, lower back pain, scleral icterus and jaundice. She was found to have marked hyperbilirubinemia, which persisted after exchange transfusion. Because of the concomitant presence of gallstones and choledocholithiasis, the patient underwent endoscopic ultrasound and laparoscopic cholecystectomy followed by endoscopic retrograde cholangiography and sphincterotomy.
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Affiliation(s)
- Haris Papafragkakis
- Department of Gastroenterology, The Brooklyn Hospital Center, 121 DeKalb Ave, Brooklyn, NY 11201, USA
| | - Mel A. Ona
- Department of Gastroenterology, The Brooklyn Hospital Center, Brooklyn, NY, USA
| | - Kinesh Changela
- Department of Gastroenterology, The Brooklyn Hospital Center, Brooklyn, NY, USA
| | - Swayamprabha Sadanandan
- Department of Pediatric Hematology/Oncology, The Brooklyn Hospital Center, Brooklyn, NY, USA
| | - Abraham Jelin
- Department of Pediatric Gastroenterology, The Brooklyn Hospital Center, Brooklyn, NY, USA
| | - Sury Anand
- Department of Gastroenterology, The Brooklyn Hospital Center, Brooklyn, NY, USA
| | - Sushil Duddempudi
- Department of Gastroenterology, The Brooklyn Hospital Center, Brooklyn, NY, USA
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Laparoscopic cholecystectomy in children with sickle cell anemia and the role of ERCP. Surg Laparosc Endosc Percutan Tech 2012; 22:139-42. [PMID: 22487628 DOI: 10.1097/sle.0b013e3182471b1c] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients with sickle cell anemia (SCA) have a high incidence of cholelithiasis and choledocholithiasis. This report is an analysis of our experience with laparoscopic cholecystectomy (LC) for children with SCA and the role of endoscopic retrograde cholangiopancreatography (ERCP). PATIENTS AND METHODS The records of children with SCA who had cholecystectomy were retrospectively reviewed for age, sex, hemoglobin level, hemoglobin electrophoresis, indication for cholecystectomy, operative time, hospital stay, and postoperative complications. They were divided into 2 groups, open cholecystectomy (OC) group and LC group, and the 2 were compared in terms of operative time, hospital stay, and postoperative complications. RESULTS Over a period of 15 years (January 1995 and December 2009), 94 children with SCA had cholecystectomy. Thirty-five (19 males and 16 females) had OC, 52 (28 males and 24 females) had LC, and 7 (4 males and 3 females) had LC and splenectomy. Their age ranged from 4 to 15 years (mean, 11.4 y). The indications for cholecystectomy were biliary dyspepsia and biliary colic (55), acute cholecystitis (7), obstructive jaundice (17), asymptomatic (12), and biliary pancreatitis (3). All those who had OC underwent intraoperative cholangiogram, 9 of them (25.7%) had common bile duct (CBD) exploration and 2 transduodenal sphincterotomy. Of those who had LC, 13 (25%) underwent preoperative ERCP, which was normal in 1, showed dilated CBD with no stones in 2, and dilated CBD with stones in 7. In 3, ERCP showed dilated CBD with enlarged, inflammed papilla suggestive of recent stone passage. Nine underwent endoscopic sphincterotomy and stone extraction followed by LC. There was no mortality; 1 (2.1%) required conversion to OC and another underwent postoperative exploration because of bleeding from an accessory cystic artery. In the LC group, 4 (7.7%) developed minor postoperative complications, whereas 8 (22.9%) in the OC group developed complications. CONCLUSIONS With proper perioperative management, LC is feasible, safe, and superior to OC in children with SCA with regard to postoperative complications, duration of hospital stay, cosmetic appearance, and postoperative recovery. LC should be the treatment of choice for both symptomatic and asymptomatic cholelithiasis in children with SCA. ERCP is a valuable diagnostic and therapeutic investigation both preoperatively and postoperatively. The sequential approach of endoscopic sphincterotomy and stone extraction followed by LC is a safe and effective approach for the management of cholelithiasis and choledocholithiasis in children with SCA.
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Issa H, Al-Salem AH. Role of ERCP in the era of laparoscopic cholecystectomy for the evaluation of choledocholithiasis in sickle cell anemia. World J Gastroenterol 2011; 17:1844-7. [PMID: 21528058 PMCID: PMC3080719 DOI: 10.3748/wjg.v17.i14.1844] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2010] [Revised: 08/06/2010] [Accepted: 08/13/2010] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the role of endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis in patients with sickle cell anemia (SCA) in the era of laparoscopic cholecystectomy (LC).
METHODS: Two hundred and twenty four patients (144 male, 80 female; mean age, 22.4 years; range, 5-70 years) with SCA underwent ERCP as part of their evaluation for cholestatic jaundice (CJ). The indications for ERCP were: CJ only in 97, CJ and dilated bile ducts on ultrasound in 103, and CJ and common bile duct (CBD) stones on ultrasound in 42.
RESULTS: In total, CBD stones were found in 88 (39.3%) patients and there was evidence of recent stone passage in 16. Fifteen were post-LC patients. These had endoscopic sphincterotomy and stone extraction. The remaining 73 had endoscopic sphincterotomy and stone extraction followed by LC without an intraoperative cholangiogram.
CONCLUSION: In patients with SCA and cholelithiasis, ERCP is valuable whether preoperative or postoperative, and in none was there a need to perform intraoperative cholangiography. Sequential endoscopic sphincterotomy and stone extraction followed by LC is beneficial in these patients. Endoscopic sphincterotomy may also prove to be useful in these patients as it may prevent the future development of biliary sludge and bile duct stones.
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Gastrointestinal and hepatic complications of sickle cell disease. Clin Gastroenterol Hepatol 2010; 8:483-9; quiz e70. [PMID: 20215064 DOI: 10.1016/j.cgh.2010.02.016] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2009] [Revised: 02/12/2010] [Accepted: 02/21/2010] [Indexed: 02/07/2023]
Abstract
Sickle cell disease (SCD) is an autosomal recessive abnormality of the beta-globin chain of hemoglobin (Hb), resulting in poorly deformable sickled cells that cause microvascular occlusion and hemolytic anemia. The spleen is almost always affected by SCD, with microinfarcts within the first 36 months of life resulting in splenic atrophy. Acute liver disorders causing right-sided abdominal pain include acute vaso-occlusive crisis, liver infarction, and acute hepatic crisis. Chronic liver disease might be due to hemosiderosis and hepatitis and possibly to SCD itself if small, clinically silent microvascular occlusions occur chronically. Black pigment gallstones caused by elevated bilirubin excretion are common. Their small size permits them to travel into the common bile duct but cause only low-grade obstruction, so hyperbilirubinemia rather than bile duct dilatation is typical. Whether cholecystectomy should be done in asymptomatic individuals is controversial. The most common laboratory abnormality is an elevation of unconjugated bilirubin level. Bilirubin and lactate dehydrogenase levels correlate with one another, suggesting that chronic hemolysis and ineffective erythropoiesis, rather than liver disease, are the sources of hyperbilirubinemia. Abdominal pain is very common in SCD and is usually due to sickling, which resolves with supportive care. Computed tomography scans might be ordered for severe or unremitting pain. The liver typically shows sickled erythrocytes and Kupffer cell enlargement acutely and hemosiderosis chronically. The safety of liver biopsies has been questioned, particularly during acute sickling crisis. Treatments include blood transfusions, exchange transfusions, iron-chelating agents, hydroxyurea, and allogeneic stem-cell transplantation.
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Abstract
Sickle cell anemia is one of the common hemoglobinopathies around the world. It results from a single change of one amino acid valine instead of glutamic acid in the hemoglobin beta change. This change leads to polymerization of the hemoglobin when the oxygen saturation is lowered, resulting in deformity of the red blood cells and microvascular occlusion. Sickle cell anemia can affect any part of the body and one of the main organs to be affected is the hepatobiliary system either directly from the sicklening process or indirectly as a result of chronic hemolysis and multiple blood transfusions. This manifests in several clinical conditions which poses diagnostic and therapeutic dilemmas to the treating physicians. These hepatobiliary manifestations will be outlined in this review.
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Affiliation(s)
- Hussain Issa
- Department of Internal Medicine, Division of Gastroenterology, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Ahmed H Al-Salem
- Department of Pediatric Surgery, Maternity and Children Hospital, Dammam, Saudi Arabia
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Irizarry K, Rossbach HC, Ignacio JRA, Winesett MP, Kaiser GC, Kumar M, Gilbert-Barness E, Wilsey MJ. Sickle cell intrahepatic cholestasis with cholelithiasis. Pediatr Hematol Oncol 2006; 23:95-102. [PMID: 16651237 DOI: 10.1080/08880010500456964] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Sickle cell intrahepatic cholestasis (SCIC) is a rare complication seen in sickle cell patients who present with sudden onset of RUQ pain, progressive hepatomegaly, mild elevation of transaminases, coagulopathy, and extreme hyperbilirubinemia. Early recognition of this entity is essential to avoid life-threatening complications. Diagnosis can be challenging given the overlap in clinical presentation with other conditions affecting the hepatobiliary biliary system in sickle cell anemia such as hepatitis, cholecystitis, and hepatic crisis. Treatment is currently limited to exchange transfusion. The authors present two patients with SCIC and cholelithiasis; the clinical picture of one is complicated by choledocholithiasis.
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Affiliation(s)
- Karina Irizarry
- Department of Pediatrics, University of South Florida College of Medicine, Tampa, Florida, USA.
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Bonatsos G, Birbas K, Toutouzas K, Durakis N. Laparoscopic cholecystectomy in adults with sickle cell disease. Surg Endosc 2001; 15:816-9. [PMID: 11443426 DOI: 10.1007/s004640000383] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2000] [Accepted: 02/11/2000] [Indexed: 02/07/2023]
Abstract
BACKGROUND Chronic hemolysis predisposes adults with sickle cell disease (SCD) to the formation of bilirubinate cholelithiasis. METHODS To study the impact of laparoscopic cholecystectomy (LC) on this groups, we reviewed our records of all patients with SCD and cholelithiasis treated electively from 1991 to 1999. During that period, 13 consecutive patients with SCD underwent elective LC for symptomatic cholelithiasis. Nine patients (69.2%) were managed with a preoperative transfusion regimen to achieve a hemoglobin value of >/=10 g/dl, independent of hemoglobin S percentage. Five patients who presented with jaundice were referred for preoperative endoscopic retrograde cholangiopancreatography (ERCP), which identified choledocholithiasis in two of them. Three other patients underwent intraoperative cholangiography, which revealed common bile duct stones in one patient. RESULTS One patient developed pyrexia for 2 days. There were no vaso-occlusive crises or deaths. The mean hospital stay was 3.3 days. CONCLUSIONS LC has proven to be a safe and efficacious method for the treatment of symptomatic cholelithiasis in this high-risk population. Hematologists are now more willing to refer early, well-prepared patients with SCD and uncomplicated gallbladder disease for elective LC.
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Affiliation(s)
- G Bonatsos
- First Department of Propaedeutic Surgery, Athens University, Hippokration Hospital, 114 Vas. Sofias Avenue, Athens, Greece
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Séguier-Lipszyc E, de Lagausie P, Benkerrou M, Di Napoli S, Aigrain Y. Elective laparoscopic cholecystectomy. Surg Endosc 2001; 15:301-4. [PMID: 11344434 DOI: 10.1007/s004640020022] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Gallbladder stones are very common in patients with sickle cell disease and are the cause of recurrent abdominal pain. Their management has been highly controversial, especially for children. Nonoperated patients and those treated on an emergency basis have a very high rate of morbidity (>50%). METHODS We performed a retrospective review of a series of 29 homozygous SS sickle cell children who underwent laparoscopic cholecystectomy between 1991 and April 1998. RESULTS Only in one case a conversion was necessary (early in the series). Exploration of the common bile duct was done via intraoperative cholangiography. There were no mortalities. The morbidity rate was 17%; (however, of the five patients concerned, four suffered from hyperthermia for 2 days. All of the children were improved and enjoyed resolution of their abdominal pain. CONCLUSIONS We believe that elective laparoscopic cholecystectomy at the earliest time possible, along with correct perioperative management, is the treatment of choice for cholelithiasis in children with sickle cell disease.
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Affiliation(s)
- E Séguier-Lipszyc
- Department of Pediatric Surgery, Hospital Robert Debré, 48 bd Sérurier, 75019 Paris, France
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Diagne I, Badiane M, Moreira C, Signate-Sy H, Ndiaye O, Lopez-Sall P, Preira-Sylla G, Camara B, Diouf S, Diack-Mbaye A, Fall M. [Cholelithiasis and homozygote drepanocytosis in children in Dakar (Senegal)]. Arch Pediatr 1999; 6:1286-92. [PMID: 10627899 DOI: 10.1016/s0929-693x(00)88890-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Cholelithiasis is a well recognized complication of sickle-cell anemia (SCA) because of chronic hemolysis. It is usually asymptomatic but may result in acute cholecystitis or cholangitis. The aim of this study was to assess prevalence of cholelithiasis and its associated factors among Senegalese children and adolescents with SCA. PATIENTS AND METHODS We analyzed the follow-up records and results of systematic clinical, biological and ultrasonographic examinations in 106 patients with SCA aged 11 months to 22 years (median: 10 years, 6 months), followed up in the Albert-Royer Children's Hospital (Dakar). RESULTS Cholelithiasis was detected in 9.4% of the patients. Gender, ethnic group, geographic origin and socioeconomic conditions did not have any association with cholelithiasis frequency. The youngest patient with cholelithiasis was 7 years old, and prevalence of cholelithiasis increased with age. The mean age at the beginning of SCA follow-up was higher among patients with cholelithiasis. They were more frequently transfused and tended to present more frequent pain crises and other complications of SCA. We found no spontaneous clinical manifestations attributed to cholelithiasis. Nevertheless, provoked right upper quadrant pain was more frequently observed in patients with cholelithiasis. Fetal hemoglobin, steady-state hemoglobin, reticulocytes count, serum bilirubin, alkaline phosphatase and transaminase levels were not significantly different in these patients, compared to the others. However, those with cholelithiasis had significantly higher mean red cell volume. CONCLUSION Prevalence of cholelithiasis appears relatively low in Senegalese patients with SCA, probably owing to the tolerance of the Senegal haplotype. Advanced age and severe chronic hemolysis are etiologic factors in evidence. We recommend systematic abdominal ultrasound at least once a year for patients older than 5 years, or when right upper quadrant pain is observed. Cholecystectomy should be performed in cases of cholelithiasis in order to prevent complications.
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Affiliation(s)
- I Diagne
- Chaire de pédiatrie, Université Cheikh Anta Diop de Dakar (UCAD), Hôpital d'enfants Albert-Royer, Sénégal
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Nourallah H, Issa H, Al-Salem AH. The role of ERCP in the evaluation, diagnosis, and therapy of biliary and pancreatic diseases in children. Ann Saudi Med 1999; 19:163-6. [PMID: 17337963 DOI: 10.5144/0256-4947.1999.163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- H Nourallah
- Departments of Medicine and Surgery, Qatif Central Hospital, Qatif, Saudi Arabia
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Al-Salem AH, Nourallah H. Sequential endoscopic/laparoscopic management of cholelithiasis and choledocholithiasis in children who have sickle cell disease. J Pediatr Surg 1997; 32:1432-5. [PMID: 9349762 DOI: 10.1016/s0022-3468(97)90555-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND/PURPOSE Cholelithiasis and choledocholithiasis are common complications of sickle cell disease (SCD). With the recent advances in laparoscopic cholecystectomy (LC), which has been used successfully for the management of cholelithiasis in children who have SCD, exclusion of choledocholithiasis before LC is of great importance. METHODS Eighteen children who had SCD, cholelithiasis, and choledocholithiasis were treated at our hospital. Seven were treated with open cholecystectomy (OC) and common bile duct (CBD) exploration, and two were treated with transduodenal sphincteroplasty. The remaining 11 patients underwent endoscopic retrograde cholangiopancreatography (ERCP), sphincterotomy, and stone extraction followed by laparoscopic cholecystectomy (LC). RESULTS A dilated CBD noted on ultrasound, elevated alkaline phosphatase, elevated total bilirubin of more than 5 mg/dL, history of pancreatitis, either singly or in combination, should raise suspicion of choledocholithiasis, and these patients together with those who have choledocholithiasis detected on ultrasound should undergo ERCP to confirm and extract the stones before LC. CONCLUSION This sequential approach of endoscopic sphincterotomy and stone extraction followed by LC is a safe and effective approach for the management of cholelithiasis and choledocholithiasis in children who have SCD.
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Affiliation(s)
- A H Al-Salem
- Department of Surgery, Qatif Central Hospital, Saudi Arabia
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