Utility of liver function tests in acute cholecystitis

Approach to Abnormal Liver Biochemistries in the Primary Care Setting

Liver biochemistries are commonly ordered in the primary care setting, and they may return abnormal even in an asymptomatic patient. Primary care physicians need to have a systematic way of interpreting any derangement in these tests so that further investigations, referrals, and management can be arranged appropriately. This review dwells into patterns of liver biochemistry derangement, common aetiologies to consider, history and examinations that are required, initial investigations to order, and when to refer urgently to the emergency department.

A high urinary urobilinogen/serum total bilirubin ratio indicates acute hepatic porphyria in patients with abdominal pain

Acute hepatic porphyria (AHP) has always been a diagnostic dilemma for physicians due to its variable symptoms. Correct diagnosis mainly depends on the detection of an elevated urinary porphobilinogen (PBG), which is not a routine test and highly relies on the physician's awareness of AHP. In the present study, we identified a more convenient indicator during routine examinations to improve the diagnosis of AHP. We found that AHP patients showed a significant higher "FALSE" urinary urobilinogen level caused by urinary PBG during the urinalysis when detected by strips impregnated with Ehrlich reagent (P < 0.05). And a remarkable increase in the urinary urobilinogen/serum total bilirubin ratio was observed in AHP patients. The area under the ROC curve of this ratio for AHP was 1.000 (95% confidence interval 1.000-1.000, P < 0.01). A cutoff value of 3.22 for this ratio yielded a sensitivity of 100% and a specificity of 100% to distinguish AHP patients from the controls. Thus, we proved that a "falsely" high urinary urobilinogen level that was adjusted by the serum total bilirubin level (urinary urobilinogen/serum total bilirubin ratio) could be used as a sensitive and specific screening marker for AHP in patients with abdominal pain.

Genotyping and population characteristics of the China Kadoorie Biobank

The China Kadoorie Biobank (CKB) is a population-based prospective cohort of >512,000 adults recruited from 2004 to 2008 from 10 geographically diverse regions across China. Detailed data from questionnaires and physical measurements were collected at baseline, with additional measurements at three resurveys involving ∼5% of surviving participants. Analyses of genome-wide genotyping, for >100,000 participants using custom-designed Axiom arrays, reveal extensive relatedness, recent consanguinity, and signatures reflecting large-scale population movements from recent Chinese history. Systematic genome-wide association studies of incident disease, captured through electronic linkage to death and disease registries and to the national health insurance system, replicate established disease loci and identify 14 novel disease associations. Together with studies of candidate drug targets and disease risk factors and contributions to international genetics consortia, these demonstrate the breadth, depth, and quality of the CKB data. Ongoing high-throughput omics assays of collected biosamples and planned whole-genome sequencing will further enhance the scientific value of this biobank.

Plasma Polyamines Decrease in Patients with Obstructive Cholecystitis

Polyamines (PAs), endogenous metabolites with a wide range of biological activities, are synthesized at a high rate in liver supporting hepatocyte proliferation and survival. The liver appears as an important regulator of plasma PAs; however, the perspective to exploit plasma PA measurements as indicators for liver function was not explored. This study aimed to evaluate the value of the plasma levels of PAs as a biomarker of pathological changes in the liver in patients with obstructive cholecystitis. The levels of polyamines and their acetylated forms were measured using HPLC/UV in the plasma of patients with obstructive cholecystitis and in healthy subjects. PA turnover was assessed by the ratio between an acetylated form of PA and PA. An effect of diet preference of cheese or meat, the major exogenous sources of PAs, smoking, and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in anamnesis was also evaluated in healthy subjects. We found that the plasma levels of spermine and acetylated spermidine decreased in patients with obstructive cholecystitis without a concurring increase in the total plasma bilirubin and amylase levels. The turnover of spermine and spermidine was also changed, suggesting a decrease in the rate of PA degradation in the liver. In healthy subjects, the PA levels tended to mirror chronic smoking and recent SARS-CoV-2 infection but were not relevant to diet factors. A number of observations indicated the role of physical exercise in the regulation of the plasma pool of PA. The decrease in plasma PA levels and index of PA turnover in the cholestasis syndrome indicate the liver’s metabolic function reduction. A conceivable effect of lung-related conditions on plasma PA, while indicating low specificity, nonetheless, speaks favorably about the high sensitivity of plasma PA measurement as an early diagnostic test in the clinic.

Abnormal liver enzymes: A review for clinicians

Liver biochemical tests are some of the most commonly ordered routine tests in the inpatient and outpatient setting, especially with the automatization of testing in this technological era. These tests include aminotransferases, alkaline phosphatase, gamma-glutamyl transferase, bilirubin, albumin, prothrombin time and international normalized ratio (INR). Abnormal liver biochemical tests can be categorized based on the pattern and the magnitude of aminotransferases elevation. Generally, abnormalities in aminotransferases can be classified into a hepatocellular pattern or cholestatic pattern and can be further sub-classified based on the magnitude of aminotransferase elevation to mild [< 5 × upper limit of normal (ULN)], moderate (> 5-< 15 × ULN) and severe (> 15 × ULN). Hepatocellular pattern causes include but are not limited to; non-alcoholic fatty liver disease/non-alcoholic steatohepatitis, alcohol use, chronic viral hepatitis, liver cirrhosis (variable), autoimmune hepatitis, hemochromatosis, Wilson’s disease, alpha-1 antitrypsin deficiency, celiac disease, medication-induced and ischemic hepatitis. Cholestatic pattern causes include but is not limited to; biliary pathology (obstruction, autoimmune), other conditions with hyperbilirubinemia (conjugated and unconjugated). It is crucial to interpret these commonly ordered tests accurately as appropriate further workup, treatment and referral can greatly benefit the patient due to prompt treatment which can improve the natural history of several of the diseases mentioned and possibly reduce the risk of progression to the liver cirrhosis.

Liver function tests as predictors of common bile duct stones in acute cholecystitis patients with a chronic history: A retrospective cohort study on the ACS-NSQIP database

ABSTRACT

Liver function tests (LFTs) use for common bile duct stone (CBDS) prediction in acute cholecystitis (AC) patients is challenging, especially in patients with chronic cholecystitis (CC) history.This study aims to describe characteristics of AC patients with CC history and assess LFTs' utility for CBDS prediction in these patients.A retrospective cohort study was conducted on adults with a diagnosis of AC and CC history included in the National Surgical Quality Improvement Program database from 2008 to 2016. Patients were categorized into CBDS- (without CBDS) and CBDS+ (with CBDS). Multivariate logistic regression was used to determine CBDS predictors.This study included 7458 patients, of which 40.2% were CBDS+. CBDS+ patients were more commonly females (64.4% vs 54.7%, P < .001). Mean levels of bilirubin (1.70 vs 0.90, P < .001), SGOT (105.9 vs 49.0, P < .001) and ALP (164.6 vs 103.8, P < .001) were significantly higher among CBDS+ patients.Significant positive predictors of CBDS were female gender, increased BMI, and abnormal bilirubin, ALP and SGOT. AC patients with CC history are more likely to have CBDS. Abnormal LFTs are significantly associated with CBDS in this patient population. Familiarity with these findings can help raise clinical suspicion of providers for earlier evaluation and management of CBDS.

Evaluation of preoperative liver function test efficacy in patients with symptomatic cholelithiasis

AIM

The present study aimed at investigating the necessity of preoperative liver function tests (LFTs) in patients with uncomplicated gallstone disease before laparoscopic cholecystectomy.

BACKGROUND

Significant relationship between common bile duct (CBD) stones and acute cholecystitis is reported. There are contradictory reports about the effect of CBD stones on liver function tests in patients (LFTs).

METHODS

In the current study, patients with symptomatic cholelithiasis who referred to hospitals during January 2015 and May 2016 were enrolled. Routine tests and ultrasonography were performed on all patients before surgery. Data were presented as means ± SD and qualitative variables as frequency (percentage) were considered. Statistical analyzes were performed with SPSS software.

RESULTS

A consecutive series of 270 patients (58 males and 212 females) who referred for laparoscopic cholecystectomy were enrolled in this retrospective study. Pre- operative LFTs were normal in 249 patients (85%) and abnormal LFT was detected in 41 patients (15 %).

CONCLUSION

This study showed that 15 % of patients with cholelithiasis without dilated CBD had impaired LFTs. Routine LFTs in preoperative evaluation of symptomatic cholelithiasis usually reveals normal findings and is not helpful in uncomplicated cholelithiasis.