Diagnostic approach to patients with cholestatic jaundice

Comparative genomic analysis of Fischer F344 rat livers exposed for 90 days to 3-methylfuran or its parental compound furan

Furan is a naturally forming compound found in heat-processed foods such as coffee, canned meats, and jarred baby food. It is concurrently found with analogues including 2-methylfuran (2-MF) and 3-methylfuran (3-MF), and toxicity studies demonstrate all are potent liver toxins. Toxicity studies found 3-MF is more toxic than either furan, or 2-MF. The present analysis assesses the transcriptional response in liver samples taken from male Fischer (F344) rats exposed to furan or 3-MF from 0 to 2.0 and 0-1.0 mg/kg bw/day, respectively, for 90 days. Transcriptional analyses found decreased liver function and fatty acid metabolism are common responses to both furan and 3-MF exposure. Furan liver injury promotes a ductular reaction through Hippo and TGFB signalling, which combined with increased immune response results in ameliorating perturbed bile acid homeostasis in treated rats. Failure to activate these pathways in 3-MF exposed rats and decreased p53 activity leads to cholestasis, and increased toxicity. Finally, BMD analysis indicate many of the most sensitive pathways affected by furan and 3-MF exposure relate to metabolism - malate dehydrogenase and glucose metabolism with BMDLs of 0.03 and 0.01 mg/kg bw/day for furan and 3-MF exposure, respectively, which agrees with BMDLs previously reported for apical and microarray data.

A case report: A rare case of icteric variant of Stauffer's syndrome

INTRODUCTION

Stauffer's syndrome is a rare paraneoplastic non metastatic hepatic dysfunction related to renal cell carcinoma. It is characterized by elevated alkaline phosphatase, erythrocyte sedimentation rate, a-2-globulin, y-glutamyl transferase, thrombocytosis, prolongation of prothrombin time and hepatosplenomegaly, in the absence of hepatic metastasis. A rare variant of it with cholestatic jaundice is described in four cases so far in literature.

CLINICAL PRESENTATION

We present a case of a patient presented with features of cholestatic jaundice who was found to have a left sided renal cell carcinoma in the work up.

DISCUSSION

This case illustrates the importance of considering paraneoplastic syndromes in mind when working up for patients presenting with hepatic dysfunctions without identifiable causes.

CONCLUSION

This may result in early identification and intervention which will result in better outcome and prolong survival rate.

Stauffer Syndrome as the Initial Presentation of Advanced Metastatic Prostate Cancer

Stauffer's syndrome is a paraneoplastic syndrome that has historically been associated with renal cell carcinoma. It is defined by the anicteric elevation of liver enzymes in the absence of liver metastasis, and the reversibility of clinical and biochemical changes upon treatment of the primary pathology. Here, we discuss the rare presentation of Stauffer's syndrome in a patient with advanced metastatic prostate cancer. A 72-year-old male presented with generalized weakness, dizziness, weight loss, and icterus who was incidentally found to have a prostatic enlargement on physical examination. The laboratory investigations and radiographic imaging confirmed the diagnosis of metastatic prostatic cancer without any evidence of mechanical biliary obstruction as confirmed by biopsy and imaging. The cancer had metastasized to pelvic sidewalls, pelvic bones, ribs, urinary bladder, and local lymph nodes. Our case signifies that a high index of suspicion for underlying cancer should be maintained in patients presenting with cholestatic liver dysfunction, with or without jaundice, especially in the absence of a recognizable mechanical etiology of cholestasis.

Management of Malignant Obstructive Jaundice: Defining the Relevance of Various Palliative Surgical Options in Resource-Challenged Settings: A Review Article

Malignant obstructive jaundice (MOJ) constitutes an important surgical problem with high morbidity and mortality worldwide. Presentation is usually delayed with a majority of patients benefitting only from palliative treatment. Surgeons practicing in developing countries face herculean task in managing MOJ due to lack of minimally invasive endoscopic procedures. Palliative surgical procedures are associated with high morbidity and sometimes mortality. Abdominal pain, generalized pruritus, and gastric outlet obstruction are some of the symptoms of MOJ requiring palliation. Successful surgical palliation may improve the overall quality of life in patients with MOJ considered fit for surgery. Bypass procedures and regional nerve blocks constitute the most effective surgical palliation available to surgeons practicing in resource-limited settings. This review article discusses the indications, the role, and types of surgical bypass procedures in the management of MOJ in contemporary surgical practice. This is important for surgeons in countries where expertise and resources for the less morbid endoscopic and radiologic approaches are not available. Relevant articles up to January 2021 published in PubMed, Google Scholar, and Hinari on the surgical management of obstructive jaundice were reviewed for inclusion. We also reviewed some modern surgical textbook topics on obstructive jaundice.

Glecaprevir/Pibrentasvir Induced Cholestatic Jaundice in a HCV Patient with Renal Failure. A Case Presentation

BACKGROUND

Direct-acting Antivirals (DAA) are currently used in the treatment of chronic HCV infection. In patients with renal failure Glecaprevir/Pibrentasvir (genotype 1-6) is recommended for its safety and efficacy.

CASE PRESENTATION

Although these pharmacological characteristics, an adverse drug reaction (ADR) has been reported during Glecaprevir/Pibrentasvir treatment, such as the development of cholestatic jaundice in an elderly patient with chronic HCV (genotype 2) infection. At examination, patient was jaundiced associated with intense pruritus.

RESULTS

Ultrasound and laboratory biochemical tests excluded a liver failure (e.g. liver cancer, and liver lithiasis) or pancreatic cancer while Naranjo probability scale (score 6) suggested an association between cholestatic jaundice and Glecaprevir/Pibrentasvir administration. About 1 month after drug discontinuation, an improvement has been documented in both jaundice and pruritus, with a normalization in bilirubin levels (total bilirubin: 0.96 mg/dL), HCV-RNA was undetected also. It is worth mentioning that although we reported the development of cholestatic jaundice upon treatment with Glecaprevir/Pibrentasvir we recorded a clinical efficacy (HCV-RNA <15 IU/L) after 4 weeks from the beginning of the treatment, with a complete remission of clinical symptoms until 7 months after drug discontinuation.

CONCLUSION

These data support the clinical efficacy of Glecaprevir/Pibrentasvir association in elderly patients, despite the sub-optimal period of treatment.

Assessment of jaundice in the hospitalized patient

Jaundice in the hospitalized patient is not an uncommon consultation for the general gastroenterologist. It is essential to explore the underlying cause of jaundice because management is largely aimed at addressing these causes rather than the jaundice itself. Although the diagnostic evaluation for jaundice can be broad, clinical judgment must be used to prioritize between various laboratory tests and imaging studies. Most importantly, clinicians must understand which conditions are emergent and/or require evaluation for liver transplantation. Further studies need to be performed to better understand the outcomes of hospitalized patients who develop jaundice.

Papel de las imágenes en el enfoque diagnóstico del paciente con ictericia

La  ictericia es un signo que describe  la coloración amarillenta de piel, escleras y mucosas por acumulación de bilirrubina. Es causa  frecuente de consulta en  los servicios de urgencias y de  consulta externa; de hecho, es muy  frecuente en el  periodo neonatal. La ictericia no es una entidad aislada sino  es el reflejo de una enfermedad específica. Por tal motivo,  luego  de  una  adecuada  evaluación  clínica  y  teniendo  los  paraclínicos pertinentes, se inicia el estudio del cuadro por  imágenes  con  una  ecografía;  según  los  hallazgos  se  continua  el  estudio  tomografía  abdominal  con  medio  de  contraste para evaluar el tracto biliar, resonancia magnética  u otros métodos no invasivos según el estado del paciente y  su  disponibilidad.  Dependiendo  de  los  resultados  es  necesario continuar con colangiopancreatografía retrógrada endoscópica como método diagnóstico, terapéutico o ambos.  

Effects of bilirubin ditaurate overload on canalicular membrane function and ultrastructure of the pig liver

AIM

Bilirubin overload caused by haemolysis of transfused blood and breakdown of extravasated blood constitutes an important causative factor of jaundice in trauma patients. Intravenous infusions of large amounts of unconjugated bilirubin (UCB) block biliary phospholipid secretion and produce canalicular membrane lesions in pigs, putatively because of enhanced cytotoxicity of bile. Severe intrahepatic cholestasis is the functional end result. The aim of the study was to investigate whether bilirubin ditaurate (BDT) overload, which also inhibits biliary phospholipid secretion, also induces intrahepatic cholestasis.

METHODS

Six pigs were infused with 2.8 g of BDT for 150 min. Six control pigs were infused with albumin sham solution for 150 min. Bile samples were analysed for bile acid- and phospholipid-secretion rates. Bile and serum samples were analysed for bilirubin concentration. Liver biopsies were obtained for scanning electron microscopic studies (SEM).

RESULTS

Biliary bile acid secretion fell by 7.7% and biliary phospholipid secretion rate fell by 88% after BDT infusion. Thus, infusion of BDT for 150 min did not cause intrahepatic cholestasis. SEM showed some variability in the size of canalicular membrane microvilli, but no evidence of gross destruction.

CONCLUSION

BDT overload markedly lowers biliary phospholipid secretion. In contrast to UCB, BDT does not induce canalicular membrane damage nor cause intrahepatic cholestasis. Sustained, marked inhibition of phospholipid secretion does therefore not adequately explain UCB-induced cholestasis. Accumulation of UCB in the canalicular membrane may be the important factor in the pathogenesis of canalicular membrane lesions and intrahepatic cholestasis during UCB overload.

Role of NF-κB in multiple organ dysfunction during acute obstructive cholangitis

AIM: To elucidate the role of NF-κB activation in the development of multiple organ dysfunction (MOD) during acute obstructive cholangitis (AOC) in rats.

METHODS: Forty-two Wistar rats were divided into three groups: the AOC group, the group of bile duct ligation (BDL group), and the sham operation group (SO group). All the animals in the three groups were killed in the 6th and 48th hour after operation. Morphological changes of vital organs were observed under light and electron microscopy. NF-κB activation was determined with Electrophoretic Mobility Shift Assay (EMSA). Arterial blood gas analyses and the serum levels of lactate dehydrogenase (LDH), alanine aminotransferase (ALT), blood urea nitrogen (BUN) and creatinine were performed. The concentrations of TNF-α and IL-6 in plasma were also measured.

RESULTS: The significant changes of histology and ultrastructure of vital organs were observed in AOC group. By contrast, in BDL group, all the features of organs damage were greatly reduced. Expression of NF-κB activation in various tissues increased in AOC group when compared to other two groups. At 6 h, the arterial pH in three groups was 7.52 ± 0.01, 7.46 ± 0.02, and 7.45 ± 0.02, and the blood pCO₂ was 33.9 ± 0.95 mmHg, 38.1 ± 0.89 mmHg, 38.9 ± 0.94 mmHg, there was difference in three groups (P < 0.05). At 48 h, the blood pHvalues in three groups was 7.33 ± 0.07, 7.67 ± 0.04, and 7.46 ± 0.03, and blood HCO₃^- was 20.1 ± 1.29 mmol·L^-1, 26.7 ± 1.45 mmol·L^-1 and 27.4 ± 0.35 mmol·L^-1, there was also difference in three groups (P < 0.05). In AOC group, Levels of LDH, ALT, BUN and creatinine were 16359.9 ± 2278.8 nkat·L^-1, 5796.2 ± 941.9 nkat·L^-1, 55.7 ± 15.3 mg/dl, and 0.72 ± 0.06 mg/dl, which were higher than in SO group (3739.1 ± 570.1 nkat·L^-1, 288.4 ± 71.7 nkat·L^-1, 12.5 ± 2.14 mg/dl, and 0.47 ± 0.03 mg/dl) (P < 0.05). Levels of plasma TNF-α and IL-6 in AOC at 48 h were 429 ± 56.62 ng·L^-1 and 562 ± 57 ng·L^-1, which increased greatly when compared to BDL group (139 ± 16 ng·L^-1, 227 ± 43 ng·L^-1) and SO group (74 ± 10 ng·L^-1, 113 ± 19 ng·L^-1) (P < 0.05).

CONCLUSION: The pathological damages and the NF-κB activation of many vital organs exised during AOC. These findings have an important implication for the role of NF-κB activation in MOD during AOC.

Intestinal damage mediated by Kupffer cells in rats with endotoxemia

AIM: To determine the in vivo effects of phagocytic blockade of Kupffer cell (KC) on the release of proinflammatory cytokines in small intestinal lesion and on the integrity of intestinal tract by using gadolinium chloride (GdCl₃) during early endotoxemia.

METHODS: Wistar rats were divided into three groups: Group A, rats were injected with endotoxin (E. coli O111:B4, a dose of 12 mg•kg⁻¹) only; Group B, rats were pretreated intravenously with 25 mg of GdCl₃ per kg 24 h are given endotoxin; and Group C, sham operation only. All animals were sacrificed 4 h after endotoxin injection. In portion of the rats of three groups, bile duct was cannulated, which the bile was collected externally. Morphological changes of ileum were observed under light microscopy and electronic microscopy. The KC were isolated from rats by collagenase perfusion and in KC, expression of TNF-α and IL-6 mRNA were determined by RT-PCR analysis. Plasma and bile TNF-α and IL-6 Levels were determined by enzyme-linked immunosorbent assay (ELISA).

RESULTS: In group A, there were neutrophil infiltration and superficial epithelial necrosis of the ileal villi, sloughing of mucosal epithelium, and disappearance of some villi. In group B, the ileal mucosal damage was much reduced. Which in group C, no significant morphological changes were seen. GdCl₃ pretreatment decreased significantly the expression of TNF-α and IL-6 mRNA in group B (4.32 ± 0.47 and 4.05 ± 0.43) when compared to group A (9.46 ± 1.21 and 9.04 ± 1.09) (P < 0.05). There was no significant expression of TNF-α and IL-6 mRNA in group C (1.03 ± 0.14 and 10.4 ± 0.13). In rats of group A, the levels of TNF-α and IL-6 in bile and plasma were 207 ± 29 ng·L^-1, 1032 ± 107 ng·L^-1, 213 ± 33 ng·L^-1, and 1185 ± 127 ng·L^-1, respectively. In group B, they were 113 ± 18 ng·L^-1, 521 ± 76 ng·L^-1, 147 ± 22 ng·L^-1, and 572 ± 54 ng·L^-1, respectively. In group C, they were 67 ± 10 ng·L^-1, 72 ± 13 ng·L^-1, 109 ± 18 ng·L^-1, and 118 ± 22 ng·L^-1 respectively. There were significant difference between the three group (P < 0.05).

CONCLUSION: KC release cytokines TNF-α and IL-6 causing damage to the integrity of intestinal epithelium and play a crucial role in the initiation and progression of intestinal mucosal damage during early endotoxemia.

Nuclear factor κB activity in patients with acute severe cholangitis

AIM: To determine the NF-κB activity in peripheral blood mononuclear cells (PBMC) in patients with acute cholangitis of severe type (ACST) and correlate the degree of NF-κB activation with severity of biliary tract infection and clinical outcome.

METHODS: Twenty patients with ACST were divided into survivor group (13 cases) and nonsurvivor group (7 cases). Other ten patients undergoing elective gastrectomy or inguinal hernia repair were selected as control group. Peripheral blood samples were taken 24 h postoperatively. PBMC were separated by density gradient centrifugation, then nuclear proteins were isolated from PBMC, and Electrophoretic Mobility Shift Assay (EMSA) used determined. The results were quantified by scanning densitometer of a Bio-Image Analysis System and expressed as relative optical density (ROD). The levels of TNF-α, IL-6, and IL-10 in the plasma of patients with ACST and healthy control subjects were determined by using an enzyme-linked immunoassay (ELISA).

RESULTS: The NF-κB activity was 5.02 ± 1.03 in nonsurvivor group, 2.98 ± 0.51 in survivor group and 1.06 ± 0.34 in control group. There were statistical differences in three groups (P < 0.05). The levels of TNF-α and IL-6 in plasma were (498 ± 53) ng·L^-1 and (587 ± 64) ng·L^-1 in nonsurvivor group, (284 ± 32) ng·L^-1 and (318 ± 49) ng·L^-1 in survivor group and (89 ± 11) ng·L^-1 and (102 ± 13) ng·L^-1 in control group. All patients with ACST had increased levels of TNF-α and IL-6, which were manyfold greater than those of control group, and there was an evidence of significantly higher levels in those of nonsurvivor group than that in survivor group (P < 0.05). The levels of IL-10 in plasma were (378 ± 32) ng·L^-1, (384 ± 37) ng·L^-1 and (68 ± 11) ng·L^-1 in three groups, respectively. All patients had also increased levels of IL-10 when compared with control group (P < 0.05), but the IL-10 levels were not significantly higher in nonsurvivors than in survivors (P > 0.05).

CONCLUSION: NF-κB activity in PBMC in patients with ACST increases markedly and the degree of NF-κB activation is correlated with severity of biliary tract infection and clinical outcome.

Liver sinusoidal endothelial cell injury by neutrophils in rats with acute obstructive cholangitis

AIM: The objective of this study is to elucidate the potential role of poly-morphonuclear neutrophils (PMN) in the development of such a sinusoidal endothelial cell (SEC) injury during early acute obstructive cholangitis (AOC) in rats.

METHODS: Twenty one Wistar rats were divided into three groups: the AOC group, the bile duct ligated group (BDL group), and the sham operation group (SO group). The common bile duct (CBD) of rats in AOC group was dually ligated and 0.2 mL of the E. coli O₁₁₁ B₄ (5 × 10⁹ cfu/mL) suspension was injected into the upper segment, in BDL group, only the CBD was ligated and in SO group, neither injection of E. coli suspension nor CBD ligation was done, but the same operative procedure. Such group consisted of seven rats, all animals were killed 6 h after the operation. Morphological changes of the liver were observed under light and electron microscope. Expression of intercellular adhesion molecule-1 (ICAM-1) mRNA in hepatic tissue was determined with reverse transcription polymerase chain reaction (RT-PCR). The serum levels of alanine aminotransferase (ALT) were determined with anutoanalyger and cytokine-induced neutrophil chemoattractant (CINC) was determined by enzyme-linked immunosorbent assay (ELISA).

RESULTS: Neutrophils was accumulated in the hepatic sinusoids and sinusoidal endothelial cell injury existed in AOC group. In contrast, in rats of BDL group, all the features of SEC damage were greatly reduced. Expression of ICAM-1 mRNA in hepatic tissue in three groups were 7.54 ± 0.82, 2.87 ± 0.34, and 1.01 ± 0.12, respectively. There were significant differences among three groups (P < 0.05). The serum CINC levels in the three groups were 188 ± 21 ng•L⁻¹, 94 ± 11 ng•L⁻¹, and 57 ± 8 ng•L⁻¹, respectively. There were also significant differences among the three groups (P < 0.05). Activity of the serum ALT was 917 ± 167 nkat•L⁻¹, 901 ± 171 nkat•L⁻¹, and 908 ± 164 nkat•L⁻¹, respectively, (P > 0.05).

CONCLUSION: Hepatic SEC injury occurs earlier than hepatic parenchymal cells during AOC. Recruitments of circulating neutrophils in the hepatic sinusoidal space might mediate the SEC injury, and ICAM-1 in the liver may modulate the PMN of accumulation.

Early diagnosis and treatment of severe acute cholangitis

AIM: To investigate the diagnostic standard for early identification of severe acute cholangitis in order to lower the incidence of morbidity and mortality rate.

METHODS: A diagnostic standard was proposed in this study as follows: documented biliary duct obstruction by ultrasound or computerized tomography or other imaging tools with the manifestation of systemic inflammatory response syndrome (SIRS). The surgical procedures included emergency common bile duct exploration with T tube insertion or cholecystostomy with secondary common bile duct exploration. And incidence of postoperative multiple organ dysfunction syndrome (MODS), duration of systemic inflammatory response and hospital mortality were analyzed.

RESULTS: Fourty-three patients conforming to the diagnostic standard described above were employed in this study. 1 patient was admitted in acutely ill condition and complicated with acute relapse of chronic bronchitis, cholecystostomy procedure was performed but the patient was complicated with postoperative acute lung injury which was treated by assisted mechanical ventilation for 5 d; 2 wk later, two-stage common bile duct Exploration and T tube insertion were performed. The remaining 42 patients underwent primary common bile duct exploration and T tube insertion, 1 developed acute lung injury and recovered 3 d later, 2 patients developed acute renal dysfunction, 1 of which recovered 2 d later and the other died on d 4. For all patients, the postoperative systemic inflammatory response persisted for 2 to 8 d with median of 3 d.

CONCLUSION: Early diagnosis of severe acute cholangitis can be made using this diagnostic standard, further development of systemic inflammatory response could be prevented and incidence of MODS as well as hospital mortality decreased.