Gut peptide changes in patients with obstructive jaundice undergoing biliary drainage: A prospective case control study

BACKGROUND

Biliary obstruction is a relatively common condition that affects approximately 5 in 1000 people annually. Malnutrition is very common in patients with biliary obstruction and since it is associated with significant morbidity and mortality, it is important to identify factors and mechanisms involved in its development.

AIM

To determine the influence of obstructive jaundice on the hormones controlling appetite and nutritive status.

METHODS

This was a prospective case control study performed in a tertiary center in Zagreb, Croatia. Patients with biliary obstruction undergoing internal biliary drainage from September 2012 until August 2013 were enrolled. After excluding patients who developed procedure related complications or were lost in the follow-up, out of initial 73 patients, 55 patients were included in the analysis, including 34 with benign and 21 with malignant disease. Meanwhile, 40 non-jaundiced controls were also included. Appetite, nutritional status, and serum ghrelin, cholecystokinin (CCK), interleukin 6 (IL-6), and tumor necrosis factor α (TNF-α) were determined at admission, 48 h and 28 d after internal biliary drainage. Chi square test was used for categorical variables. Continuous variables were analysed for normality by Kolmogorov–Smirnov test and relevant non-parametric (Mann-Whitney, Kruskal-Wallis, and Friedman) or parametric (t-test and analysis of variance) tests were used.

RESULTS

Patients with obstructive jaundice were significantly malnourished compared to controls, regardless of disease etiology. Plasma ghrelin and CCK levels were significantly higher in patients with obstructive jaundice. Serum bilirubin concentrations were negatively correlated with ghrelin levels and positively correlated with TNF-α, but had no correlation with CCK concentrations. After internal biliary drainage, a significant improvement of nutritional status was observed although serum concentrations of ghrelin, IL-6, and TNF-α remained significantly elevated even 28 d after the procedure. CCK levels in patients without malnutrition remained elevated 28 d after the procedure, but in patients with malnutrition, CCK levels decreased to levels comparable with those in the control group. We have not established any correlation between appetite and serum levels of ghrelin, CCK, IL-6, and TNF-α before and after biliary drainage.

CONCLUSION

Possible abnormalities in ghrelin and CCK regulation may be associated with the development of malnutrition during the inflammatory response in patients with biliary obstruction.

Role of Endoscopic Ultrasound in Liver Disease: Where Do We Stand?

As the burden of liver disease in the general populace steadily increases, so does the need for both advanced diagnostic and treatment options. Endoscopic ultrasound is a reliable diagnostic and therapeutic method that has an established role, foremost in pancreatobiliary pathology. This paper aims to summarize the growing role of endoscopic ultrasound in hepatology based on the search of the current literature. A number of applications of endoscopic ultrasound are reviewed, including both noninvasive methods and tissue acquisition in focal and diffuse liver disease, portal hypertension measurement, detection and management of gastric and esophageal varices, treatment of focal liver lesions and staging of pancreatobiliary malignancies, treatment of cystic and solid liver lesions, as well as liver abscess drainage. Both hepatologists and endoscopists should be aware of the evolving role of endoscopic ultrasound in liver disease. The inherent invasive nature of endoscopic examination limits its use to a targeted population identified using noninvasive methods. Endoscopic ultrasound is one the most versatile methods in gastroenterology, allowing immediate access with detection, sampling, and treatment of digestive tract pathology. Further expansion of its use in hepatology is immanent.

Candidemia after endoscopic therapy with lumen-apposing metal stent for pancreatic walled-off necrosis

Necrotizing pancreatitis remains a challenging and unpredictable condition accompanied by various complications. Endoscopic ultrasound-guided transmural drainage and necrosectomy have become the standard treatment for patients with walled-off necrosis (WON). Endoscopic therapy via lumen-apposing metal stents (LAMS) with large diameters has shown success in the management of pancreatic fluid collections, but there are few data on specific complications of that therapy. We report a case of infected WON and concomitant fungemia following LAMS placement and necrosectomy. In addition, a systematic literature review of current related studies has been provided.

Therapy of nonalcoholic fatty liver disease: current status

Nonalcoholic fatty liver disease (NAFLD), the hepatic manifestation of the metabolic syndrome, has become a common entity in clinical practice. In most of the patients it presents as simple steatosis with nonprogressive clinical course. However, some patients have progressive form of NAFLD, nonalcoholic steatohepatitis (NASH), and are at increased risk of developing cirrhosis and hepatocellular carcinoma. NAFLD treatment includes lifestyle modifications and pharmacotherapy aiming at increasing insulin sensitivity, and attenuating inflammation and hepatic fibrosis. Weight reduction has consistently been shown to reduce levels of liver enzymes and insulin resistance. Although dietary intervention and exercise remain the first-line therapy, due to low patients compliance to these measures pharmacotherapy or surgical approaches are often required. Metformin and thiazolidinediones may improve insulin sensitivity, serum aminotransferase level and liver histology. However, little evidence exists regarding their sustained effects after drug discontinuation which, together with their side effects, limits their widespread use in clinical practice. Statins appear to be safe agents for the treatment of hyperlipidemia, although trials documenting their efficacy in NAFLD are scarce. Based on the recent clinical trials, weight loss medication orlistat, ursodeoxycholic acid and antioxidant agents could potentially be used as adjunctive therapy. Considering still largely controversial clinical data regarding pharmacological agents, their high cost and known side-effects, lifestyle modifications at present remain the only essential considerations in the NAFLD treatment.

Pericarditis in exacerbation of ulcerative colitis

Acute pericarditis occurs very rarely in association with inflammatory bowel disease (IBD). It has been described both as an extraintestinal manifestation of IBD and as an adverse drug reaction in IBD treatment. We present a case of a 26-year-old female patient with a severe exacerbation of ulcerative colitis, who was previously under long-term treatment with mesalazine and low-dose prednisone. The literature on pericardial involvement in IBD is reviewed.