The role of ischemia-modified albumin, presepsin, delta neutrophil index, and inflammatory markers in diagnosing acute cholecystitis

BACKGROUND

The purpose of this study is to determine the significance of markers such as C-reactive protein, procalcitonin, complete blood count parameters, delta neutrophil index, ischemia-modified albumin, presepsin, and oxidative stress indicators, which are associated with inflammation, oxidative stress, and ischemia in the pathology and diagnosis of acute cholecystitis in adults.

METHODS

Patients diagnosed with acute cholecystitis in the emergency department and healthy individuals in the control group were included in the study. Routine blood count and biochemistry analyses were performed on the participants. Blood serum was used to measure ischemia-modified albumin, presepsin, and oxidative stress indicators.

RESULTS

White blood cell count, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, delta neutrophil index, C-reactive protein, procalcitonin, ischemia-modified albumin, ischemia-modified albumin to albumin ratio, presepsin, and oxidative stress indicators were significantly higher in patients with cholecystitis compared to the control group. Measurements of white blood cell count, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and delta neutrophil index can be included as part of the complete blood count. The complete blood count parameters are readily available and do not incur additional costs to the healthcare system.

CONCLUSION

The authors believe that the neutrophil-to-lymphocyte ratio, delta neutrophil index, ischemia-modified albumin, ischemia-modified albumin to albumin ratio, and presepsin values can be used as new markers in the diagnosis of acute cholecystitis due to their high sensitivity, specificity, and low negative likelihood ratio.

Percutaneous transhepatic gallbladder drainage followed by elective laparoscopic cholecystectomy for patients with moderate to severe acute cholecystitis

Percutaneous transhepatic gallbladder drainage followed by laparoscopic cholecystectomy (PTGBD+LC) is one treatment option for patients with moderate to severe acute cholecystitis (AC). However, the impact of PTGBD on operative difficulties in performing LC is controversial. We designed this retrospective study to clarify the surgical outcomes after PTGBD+LC for the management of patients with moderate to severe AC.The medical records of 85 patients who underwent LC for moderate to severe AC from January 2013 to September 2016 were evaluated. They were divided into 2 groups based on the type of management: group A received PTGBD+LC, and group B received LC without drainage. We compared the patient characteristics, laboratory data which were obtained immediately before surgery or PTGBD at index admission, and surgical outcomes between the 2 groups. We also evaluated possible predictive factors associated with prolonged operative duration after PTGBD+LC.Patients in group A were older and had more comorbidities than those in group B. The laboratory tests obtained at index admission in group A showed higher serum levels of C-reactive protein (CRP) and alkaline phosphatase, and lower albumin levels than those in group B. The surgical outcomes after LC were similar between the 2 groups. However, operative duration was significantly shorter in group A (P = .012). In group A, a higher serum level of CRP was a predictive factor for a prolonged operation (hazard ratio 1.126; 95% confidence interval 1.012-1.253; P = .029). In conclusion, PTGBD+LC can shorten the operative duration in patients with moderate to severe AC, which might improve surgical outcomes in elderly patients with comorbidities, and elevated CRP values predicted a prolonged operation after PTGBD.

[Age-related peculiarities of acute cholecystitis]

In the present study the analysis of dynamics of basic laboratory parameters of patients with acute cholecystitis (AC) in the four age groups subdivided according to the WHO classification into young, middle age, elderly and senile was carried out. The most pronounced changes were found in the senile age group in which the AC was accompanied by the decreased number of erythrocytes, low hemoglobin and total protein, leukocytosis, lower percentage of lymphocytes and the highest levels of ALT, AST, bilirubin and urea. Changes in the elderly and senile groups differed and in a number of cases were opposite. In the elderly and especially in the senile group the dynamics of the studied parameters related to surgery, was poorly expressed. These findings can be used in the preparation of the elderly and senile patients for AC surgery.

[CLINICAL FEATURES DURING THE ACUTE CHOLECYSTITIS IN THE OLDER AGE GROUP OF PATIENTS]

One of the most popular abdominal diseases is an acute cholecystitis. that’s why is very actual in acute cholecystitis the study of clinical features in the older age group of patients in improving of preoperative diagnosis and adequate option of treatment. In the research were involved 1273 patients, wiich were the patients during 2007-2014 years in Medical center of Yerevan, department of Laporacopic surgery, who suffered from acute cholecystitis. Research findings from the data analysis allows us to assume that the characteristics of the older age group of patients during the acute cholecystitis are difficult to do some surgical intervention and it needs very clever prediction for treatment.

[HEMOSTASIOLOGIC INDICES AFTER LAPAROSCOPIC CHOLECYSTECTOMY FOR AN ACUTE CHOLECYSTITIS]

The indices of coagulometry and thromboelastography (THEG) were determined in 60 patients, suffering various forms of an acute cholecystitis. Preoperatively the coagulometry indices have had a hypercoagulation tendency while the disease severity enhances. After performance of laparoscopic cholecystectomy the most essential changes of indices were observed. In the patients after severe operation there was observed accelerated kinetics of the blood clotting, witnessed by the THEG indices. The risk of the hemorrhage occurrence restricts application of medicinal thromboprophylaxis.

Elevated plasma visfatin levels correlate with conversion of laparoscopic cholecystectomy to open surgery in acute cholecystitis

Visfatin correlates with inflammation and its levels in peripheral blood are associated with some inflammatory diseases. This study aimed to assess the relationship between plasma visfatin levels and conversion of laparoscopic cholecystectomy to open surgery in acute cholecystitis. One hundred and forty-six acute cholecystitis patients and 146 sex- and age-matched healthy controls were recruited and their plasma visfatin levels were determined using an enzyme immunoassay. 17 patients (11.6%) underwent conversion. Plasma visfatin levels were statistically significantly elevated in all patients (97.2±41.8ng/mL), those with (161.4±71.3ng/mL) or without conversion (88.7±26.9ng/mL), compared to controls (40.3±13.3ng/mL, all P<0.001). A linear regression analysis showed that plasma visfatin levels were positively associated with plasma C-reactive protein levels (t=0.510, P<0.001). A logistic-regression analysis showed that age [odds ratio (OR) 1.160, 95% confidence interval (CI) 1.011-1.332, P=0.035] and plasma visfatin levels (OR 1.035, 95% CI 1.005-1.066, P=0.022) appeared to be the independent predictors of conversion. A receiver operating characteristic curve analysis found that plasma visfatin levels predicted conversion with high area under curve (AUC) (AUC, 850; 95% CI, 0.781-0.903). The AUC of the visfatin concentration was similar to that of age (AUC, 0.738; 95% CI, 0.659-0.807) (P=0.188). Visfatin improved the AUC of age to 0.914 (95% CI, 0.856-0.954) (P=0.011) using a combined logistic-regression model. Thus, high plasma levels of visfatin are associated with systemic inflammation, and may independently predict conversion of laparoscopic cholecystectomy to open surgery in acute cholecystitis.

The Impact of Body Mass Index as a Predictive Factor of Steatocholecystitis

BACKGROUND/AIMS

Obesity is a chronic inflammatory condition and is strongly linked to raised levels of pro-inflammatory factors and may lead to fatty infiltration of multiple internal organs including the gallbladder and liver, causing organ dysfunction. This study was performed to evaluate the relationship between body mass index (BMI) and acute and chronic cholecystitis, and cholecystitis and cholesterolosis. We investigated the clinical implications of BMI as a predictive factor of cholesterol associated cholecystitis.

METHODS

This retrospective study covered the period from January 2007 to December 2011, we included 1,158 patients who had cholecystectomy. We excluded patients with gallbladder cancer, adenomyomatosis, and cholesterolosis without cholecystitis. Finally, we investigated the data of a total of 1,109 patients with cholecystitis. Laboratory test results and clinical data such as age, sex, BMI, height, weight and underlying diseases were examined. We retrospectively investigated acute and chronic cholecysti tis, cholesterol polyps, and other gallbladder diseases such as gallbladder cancer and adenomyomatosis according to the histopathologic findings.

RESULTS

There was a significant difference of BMI between patients with cholecystitis with cholesterolosis and without cholesterolosis (P = 0.001). Among patients who had cholecystitis with cholesterolosis, the BMI was 25.2 kg/m2. Among patients with cholecystitis without cholesterolosis, the average BMI was 24.3 kg/m2. Weight, systolic blood pressure, platelet count, glucose, triglyceride, and LDL-cholesterol were different between the groups above (P < 0.05). However, there was no significant difference in BMI between acute and chronic cholecystitis (P = 0.05).

CONCLUSIONS

BMI was associated with steatocholecystitis. However, we cannot predict whether cholecystitis is acute or chronic according to the BMI. We suggest that BMI can be used as one of the predictive factors of steatocholecystitis for obese patients.

[Dependence of the operation stress degree from the kind of operative intervention for an acute cholecystitis in the patients with high operative-anesthesiological risk]

The results of comparison between the operation stress degree in various kinds of surgical interventions, performed for an acute cholecystitis, using determination of cortizol, prolactin and glucose content before the operation, intraoperatively and postoperatively in 50 patients, are adduced. There was established, that the largest (in 5.3 times) and the most durable (more than 24 hours) intr erative raising of the cortizol level in the blood serum was noted in patients, to whom open cholecystectomy (OCH) was done, and the minimal (in 2.2 times) and the least durable (up to 1 hour)--while performing transcutaneous transhepatic draining (TTD) of gallbladder under ultrasonographic control. While performance of laparoscopic cholecystectomy (LCH) there was noted the most pronounced intraoperative raising of prolactin level (in 3.6 times) and more rapid its lowering (during 24 hours) in comparison with such while the OCH performance (during 72 hours). In TTD there was observed the minimal intraoperative inhancing of the prolactin level (in 2.3 times) and its duration (during 1 hour) postoperatively. The above mentioned have witnessed, that while TTD of gallbladder performance stimulation of the anterior hypophysis is significantly lesser, than while LCH and OCH.

Quantitative analysis of troponin I serum values in patients with acute cholecystitis

The diagnosis and staging of acute cholecystitis, upon a lot of diagnostic methods and some scoring systems, is still a great clinical problem. The aim of the study was to investigate if serum Troponin I is elevated in patients with acute cholecystitis. Following informed consent, 65 patients with clinical and laboratory signs of acute cholecystitis were enrolled. All patients had measured serum Troponin I level and an abdominal ultrasound was done before definitive treatment was performed. Increased serum Troponin I level was found in most patients with severe form of acute cholecystitis (p < 0.00001). It reached sensitivity of 94.5% and specificity of 57.1% of this test. In multiple regression analysis Troponin I significantly correlated (p < 0.05) with the serum aspartate aminotransferase (r = 0.27), gamma-glutamyl transferase (r = 0.25) and gallbladder wall (> 6 mm) thickness (r = 0.58). Our study confirms that in most patients with severe and acute cholecystitis, serum Troponin I is increased. Troponin I level is in a lower range than it would be in patients with cardiac muscle damage or necrosis. Measuring serum Troponin I is a fast, reliable and widely performed test that could, with other routinely measured parameters, help in early diagnosis of the severe form of acute cholecystitis.

[Changes of oxidative homeostasis in acute experimental cholecystitis]

Variations of the indices of endogenous intoxication, lipid peroxidation, oxidative modification of proteins, and antioxidant system operation have been studied in animals with acute experimental cholecystitis. The possibility and effectiveness of using succinate-containing drugs reamberin and mexidol for the correction of these impairments has been assessed. In the present study, reamberin effectively reduced the intensity of lipid peroxidation and protein modification in experimental animals.

'Lewisham scoring system' to facilitate the clinical diagnosis of empyema

INTRODUCTION

Patients with empyema of gall bladder have a higher mortality rate. We hypothesised a scoring system, which we call the Lewisham Score, to predict the development and diagnosis of empyema.

MATERIAL AND METHODS

Patient with histologically proven acute cholecystitis who underwent operation over a five year period (2004-2009) were selected and a retrospective cohort analysis of those who developed empyema vs. simple acute cholecystitis was performed. Various parameters and the Lewisham score were compared.

RESULTS

Patients with empyema were elderly females with a higher C-reactive protein and had a higher Lewisham Score of > 5 and those with simple cholecystitis had a lower Lewisham score (< 4) and lower C-reactive protein.

DISCUSSION

Patients with proven acute cholecystitis and a Lewisham score > 5 should undergo cholecystectomy at the same admission.

Serum gamma glutamyl transferase and alkaline phosphatase in acute cholecystitis

BACKGROUND

The serum level of gamma glutaryl transferase and alkaline phosphatase is raised in acute calculus cholecystitis and common bile duct stone. However, the rise in serum level of these enzymes in acute cholecystitis implies stone in the common bile duct is not well studied. Thus, it may lead to retained CBD stone on one side and unnecessary CBD exploration on the other during emergency laparoscopic cholecystectomy. The objective of the study is to predict presence of CBD stone by assessing serum level of gamma-glutamyltransferase (gamma-GT)and alkaline phosphatase.

METHODS

A prospective study was designed which included 40 patients with clinically diagnosed and radiologically confirmed acute cholecystitis and 40 patients who had choledocholithiasis with or without cholangitis. Their serumgamma glutaryl transferase and alkaline phosphatase were analyzed.

RESULTS

Both acute cholecystitis and CBD pathology had significant increase in alkaline phosphatase (p-value: 0.05). However, in acute cholecystitis there was 1.69±0.118 fold increase and in CBD pathology there was 2.5±0.57 fold increase in alkaline phosphatase than normal.(130 IU /L). There was no statistically significant difference ingamma- GT in both acute cholecystitis and CBD pathology(p-value: 0.390). However it increases by 2.8±0.47fold in acute cholecystitis and by 2.2±0.16 in CBD pathology(p value: 0.627).

CONCLUSIONS

Although there is rise in serumγ-GT and alkaline phosphatase level in acute cholecystitis and CBD stone,only more than 2.5 fold rise in serum alkaline phosphatase level predicts CBD stone.

[Antioxidative defense parameters in acute and chronic cholecystitis]

A hundred and fifty-two patients cholelithiasis were examined. Among them, 69 and 83 patients were operated on for acute destructive and chronic cholecystitis, respectively. In destructive cholecystitis, there is a high lipid oxidation rate accompanied by the elevated levels of nonenzymatic antioxidant ceruloplasmin. The low activity of catalase and ceruloplasmin and the decreased content of ascorbic acid suggest the depletion of antioxidative defense in patients with cholelithiasis with significant liver disease. The magnitude of changes in the activity of antioxidative enzymes and the level of the nonenzymatic antioxidant ascorbic acid depend on the state of the liver.

[Assessment of severity assessment and prognosis of pyodestructive abdominal diseases (with editor's comment)]

Leukocytic index of intoxication (LII), number of leukocytes and lymphocytes in blood were compared with clinical symptoms and histological examination of removed organs in patients with acute pyodestructive diseases of abdominal organs. Correlation between LII and inflammation severity was revealed. It is also demonstrated that high LII with low level of lymphocytes is a negative prognostic sign.

The effect of laparoscopy on the IGF system in patients diagnosed with acute cholecystitis

OBJECTIVE

IGFs and IGF binding proteins in the circulation are subject to modulation by a number of catabolic states including inflammation, trauma and surgery. We sought to determine the impact of laparoscopy on the IGF system in patients diagnosed with acute cholecystitis.

DESIGN

The components of the IGF system, cortisol, glucose and insulin concentration in both the serum and urine of patients were compared to those from a healthy group of subjects. An additional comparison was made between pre- and post-laparoscopically assisted patients.

PATIENTS

Thirty patients diagnosed with acute cholecystitis and 81 matched controls were included in the study.

MEASUREMENTS

Radioimmunoassays were used to determine the IGF-I, IGF-II, insulin and cortisol concentrations. The concentration of IGFBP-3 was measured using an immunoradiometric assay. The GOD-PAP method was used to determine the glucose concentration. Gel filtration chromatography was performed to calculate the IGF binary/ternary complex ratio. The amount of sialic acid in IGFBP-3 was determined by affinity chromatography. The presence of IGFBPs in serum was determined by both immunoblotting and ligandblotting.

RESULTS

The concentrations of circulating IGF-I, IGF-II and IGFBP-3 were significantly reduced in pre-operative patients compared to healthy subjects. No further reductions were observed post-laparoscopy. Immunoblotting and ligandblotting demonstrated a decreased amount of IGFBP-3 in both pre- and post-operative patients compared to healthy subjects. Increased levels of IGFBP-2 and IGFBP-1 were observed in pre-operative patients compared to healthy subjects, but laparoscopy did not cause further elevation. No alteration in the IGF binary/ternary complex ratio was witnessed between any of the study groups. A significant increase in the sialic acid content of IGFBP-3 was seen in both patient groups when compared to healthy subjects. The level of urinary cortisol was significantly increased in post-operative patients, whereas the urinary IGF-I concentration was decreased compared to healthy subjects.

CONCLUSIONS

Our results indicate that acute cholecystitis causes several significant changes in the circulating IGF system. Laparoscopy, however, does not aggravate such changes, but elevates urinary cortisol.

Acute acalculous cholecystitis and pancreatitis in a patient with concomitant leptospirosis and scrub typhus

Concomitant leptospirosis and scrub typhus is rare. The spectrum of clinical severity for both scrub typhus and leptospirosis ranges from mild to fatal. Acute pancreatitis and cholecystitis are infrequent complications in adult patients with either leptospirosis or scrub typhus. We report a case of leptospirosis and scrub typhus coinfection in a 41-year-old man presenting with acute acalculous cholecystitis, pancreatitis and acute renal failure. Abdominal computed tomography revealed edematous change of the gallbladder without intrahepatic or pancreatic lesions. The patient was successfully treated with doxycycline and ceftriaxone, and supportive management.

Depletion of serum L-arginine in patients with acute pancreatitis

INTRODUCTION

Acute pancreatitis may be initiated by interference with the pancreatic outflow to the duodenum. This flow is normally regulated by reflex relaxation of the sphincter of Oddi in which nitric oxide is an important mediator.

AIM

To test the hypothesis that acute pancreatitis involves a depletion in serum L-arginine resulting in impaired production of nitric oxide.

METHODS

We measured serum L-arginine and L-citrulline and urinary nitrite/nitrate concentrations 1 to 3 days after the onset of symptoms in 11 patients with gallstone pancreatitis, 10 patients with alcoholic pancreatitis, and 6 patients with idiopathic pancreatitis. We compared their results with those from control groups of 13 healthy blood donors, 9 patients fasting before hernia operations, 8 patients with acute cholecystitis, and 9 alcoholic subjects but no pancreatitis. Serum arginine and citrulline concentrations were measured with high performance liquid chromatography, and urinary nitrite/nitrate spectrophotometrically.

RESULTS

Patients with acute pancreatitis, of whatever cause, had lower serum L-arginine and L-citrulline concentrations than controls. Patients with gallstone and idiopathic pancreatitis also have reduced urinary concentrations of nitrite and nitrate but this was not seen in patients with alcoholic pancreatitis.

CONCLUSIONS

L-arginine and L-citrulline concentrations are depleted in the serum of patients with acute pancreatitis. Reduced urinary nitrite and nitrate in gallstone pancreatitis indicate that there is a defect formation of nitric oxide. This may cause a functional obstruction of the outflow of pancreatic juice to the duodenum and so may be involved in the pathophysiology of acute pancreatitis.