Increase in serum total cholesterol and low-density lipoprotein cholesterol by high-dose chenodeoxycholic acid in patients with radiolucent gallstones significantly reversed during preventive low dose after gallstone dissolution

This study examines the effects of high-dose chenodeoxycholic acid (CDCA) on serum lipids and lipoproteins in 25 patients who underwent a 12-month therapy with CDCA for the dissolution of cholesterol gallstones. All patients received a daily dose of CDCA of 15 mg/kg body weight. Complete dissolution of gallstones was achieved in 16 cases. After 6 months of therapy the mean total cholesterol levels and low-density lipoprotein cholesterol (C-LDL) significantly increased (p less than 0.001). The decrease of mean triglyceride levels was significant too (p less than 0.01), although it was greater among patients with effective gallstone dissolution than in patients with persistent gallstones. The effects of high-dose CDCA after 12 months of therapy were similar to those observed at 6 months. 12 patients of the gallstone dissolution group were treated with a continuous low dose of CDCA (250 mg/day) for preventing gallstone recurrence. 6 months after dissolution, the mean total cholesterol levels and C-LDL significantly decreased (p less than 0.01 and less than 0.05, respectively). High-dose administration of CDCA produced an increase in total cholesterol and C-LDL, but did not alter high-density lipoprotein cholesterol levels. These effects were significantly reversed when a preventive low dose of CDCA was given after gallstone dissolution.

[Study of patients referred for elevated ferritin levels and/or transferrin saturation: significance of non-alcoholic fatty liver disease]

OBJECTIVE

To determine the etiology of increased ferritin concentrations and/or transferrin saturation in patients in whom classical causes were ruled out.

PATIENTS AND METHOD

We studied 43 patients (35 males and 8 females) who were referred for ferritinemia greater than 300 ng/ml and or a transferrin saturation index (TSI) greater than 40%. In all patients, glycemia, cholesterol, triglycerides, uric acid, total and fractionated bilirubin, transaminase, gammaglutamyltranspeptidase, sideremia, TSI, ferritin, HFE gene mutations, ceruloplasmin and total 24-hour urine porphyrin were evaluated and abdominal ultrasonography was performed. In 14 patients liver biopsy was performed.

RESULTS

Fifty-three percent was overweight and 19% was obese. Alterations in carbohydrate metabolism were detected in 33%, hypercholesterolemia was found in 14%, hypertriglyceridemia in 35%, and hyperlipemia type IIb in 16%. Thirty-two percent showed isolated elevated ferritin, 12% had elevated TSI and 56% showed elevation of both. Transaminase levels were normal in 61%. No mutation in the HFE gene was found in 10 patients, the H63D/wt mutation was found in 18, C262Y/wt in 1, C282Y/H63D in 5, C282Y/C282Y in 4, H63D/H63D in 3 and Ser65cys/wt in 1. Ultrasonography revealed steatosis in 19 patients (44%). Definitive diagnoses were HFE-linked hemochromatosis (4 patients), juvenile hemochromatosis (1 patient), hepaticocutaneous porphyria (1 patient), and non-alcoholic fatty liver disease (22 patients; 51%). Most of the remaining patients could be included under insulin resistance syndrome. Phlebotomy was performed in 25 patients, with improvement in clinical and laboratory parameters.

CONCLUSIONS

Non-alcoholic fatty acid disease is frequently detected in patients with iron metabolism disorders. These patients should undergo investigations for metabolic alterations and liver ultrasonography and, if necessary, biopsy. Phlebotomy can be useful in the treatment of these patients.

[Etiopathogenesis of non-alcoholic steatohepatitis]

The <<double impact>> theory is the most widely accepted explanation for the pathogenesis of non-alcoholic steatohepatitis, while insulin resistance is a key factor. In the <<first impact>> the increased afflux of fatty acids to hepatocytes combined with decreased triglyceride elimination and lower fatty acid oxygenation leads to steatosis. The steatosis is not always quiescent, since the accumulated fatty acids are susceptible to a <<second impact>> in which the following factors intervene: a) oxidative stress with an increase in the production of oxygen free radicals which activate transcription factors such as NF-kappa, facilitating the formation of cytokines (tumor necrosis factor-alpha, tumor growth factor beta 1, interleukin-8 and Fas ligands; b) lipid peroxidation with the formation of malondialdehyde and 4-hydroxynonenal, promoting the afflux of inflammatory cells to the liver, depleting antioxidants such as glutathione, inducing the formation of Mallory bodies and increasing collagen synthesis on activating stellate cells, and c) leptin, endotoxins and iron overload, which together induce the lesions of steatohepatitis.

[Chronic colonic pseudo-obstruction secondary to neuroleptics]

Colonic pseudo-obstruction is characterized by non-mechanical chronic colonic dilatation. It is an infrequent entity that can be provoked by multiple causes, among them pharmacological. We present the case of a 74-year-old female psychiatric patient who presented abdominal bloating, diarrhea, intense electrolytic alterations and marked radiographic colonic dilatation after treatment with a neuroleptic (zuclopenthixol decanoate). Organic obstruction and other causes were ruled out and the final diagnosis was chronic colonic pseudo-obstruction secondary to the use of neuroleptics. Cisapride (20 mg/8 h) produced a slight improvement in symptoms but colonic dilatation was permanent.

[Extracapsular hepatic adenoma. Case report and literature review]

BACKGROUND

Hepatic adenomas are uncommon epithelial tumours. They usually appear in women between 20 and 44 years old. They are commonly located in the right hepatic lobe and are typically solitary masses. Multiple adenomas can present in patients with prolonged use of oral contraceptive pills, glycogen storage diseases and hepatic adenomatosis.

CLINICAL CASE

A 35 year-old woman without any significant past medical history, with a chief complaint that started in December 2012 with oppressive, mild intensity abdominal pain located in right upper quadrant in the abdomen on deep palpation. With an abdominal ultrasound showing a mass of 91×82×65cm located in the right flank, isoechogenic with internal vascularity. Contrast computed tomography scan showing an ovoid tumour with circumscribed borders, with heterogenic intense reinforcement and displacement of adjacent structures with dimensions of 88×71×80cm. In laparotomy, excision of the tumour and cholecystectomy with the trans surgical findings of an 8cm tumour with a pedicle containing one artery and one vein coming from the hepatic free border with strong adhesions to the gallbladder. Pathologic diagnosis: Extracapsular hepatic adenoma.

CONCLUSIONS

Incidence of hepatic adenomas has increased in the last decades, in a parallel fashion with the introduction of oral contraceptive pills, showing association with glycogen storage diseases and to a lesser degree with diabetes and pregnancy. Diagnosis is clinical with the aid of imaging studies. Prognosis of hepatic adenomas is not well established, therefore, management depends on symptoms, size, number, location and certainty of diagnosis.

[Usefulness of magnetic cholangioresonance in the study of hepatobiliary disease in patients adults with cystic fibrosis]

INTRODUCTION

Because alterations in the bile ducts found in cystic fibrosis mimic those found in primary sclerosing cholangitis, magnetic resonance cholangiography (MRC) could be a useful diagnosis technique, especially because it is non-invasive.

MATERIAL AND METHODS

We prospectively studied 26 adult patients with cystic fibrosis. Of these, 11 had liver disease previously diagnosed on the basis of symptomatology, physical examination, liver function tests and abdominal ultrasound (group A) and 15 had no apparent liver disease (group B). In all patients liver function tests, abdominal ultrasound and MRC using 1.5 Teslas General Electric and Siemens systems were carried out. The images were interpreted blind by two radiologists with experience in the interpretation of biliary alterations in cystic fibrosis.

RESULT

In 6 of the 11 patients in group A, MRC showed signs of liver cirrhosis (nodularity, irregular surface, splenomegaly, varicosity); 4 patients showed rose-colored images in the choledoch and intrahepatic ducts; of the 5 patients with previous non-cirrhotic liver disease, 2 showed rose-colored intrahepatic ducts, 2 showed dilatation of the intrahepatic ducts and 1 showed hepatosplenomegaly with hepatic steatosis. Of the 15 patients in group B, bile duct anomalies were found in 5. Of these, 3 showed rose-colored images of the hepatic ducts and/or choledoch, 1 showed stenosis of the common hepatic duct with rigidity of the intrahepatic ducts and 1 showed irregularities in the caliber of the intrahepatic ducts without dilatation, which were suspicious for intrahepatic lithiasis.

CONCLUSIONS

MRC is a useful technique in the study of hepatobiliary disease in cystic fibrosis because it detected anomalies in all our patients previously diagnosed with liver disease and revealed ductal lesions not revealed by other non-invasive techniques.

[Remnant gallbladder cholecystitis, an increasingly common entity: Case report]

BACKGROUND

Subtotal cholecystectomy was described in 1985 as an alternative to total cholecystectomy in cases of difficult cholecystectomy. It was classified as reconstituted and fenestrated subtotal. In spite of being a viable alternative, up to 10.6% of biliary leakage is reported and 2.2% of patients present with cholecystitis of the gallbladder remnant. The objective of this report is to describe and emphasize the importance of an adequate diagnosis of complications in patients with a history of subtotal cholecystectomy.

CLINICAL CASE

72-year-old male with a history of open subtotal cholecystectomy 6 years prior to his admission to the emergency department due to right hypochondrium pain and vomiting. He had a history of biliary pancreatitis and choledocholithiasis after subtotal cholecystectomy resolved by endoscopic retrograde cholangiopancreatography (ERCP). It was decided to admit the patient and a diagnosis of cholecystitis of the gallbladder remnant was made. Laparoscopic cholecystectomy of the remnant was performed with subsequent clinical resolution.

CONCLUSIONS

Although subtotal cholecystectomy may be the only option in cases of difficult cholecystectomy, it may result in future complications. The possibility of more complex surgical reinterventions should be considered. Our case report demonstrates that total cholecystectomy in cases of cholecystitis should be performed whenever possible to avoid potential complications caused by subtotal cholecystectomy.

[Chronic autoimmune hepatitis following cholestatic hepatitis caused by droxicam]

Droxicam in a nonsteroid antiinflammatory from the oxicam family which acts as a pro-drug, being transformed into pyroxicam after being hydrolized in the stomach and has induced several cases of cholestatic or mixed hepatitis. A clinical observation in which droxicam provoked initial cholestatic hepatitis which later developed into chronic autoimmune hepatitis is presented. It has been postulated that, after causing cholestatic hepatitis by hypersensitivity and within the context of a previous autoimmune entity such as vitiligo, this drug triggered a silent autoimmune liver disease which was demonstrated clinical, analytical and histopathological manifestations 18 months later and required permanent immunosuppressive treatment.

[Droxicam-induced toxic hepatitis]

We present four cases of hepatitis with clinical features indicating a direct link with Droxicam. In all the cases, the presentation was that of acute hepatitis with subsequent resolution, whereas one patient developed autoimmune chronic active hepatitis. A full evaluation including ultrasound, liver biopsy, and serologic markers supported the diagnosis. Due to the fact that the "Dirección General de Farmacia y Productos Sanitarios" has approved the postponement of dispensation of products with Droxicam from February 25, 1995, this drug should not be considered anymore in the future as a potential cause of liver injury (acute or chronic hepatitis).

[Wilson's disease: difficulties in diagnosis and therapeutic management in our country]

The clinical analytical and therapeutic results of a retrospective study of 11 cases of Wilson's disease carried out in "La Fe" Hospital in Valencia are presented. The disease had a neurological onset in 5 cases, an hepatic onset in 4 cases (3 acute hepatitis and 1 chronic hypertransaminemia), 2 cases started as an acute hemolytic anemia; one of the outbreaks occurred during a period of treatment interruption. Diagnosis showed some difficulty in one case since the disease was associated with positive hepatitis B markers, positive anti HIV antibodies and initially normal ceruloplasminemia values. The diagnostic difficulties derived from the interpretation of ceruloplasminemia, and blood and urine copper levels are pointed out as well as the difficulties encountered in our environment to determine intrahepatic copper levels and to perform a kinetic study with radioactive copper both of which are of vital importance to confirm doubtful cases. Two patients became pregnant in the course of the disease having normal pregnancies and deliveries, without any apparent abnormalities in the newborns. Treatment with D-Penicillamine was started in 9 cases, observing a low to moderate intolerance in 7 cases; there was one case of severe intolerance for which treatment had to be interrupted. The new therapeutical approaches based on the use of trientine (not available in our country) are discussed, together with the expectations of liver transplant in this disease.

[Acute hepatitis due to heatstroke]

The hepatic injury is a nearly constant event in the course of a heatstroke, which rarely evolves to a severe liver failure. In these cases, the patient's survival is conditioned to an early treatment and, sometimes, an orthotopic liver transplantation is needed. We report a case of severe acute hepatitis in a 17-year-old man, due to a heatstroke during a vigorous exercise in a training program. High ambient temperature and a long time without training predisposed to the development of heatstroke in this patient. Outcome was favourably, with a total recovery in a few weeks.

[Digestive alterations in cystic fibrosis. Retrospective study of a series of 46 adult patients]

The clinical histories of 46 adult patients (24 men and 22 women, mean age 20.6 +/- 5.1 years) diagnosed of cystic fibrosis were reviewed evaluating the digestive alterations. The age at diagnosis of cystic fibrosis was 5.63 +/- 5.3 years (range: newborns-19 years). The initial diagnosis was established by ileus meconium, in four, lung disease in 15, steatorrhea in 12, lung disease and steatorrhea in 13 and following the diagnosis of cystic fibrosis in siblings in two. Four patients presented ileus meconium, nine occlusive syndrome of the distal intestine, 42 steatorrhea (20 severe, 12 moderate and 10 mild), with the severity of the steatorrhea not being associated with the severity of the respiratory insufficiency. Two patients presents rectal prolapse, five gastroesophageal reflux syndrome (four with hiatal hernia), six cholelithiasis, one recurrent pancreatitis without detection of biliary lithiasis, one neonatal cholestasis and 10 malnutrition (five severe and five moderate) fundamentally in relation to the severity of the lung disease and, to a lesser degree, liver disease. In 10 patients chronic liver disease was diagnosed corresponding to established cirrhosis in seven, indicating liver transplantation in two. In most cases, the liver disease was already manifest in adolescence even in the cirrhotic stage. Cholangiography by magnetic resonance was useful in the study of liver disease showing abnormalities which imitated primary sclerosing cholangitis. Treatment with ursodesoxicholic acid at a dosis of 20 mg/kg/day led to a significant decrease in the transaminase values and overall of gammaglutamyltranspeptidase but did not avoid complications in the cirrhotic stages. Genetic studies performed in 36 patients detected the delta F508 mutation in 69.4%, being found in almost all of the patients with ileus meconium, occlusive syndrome of the distal intestine, liver disease, cholelithiasis and malnutrition.