[Persistent elevation of Ca 19-9 and an unexpected finding. A case report]

BACKGROUND

Tumour markers are substances produced by the tumour itself, or by the host in response to a tumour. These markers could be measured either in the blood or in body secretions. One of the most common tumour markers used in gastrointestinal diseases is Ca 19-9. It is the marker most used for pancreatic cancer, but can be elevated in many benign processes. Thus, it is not a specific marker.

CLINICAL CASE

The case is presented of a male patient with 4 years of moderate abdominal pain, weight loss, and persistent elevation of Ca 19-9. After an extensive work-up, renal and hepatic cysts were found, as well as steatosis and, apparently, a gallbladder polyp. With these findings and the persistent elevation of Ca 19-9, it was decided to operate the patient. An exploratory laparoscopy was performed showing multiple, yellowish nodular lesions all over the hepatic surface suggestive of metastases, as well as simple hepatic cysts. Pathology reported biliary hamartomas, steatosis, and chronic cholecystitis. After 2years of follow up, although there is no evidence of malignant neoplasia, there is still an elevation of Ca 19-9.

CONCLUSION

The persistent elevation of Ca 19-9 is probably due to the presence of multiple benign diseases such as steatosis, urolithiasis, hepatic and renal cysts, and cholecystitis. An algorithm is needed for healthy patients with elevated levels of Ca 19-9 marker, in order to lower costs, avoid misdiagnoses, and improve management.

[Serious Coagulation Dysfunction in a Patient with Gallstone-related Cholecystitis Successfully Treated with Vitamin K]

An 85-year-old woman with a diagnosis of choledocholithiasis due to common duct stones gradually developed severe coagulation dysfunction over the course of 27 days after hospitalization. Initial clinical findings were fever, general malaise, and obstructive jaundice. She was treated with fasting, and received cephem antibiotics containing N-methyl-thio-tetrazole. Because the common duct stones were not removed endoscopically, cholecystectomy was scheduled. Coagulation on admission was normal, but gradually became impaired. On the scheduled day of the operation, 27 days after hospitalization, coagulation [both prothrombin time (PT) and activated partial thromboplastin time (APTT)] were severely impaired PT, < 10%; PT-international normalized ratio, 6.29; and APTT, 71.6 s. No other abnormalities were identified. Surgery was postponed and antibiotics were discontinued. Simultaneously, administration of vitamin K was initiated. Six days after starting vitamin K, coagulation dysfunction had resolved and the surgery was safely performed under general anesthesia combined with thoracic epidural anesthesia. Care is warranted regarding coagulation dysfunction due to vitamin K deficiency in patients with hepatobiliary disease treated by fasting and antibiotics.

ENDOTHELIAL DYSFUNCTION IN PATIENTS WITH HYPOTHYROIDISM AND CONCOMITANT CHRONIC CHOLECYSTITIS

Activity of endothelial dysfunction markers in patients with hypothyroidism and concomitant chronic cholecystitis was investigated. In patients with hypothyroidism and chronic cholecystitis a increased lactate dehydrogenase and alkaline phosphatase activity was observed, accompanied by the manifestation of cholestasis. In this patients increased vascular endothelium growth factor plasma level and endotheliocytes number was detected, attested the accelerated severity of endothelium dysfunction. Inverse correlation between the vascular endothelium growth factor plasma concentration, desquamated endotheliocytes number in peripheral blood and bilirubin level was detected, that points to the protective role of bilirubin in the prevention of the endothelium dysfunction development.

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.

[Influence of ursodeoxycholic acid on the immune status of patients with cholesterosis of gall-bladder depending on cholesterol index in blood]

Application of ursodeoxycholic acid in a standard dosage for 3 months provided a positive effect in relation to the indexes of the immune system for patients with the cholesterosis of gall-bladder. It is shown that medicine assists renewal of T-cell immunity, renders positive influence on B-link and renewal of index of immunoregulation can be seen. Reliable increase of specific receptors to CD25, HLA-DR and high level of CD95 testifies about including of the scray reaction of organism under influence of ursodeoxycholic acid on the remaining high indexes of B-cell of immunity. At the initial indexes of lipid spectrum, corresponding to the norm, the efficiency of normalization of immunological changes is more considerable than at the higher level of general cholesterol of serum of blood.

Tumor biomarkers: help or mislead in the diagnosis of xanthogranulomatous cholecystitis?-analysis of serum CA 19-9, carcinoembryonic antigen, and CA 12-5

BACKGROUND

Xanthogranulomatous cholecystitis (XGC) is a rare type of gallbladder inflammation. Unlike other cholecystitis, it can be easily misdiagnosed as gallbladder cancer based on radiological images. In response to misdiagnosis, extended surgical treatments are inappropriately given to patients, which is not beneficial to their health and/or recovery. In this study, we set out to determine whether tumor biomarkers can help to avoid misdiagnosis in patients with XGC.

METHODS

Between January 2005 and January 2012, a total of 37 preoperative patients at Sir Run Run Shaw Hospital were suspicious of having gallbladder cancer and was pathologically confirmed to be XGC after surgical operations. Before operations, all patients received a tumor biomarker test to verify diagnosis, which included serum CA 19-9, carcinoembryonic antigen (CEA), and CA 12-5.

RESULTS

A measured amount (54.05%) of cases (20 in 37) had at least one elevation over the thresholds of CA 19-9 (37 IU/L), CEA (5 ng/ml), and CA 12-5 (35 IU/L), which increased the suspicion of malignancy and consequently enhanced the difficulty to make right diagnosis of XGC as benign. 45.95% of cases (17 in 37) had an elevation in CA 19-9. 2.70% of cases (one in 37) had an elevation in CEA and 24.32% of cases (nine in 37) had an elevation in CA 12-5. Analysis with Fisher's exact test discovered that the presence of common bile duct stone was a contributor to elevations of CA19-9 in patients with XGC. However, even in cases without common bile duct stones, 42.86% of patients (nine in 21) had elevations of at least one tumor biomarker. Among them, 26.09% of patients (six in 21) had elevations of CA 19-9, with the maximum of 536.29 IU/L.

CONCLUSIONS

The elevations of tumor biomarkers in XGC were frequent, suggesting their inabilities to clarify the disease's nature, especially when there was a suspicion of gallbladder cancer. Intraoperative frozen pathology of gallbladder might be a possible solution. However, it is against the en bloc surgical principle and has the potential to cause tumor cell spreading. More research should be conducted, such as the discovery of a novel biomarker, so that XGC can less likely be misdiagnosed as malignancy until the final pathological judgment.

[Correlation analysis of liver function and blood flow in children with chronic cholecystocholangitis]

Presented correlation relationship between the functional state of the liver and arterial blood flow in children with chronic cholecystocholangitis. Found increases in the number of pigment and enzyme metabolism of liver, which directly depends on the slowing of blood flow in the basin of the hepatic artery. Is proved the inverse relationship growth of angular indices of internal blood flow in the hepatic artery on the lowering proteins.

Caution in interpretation of the tumor marker CA 19.9 in patients with obstructive jaundice: illustrative case reports

BACKGROUND

Carbohydrate antigen (CA) 19.9 is a Lewis blood group oligosaccharide antigen which exists in fixed and soluble forms. The CA 19.9 antigen is synthesized by epithelial cells of the gastrointestinal tract, pancreatic duct, and biliary tree. The CA 19.9 antigen is commonly used as a tumor marker for malignancies of the pancreas and biliary tract. High levels (> 300 U/ml) of antigen have strongly suggested malignant processes.

METHODS

Four patients are described with markedly elevated levels of CA 19.9 due to benign calculous disease.

RESULTS

Three of four patients underwent endoscopic stone removal followed by cholecystectomy; the fourth patient spontaneously passed stones and had a subsequent cholecystectomy with benign inflammatory pathology. Removal or passage of the obstructing stones produced normalization of the CA 19.9 in each case even with long-term follow-up up to one year. All pathology specimens were interpreted as benign.

CONCLUSIONS

Marked elevations of CA 19.9 may be found in benign obstructive disease and should be interpreted with caution until biliary obstruction is relieved.

[Quality of life of patients with gallstone disease and gallbladder cholesterosis in the conservative and surgical treatment]

OBJECTIVE

to investigate the quality of life of patients with gallstone disease and gall bladder cholesterosis on a background of conservative therapy and after surgery.

MATERIALS AND METHODS

the study involved 60 patients with GSD and GBC treated conservatively, 75 patients with GSD and GBC treated surgically, the control group - 35 men aged of 20,6 +/- 1,2. A survey using questionnaires GIC, SF-36, ultrasound, radiography, CT of the abdomen, cholecystography, examined the range of blood lipids.

RESULTS

reduction in QOL in the CL was detected in 92.8% of patients on all scales, progressing during the exacerbation of the disease (58.3%). The overall QOL score was reduced (up to 92,5 +/- 7,0) when compared with CG (346,7 +/- 8,2, p <0,001) and the maximum score (410.0). Conservative therapy improves the QOL of patients with gallstone disease in 50.7% of cases at all scales. The overall score increased to 155,9 +/- 5,6, p < 0,001, but remained lower than in the CG. When GBC reduced QOL was found in 75.8% of patients on all scales, progressing during the exacerbation of the disease (40.8%). Contact of worsening QOL with the duration of relapse stable disease (p < 0,001). Conservative therapy improves the QOL of patients with GBC in 54.1% of cases at all scales. The overall score has increased from 51,9 +/- 5,5 to 135,1 +/- 2,6 (p< 0.001), but remained lower than in the CG. QOL of patients with GSD and GBC reduced by all indicators, the GSD to a greater extent. In patients with GSD main factors reducing the QOL are pain (34.5% and 100% in the period of exacerbation of the disease) and non-use of previously familiar food (62.0%) because of fear of pain attack at GBC - emotional quotient (66.9% - thought about the inevitability of surgery and the possibility of malignancy). When GSD QOL of patients before CE decreased (93.6%) to a greater extent than in patients prior to conservative treatment due to the pain factor (65.4%), total score amounted to 86,4 +/- 5,1 and 92,5 +/- 7,0, respectively, p <0.05. The main factors of nuclear explosion-QOL differences were pain attacks (65.4% and 35.7%) and emotional quotient. The factors of higher-QOL after the CE (59.1%) are the elimination of pain attack (100%), normalization of stool. The total score improved from 86,4 +/- 5,1 to 128,4 +/- 6,3, p <0,001, but remained lower than in the CG (p <0,001) and a comparison with the highest scores (p < 0,001). When GBC quality of life of patients before CE decreased (95.1%) to a greater extent than in patients prior to conservative treatment (75.8%) due to emotional factors: the thought of the possibility of malignancy. The total score was 40,2 +/- 5,3 and 51,9 +/- 5,5, respectively, p<0.05. Surgical treatment improves QOL of patients with GBC (61.8%) in all major scales. The total score improved from 40,2 +/- 5,3 to 122,6 +/- 6,0, p < 0,001, but remained lower than in the CG (p < 0,001) and a comparison with the highest scores (p < 0,001).

CONCLUSION

the results allow us to recommend a conservative therapy for cholelithiasis patients as a method of choice in the presence of indications for its place-of. The determining factor is the density of lithotherapy concrement, as measured by CT. In case of impossibility of conservative therapy should prompt surgical treatment of cholelithiasis before the development of irreversible changes in the organs of hepato-pancreatoduodenal system.

[The content of nitrite and N-nitroso compounds of plasma as a diagnostic test of nonspecific inflammation]

The authors' enzymatic sensor was applied to identify the content of nitrite and nitroso compounds of blood plasma in normal condition and under various inflammatory diseases. It is established that in normal conditions blood plasma contains nitrite, N-nitroso compounds (RNNO) and S-nitroso compounds (RSNO) in concentrations less than 100 nm. The plasma pool of nitroso compounds includes basically thiolferous nitrosate ferrum complex in concentration 3-20 microm. The concentration of nitrite in plasma is from 10 to 150 microm. The concentration (nitrite+RNNO) increases dramatically under inflammatory diseases. This indicator was 0.3-1.0 microm in examined patients with acute and chronic pancreatitis, cholecystitis, ENT diseases of inflammatory character and ARD. In the case of acute appendicitis the indicator reached 10 micro. In case of successful treatment the content (nitrite+RNNO) decreased to the concentration lower than 100 nm. The content of other nitrite and N-nitroso compounds had no reliable variations. Because of this, largely implemented evaluation of intensity of nitric oxide production by the aggregate indicator of nitrites content (NO(x)) in blood seems ambiguous. The reason is that in normal conditions nitrite is presented in trace amount and considerable quantity of nitrate can enter the organism in an exogenous way. Besides that the content of nitrite can depend on kidneys filterability. At the same time, based on the obtained data, the content (nitrite+RNNO) in plasma in concentrations higher than 150 nm are definitely to be considered as pathology.

Role of liver function enzymes in diagnosis of choledocholithiasis in biliary colic patients

Liver functional tests due to inflammatory process which induced by cholecystitis might changed and some clinicians suggested that these changes might help us to stone prediction in common bile ducts and decrease hazards of performing ERCP and other invasive procedures. Present study was performed for assessment of role of liver functional test in diagnosis of common bile duct stone in patients with cholecystitis and help in their management. Present prospective study was performed between April 2010 and March 2011 on 350 patients who come to our hospital with cholecystitis or biliary colic diagnosis. Patients with cholesistitis diagnosis were underwent operation for removing gall bladder stone and retrograde cholangiopancreatography (ERCP) was performed for patients with suspicious to biliary colic and common bile duct (CBD) stones. Ultrasonography, aspartate aminotransferases (AST), alanine aminotransferases (ALT), alkaline phosphatase (ALP) and direct and total serum bilirubin were measured for all of participated patients. Mean of AST. ALT, ALP and total and direct bilirubin were had no significant differences between two study groups. In logistic regression analysis, after entering into the model only CBD diameter (OR: 20; P=0.00) and elevated serum level of ALT (OR: 2; P=0.04) were remained into the model and were known as independent predictor of cholelithiasis. Elevated level of liver enzymes had not main role in CBD diagnosis and ERCP had no to perform for suspicious CBD stone only with elevated liver enzyme and even with normal ultrasonography findings. Endosonography as non invasive procedure recommend for patients before ERCP.

Significance of decoy receptor 3 in sera of hepatocellular carcinoma patients

OBJECTIVE

Decoy receptor 3 (DcR3), a member of the tumor necrosis factor receptor superfamily, is amplified and over-expressed in various cancers. The objective of the present study was to investigate the concentration of DcR3 in sera of hepatocellular carcinoma (HCC) patients and its clinical significance.

METHODS

Serum concentrations of DcR3 were measured by enzyme-linked immunosorbent assay (ELISA) in 67 patients with HCC, 8 with liver cirrhosis, 17 with cholecystitis, and in 28 healthy individuals. Immunohistochemistry was employed to access protein expression of DcR3 in the corresponding HCC tissues.

RESULTS

Serum concentrations of DcR3 in patients with HCC or cirrhosis were significantly higher than in healthy individuals (P < 0.01). Moreover, serum concentrations of DcR3 in HCC patients were associated with TNM stage, para-cirrhosis, capsular infiltration, and metastasis or recurrence of disease (P < 0.05). There was a positive correlation between the serum concentration of DcR3 and protein expression in HCC tissues (r = 0.472, P < 0.01).

CONCLUSIONS

The high serum concentration of DcR3 might play a certain role in pathogenesis, progress, and metastasis of HCC. Moreover, DcR3 might serve as a valuable molecular indicator in early diagnosis and contribute to predicting the clinical outcome in HCC patients.

'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.

[Application of chromatography methods for the diagnostics of systemic inflammation]

Specific manifestations of systemic inflammation in patients with acute destructive cholecystitis in the postoperative period were studied by the methods of high-precision exclusive liquid chromatography with chromatograph "Trirotar" (Japan) with columns "Polysep G-5", "Toyopearl-Sw - 2000-2500". It was found that systemic inflammation was accompanied by active accumulation of middle- and low-molecular mass. Later their spectrum was found to change when going over to unfavorable clinical course. In patients with septic shock there occurred enrichment of the chromatographic picture spectrum with new peaks (substances which can be considered as endotoxins), decrease of the albumin concentration, as well as increase of dispersity of the biochemical composition of blood.

[Possibility of correction of the lipid disorders in patients with cholelithiasis and gallbladder cholesterosis]

OBJECTIVE

To evaluate the possibility of incorporating organic drugs Hepatosan and Entherosan in the complex therapy of patients with gallstone disease and gall bladder cholesterosis (reticulated polypus form) on the basis of literature data and own research.

RESULTS

It has been found that the physiological effect of drugs Entherosan and Hepatosan is directed on the improvement cavity and wall digestion processes, that leads to the reduction (disappearance) of dyspeptic symptoms (eliminating discomfort in the epigastrium, bloating, diarrhea) in most of the patients. The main features of Entherosan are: normalization of gastro-intestinal tract motor activity, intestinal microflora, enteroprotective effect of the drug and its influence on intestinal and cellular pools of cholesterol that leads to the activation of cavitary and parietal digestion. The essential point of Hepatosan is to stimulate 7alpha-hydroxylase, resulting in strengthening of cholesterol oxidation and to an increase the pool of LCD in enterohepatic circulation. This factor, coupled with hepatoprotective action of the drug, ensures the deletion of biliary insufficiency.

CONCLUSION

The incorporation of drugs Entherosan and Hepatosan in the complex conservative therapy of cholelithiasis and reticulated polypus forms of gall bladder cholesterosis is pathogenetically substantiated.

[Serum iron level in the patients with inflammatory abdominal diseases]

In our study we investigated serum iron levels in the patients with localized or generalized peritonitis. These values were compared in group of 52 patients with acute peritonitis against group of 39 patients without inflammation within peritoneal cavity. The serum iron levels and Total Iron Binding Capacity (TIBC) was indicated in both group. Acute intraabdominal inflammation induced in all patients a state of hypoferremia. However, medium decline of iron level in patients with acute appendicitis or cholecystitis was smaller compare with that observed among the patients with generalized peritonitis caused by perforation of duodenal ulcer, perforation of large bowel diverticula or perforation of small bowel. It has been suggested that decline in iron serum level observed in those patients can be an element of metabolic response to trauma and represents a part of the innate immune system and thus constitutes the first line defence against infection. However, based on presently available knowledge we can not yet finally evaluate the clinical implication of serum iron monitoring in diagnosis and prognosis of the patients with peritonitis.

[Toxic plasma concentration of clozapine in inflammatory processes]

Clozapine has a narrow therapeutic range. The threshold value for plasma concentrations is 350 μg/l. If plasma concentrations exceed that value, serious side-effects can occur. An increase in plasma concentrations can occur as a result of inflammatory processes which may or may not be caused by an infection. Two cases are discussed in which the plasma concentration of clozapine increased as a result of an inflammatory reaction and signs of intoxication were observed. These developments seemed to be due to cholecystitis and bacterial pneumonia respectively. The clinical presentation and pathophysiology are discussed in relation to inflammatory processes.

[Lithogenicity of bile and serum lipoproteins (A) in cholelitiasis in women]

Blood serum Lp (a) level's increasing accompanied significant rising of gallbladder bile lithogenicity in the women with gallstone disease (GSD) with verified cholesterol gallstones. Apolipoprotein (a) (Apo (a)) isoforms B, S1 (most atherogenic) frequency in the women with GSD was significantly higher, and isoforms Apo (a) 0, S4 - significantly lower than in the women in control group without GSD. Gallbladder bile was significantly more lithogenic in the women with GSD who had Apo (a) B and S1 isoforms than in women with GSD with isoforms Apo (a) 0 and S4.

[Immunoglobulin G4-associated diseases of the digestive system--new problem in gastroenterology]

This review presents the latest information on new clinical and pathological syndrome in gastroenterology, forming the foundation of which is tissue infiltration of IgG4-positive plasma cells. Considered clinical variants of IgG4-associated diseases of the digestive system: IgG4-associated cholecystitis, holangita and autoimmune pancreatitis.

[Comparative estimation of traumaticity of laparoscopic and open cholecystectomy according to objective methods of investigation]

The results of clinic-laboratory investigations were adduced, which confirm objectively the lesser traumaticity of laparoscopic cholecystectomy (LCE) in comparison with open cholecystectomy in patients, suffering an acute cholecystitis. While investigation of the patients blood serum, in whom LCE or open cholecystectomy was performed, using laser correlation spectroscopy (LCS), and performance of malonic dialdehide and dienic conjugate content determination, more rapid restoration of homeostasis parameters was proved after LCE, trusting its lesser traumaticity.

Gallbladder Mass with a Carbohydrate Antigen 19-9 Level in the Thousands: Malignant or Benign Pathology? Report of a Case

Tumor markers such as carbohydrate antigen 19-9 (CA 19-9) are commonly measured in the serum of patients with suspected pancreaticobiliary malignancies. Moderate elevations of CA 19-9 may be seen in benign disease, but levels in the thousands are indicative of malignancy. We report the case of a 64-year-old man with an elevated CA 19-9 of 5791 U/ml and radiological findings suggestive of metastatic gallbladder carcinoma. The patient underwent cholecystectomy and excision of a common bile duct stricture, with hepaticojejunostomy and liver biopsy. The final surgical pathology was consistent with xanthogranulomatous cholecystitis (XGC) and the elevated CA 19-9 returned to normal postoperatively. Thus, an elevated CA 19-9 level, even in the thousands, should not preclude patients from an operation if a mass is deemed resectable. Thorough investigation and treatment may result in a curative operation even if unresectable malignant disease is initially suspected.

[Clinical significance of the functional and structural changes in the intestines in chronic cholecystitis]

The aim of the study was to determine the clinical significance of intestinal functional and structural alterations in biliary pathology. Clinical, endoscopic, morphological, and morphometric methods were used. The subjects of the study were 62 patients with functional gall bladder disorder, 90 patients with chronic calculous cholecystitis, and 90 patients who had undergone cholecystectomy for cholelithiasis. The study found that biliary lithogenesis was associated with intestinal dysbiosis, changes in the qualitative density of erythrocytes immunopositive to motilin and substance P, and inflammatory changes in the intestines. After cholecystectomy, changes in intestinal microecology progressed, inflammatory and atrophic changes in the intestinal mucosa appeared or deepened, the qualitative density of erythrocytes immunopositive to motilin and substance P decreased, and colon polyps appeared more frequently.

[Effect of ursodeoxycholic acid on the characteristics of lipid metabolism in cholelithiasis and gall-bladder cholesterosis]

The article represents data demonstrating influence of ursodeoxicholic acid on the characteristics of lipidic interchange during cholesterin assosiated diseases of biliary tract. It has been shown that hypercholesterolemias occur in 64% of cases under cholelithiasis and in 56% of cases under gall-bladder cholesterosis. Slow rising of level of total cholesterol (within 5.3-6.1 mmole/l) is registered in 68% of cases under cholelithiasis and in 69% of cases under gall-bladder cholesterosis, higher hypercholesterolemia occurs rare and doesn't exceed 2-4% of cases. Disappearance of hypercholesterolemia after 3-month course of treatment with Ursosan has been registered in 45% of patients with cholelithiasis and in 49% of patients with gall-bladder cholesterosis. Other patients showed positive dynamics, and level of total cholesterol made up in general 5.6 mmoles/l under cholelithiasis and 5.4 mmoles/l uder gall-bladder cholesterosis.

Obstructive cholelithiasis and cholecystitis in a keeshond

A 10-year-old, neutered male, keeshond was presented for vomiting, lethargy, icterus, and anorexia. Obstructive cholelithiasis was diagnosed based on analysis of a serum biochemical profile, abdominal radiographs, and ultrasonography. Choleliths were removed from the gall bladder and common bile duct via a cholecystotomy.

Abdominal manifestations in childhood-onset systemic lupus erythematosus

BACKGROUND

Childhood-onset lupus erythematosus is a rare disorder of unknown origin.

OBJECTIVES

To describe the frequency of gastrointestinal manifestations at presentation of systemic lupus erythematosus SLE and at follow-up, and discuss the specific causes of these manifestations.

METHODS

Medical records of 201 patients with childhood-onset SLE followed up in French paediatric nephrological, haematological and rheumatological centres were reviewed and abstracted for gastrointestinal manifestations.

RESULTS

Gastrointestinal involvement was recorded in 39 (19%) children. The median (range) age at the time of initial gastrointestinal manifestations was 11.3 (4.5-16) years. Gastrointestinal symptoms were present at or occurred within 1 month after diagnosis in 32% patients. Abdominal pain was the most frequent symptom, present in 34 (87%) patients. It was mostly related to lupus involvement, especially ascites (n = 14) and pancreatitis (n = 12), more rarely to treatment-induced events (n = 1) or infection (n = 1) and never to events unrelated to SLE. Three children with surgical abdomen underwent a laparotomy before SLE was diagnosed, with a final diagnosis of lupus peritonitis and lupus acalculous cholecystitis. C reactive protein values were <40 mg/l in all but two patients who had surgical abdomen. Abdominal ultrasonography and computed tomography scans were abnormal in 58% and 83% of the evaluated patients, respectively. Corticosteroids, associated with intravenous cyclophospamide in eight patients, led to complete remission of gastrointestinal involvement in 30 of 31 treated patients.

CONCLUSION

Gastrointestinal involvement is common in children with SLE, and is mainly due to primary lupus involvement. Corticoidsteroid treatment should be promptly considered in children with lupus presenting with abdominal pain after infectious disease; side effects of treatment and intestinal perforation have been excluded.

Pitfalls and problems of relying on serum troponin

Cardiac troponin (cT) is released after myocardial damage. In the appropriate clinical setting, a measured elevation of cT can increase the diagnostic rate of myocardial infarction and acute coronary syndrome. Elevations of cT, however, can occur in a wide variety of other clinical situations. Failure to recognize this can lead to an over-diagnosis of myocardial infarction (MI). We present clinical cases from our institution that illustrate this diagnostic problem, and review similar cases in the literature. We also discuss the implications of an erroneous diagnosis of myocardial infarction, for the patient and for the health services.

[Haemocholecyst: a rare complication of anticoagulant treatment]

We report a case of a 50-year-old woman, taking antivitamin K for double mitro-aortic valvular replacement, having presented a clinical picture of acute cholecystitis with marked hypotension. The radiological and biologic exams showed a deep hypocoagulability, vesicular gallstones, a haemoperitoneum and retroperitoneal haematoma. After correction of biological anomalies, the patient was operated. The gallbladder was distended containing large clots and four stones without any evidence of perforation. One of the gallstones led to cystic duct obstruction. Haemocholecyst is a rare complication of anticoagulant therapy, which may occur in the setting of gallbladder stones. The usual complication was the vesicular perforation. In spite of its rarity, haemocholecyst should be suspected when an anticoagulant treated patient presents symptoms of acute cholecystis with or without haemorrhagic shock.

Changes in the blood coagulation, fibrinolysis, and cytokine profile during laparoscopic and open cholecystectomy

BACKGROUND

It has long been known that a hypercoagulability state develops after surgery. A surge in circulating cytokine levels is also commonly found in the postoperative period. These cytokines have all been shown to be capable of inducing a hypercoagulability state. Recently laparoscopic cholecystectomy (LC) has been introduced, and its advantages over the open procedure seem related to the reduced surgical trauma. LC is associated with a diminished acute-phase response compared with the open procedure. Our present knowledge on the influence of laparoscopic upon coagulation and fibrinolysis is incomplete and based on a few studies.

METHODS

The aim of this prospective, nonrandomized study was to investigate hemostatic system alterations in patients who undergo open and laparoscopic cholecystectomy. In addition we also measured the plasma cytokine profile to explore any relationship between changes in plasma cytokine levels and postoperative coagulation profile. Between September 1999 and April 2002, 71 patients were nonrandomly assigned to open (group 1) or laparoscopic cholecystectomy (group 2). All patients from group 1 were operated by a surgical team different from ours, who prefers the OC procedure. The patients with acute cholecystitis were excluded. Prothrombin fragment 1.2 (F1.2), thrombin-antithrombin (TAT), fibrinogen, soluble fibrin, antithrombin III (AT), protein C, plasminogen, and D-dimer levels were measured at baseline and at 1, 24, 48, and 72 h postoperatively. Serial serum levels of IL-1beta and IL-6 were measured by colorimetric enzyme-linked immunosorbent assay (ELISA).

RESULTS

Plasma levels of F1.2, TAT, fibrinogen, soluble fibrin, and D-dimer increased significantly in group 1. Plasma levels of AT, protein C, and plasminogen decreased in both groups. In the OC group, the serum IL-3 and IL-6 levels began to significantly increased as early as 1 h from the beginning of the operation, revealing a peak at the sixth hour. When IL-6 and IL-1 levels were markedly elevated also, F1.2, fibrinogen, and soluble fibrin levels were increased.

CONCLUSIONS

Only mild hypercoagulability was observed in patients who had undergone laparoscopic cholecystectomy. The cytokine surge was correlated with hypercoagulability. There was in fact a positive correlation between IL-6 level and hypercoagulability. The correlation between cytokine levels and coagulation activation may be related to the type of surgery performed. Further studies are required to investigate these issues.

[Biochemical characteristics of hepatic functions in different clinical forms of chronic opisthorchiasis]

The main biochemical indices of hepatic functions (the activities of alanine aminotransferase, aspartate aminotransferase, gamma-glutamyl transferase, alkaline phosphatase, alpha-amylase, choline esterase and the concentrations of total bilirubin, cholesterol, and glucose) were studied in the sera of 256 patients with chronic opisthorchiasis. It was found that with diseases manifested in different clinical forms (cholangitis, cholecystitis, cholangiocholecystitis, cholangiohepatitis, cholecystitis in combination with pancreatitis), most study indices are within the normal ranges, but significantly differ from the means in a group of apparently healthy individuals. The findings suggest that such clinical forms of opisthorchiais as cholangiocholecystitis and cholangiohepatitis are characterized by manifestations of cytolysis and cholestasis, as cholecystitis is manifested by cytolysis, as cholecystitis in combination with pancreatitis, by cholestasis, and as cholangitis, by cholestasis and hepatic cell insufficiency. It is possible that further studies will provide evidence for how to correct detected disorders during pathogenetic therapy.

[Specifics of sub-fractional serum composition in patients with acute cholecystitis depending on the gallbladder destruction degree]

Subfractional composition of the blood serum proteins was studied up in 120 patients with an acute cholecystitis. Using laser-correlational spectroscopy it is possible to perform differential diagnosis of destructive and nondestructive forms of an acute cholecystitis with 78-80% trustworthiness, what may be applied for express-diagnosis and for conduction of further diagnostic and medicinal measures.

[Ultrastructural and morphometric characteristics of neutrophilic granulocytes of blood]

Ultrastructural and morphometric characteristics of neutrophilic granulocytes (NG) of blood were investigated. It was found that every cell size fraction distinguished by its own morphologic type of NG and its specified quantitative and qualitative characteristic of primary granules. There is a close interrelation between morphometric and ultrastructural characteristics, and such parameters as perimeter, area of NG, and area of primary granules can be considered as criteria of the NG functional state.

Oxidative stress before and after operation in patients with chronic cholecystitis containing gallstone

To study the relationship of oxidative, antioxidative constituents and antioxidases in blood with chronic cholecystitis containing gallstone, levels of lipoperoxides (LPO), nitric oxide (NO), vitamin C(VC), vitamin E (VE) and beta-carotene (beta-CAR) in plasma as well as level of LPO, activities of superoxide dismulase (SOD), catalase (CAT) and glutathione peroxidase (GSH-Px) in erythrocytes were investigated by spectrophotometric assay in 107 patients with this condition (PCg) and 100 healthy volunteers (HVs). Compared with HVs group, the average value of LPO and NO in plasma and that of LPO in erythrocytes of PCg group were significantly increased (P < 0.0001), while that of VC, VE and beta-CAR in plasma and the average activities of SOD, CAT and GSH-Px in erythrocytes were significantly decreased (P < 0.0001). Linear regression and correlation analysis for 107 preoperative PCg showed that the value of LPO and NO in plasma and that of LPO in erythrocytes of PCg gradually increased (P < 0.0001), representing a significant linear positive correlation. The value of VC, VE and beta-CAR in plasma and that of SOD, CAT and GSH-Px in erythrocytes of PCg gradually decreased (P < 0.0001), representing a significant linear negative correlation. Stepwise regression and correlation analysis for 107 preoperative PCg suggested that the closest correlation was observed between the course of disease and the value of NO and VC in plasma and that of SOD, GSH-Px and LPO in erythrocytes, r = 0.7306, F = 32.1408, P < 0.0001. Compared with the preoperative PCg group, the average value of LPO and NO in plasma and that of LPO in erythrocytes of the postoperative PCg group were significantly decreased (P < 0.0001). Furthermore, the average value of VC in plasma and that of SOD, CAT and GSH-Px in erythrocytes of the postoperative PCg group were significantly increased (P < 0.0001), whereas no significant difference was found between their average value of VE and beta-CAR in plasma. These findings suggested that oxidative stress was an aggravating pathological condition in PCg group. Therefore, we recommend that in treating PCg, antioxidants such as VC, VE, beta-CAR should be given in order to alleviate their potential oxidative damages.

Preoperative evaluation to predict technical difficulties of laparoscopic cholecystectomy on the basis of histological inflammation findings on resected gallbladder

BACKGROUND

No papers have heretofore documented histological studies of cases involving the inflammation of resected gallbladder or examined surgical difficulties on the basis of pathological findings.

METHODS

On the basis of the histological inflammation findings on the resected gallbladders of 437 patients who underwent laparoscopic cholecystectomy (LC), the factors affecting the technical difficulty of the operation were examined through preoperative clinical findings (13 items), diagnostic imaging (22 items), and blood test findings (6 items), using multivariate analysis.

RESULTS

In accordance with the four-stage classification of inflammation findings for the resected gallbladder, the inflammation findings on the resected gallbladder indicated a higher correlation with the time required for gallbladder dissection (30.2 +/- 16.3 minutes) than with the operation time (77.6 +/- 32.7 minutes). Thus, the technical difficulty of the operation was judged according to the time required for gallbladder dissection. For the preoperative findings on 418 patients who underwent successful LC, the most influential factors on the time required for gallbladder dissection were the presence of abnormal findings on computed tomography, the degree of fever, obesity index, nonvisualized gallbladder cholangiography, and cystic duct length. According to the multiple regression equation of these five factors, the gallbladder dissection for the 19 patients who underwent conversion to open cholecystectomy (OC) due to extreme inflammation was calculated to require 61.9 +/- 12.3 minutes, and the patients who showed a gallbladder dissection time longer than 49.6 minutes were judged to have high technical difficulty predicted from the preoperative evaluation. In the preoperative evaluation, sensitivity was 79.6%, specificity was 97.6%, accuracy was 95.0%, positive predictive value was 85.0%, and negative predictive value was 96.6%. Next, each finding was scored on the basis of a multiple regression equation of five factors, and the technical difficulty of the operation was quantified using these scores. The score of the patients who underwent conversion to OC was 8.0 +/- 2.0, and the patients who showed a score higher than 6 were judged to have high technical difficulty. Almost the same results as in the aforementioned preoperative evaluation were obtained using these scores.

CONCLUSION

The judgment using the scores was satisfactory in terms of the simplicity of evaluating the technical difficulties associated with each patient and the ease of obtaining information for each factor. The quantification of technical difficulty using the scores is useful for preoperative prediction of which patients will have difficulties in gallbladder dissection and the conversion to OC in LC. Our results suggest that the consideration of technical difficulties is important for conducting safe operations with avoiding intraoperative complications.

[The effect of combined therapy with a salt solution of Poltava bischofite on the clinical status, adaptive hormone level and blood rheology in patients with ischemic heart disease and chronic inflammatory diseases of the liver and gallbladder]

Efficiency has been studied of a combined treatment involving the use of mineral baths with the brine of bischofite Poltavsky. Bischofite is a natural efficacious preparation, low-cost, it is easily obtainable. The Poltava lands abound in bischofite deposits.

Open and laparoscopic cholecystectomy in acquired immunodeficiency syndrome: indications and results in fifty-three patients

BACKGROUND

Although acute cholecystitis is one of the most common indications for abdominal surgery in patients with acquired immunodeficiency syndrome (AIDS), previous studies have reported disappointingly high morbidity and mortality among those patients who have undergone cholecystectomy. The aims of this study were to analyze the indications for and the outcome of cholecystectomy performed for acute cholecystitis in patients with AIDS.

METHODS

We retrospectively reviewed the hospital charts of 53 patients with AIDS who underwent open or laparoscopic cholecystectomy from 1992 to 1997. Statistical analysis using the chi-square, Student's t, and Fisher exact tests was conducted to determine whether cause of cholecystitis, type of surgical approach, and CD4+ T-lymphocyte count influenced outcome.

RESULTS

The clinical findings and imaging by ultrasonography were always reliable in establishing diagnosis and guiding treatment of acute cholecystitis. Open cholecystectomy was performed in 24 patients (45%). The procedure was begun laparoscopically in 29 patients (55%) and converted to open in 4 (14%). The pathologic findings showed acalculous cholecystitis in 19 patients (36%) and cholelithiasis in 32 (60%). Morbidity was 34% and mortality was 2%. Type of operative approach, cause of cholecystitis, and CD4+ T-lymphocyte count (greater or less than 50 cells/mm3) did not significantly affect morbidity and mortality. The length of hospital stay was significantly influenced by the CD4+ T-lymphocyte count.

CONCLUSIONS

These findings suggest that in most patients with AIDS, laparoscopic or open cholecystectomy may be performed with significant but acceptable morbidity and low mortality.

[Functional-metabolic activity of leukocytes in patients with cholecystitis]

Functional condition of basic components of the microbicidal system (cation protein myeloperoxidase, acid phosphatase) and spontaneous NB-test of neutrophylic leukocytes' activity values were studied with the aid of cytochemical methods in 175 patients: with acute cholecystitis (133) and exacerbation of chronic one (42). As a result of performed examinations various changes of intraleukocytic components and activity of spontaneous HB-test, of neutrophils were established, which depended on phase, severity of the disease and morphological changes and manifestations of pathological process. The determined changes of intracellular components and activity of spontaneous HB-test values of leukocytes in patients with acute and chronic cholecystitis demonstrate the tension of nonspecific reactivity of the organism.

[The antioxidant system of patients with chronic inflammatory liver diseases after exposure to ionizing radiation]

Commonly seen in liquidators of the effects of the Chernobyl accident are affections of the liver (chronic hepatitis) and bile tract (chronic calculous cholecystitis) accompanied by IHD. The above patients demonstrate enhancement of the antioxidant defence in the blood with the values for free-radical peroxidation remaining unchanged. Absolute values for blood content of LTV4 in chronic active hepatitis were found out to be low, which fact suggests that such patients need to be kept under periodic oncological surveillance.

[Clinical study on plasma beta-endorphin levels in patients with wetness-heat zheng of the liver and gallbladder]

The plasma concentrations of beta-endorphin was determinated by radioimmunoassay in 75 patients with Wetness-Heat Zheng of Liver and Gallbladder, 23 patients with Insufficient Liver Zheng, 13 patients with Insufficient Spleen Zheng and 30 healthy subjects (control group). Compared with the control group, the plasma beta-EP levels were increased in Wetness-Heat Zheng of Liver and Gallbladder and Insufficient Liver Zheng. The patients with different diseases that were diagnosed to be Wetness-Heat Zheng of Liver and Gallbladder presented high levels of plasma beta-EP. It is suggested that the plasma beta-EP is an important change in the syndrome of Wetness-Heat Zheng of Liver and Gallbladder, and may be used as a diagnostic index.

Lack of neurohumoral response to pneumoperitoneum for laparoscopic cholecystectomy

BACKGROUND

Pneumoperitoneum (PP) for laparoscopic surgery induces prompt changes in circulatory parameters. The rapid onset of these changes suggests a reflex origin, and the present study was undertaken to evaluate whether release of vasopressor substances could be responsible for these alterations. The influence of two different anesthesia techniques was also evaluated.

METHODS

American Society of Anesthesiologists (ASA) class I patients, scheduled for laparoscopic cholecystectomy, were investigated. The first group (n = 10) was anesthetized intravenously. The second group (n = 6) had inhalation anesthesia. Plasma vasopressin, catecholamines, and plasma renin activity were investigated as neurohumoral vasopressor markers of circulatory stress. The general stress response to surgery was assessed by analysis of plasma cortisol.

RESULTS

Induction of pneumoperitoneum caused no apparent activation of vasopressor substances, although several hemodynamic parameters responded promptly.

CONCLUSION

The hemodynamic alterations, seen at the establishment of PP during stable anesthesia, cannot be explained by elevation of vasopressor substances in circulating blood.

[Intravascular blood coagulation in patients with acute destructive cholecystitis with paravesical infiltration]

Data are submitted on changes in the system of regulation of the aggregate state of blood, that result in the development of the second stage of intravascular hemocoagulation syndrome in patients with destructive forms of cholecystitis presenting with paravesicular infiltration in the preoperative period. Disruptions in hemostasis remain after surgery, which fact attests to the need for working out efficient pathogenetically validated methods of correction thereof for the combined treatment of the pathology in question to be raised to a much higher level.

[The indices of lipid metabolism in the blood plasma of patients with chronic calculous cholecystitis]

AIM

The study of lipid fraction spectrum in plasma of patients with chronic calculous cholecystitis (CCC) before and after the operative intervention.

MATERIALS AND METHODS

28 female patients with CCC. Plasma lipids were measured before the operation, 1 and 5 days after it, at the discharge from hospital and in healthy donors.

RESULTS

Before the operation blood concentrations of total lipids, triacylglycerins, phosphatidylcholine and phosphatidylethanolamine were elevated. Cholesterol, lisophosphatidylcholine and sphingomyelin, cholesterol/phospholipids ratio were subnormal. The same changes of the lipids persisted 1 and 5 days after the surgery and at discharge.

CONCLUSION

Plasma lipids in CCC patients are not corrected early after the surgery and require drug correction.

Influence of diagnostic and treatment factors in the population pharmacokinetics of gentamicin

Using the NONMEM program, the population kinetics of gentamicin were retrospectively studied in a series of 51 patients with different pathologies undergoing treatment (single or three daily doses) with gentamicin whose serum gentamicin levels were being monitored. Renal function, the type of treatment and cancer proved to be the covariates which affected drug clearance, while patient weight was found to govern the distribution volume. The distribution coefficient of gentamicin in the patients was 0.37 litres/kg, justifying gentamicin doses higher than those used conventionally. The optimized population model allowed us to simulate drug serum levels at 8 and 12h, as well as the area under the curve of gentamicin and its variability in patients with high distribution volumes when dosage regimens based on a single daily dose administration are implemented.