
1: Medicina (Kaunas). 2008;44(12):969-76.

Percutaneous transhepatic biliary stenting: the first experience and results of
the Hospital of Kaunas University of Medicine.

Dambrauskas Z, Paskauskas S, Lizdenis P, Uktveris R, Pranculis A, Kaupas RS,
Barauskas G, Pundzius J.

Department of Surgery, Kaunas University of Medicine, Eiveniu 2, 50009 Kaunas,
Lithuania. zilvinas.dambrauskas@gmail.com

Malignant biliary obstruction may be caused by cholangiocarcinoma and other
nonbiliary carcinomas. At the time of diagnosis, 90% of patients with malignant
obstructive jaundice may benefit from palliative treatment only. The objective of
palliation is to relieve jaundice-related symptoms, prevent cholangitis, prolong 
survival, and improve quality of life. Percutaneous transhepatic biliary stenting
is a well-established procedure used in patients with malignant obstruction of
intra- and extrahepatic bile ducts. Twelve patients (9 women, 3 men; mean age, 68
years; range, 44-88 years) with inoperable malignant biliary obstruction were
selected for percutaneous transhepatic biliary stenting with metallic stents in
the period from January to December 2007. Technical and clinical success rate in 
this patient series was 83% and 80%, respectively. Minor and major complications 
occurred in 17% and 8% of cases, respectively, which is in the range reported by 
the others. This is our first experience of percutaneous transhepatic biliary
stenting at the Hospital of Kaunas University of Medicine and, to our knowledge, 
the first reported patient series in Lithuania. These first results encourage
expanding effective palliation by the employment of the percutaneous transhepatic
biliary stenting in patients with nonresectable malignant biliary obstruction or 
in case of a recurrent disease after curative surgery. The cost effectiveness of 
percutaneous transhepatic biliary stenting against percutaneous transhepatic
biliary drainage has yet to be evaluated in a prospective manner. However,
immediate clinical benefits and positive short-term outcomes are unequivocal.

PMID: 19142055 [PubMed - indexed for MEDLINE]

2: J Gastrointest Cancer. 2007;38(1):28-31.

Duodenal MALT lymphoma presenting with obstructive jaundice: report of a case and
review of the literature.

Usmani SZ, Ding L, Abu-Rashed AH, Saleh HA.

Department of Hematology-Oncology, University of Connecticut Health Center,
Farmington, CT, USA.

BACKGROUND: Mucosa-associated lymphoid tissue (MALT) lymphoma is a rare type of
non-Hodgkin's lymphoma. The most common site for MALT lymphoma is the stomach.
CASE REPORT: We are reporting a case of a 57-year-old man who presented with
obstructive jaundice and was found to have duodenal MALT lymphoma. Unlike gastric
MALT lymphoma which is responsive to Helicobacter pylori eradication therapy,
duodenal MALT lymphoma does not have a definitive treatment. DISCUSSION: To our
knowledge, this is the first report of a duodenal MALT lymphoma presenting
clinically as obstructive jaundice. We describe this case to alert physicians to 
consider this disease in the differential diagnosis of obstructive jaundice.

Publication Types: 
    Case Reports

PMID: 19065720 [PubMed - indexed for MEDLINE]

3: J Pak Med Assoc. 2008 Nov;58(11):616-21.

Jaundice in falciparum malaria; changing trends in clinical presentation--a need 
for awareness.

Ahsan T, Ali H, Bkaht SF, Ahmad N, Farooq MU, Shaheer A, Mahmood T.

Department of Medicine, Jinnah Poastgraduate Medical Centre, and Postgraduate
Training Institute, Karachi, Pakistan.

OBJECTIVES: To describe the clinical characteristics, laboratory parameters and
prognostic factors in patients with falciparum malaria (FM) with jaundice.
METHODS: A cross-sectional comparative study was conducted at the Department of
Medicine, medical unit II, Jinnah Postgraduate Medical Centre, Karachi. Adult
patients with jaundice and smear positive plasmodium falciparum infection, who
fulfilled the inclusion criteria were selected for the study from amongst all
cases of FM who presented during the study period. Patients were divided in to
two groups on the basis of rising bilirubin and adverse outcome. The data was
analyzed on SPSS ver 12. Results were expressed as, percentages, mean and
standard deviations. P-value < 0.05 was taken as significant. RESULTS: Among 76
patients of FM, 35 (46.05%) developed jaundice. Fifteen (42.86%) patients had
bilirubin 3-10 mg/dl while 20 (57.14%) had bilirubin > 10 mg/dl. Comparative
analysis of the groups showed that elevation of ALT and AST was modest in
comparison with conjugated hyperbilirubinaemia while prolonged duration of illnes
impaired consciousness, hepatomegaly, acute renal failure with deranged renal
parameters, low platelet counts and high parasite density were significantly
associated with rising bilirubin and adverse outcome. Twenty-one (60%) patients
recovered completely while 14(40%) succumbed to the disease. CONCLUSION: FM is
one of the causes of severe jaundice in adults in this part of the world. This
presentation of complicated FM needs to be recognized globally in order to
institute prompt and specific therapy. Delayed diagnosis and inappropriate
treatment is the leading cause of complications and increased mortality in FM.

Publication Types: 
    Comparative Study

PMID: 19024133 [PubMed - indexed for MEDLINE]

4: Bull Exp Biol Med. 2008 Jan;145(1):33-6.

Relationship between parameters of lipid peroxidation during obstructive jaundice
and after bile flow restoration.

Dudnik LB, Tsupko AN, Shupik MA, Akhaladze GG, Galperin EI, Latonova LV, Pantaz
EA, Alessenko AV.

E. M. Emanuel Institute of Biochemical Physics, Russian Academy of Sciences.
ibd@sky.chph.ras.ru

Restoration of bile flow after 9-day cholestasis in rat liver normalized the
content of lipid peroxidation products. The removal of the cholestatic factor
after 12-day cholestasis was not followed by recovery of these parameters. We
showed that measurement of serum concentration of lipid peroxidation products in 
patients with cholelithiasis during the preoperative period holds promise for
selection of the optimum time for surgical treatment and prediction of the risk
of postoperative complications.

PMID: 19023996 [PubMed - indexed for MEDLINE]

5: Ann Pharmacother. 2008 Dec;42(12):1887-92. Epub 2008 Nov 18.

Successful treatment of fosinopril-induced severe cholestatic jaundice with
plasma exchange.

Chou JW, Yu CJ, Chuang PH, Lai HC, Hsu CH, Cheng KS, Peng CY, Chiang IP.

Division of Gastroenterology and Hepatology, Department of Internal Medicine,
China Medical University Hospital, Taichung, Taiwan.

OBJECTIVE: To describe a case of fosinopril-induced severe cholestatic jaundice
successfully treated with plasma exchange. CASE SUMMARY: A 78-year-old Taiwanese 
male presented with yellowish skin and generalized itching one month after
starting fosinopril 10 mg once a day. Other drugs taken by the patient were
excluded as the probable cause of jaundice. Diagnostic modalities, including
abdominal ultrasound, computed tomography, and endoscopic retrograde
cholangiopancreatography, revealed no evidence of biliary tract obstruction or
intraabdominal tumor. According to the Council for International Organizations of
Medical Science (CIOMS) scale, fosinopril was a highly probable cause of the
patient's jaundice. Liver biopsy showed cholestasis without bile duct damage.
Based on results of the CIOMS scale assessment and pathological characteristics
of the liver, the diagnosis was highly probable that fosinopril had induced
cholestatic jaundice in our patient. During hospitalization, the patient
developed severe jaundice and liver failure, despite conservative treatment and
withdrawal of fosinopril. He underwent a 5-day course of plasma exchange therapy,
and the serum bilirubin level declined rapidly after treatment. His liver
function returned to normal 2 months after treatment. DISCUSSION:
Angiotensin-converting enzyme (ACE) inhibitor-induced hepatotoxicity is rare and 
only a few cases, with most involving captopril, have been reported in the
English-language literature. Hepatotoxicity caused by fosinopril is extremely
rare. Most ACE inhibitor-induced hepatotoxicity is mild and transient, but it can
be fatal. Although orthotopic liver transplantation (OLT) is the standard method 
for treating drug-induced liver failure, plasma exchange therapy is an
alternative therapeutic method or a bridge to OLT for treating liver failure.
CONCLUSIONS: Plasma exchange therapy may play a valuable role in the treatment of
fosinopril-induced cholestatic jaundice and liver failure. This intervention can 
be considered for temporary liver support until recovery or OLT.

Publication Types: 
    Case Reports

PMID: 19017832 [PubMed - indexed for MEDLINE]

6: World J Surg Oncol. 2008 Nov 11;6:120.

Lung adenocarcinoma presenting as obstructive jaundice: a case report and review 
of literature.

Pericleous S, Mukherjee S, Hutchins RR.

Department of HPB Surgery, Imperial College, Hammersmith Hospital campus, London,
UK. s.pericleous@imperial.ac.uk

BACKGROUND: Lung cancer is known to metastasize to the pancreas with several case
reports found in the literature, however, most patients are at an advanced stage 
and receive palliative treatment. CASE PRESENTATION: We describe the case of a 56
year old male patient who presented with a picture of obstructive jaundice.
Investigations revealed an obstructing lesion in the pancreas and a further
lesion in the lung with benign appearances. The patient underwent a
pancreatectomy and, unexpectedly, the histology of the resected specimen
demonstrated metastatic adenocarcinoma of bronchogenic origin. He was referred to
a cardiothoracic team who proceeded to resect the patient's thoracic lesion
before administration of adjuvant chemotherapy. The patient was reviewed 18
months post operatively and remains symptom free with no clinical or radiological
evidence of recurrence. We were unable to identify any previous case reports (of 
lung adenocarcinoma) with such a presentation which were ultimately treated with 
resection of both lesions. CONCLUSION: Similar situations are bound to arise
again in the future and we believe that this report could demonstrate that there 
is a case for aggressive surgical management in a highly selected group of
patients: those with NSCLC and a synchronous solitary pancreatic deposit.

Publication Types: 
    Case Reports
    Review

PMID: 19014447 [PubMed - indexed for MEDLINE]

7: J Atheroscler Thromb. 2008 Oct;15(5):276-80.

A case of obstructive jaundice with severe hypercholesterolemia probably due to
lipoprotein-Y.

Murano T, Oyama T, Miyashita Y, Shirai K.

Department of Research and Development, Toho University Sakura Medical Center,
Chiba, Japan.

AIM: We analyzed the lipoproteins of a patient with pancreatic cancer causing
obstructive jaundice, with marked hypercholesterolemia. METHODS: The patient was 
a 49-year-old female. Serum total cholesterol, triglyceride, LDL-cholesterol and 
HDL-cholesterol levels were 1,170 mg/dL, 282 mg/dL, 1,070 mg/dL and 53 mg/dL,
respectively. Cholesterol ester and lecithin:cholesterol acyltransferase
decreased, and so-called remnant like particle-cholesterol increased remarkably. 
RESULTS: Fractionation of the patient's serum by polyacrylamide gel disc
electrophoresis showed an abundant VLDL fraction, whereas agarose gel
electrophoresis demonstrated a high level of beta-lipoprotein. Sepharose 6B gel
filtration of the serum revealed that the levels of free cholesterol and
apolipoprotein B were high in the VLDL- corresponding fraction. CONCLUSION: The
results suggested that the high cholesterol level was due to the presence of
abnormally large particles rich in free cholesterol and apoB, and this abnormal
fraction may correspond to lipoprotein-Y that was increased in obstructive
jaundice.

Publication Types: 
    Case Reports

PMID: 18981653 [PubMed - indexed for MEDLINE]

8: JOP. 2008 Nov 3;9(6):719-24.

Obstructive jaundice in a patient with mycosis fungoides metastatic to the
pancreas. EUS findings.

Gottlieb K, Anders K, Kaya H.

Endoscopic Ultrasound, Deaconess Medical Center Department of Pathology, Cancer
Care Northwest, Spokane, WA, USA. klausg@u.washington.edu

CONTEXT: Cutaneous T-cell lymphomas such as mycosis fungoides are uncommon
neoplasms with a long and often relatively indolent course. Some eventually
metastasize to lymph nodes or visceral organs but there are to our knowledge only
two prior reports which describe clinically relevant pancreas involvement. CASE
REPORT: We present the case of a 52-year-old man with mycosis fungoides who
developed abdominal pain and jaundice. Endoscopic ultrasound guided-fine needle
aspiration biopsies of a peculiar infiltrative appearing mass in the head of the 
pancreas revealed T-cell lymphoma cells. CONCLUSION: There is an increased
incidence of second primaries in cutaneous T-cell lymphomas and a biopsy
diagnosis of new intra-abdominal masses is essential.

Publication Types: 
    Case Reports

PMID: 18981554 [PubMed - indexed for MEDLINE]

9: G Chir. 2008 Oct;29(10):403-6.

Endoscopic cytology in biliary strictures. Personal experience.

Geraci G, Pisello F, Arnone E, Modica G, Sciumè C.

University of Palermo, Section of General and Thoracic Surgery, Service of
Diagnostic and Operative Digestive Endoscopy, Palermo.

INTRODUCTION: The differential diagnosis between malignant and benign biliary
strictures is the cornerstone of the management of jaundiced patients. The aim of
our study is to define the role of cytology of the bile withdrawn during
endoscopic retrograde cholangiopancreatography (ERCP), to reach a diagnosis of
the nature of biliary stricture. PATIENTS AND METHODS: This retrospective study
was conducted on 67 consecutive patients affected of ingravescent obstructive
jaundice who underwent ERCP+/-PTE (percutaneous transhepatic endoscopic)+bile
withdrawn+stenting. We founded hilar stricture in 21 patients (31.3%), middle
third the common duct stricture in 17 (25.3%), and lower third stricture in 28
patients (41.4%). In one patient (2%) the cholangiography did not show any
stricture, but we continued with the withdrawn of bile after positioning a
naso-biliary drainage. RESULTS: Diagnosis was made in only 40 of 65 patients
(61.5%) and no epithelial lining cells of the biliary tree was found in the
remaining 25 patients (38.5%). The presence of neoplasm in the pancreato-biliary 
tract was excluded (absence of malignant cells) in 25 of 40 diagnostic exams
(62.5%). During follow-up only 7 of these 25 patients resulted in having a benign
disease (true negatives 28%) while the remaining 18 cases were diagnosed with
malignant neoplasm of the pancreato-biliary tract (false negatives 72%). Nine of 
14 with positive cytology for carcinoma were diagnosed with cholangiocarcinoma
(65%), 4 with pancreatic (28%) and 1 with ampullary carcinoma. Of 25
non-diagnostic samples, 5 (20%) resulted as benign, 20 (80%) as malignant. The
statistical analysis by chi-square test allowed us to conclude that bile
cytology, if diagnostic, is significantly valid in identifying carcinoma of the
pancreato-biliary tract (p<0.05) instead, considering the high rate of non
diagnostic samples, its meaning is limited (p=0.09). DISCUSSION: Exfoliative
cytology of bile samples obtained during ERCP is easier and less invasive method 
to determine the diagnosis of biliary strictures, but due to its low sensibility,
varying from 6 to 63%, it doesn't appear accurate to establish a definite
diagnosis; the stricture dilatation before the withdrawal increases the
diagnostic sensibility and accuracy of the cytological exam. CONCLUSION: Bile
withdrawn for cytology during ERCP is a safe method with no increasing in
patient's morbidity. It allows a diagnostic orientation in 75% of the patients.
Bile withdrawn after dilatation of stricture allows improves sensibility and
accuracy. Negative results does not exclude malignant disease, however, if
positive, it is considered diagnostic (positive predictive value 100%).

PMID: 18947461 [PubMed - indexed for MEDLINE]

10: World J Gastroenterol. 2008 Oct 21;14(39):6078-82.

Endoscopic ultrasound-guided choledochoduodenostomy in patients with failed
endoscopic retrograde cholangiopancreatography.

Itoi T, Itokawa F, Sofuni A, Kurihara T, Tsuchiya T, Ishii K, Tsuji S, Ikeuchi N,
Moriyasu F.

Department of Gastroenterology and Hepatology, Tokyo Medical University
Shinjuku-ku, Nishishinjuku 6-7-1, Tokyo 160-0023, Japan. itoi@tokyo-med.ac.jp

Endoscopic ultrasonography (EUS)-guided biliary drainage was performed for
treatment of patients who have obstructive jaundice in cases of failed endoscopic
retrograde cholangiopancreatography (ERCP). In the present study, we introduced
the feasibility and outcome of EUS-guided choledochoduodenostomy in four patients
who failed in ERCP. We performed the procedure in 2 papilla of Vater, including
one resectable case, and 2 cases of cancer of the head of pancreas. Using a
curved linear array echoendoscope, a 19 G needle or a needle knife was punctured 
transduodenally into the bile duct under EUS visualization. Using a biliary
catheter for dilation, or papillary balloon dilator, a 7-Fr plastic stent was
inserted through the choledochoduodenostomy site into the extrahepatic bile duct.
In 3 (75%) of 4 cases, an indwelling plastic stent was placed, and in one case in
which the stent could not be advanced into the bile duct, a naso-biliary drainage
tube was placed instead. In all cases, the obstructive jaundice rapidly improved 
after the procedure. Focal peritonitis and bleeding not requiring blood
transfusion was seen in one case. In this case, pancreatoduodenectomy was
performed and the surgical findings revealed severe adhesion around the
choledochoduodenostomy site. Although further studies and development of devices 
are mandatory, EUS-guided choledochoduodenostomy appears to be an effective
alternative to ERCP in selected cases.

Publication Types: 
    Case Reports

PMID: 18932289 [PubMed - indexed for MEDLINE]

11: World J Gastroenterol. 2008 Oct 21;14(39):6060-4.

Therapeutic effect of traditional Chinese medicine on coagulation disorder and
accompanying intractable jaundice in hepatitis B virus-related liver cirrhosis
patients.

Li YM, Yang HZ, Guan WB, Ke QS, Dai M, Xie HP, Zhang SJ.

Department of TCM, The Third Affiliated Hospital of Sun Yat-Sen University,
Guangdong Province, China.

AIM: To observe the therapeutic effects of new traditional Chinese medicine (TCM)
therapy on coagulation disorder and accompanying intractable jaundice in
HBV-related liver cirrhosis patients. METHODS: Using stratified random sampling
according to fibrinogen (Fib) levels, 145 liver cirrhosis patients due to
hepatitis B complicated by coagulation disorder were treated. Of them, 70 in
research group were treated with TCM by "nourishing yin, cooling blood and
invigorating blood circulation" and Western medicine, 75 in control group were
treated with conventional Western medicine. The indexes of liver function,
coagulation function and bleeding events were observed and compared. RESULTS: The
prothrombin time (PT) was shorter and the fibrinogen (Fib) level was higher in
the research group than in the control group (Fib = 1.6-2.0 g/L, 1.1-1.5 g/L, and
< or = 1.0 g/L). The total bilirubin (TBIL) level was significantly lower in the 
research group than in the control group, except for the subgroup of FIB < or =
1.0 g/L. CONCLUSION: TCM therapy can improve coagulation fuction and decrease
TBIL.

Publication Types: 
    Randomized Controlled Trial
    Research Support, Non-U.S. Gov't

PMID: 18932286 [PubMed - indexed for MEDLINE]

12: Niger Postgrad Med J. 2008 Sep;15(3):197-9.

Ovarian Non-Hodgkin's Lymphoma presenting as obstructive jaundice - a case
report.

Fadiora SO, Mabayoje VO, Oboro VO, Ojemakinde KA, Bello TO, Adeniji AA.

OBJECTIVE: To highlight the importance of considering abdominal Lymphoma as a
differential diagnosis in the management of obstructive jaundice. PATIENT: A 51
year old female who presented with abdominal swelling associated with features of
obstructive jaundice. Significant findings included jaundice on examination, with
abdominal ascites. Laparotomy revealed three litres of icteric fluid. There was a
huge left ovarian tumour measuring 14cm x 12cm. Massive peritoneal seedling
involved the whole abdomen and pelvis was noted. Following surgery allowing for
adequate wound healing, the patient was placed on appropriate chemotherapy.
INVESTIGATION/DIAGNOSIS: Histology of excision biopsy revealed high grade
Non-Hodgkins's Lymphoma. Screening for human deficiency virus (HIV) was negative.
However the erythrocyte sedimentation rate (ESR) was raised at 92 mm Westergren
in the first hour. The liver function tests were deranged with total bilirubin of
274 mmol/l and conjugated bilirubin of 204 mmol. serum Ast and Alt were also
significantly raised. Total proteins, urea and electrolytes remained essentially 
within normal limits. The patient was placed on CHOP combination therapy. She
attained remission after four cycles of chemotherapy and was discharged home.
CONCLUSION: Abdominal Non-Hodgkin's Lymphoma should be a strong consideration in 
the management of obstructive jaundice.

Publication Types: 
    Case Reports

PMID: 18923596 [PubMed - indexed for MEDLINE]

13: Hepatobiliary Pancreat Dis Int. 2008 Oct;7(5):515-9.

Obstructive jaundice in Iran: factors affecting early outcome.

Moghimi M, Marashi SA, Salehian MT, Sheikhvatan M.

Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
swt_f@yahoo.com.

BACKGROUND: Understanding any factors which influence the morbidity and mortality
in patients with obstructive jaundice in each society will better guide
appropriate management and lead to improved survival. This study aimed to assess 
baseline etiologies, clinical manifestations, diagnostic results, and morbidity
and mortality related to obstructive jaundice in Iranian patients. METHODS: The
hospital recorded files of 133 patients with the final diagnosis of obstructive
jaundice who had been admitted to the Taleqhani Hospital in Tehran between
January 2001 and September 2004 were reviewed. RESULTS: The most common
etiologies of obstructive jaundices were neoplasia and then common bile duct
stone in the two genders. The results of ultrasonography were positive in less
than half of the patients. However, the most positive results were related to
endoscopic retrograde cholangiopancreatography (ERCP). The in-hospital mortality 
rate in patients less than 50 years old and elderly patients was 0% and 6.76%,
respectively. The in-hospital morbidity rate was 2.25% and 7.51%, respectively in
both patients and it was commonly related to infection of ulcer (44.46%),
pneumonia (14.75%), myocardial infarction (14.75%), and subdiaphragmatic abscess 
(11.29%). In patients with a diagnosis of benign obstruction, only one patient
died of severe sepsis. In malignant group, preoperative characteristics, such as 
weight loss (P=0.015) and serum bilirubin concentration more than 16 mg/dl and
postoperative complications, such as sepsis (P<0.001), cardiac arrest (P<0.001), 
and hepatic coma (P<0.001) were main predictors for the in-hospital mortality
rate. CONCLUSION: Although the mortality and morbidity of obstructive jaundice in
our study are less than those in other studies, the determination of preoperative
clinical and laboratory indices and postoperative complications of patients is
needed for the control of mortality and morbidity rate.

Publication Types: 
    Research Support, Non-U.S. Gov't

PMID: 18842499 [PubMed - indexed for MEDLINE]

14: Hepatology. 2008 Nov;48(5):1718-23.

Extrahepatic cholestasis increases liver stiffness (FibroScan) irrespective of
fibrosis.

Millonig G, Reimann FM, Friedrich S, Fonouni H, Mehrabi A, Büchler MW, Seitz HK, 
Mueller S.

Department of Medicine and Center for Alcohol Research, Liver Disease and
Nutrition, Salem Medical Center, University of Heidelberg, Heidelberg, Germany.

Transient elastography (FibroScan [FS]) is a novel non-invasive tool to assess
liver fibrosis/cirrhosis. However, it remains to be determined if other liver
diseases such as extrahepatic cholestasis interfere with fibrosis assessment
because liver stiffness is indirectly measured by the propagation velocity of an 
ultrasound wave within the liver. In this study, we measured liver stiffness
immediately before endoscopic retrograde cholangiopancreatography and 3 to 12
days after successful biliary drainage in patients with extrahepatic cholestasis 
mostly due to neoplastic invasion of the biliary tree. Initially elevated liver
stiffness decreased in 13 of 15 patients after intervention, in 10 of them
markedly. In three patients, liver stiffness was elevated to a degree that
suggested advanced liver cirrhosis (mean, 15.2 kPa). Successful drainage led to a
drop of bilirubin by 2.8 to 9.8 mg/dL whereas liver stiffness almost normalized
(mean, 7.1 kPa). In all patients with successful biliary drainage, the decrease
of liver stiffness highly correlated with decreasing bilirubin (Spearman's rho = 
0.67, P < 0.05) with a mean decrease of liver stiffness of 1.2 +/- 0.56 kPa per 1
g/dL bilirubin. Two patients, in whom liver stiffness did not decrease despite
successful biliary drainage, had advanced liver cirrhosis and multiple liver
metastases, respectively. The relationship between extrahepatic cholestasis and
liver stiffness was reproduced in an animal model of bile duct ligation in
landrace pigs where liver stiffness increased from 4.6 kPa to 8.8 kPa during 120 
minutes of bile duct ligation and decreased to 6.1 kPa within 30 minutes after
decompression. Conclusion: Extrahepatic cholestasis increases liver stiffness
irrespective of fibrosis. Once extrahepatic cholestasis is excluded (e.g., by
liver imaging and laboratory parameters) transient elastography is a valuable
tool to assess liver fibrosis in chronic liver diseases.

Publication Types: 
    Research Support, Non-U.S. Gov't

PMID: 18836992 [PubMed - indexed for MEDLINE]

15: Pak J Biol Sci. 2008 May 15;11(10):1394-7.

Evaluation of glucose-6-phosphate dehydrogenase deficiency without hemolysis in
icteric newborns at Mazandaran province, Iran.

Ahmadi AH, Ghazizadeh Z.

Faculty of Pharmacy, Mazandaran University of Medical Sciences, Sari, Iran.

This study was carried out with the aim of evaluating the prevalence of G6PD
deficiency, the prevalence of hemolysis with enzyme deficiency and determining
the severity of icterus in the hospitalized newborns in our hospital. This
prospective descriptive study has been conducted on 1018 icteric newborns
admitted to the Bo-Ali Hospital from 2004 to 2007. The dataset included: age,
sex, total and direct bilirubin, hemoglobin, reticulocyte count, blood group and 
Rh of mother and newborn, direct Coombs, G6PD level and the type of treatment.
All data was analyzed by using statistical method. From 1018 neonates, 138
neonates (13.6%) were found to have G6PD deficiency. The male to female ratio was
3 to 1 (104 male and 34 female neonates). From 138 neonates with G6PD deficiency,
hemolysis was seen in 15 neonates (10.9%) and the rate of G6PD deficiency with
hemolysis was 1.6%. Out of 138 patients with G6PD deficiency, 2 patients (0.2%)
had blood exchange transfusion. In this study the prevalence of G6PD deficiency
in icteric newborns was considerably high and most of them were non hemolytic, so
we recommend G6PD test as a screening program for every newborn at the time of
delivery.

Publication Types: 
    Evaluation Studies
    Research Support, Non-U.S. Gov't

PMID: 18817276 [PubMed - indexed for MEDLINE]

16: Am J Med Sci. 2008 Sep;336(3):230-6.

Plasma superoxide radical in jaundiced patients and role of xanthine oxidase.

Assimakopoulos SF, Grintzalis K, Thomopoulos KC, Papapostolou I, Georgiou CD,
Gogos C, Vagianos CE.

Department of Internal Medicine, University of Patras, Patras, Greece.
sassim@upatras.gr

BACKGROUND: In the experimental setting, obstructive jaundice induces oxidative
stress in several extrahepatic tissues (systemic phenomenon), which is at least
partly attributed to activation of the enzyme xathine oxidase. Very little is
known on this important issue in patients with cholestasis. The present study was
designed to (a) assess directly oxidative stress in the blood of patients with
obstructive jaundice by measuring superoxide radical, and (b) investigate ex vivo
whether xanthine oxidase (XO) is the source of this radical. METHODS: Twelve
patients with malignant obstructive jaundice and no signs of cholangitis, 12
nonjaundiced disease-controls with a localized gastrointestinal malignancy, and
12 healthy-controls were enrolled in the study. Superoxide radical levels were
measured in the whole blood (plasma and cells) and in plasma previously
separated. These measurements were also done in blood samples in the presence of 
the specific XO inhibitor allopurinol. RESULTS: Superoxide radical levels were
significantly increased in the plasma fraction of whole blood in jaundiced
patients when compared with disease-controls (P < 0.001) and healthy-controls (P 
< 0.001), whereas disease-control patients presented significantly increased
superoxide radical levels when compared with healthy-controls (P < 0.001). No
differences in superoxide radical levels in the blood cells were detected between
jaundiced patients and disease-controls. In jaundiced patients, superoxide
radical levels in the plasma fraction of whole blood were positively correlated
with the degree of cholestasis. The addition of allopurinol to whole blood
samples decreased superoxide radical in the plasma fraction of jaundiced patients
to the disease-control level (P < 0.001), whereas it had no effect on superoxide 
radical levels in the cell fraction. No superoxide radical was detected in
fractionated plasma in all cases. CONCLUSIONS: These data show that increased
superoxide radical in the plasma of jaundiced patients is possibly formed from a 
source in the cytoplasmic membrane of blood cells and secreted into plasma. The
reversal of this phenomenon by allopurinol, ex vivo, indicates that a blood cell 
membranous XO might be the source of increased plasma superoxide radical in
patients with extrahepatic cholestasis.

PMID: 18794617 [PubMed - indexed for MEDLINE]

17: Med Hypotheses. 2008 Dec;71(6):879-80. Epub 2008 Sep 11.

Increased sleep tendency in jaundiced infants: role of endogenous CO.

Ozkan H, Tuzun F, Kumral A, Yesilirmak D, Duman N.

Dokuz Eylul University Faculty of Medicine, Department of Pediatrics,
Balçova-Izmir, Turkey. hasan.ozkan@deu.edu.tr

Carbon monoxide formed from the breakdown of heme to bilirubin is produced at a
rate equal to the rate of bilirubin synthesis. During long-term clinical
experiences we have observed that jaundiced newborns tend to sleep more than the 
unjaundiced ones. There is no clear evidence about the role of endogenous CO in
sleep physiology, but increased CO production in jaundiced newborns probably
plays role in increased sleep state due to the regulatory effects on sleep
circadian rhythm and REM-sleep, via cholinergic system activation.

PMID: 18789603 [PubMed - indexed for MEDLINE]

18: Ann Surg Oncol. 2008 Nov;15(11):3138-46. Epub 2008 Sep 12.

Preoperative resolution of jaundice following biliary stenting predicts more
favourable early survival in resected pancreatic ductal adenocarcinoma.

Smith RA, Dajani K, Dodd S, Whelan P, Raraty M, Sutton R, Campbell F, Neoptolemos
JP, Ghaneh P.

Division of Surgery and Oncology, School of Cancer Studies, Royal Liverpool
University Hospital, 5th Floor UCD Building, Daulby St, Liverpool L69 3GA, UK.
rsmith3@liverpool.ac.uk

INTRODUCTION: Despite the widespread use of endoscopic biliary stenting in
patients presenting with potentially resectable pancreatic cancer, there is no
general consensus regarding whether this represents a superior management
approach over expeditious surgical intervention. The objective of this study was 
to investigate the influence of preoperative biliary stenting and resolution of
jaundice on subsequent postoperative survival following resection for pancreatic 
cancer. METHODS: 155 patients undergoing partial pancreatoduodenectomy for
pancreatic ductal adenocarcinoma between January 1997 and August 2007 were
identified from a prospectively maintained database. RESULTS: There was no
survival difference when comparing patients undergoing preoperative biliary
drainage (n = 130) with those who did not (n = 25) (log rank, P = 0.981). When
analysing individual prognostic factors as continuous variables in univariate Cox
analysis, lower albumin levels (P = 0.016), elevated alkaline phosphatase levels 
(P = 0.011) and elevated CRP levels (P = 0.021) were associated with poorer
overall survival. Multivariable Cox regression demonstrated that both albumin (P 
= 0.008) and CRP (P = 0.038) remained significant independent predictors of
overall survival alongside lymph node ratio (P = 0.018). Although preoperative
bilirubin levels were not associated with overall survival when analysed as a
continuous variable (Cox, P = 0.786), the presence of jaundice (i.e., bilirubin
>35 micromol/l) at the time of surgery was a significant adverse predictor of
early survival in patients undergoing preoperative biliary drainage
(Breslow-Gehan-Wilcoxon, P = 0.013) and remained a significant predictor of early
survival when included in a further Cox analysis with censoring of cases who
survived beyond 6 months (Cox, P = 0.017). CONCLUSION: These results suggest that
the presence of jaundice at the time of resection has an adverse impact on early,
but not overall, postoperative survival in pancreatic cancer patients undergoing 
preoperative biliary drainage.

Publication Types: 
    Research Support, Non-U.S. Gov't

PMID: 18787902 [PubMed - indexed for MEDLINE]

19: Br J Radiol. 2008 Sep;81(969):e225-7.

Evolution of idiopathic fibrosing pancreatitis--MRI features.

Armstrong EM, Tolan DJ, Verbeke CS, Sheridan MB.

Department of Clinical Radiology, Derriford Hospital, Plymouth, Devon PL6 8DH,
UK. euan.armstrong@ukonline.co.uk

Here, the clinical and imaging features of idiopathic fibrosing pancreatitis are 
described, including a description of the evolution of MRI features in a patient 
treated successfully with biliary stenting alone. Thus, not all masses of the
pancreatic head in the paediatric population need to be managed surgically.

Publication Types: 
    Case Reports

PMID: 18769009 [PubMed - indexed for MEDLINE]

20: World J Gastroenterol. 2008 Aug 28;14(32):5032-8.

Differentiation of malignant and benign proximal bile duct strictures: the
diagnostic dilemma.

Kloek JJ, van Delden OM, Erdogan D, ten Kate FJ, Rauws EA, Busch OR, Gouma DJ,
van Gulik TM.

Department of Surgery, Academic Medical Center, University of Amsterdam,
Amsterdam, Netherlands.

AIM: To identify the criteria for the differentiation of hilar cholangiocarcinoma
(HCCA) from benign strictures. METHODS: A total of 68 patients underwent
resection of lesions suspicious for HCCA between 1998 and 2006. The results of
laboratory investigations, imaging studies and brush cytology were collected.
These findings were analyzed to obtain the final diagnosis. RESULTS: Histological
examination of the resected specimens confirmed HCCA in 58 patients (85%, group
I) whereas 10 patients (15%, group II) were diagnosed to have benign strictures. 
The most common presenting symptom was obstructive jaundice in 77% patients (79% 
group I vs 60% group II, P = 0.23). Laboratory findings showed greater elevation 
of transaminase levels in group I compared to group II. The various imaging
modalities showed vascular involvement exclusively in the malignant group (36%, P
< 0.05). Brush cytology was positive for malignant cells in only 50% patients in 
group I whereas none in group II showed malignant cells. CONCLUSION: Despite
improvements in imaging techniques, 10 patients (15%) with a presumptive
diagnosis of HCCA were ultimately found to have benign strictures. Except for
vascular involvement which was associated significantly with malignancy, there
were no conclusive features of malignancy on regular imaging modalities. This
uncertainty should be taken into account when patients with a suspicious lesion
at the liver hilum are considered for resection.

PMID: 18763286 [PubMed - indexed for MEDLINE]

21: J Gastroenterol. 2008;43(8):637-40. Epub 2008 Aug 17.

Temporary endosonography-guided biliary drainage for transgastrointestinal
deployment of a self-expandable metallic stent.

Fujita N, Noda Y, Kobayashi G, Ito K, Obana T, Horaguchi J, Takasawa O, Sugawara 
T.

Department of Gastroenterology, Sendai City Medical Center, 5-22-1 Tsurugaya,
Sendai, 983-0824, Japan.

Endosonography-guided biliary drainage (ESBD) is now gaining acceptance as a
useful alternative for the management of obstructive jaundice.(1) At present,
ESBD is used mainly to establish an anastomosis between the biliary tree and the 
duodenum, stomach, jejunum, or esophagus by placing a stent so as to bridge the
bile duct and alimentary tract. We herein report a new application of ESBD, that 
is, its temporary use for gaining access to the bile duct in order to deploy a
self-expandable metallic stent (SEMS) via the transhepatic route. In a patient
with pylorus stenosis due to advanced gastric cancer with extrahepatic bile duct 
obstruction caused by nodal metastasis, a plastic stent was placed temporarily by
ESBD to bridge the esophagus and the left hepatic duct. Ten days later, the stent
was retrieved, leaving a guidewire in the bile duct, and a delivery unit of a
SEMS was introduced into the bile duct over the guidewire via the sinus tract.
The SEMS was then successfully deployed through the stenosis. No stent was left
in the sinus tract. This procedure yields a mature fistula through which a
delivery unit can be safely introduced into the bile duct followed by uneventful 
deployment of a SEMS.

Publication Types: 
    Case Reports

PMID: 18709487 [PubMed - indexed for MEDLINE]

22: Cochrane Database Syst Rev. 2008 Jul 16;(3):CD005444.

Preoperative biliary drainage for obstructive jaundice.

Wang Q, Gurusamy KS, Lin H, Xie X, Wang C.

Endocrinology Department, West China Hospital, Sichuan University, No 37 Guo Xue 
Xiang, Chengdu, Sichuan Province, China, 610041.

BACKGROUND: Obstruction in the biliary drainage system causes a rise in serum
bilirubin levels (obstructive jaundice). Studies have shown that surgery for
severe obstructive jaundice is associated with high peri-operative mortality and 
morbidity. Jaundice has been considered as a potential risk factor for poor
outcome, and pre-operative biliary drainage has been proposed as a method of
reversing the pathophysiologic disturbance seen in patients with obstructive
jaundice. OBJECTIVES: To determine the benefits and harms of pre-operative
biliary drainage (ie, endoscopic sphincterotomy with stent insertion or
percutaneous transhepatic biliary drainage) in obstructive jaundice. SEARCH
STRATEGY: We searched The Cochrane Hepato-Biliary Group Controlled Trials
Register (CHBG), the Cochrane Central Register of Controlled Clinical Trials
(CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, the Chinese BioMedical
Literature on disc (CBM disc), and the Chinese Medical Current Contents (CMCC).
All databases were searched up to October 2006. SELECTION CRITERIA: We considered
for inclusion randomised clinical trials comparing biliary drainage followed by
surgery and direct surgery performed for obstructive jaundice. DATA COLLECTION
AND ANALYSIS: We collected the available data on the characteristics of the
trial, methodological quality of the trials, mortality, morbidity, and hospital
stay as reported in each trial. We analysed the data with both the fixed-effect
and the random-effects models, using RevMan Analysis. For each outcome, we
calculated the odds ratio (OR) with 95% confidence intervals (CI) based on
intention-to-treat analysis. MAIN RESULTS: Five trials with 320 patients (160 in 
each group) were included. Four trials (n = 235) compared percutaneous
transhepatic biliary drainage with direct surgery, and one trial (n = 85)
compared pre-operative endoscopic drainage with direct surgery. All trials were
of low methodological quality. There was no significant difference in mortality
(OR 1.14, 95% CI 0.60 to 2.10) between the pre-operative biliary drainage group
and the direct surgery group. No significant difference was found in mortality
(OR 1.16, 95% CI 0.56 to 2.41), overall morbidity (OR 1.35, 95%CI 0.48 to 3.83), 
and in different complications between the percutaneous transhepatic biliary
drainage group and the direct surgery group. The trial comparing pre-operative
endoscopic drainage and direct surgery showed no significant difference in
mortality (OR 1.09, 95% CI 0.32 to 3.68), but found higher morbidity in the
endoscopic drainage group. The overall hospital stay was 8 to 17 days shorter in 
the direct surgery group. AUTHORS' CONCLUSIONS: Our analyses neither supports nor
refutes pre-operative biliary drainage for patients with obstructive jaundice
needing surgery. In some specific lesion site it may cause more complications.
Pre-operative biliary drainage also prolonged hospital stay and increased cost.
However, the strength of evidence is low because of the poor quality of the
included trials. More rigorously designed randomised clinical trials with larger 
sample size and advanced techniques and drugs are needed.

Publication Types: 
    Meta-Analysis
    Review

PMID: 18677779 [PubMed - indexed for MEDLINE]

23: JOP. 2008 Jul 10;9(4):520-5.

A case of obstructive jaundice caused by impaction of a pancreatic stone in the
papilla for which a needle knife precut papillotomy was effective.

Naitoh I, Nakazawa T, Ohara H, Ando T, Hayashi K, Okumura F, Togawa S, Kitajima
Y, Ban T, Miyabe K, Ueno K, Yamashita H, Joh T, Sano H.

Department of Gastroenterology and Metabolism, Nagoya City University Graduate
School of Medical Sciences, Nagoya, Japan.

CONTEXT: Obstructive jaundice in chronic pancreatitis is generally caused by
stenosis of the bile duct in the pancreas. Obstructive jaundice caused by the
impaction of a pancreatic stone in the papilla is markedly rare, with only seven 
cases reported to date. CASE REPORT: We report a case of obstructive jaundice
caused by the impaction of a pancreatic stone in the papilla. A 41-year-old male 
with chronic pancreatitis was admitted because of epigastric pain. Blood analysis
revealed increased levels of hepatobiliary system enzymes, mild jaundice and an
increase in pancreatic enzymes. Computed tomography revealed a number of
pancreatic stones in the main pancreatic duct, and a stone with a diameter of
about 1 cm in the pancreatic head. Swelling of the papilla was observed using
duodenoscopy while endoscopic ultrasonography revealed a strong echo with
acoustic shadows in the papilla. Percutaneous transhepatic biliary drainage was
performed for the obstructive jaundice. Contrast medium from the percutaneous
transhepatic biliary drainage route regurgitated into the pancreatic duct and
revealed the impaction of pancreatic stones in the common channel. The patient
was referred to our hospital for treatment of the stone impaction. We performed a
needle knife precut papillotomy and extracted a white stone which was diagnosed
as a pancreatic stone by composition analysis. CONCLUSION: Impaction of a
pancreatic stone in the papilla is a markedly rare cause of obstructive jaundice 
in chronic pancreatitis. A needle knife precut papillotomy was effective in
removing the impacted pancreatic stone in the papilla.

Publication Types: 
    Case Reports
    Review

PMID: 18648146 [PubMed - indexed for MEDLINE]

24: Redox Rep. 2008;13(4):179-84.

Superoxide radical formation in diverse organs of rats with experimentally
induced obstructive jaundice.

Assimakopoulos SF, Mavrakis AG, Grintzalis K, Papapostolou I, Zervoudakis G,
Konstantinou D, Chroni E, Vagianos CE, Georgiou C.

Department of Internal Medicine, School of Medicine, University of Patras,
Patras, Greece. sassim@upatras.gr

Oxidative stress seems to be a cardinal feature of cholestasis, implicated in the
pathophysiology of organ injury not only in the liver, but also in several
extrahepatic tissues. The present study was designed to assess directly oxidative
stress in vital organs of experimentally jaundiced rats by measuring the key
oxidative stress marker superoxide radical (O2(*-)). Twelve male Wistar rats
underwent laparotomy and were divided into two groups - group I (n = 6) sham
operated, and group II (n = 6) bile-duct ligated. Ten days later, the O2(*-)
formation rate was quantified in liver, intestine, kidney and heart of all
animals. These measurements were done by application of a new ultrasensitive
fluorescent assay for the in vivo quantification of O2(*-), which is based on the
1:1 molar stoichiometric reaction of O2(*-) with dihydroethidine (DHE, an O2(*-) 
trap) that results in the formation of the specific product 2-OH-ethidium.
2-OH-Ethidium was measured by fluorescence in rats' organs and its formation rate
was converted to O2(*-) production rate. As compared to sham-operated rats, in
jaundiced rats there was a significant increase of O2(*-) in the intestine (136%,
P < 0.01), liver (104%, P < 0.01), and kidney (95%, P < 0.01), whereas there was 
no significant difference in heart O2(*-) levels. Superoxide radical may play an 
important role in the pathophysiology of cholestatic liver injury, intestinal
barrier failure and renal failure, associated with postoperative morbidity and
mortality in obstructive jaundice. On the contrary, O2(*-) and oxidative stress
are possibly not implicated in the pathophysiology of hepatic cardiomyopathy.

PMID: 18647488 [PubMed - indexed for MEDLINE]

25: Saudi Med J. 2008 Jul;29(7):989-93.

The effects of combined use of glutamine and growth hormone on the bacterial
translocation associated with obstructive jaundice.

Celebi F, Ozturk G, Kizilkaya M.

Department of General Surgery, Ataturk University School of Medicine, Erzurum,
Turkey. fcelebi@atauni.edu.tr

OBJECTIVE: To investigate the effects of combined use of glutamine and growth
hormone on bacterial translocation. METHODS: The study was performed at the
laboratories of the Department of Physiology at Ataturk University Medical
School, Erzurum, Turkey between June and September 2007. Forty rats divided into 
5 groups of 8, were included in the study. In the study groups, the common bile
duct was ligated to obtain obstructive jaundice. The rats in the control group CG
were given sodium chloride, in the glutamine group GLG they were given glutamine,
in the growth hormone group GHG, growth hormone, and in the glutamine + growth
hormone group GLGHG glutamine + growth hormone at equal doses by the same
methods. Blood, spleen, liver, lymph node, and cecal content samples were
obtained. Total bilirubin TB, alkaline phosphates ALP, and gamma glutamine
transferase GGT activities were evaluated. RESULTS: In the CG, cecal contents
were higher than in the GLG, and cecal contents and BT were higher than in the
GHG and the GLGHG. The BT rate was the lowest in the GLGHG, with a borderline
difference with the values of the GLG and GHG. CONCLUSION: We found that in
preventing BT, combined use of glutamine, and growth hormone was more effective
than using each of these agents alone.

PMID: 18626527 [PubMed - indexed for MEDLINE]

26: J Clin Virol. 2008 Oct;43(2):216-8. Epub 2008 Jul 10.

Human cytomegalovirus infection in infants with prolonged neonatal jaundice.

Goedhals D, Kriel J, Hertzog ML, Janse van Rensburg MN.

Department of Medical Microbiology and Virology, Faculty of Health Sciences,
University of the Free State, PO Box 339 (G23), Bloemfontein 9300, South Africa. 
gnvrdg.md@ufs.ac.za

BACKGROUND: Although human cytomegalovirus (HCMV) infection in infants has been
associated with liver disease, the role of HCMV in infants presenting with
prolonged neonatal jaundice is unclear as this clinical picture can be caused by 
a broad spectrum of underlying conditions. OBJECTIVES: This study aimed to
determine a possible role for HCMV infection in infants with prolonged
cholestatic neonatal jaundice that could facilitate the appropriate use of
diagnostic assays and specific treatment in this condition. STUDY DESIGN: HCMV
immunohistochemical staining was performed on liver biopsy specimens received for
histopathological examination from 85 infants (mean age 3 months) with a clinical
history of prolonged neonatal jaundice. HCMV serology was also performed.
RESULTS: One infant with a histological diagnosis of HCMV hepatitis was also
positive by immunohistochemical staining, while all other tissue specimens were
negative for HCMV. HCMV IgG was positive in 92.3% and HCMV IgM in 39.7% of the
infants (n=78). CONCLUSIONS: The serological results confirm the ubiquitous
nature of HCMV with many primary infections occurring within the first year of
life. Despite this, HCMV hepatitis was uncommon in this cohort.

PMID: 18619898 [PubMed - indexed for MEDLINE]

27: Z Gastroenterol. 2008 Jul;46(7):700-3.

A 9-year retained T-tube fragment encased within a stone as a rare cause of
jaundice.

Hoffman A, Kiesslich R, Galle PR, Neurath MF.

1st Medical Clinic, Johannes Gutenberg University of Mainz, Mainz, Germany.
Ahoff66286@aol.com

Biliary diseases such as cholangitis may cause jaundice and liver damage. Here,
we report on an unusual cause of jaundice in an 84-year-old man 9 years after
cholecystectomy. Ultrasound analysis revealed unclear extrahepatic cholestasis
and subsequent ERCP showed a large biliary stone surrounding a T-tube fragment
that had remained in the common bile duct for more than 9 years after surgery.
The tip of the drainage and the stone could be successfully removed using Dormia 
baskets. This case suggests that plastic material accidentally left in the common
bile duct favours the development of large biliary casts when present over long
periods of time.

Publication Types: 
    Case Reports

PMID: 18618382 [PubMed - indexed for MEDLINE]

28: Hepatogastroenterology. 2008 Mar-Apr;55(82-83):596-9.

Sequential magnetic resonance imaging for evaluation of Kupffer cell function.

Saito T, Abe T, Tsuchiya T, Satoh Y, Kenjo A, Kimura T, Gotoh M.

Department of Surgery I, School of Medicine, Fukushima Medical University,
Fukushima, Japan.

BACKGROUND/AIMS: Kupffer cells play an important role in liver regeneration and
depression of their function is associated with poor outcome. However, there is
no clinically safe and reliable method for evaluating Kupffer cell function.
METHODOLOGY: We used magnetic resonance imaging following injection of
superparamagnetic iron oxide, which is trapped by Kupffer cells, to evaluate
Kupffer cell function in 14 patients, including 6 with normal liver and 8 with
obstructive jaundice T1-weighed signal intensity of the liver parenchyma was
examined every 4 minutes for 60 min after superparamagnetic iron oxide injection.
RESULTS: Signal intensity values gradually decreased in both groups after
accumulation of iron in the liver. Serum iron levels equally and significantly
increased in both groups. In contrast, the values of relative enhancement,
percentage of signal intensity of precontrast to postcontrast, between 8-20
minutes after superparamagnetic iron oxide injection were significantly higher in
obstructive jaundice group than in the control, indicating Kupffer cell
dysfunction in obstructive jaundiced liver. CONCLUSIONS: These results indicate
that chronological magnetic resonance imaging with superparamagnetic iron oxide
is a suitable method for assessment of Kupffer cell function in patients with
obstructive jaundice.

PMID: 18613415 [PubMed - indexed for MEDLINE]

29: World J Gastroenterol. 2008 Jul 7;14(25):4093-5.

Non-Hodgkin lymphoma as a cause of obstructive jaundice with simultaneous
extrahepatic portal vein obstruction: a case report.

Hashimoto M, Umekita N, Noda K.

Department of Surgery, Tokyo Metropolitan Bokutoh General Hospital, 4-23-15
Kohtohbashi, Sumida-ku, Tokyo 130-8575, Japan. hashimom-tky@umin.ac.jp

Non-Hodgkin lymphoma is a rare cause of biliary obstruction. To the best of our
knowledge, non-Hodgkin lymphoma in the peripancreatic region causing obstructive 
jaundice with simultaneous portal vein (PV) invasion has not yet been reported.
We present a 50-year-old patient with obstructive jaundice whose extrahepatic
portal vein was obstructed by the invasion of a peripancreatic non-Hodgkin
lymphoma. The patient denied any other symptoms such as recurrent fever, night
sweat and loss of body weight. Computed tomography (CT) revealed a 10 cm mass in 
the retroperitoneal space behind the head of the pancreas causing obstruction of 
the distal bile duct and the PV. A pylorus-preserving pancreaticoduodenectomy
combined with a PV resection was performed. The PV was reconstructed using an
autologous right internal jugular vein graft. The resected specimen showed
endoluminal invasion of both the bile duct and the PV. Histological examination
showed the mass consisting of diffuse sheets of large malignant lymphoid cells.
These cells were positive for CD20 and CD79a, partially positive for CD10, and
negative for CD3, CD4, CD5, CD8 and CD30. The pathologic diagnosis was diffuse
large B-cell type non-Hodgkin lymphoma and the patient was transferred to the
Department of Hematology and Oncology for chemotherapy. He received four cycles
of combined chemotherapy including cyclophosphamide, doxorubicin, vincristine and
prednisone plus rituximab, and three cycles of intrathecal chemoprophylaxis
including methotorexate, cytosine arbinoside and prednisone. The patient is alive
with no evidence of the disease for 7 mo after operation and will receive
additional courses of chemotherapy.

Publication Types: 
    Case Reports

PMID: 18609698 [PubMed - indexed for MEDLINE]

30: World J Gastroenterol. 2008 Jun 21;14(23):3729-32.

Honey prevents hepatic damage induced by obstruction of the common bile duct.

Erguder BI, Kilicoglu SS, Namuslu M, Kilicoglu B, Devrim E, Kismet K, Durak I.

Department of Biochemistry, Ankara University Faculty of Medicine, Ankara 06100, 
Turkey. imgeerguder@yahoo.com

AIM: To examine the possible effects of honey supplementation on hepatic damage
due to obstruction of the common bile duct in an experimental rat model. METHODS:
The study was performed with 30 male rats divided into three groups: a sham
group, an obstructive jaundice group, and an obstructive jaundice plus honey
group. At the end of the study period, the animals were sacrificed, and levels of
nitric oxide (NO), and NO synthase (NOS) activities were measured in liver
tissues, and levels of adenosine deaminase (ADA) and alanine transaminase (ALT)
activities were measured in serum. RESULTS: Blood ALT and ADA activities were
significantly elevated in the jaundice group as compared to those of the sham
group. In the obstructive jaundice plus honey group, blood ALT and ADA activities
were significantly decreased as compared to those of the jaundice group. In
erythrocytes and liver tissues, NO levels were found to be significantly higher
in the obstructive jaundice plus honey group compared to those of the sham group.
Additionally, NO levels were found to be significantly higher in liver tissues
from the animals in the obstructive jaundice plus honey group than those of the
jaundice group. CONCLUSION: Honey was found to be beneficial in the prevention of
hepatic damage due to obstruction of the common bile duct.

PMID: 18595140 [PubMed - indexed for MEDLINE]

31: J Gastroenterol. 2008;43(5):390-6. Epub 2008 Jul 1.

Decreased expression of intestinal chemokine TECK/CCL25 in experimental
obstructive jaundice and its reversal following internal biliary drainage.

Matsumoto T, Ajiki T, Kajiwara E, Mita Y, Fujita T, Morimoto H, Miyazawa M, Ku Y.

Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe
University Graduate School of Medical Sciences, 7-5-2 Kusunoki-cho, Chuo-ku,
Kobe, 650-0017, Japan.

BACKGROUND: Although bacterial translocation is a significant problem in patients
with obstructive jaundice, how translocation is promoted in this situation is not
clearly understood. We previously reported the recovery of gut mucosal
T-lymphocyte numbers in jaundiced rats following internal biliary drainage. This 
suggests that bile in the intestinal lumen promotes T-lymphocyte redistribution
into the gut mucosa. To test this hypothesis, we have examined the expression
patterns of chemokines that play an important role in lymphocyte recruitment into
the small intestine. METHODS: Four groups of rats receiving one of the following 
surgical procedures were studied: a sham operation (SHAM), common bile duct
ligation (CBDL), CBDL followed by external drainage, or CBDL followed by internal
drainage. Expression levels of intestinal mRNAs encoding TECK, MECK, and LARC
chemokines were assessed using real-time polymerase chain reaction. Distribution 
of chemokine mRNA in the rat ileum was examined using in situ hybridization
(ISH). RESULTS: Following surgery, the expression levels of TECK mRNA decreased
significantly in the CBDL group compared with in the SHAM group. While TECK
expression did not recover after external drainage, it recovered to a near-normal
level after internal drainage. Expression levels of MECK and LARC mRNAs were
similar among all groups. ISH confirmed strong expression of TECK mRNA in the
epithelial cells of the small intestine. CONCLUSIONS: These results indicate that
bile may contribute to high expression levels of TECK/CCL25 mRNA in the small
intestine. Bile may also have a role in regulating the distribution of gut
mucosal T lymphocytes by promoting TECK production from epithelial cells.

Publication Types: 
    Comparative Study

PMID: 18592157 [PubMed - indexed for MEDLINE]

32: Chem Biol Interact. 2008 Jul 30;174(2):79-87. Epub 2008 May 18.

Melatonin exerts a more potent effect than S-adenosyl-l-methionine against iron
metabolism disturbances, oxidative stress and tissue injury induced by
obstructive jaundice in rats.

Muñoz-Castañeda JR, Túnez I, Herencia C, Ranchal I, González R, Ramírez LM,
Arjona A, Barcos M, Espejo I, Cruz A, Montilla P, Padillo FJ, Muntané J.

Liver Research Unit, Reina Sofía University Hospital, Córdoba, Spain.

Melatonin and S-adenosyl-l-methionine (SAMe) prevent oxidative stress and tissue 
dysfunction in obstructive jaundice (OJ). Lipid peroxidation is exacerbated in
the presence of trace amounts of iron (Fe). The study investigated the regulation
by melatonin and SAMe the induction of oxidative stress, iron metabolism
disturbances and tissue injury in an experimental model of OJ. Different
parameters of lipid peroxidation, antioxidant status, tissue injury and Fe
metabolism were determined in liver and blood. OJ induced Fe accumulation in
liver, and increased transferrin (Tf) saturation and loosely bound Fe content in 
blood. Melatonin, and SAMe at lesser extent, enhanced protein Tf content in liver
and blood, that reduced loosely bound Fe content in blood. Melatonin and SAMe did
not affect ferritin (FT) and Tf mRNA expression, but reduced Tf receptor (TfR)
mRNA expression in liver. In conclusion, the effect of melatonin and SAMe on Fe
metabolism may be included in the beneficial properties of these agents on lipid 
peroxidation and tissue injury induced by OJ.

Publication Types: 
    Research Support, Non-U.S. Gov't

PMID: 18571630 [PubMed - indexed for MEDLINE]

33: Shock. 2008 Jul;30(1):69-74.

Kupffer cell blockade improves the endotoxin-induced microcirculatory
inflammatory response in obstructive jaundice.

Abrahám S, Szabó A, Kaszaki J, Varga R, Eder K, Duda E, Lázár G, Tiszlavicz L,
Boros M, Lázár G Jr.

Department of Surgery, University of Szeged, Szeged, Hungary.

Cholestasis predisposes to hypersensitivity to LPS, leading to potential septic
complications. We set out to characterize the involvement of Kupffer cell (KC)
activation in the hepatic microcirculatory and structural consequences of
obstructive jaundice in the presence and absence of acute endotoxemia. The
hepatic microcirculatory consequences of 3-day extrahepatic bile duct ligation
(BDL) were assessed in rats. The contributions of changes in hepatic perfusion,
leukocyte influx, and proinflammatory cytokine release to the development of
hepatic structural damage were also determined. Furthermore, the corresponding
consequences of BDL in combination with acute (2-h) endotoxemia (1 mg kg(-1) LPS,
i.v.) were compared with those observed after LPS alone. In a second series, the 
same protocols were applied in identical groups of rats where the KC function was
inhibited with 24-h gadolinium chloride pretreatment (10 mg kg(-1), i.v.). Bile
duct ligation induced minor inflammatory reactions but caused a marked reduction 
in hepatic sinusoidal perfusion and severe histological damage. LPS treatment,
however, elicited an approximately 5-fold increase in leukocyte adherence in the 
central venules and pronounced IL-6 and TNF-alpha release, but without
significant structural damage. The combination of BDL with LPS enhanced the
perfusion failure, leukocyte sticking/deposition, and proinflammatory cytokine
release; most of these changes can be effectively ameliorated by gadolinium
chloride. In conclusion, when obstructive jaundice is followed by a second hit of
LPS, perfusion failure, liver inflammation, and structural damage are enhanced,
the KCs playing a decisive role in this scenario. Therapeutic strategies aimed at
KC blockade can potentially reduce the risk of inflammatory complications in
cholestasis.

Publication Types: 
    Research Support, Non-U.S. Gov't

PMID: 18562926 [PubMed - indexed for MEDLINE]

34: World J Gastroenterol. 2008 Jun 7;14(21):3410-5.

Effect of honey on bacterial translocation and intestinal morphology in
obstructive jaundice.

Gencay C, Kilicoglu SS, Kismet K, Kilicoglu B, Erel S, Muratoglu S, Sunay AE,
Erdemli E, Akkus MA.

Ankara Training and Research Hospital, 4th General Surgery Department, 06340,
Ulucanlar, Ankara 06370, Turkey.

AIM: To evaluate the effects of honey on bacterial translocation and intestinal
villus histopathology in experimental obstructive jaundice. METHODS: Thirty
Wistar-Albino rats were randomly divided into three groups each including 10
animals: group I, sham-operated; group II, ligation and section of the common
bile duct (BDL); group III, bile duct ligation followed by oral supplementation
of honey (BDL + honey) 10 g/kg per day. Liver, blood, spleen, mesenteric lymph
nodes, and ileal samples were taken for microbiological, light and transmission
electrone microscopic examination. RESULTS: Although the number of villi per
centimeter and the height of the mucosa were higher in sham group, there was no
statistically significant difference between sham and BDL + honey groups (P >
0.05). On the other hand, there was a statistically significant difference
between BDL group and other groups (P < 0.05). The electron microscopic changes
were also different between these groups. Sham and honey groups had similar
incidence of bacterial translocation (P > 0.05). BDL group had significantly
higher rates of bacterial translocation as compared with sham and honey groups.
Bacterial translocation was predominantly detected in mesenteric lymph nodes.
CONCLUSION: Supplementation of honey in presence of obstructive jaundice
ameliorates bacterial translocation and improves ileal morphology.

PMID: 18528939 [PubMed - indexed for MEDLINE]

35: Eur Surg Res. 2008;41(2):231-7. Epub 2008 Jun 5.

Effect of propolis on oxidative stress and histomorphology of liver tissue in
experimental obstructive jaundice.

Kismet K, Sabuncuoglu MZ, Kilicoglu SS, Kilicoglu B, Devrim E, Erel S, Sunay AE, 
Erdemli E, Durak I, Akkus MA.

4th General Surgery Department, Ankara Training and Research Hospital, Ankara,
Turkey. kemalkismet@yahoo.com

BACKGROUND: Propolis is a natural product collected by honey bees from various
plant sources. We aimed to determine the possible effects of propolis on
oxidative stress and hepatocyte apoptosis in experimental obstructive jaundice.
METHODS: Thirty rats were divided into three groups: group I, sham-operated;
group II, ligation and division of the common bile duct (BDL); group III, BDL
followed by oral supplementation of propolis in a daily dose of 100 mg/kg. Liver 
samples were examined under the light microscope and transmission electron
microscope. Hepatocyte apoptosis was quantitated using the transferase-mediated
uridine nick end labeling (TUNEL) assay. Plasma and liver malondialdehyde (MDA)
levels and glutathione peroxidase (GSH-Px) activities were measured. RESULTS: The
plasma and liver levels of MDA were significantly lower in the propolis group
than in the BDL group (p < 0.05 and 0.014, respectively). Although liver GSH-Px
activities were significantly higher in the propolis group than in the BDL group 
(p < 0.001), there was no significant difference between the plasma GSH-Px
activities of these groups (p > 0.05). In the propolis group, the enlargement of 
hepatocytes, dilatation of canaliculi and the edema regressed. The regenerating
and normal hepatocytes were demonstrated. In the TUNEL assay, propolis
administration reduced hepatocyte apoptosis. CONCLUSION: Propolis showed a
significant hepatoprotective effect in this experimental obstructive jaundice
model. 2008 S. Karger AG, Basel

Publication Types: 
    Research Support, Non-U.S. Gov't

PMID: 18525208 [PubMed - indexed for MEDLINE]

36: Am J Surg. 2008 Sep;196(3):e3-4. Epub 2008 Jun 2.

Liver hemangioma complicated by obstructive jaundice.

Losanoff JE, Millis JM.

Department of Surgery (11S), Wayne State University and John D. Dingell VA
Medical Center, 4646 John R, Detroit, MI, 48201 USA. jelosanoff@yahoo.com

This report describes a liver hemangioma causing obstructive jaundice, an
extremely rare condition that has been reported on 3 previous occasions. A
hemangioma can compress the major bile ducts and require partial hepatectomy for 
a successful outcome.

Publication Types: 
    Case Reports

PMID: 18519125 [PubMed - indexed for MEDLINE]

37: Acta Chir Iugosl. 2008;55(1):115-8.

The first transendoscopic plastic to self-expandable metal stent replacement in
Serbia and Montenegro using a diagnostic duodenoscope.

Bulajić M, Milojković B, Jakovljević M, Milosević P, Gazivoda I, Sankovic Z,
Bulajić M.

Endoscopy Unit, Clinical Hospital Center Dr D. Misović-Dedinje, Belgrade, Serbia.

Studies have shown that SEMS remain patient longer with fewer associated
complications compared with conventional plastic strents. Zilver stent, a nitinol
zig-zag mash SEMS has a special advantage, having a thin introducer diameter of 7
Fr with a fully deployed span of 10mm. For a 48-year-old woman presented with
obstructive jaundice and a diagnosis of unresectable pancreatic carcinoma with
consequent stenosis of common bile duct (CBD), infiltration of local blood
vessels and life expectancy longer than six months, it was decided that an
endoscopic palliative drainage procedure should be performed. The technique of
transendoscopic plastic to metal stent exchange is described, using a diagnostic 
duodenoscope. The patient lived 7 months after implementation of Zilver stent and
died anicteric due to progression of a primary disease. The transendoscopic
plastic to metal stent exchange is feasible palliative method which requires a
basic endoscopic equipment and experienced staff and therefore is applicable in
developing countries as well.

Publication Types: 
    Case Reports

PMID: 18510071 [PubMed - indexed for MEDLINE]

38: Hepatogastroenterology. 2008 Jan-Feb;55(81):54-7.

Role of percutaneous transhepatic biliary drainage in patients with obstructive
jaundice caused by local recurrence of gastric cancer.

Makino T, Fujitani K, Tsujinaka T, Hirao M, Kashiwazaki M, Nakamori S, Ikenaga M,
Mishima H, Masuda N, Sawamura T.

Department of Surgery, Osaka National Hospital, Chuo-ku, Osaka, Japan.

BACKGROUND/AIMS: We reviewed the medical records of patients with obstructive
jaundice caused by the local recurrence of gastric cancer to clarify the role of 
percutaneous transhepatic biliary drainage (PTBD). METHODOLOGY: Eleven patients
with a mean age of 60.1 years (range: 51-71 years) underwent PTBD because of
obstructive jaundice caused by the extrahepatic recurrence of gastric cancer.
RESULTS: Jaundice was relieved in all the patients, and the serum total bilirubin
(T-bil) level decreased from 12.2 to 2.1 mg/dL. No major complications associated
with the execution of PTBD occurred. Although various symptoms caused by
jaundice, such as anorexia, itching, nausea, abdominal pain, and fever, were
relieved in all the patients within one week after PTBD, general fatigue
persisted in 3 patients and abdominal fullness persisted in one. Seven of the 11 
patients were discharged from the hospital after the execution of PTBD and
remained at home for a median of 93 days. The median survival time (MST) of the
remaining 4 patients who could not be discharged was 48 days. Chemotherapy was
added in 5 patients after the execution of PTBD; these patients exhibited a
significantly longer MST of 247 days, compared to 62 days among the patients who 
did not receive chemotherapy (P=0.0176). CONCLUSIONS: PTBD was safely conducted
and improved the quality-of-life of patients with obstructive jaundice caused by 
the local recurrence of gastric cancer. Furthermore, the use of chemotherapy
after PTBD might prolong patient survival although RCT (randomized controlled
trial) study should be performed to assess the precise effect of chemotherapy
after PTBD.

PMID: 18507078 [PubMed - indexed for MEDLINE]

39: World J Gastroenterol. 2008 May 21;14(19):3098-100.

Tuberculous lymphadenitis as a cause of obstructive jaundice: a case report and
literature review.

Colovic R, Grubor N, Jesic R, Micev M, Jovanovic T, Colovic N, Atkinson HD.

Institute for Digestive Diseases, First Surgical Clinic, Clinical Center of
Serbia, Koste Todorovica 6, Belgrade 11000, Serbia.

Obstructive jaundice secondary to tuberculosis (TB) is extremely rare. It can be 
caused by TB enlargement of the head of the pancreas, TB lymphadenitis, TB
stricture of the biliary tree, or a TB mass of the retroperitoneum. A 29-year-old
man with no previous history of TB presented with abdominal pain, obstructive
jaundice, malaise and weight loss. Ultrasonography (US), computer tomography (CT)
scan and endoscopic retrograde cholangiopancreatography (ERCP) were suggestive of
a stenosis of the distal common bile duct (CBD) caused by a mass in the posterior
head of the pancreas. Tumor markers, CEA and CA19-9 were within normal limits. At
operation, an enlarged, centrally caseous lymph node of the posterior head of the
pancreas was found, causing inflammatory stenosis and a fistula with the distal
CBD. The lymph node was removed and the bile duct resected and anastomosed with
the Roux-en Y jejunal limb. Histology and PCR based-assay confirmed tuberculous
lymphadenitis. After an uneventful postoperative recovery, the patient was
treated with anti-tuberculous medication and remained well 2.5 years later.
Though obstructive jaundice secondary to tuberculous lymphadenitis is rare,
abdominal TB should be considered as a differential diagnosis in
immunocompromised patients and in TB endemic areas. Any stenosis or fistulation
into the CBD should also be taken into consideration, and biliary bypass surgery 
be performed to both relieve jaundice and prevent further stricture.

Publication Types: 
    Case Reports
    Review

PMID: 18494068 [PubMed - indexed for MEDLINE]

40: World J Gastroenterol. 2008 May 21;14(19):3000-5.

Diagnosis and initial management of cholangiocarcinoma with obstructive jaundice.

Tajiri T, Yoshida H, Mamada Y, Taniai N, Yokomuro S, Mizuguchi Y.

Department of Surgery, Nippon Medical School, Bunkyo-ku, Tokyo 113-8603, Japan.
tajirit@nms.ac.jp

Cholangiocarcinoma is the second most common primary hepatic cancer. Despite
advances in diagnostic techniques during the past decade, cholangiocarcinoma is
usually encountered at an advanced stage. In this review, we describe the
classification, diagnosis, and initial management of cholangiocarcinoma with
obstructive jaundice.

Publication Types: 
    Review

PMID: 18494050 [PubMed - indexed for MEDLINE]

41: World J Gastroenterol. 2008 May 14;14(18):2818-24.

Effect of oophorectomy and exogenous estrogen replacement on liver injury in
experimental obstructive jaundice.

Ucan HB, Kaplan M, Salman B, Yilmaz U, Mentes BB, Aybay C.

Department of General Surgery, Gazi University School of Medicine, Besevler
06500, Ankara, Turkey.

AIM: To investigate the role of estrogen on liver injury in an experimental
obstructive jaundice model. METHODS: Three groups of female rats were
constituted; group 1 was oophorectomized and given E2 (n = 14), group 2 was
oophorectomized and given placebo (n = 14), and group 3 was sham operated (n =
14). Fourteen days following constitution of bile duct ligation, all groups were 
compared in terms of serum tests, histopathologic parameters, and tissue levels
of IFN-gamma and IL-6. RESULTS: The parameters representing both the injury
and/or the reactive response and healing were more pronounced in groups 1 and 2
(c2 = 17.2, c2 = 10.20; c2 = 12.4, P < 0.05). In the sham operated or E2
administered groups significantly lower tissue levels of IFN-gamma and higher
IL-6 levels were found. In contrast, high IFN-gamma and low IL-6 tissue levels
were found in the oophorectomized and placebo group (P < 0.001). Kupffer cell
alterations were observed to be more pronounced in the groups 1 and 3 (c2 = 6.13,
P < 0.05). CONCLUSION: Our study indicates that E2 impaired liver functions,
accelerated both the liver damage and healing. In the conditions of bile duct
obstruction, estrogen significantly changed the cytokine milieu in the liver.

PMID: 18473404 [PubMed - indexed for MEDLINE]

42: Pediatr Surg Int. 2008 Jul;24(7):837-42. Epub 2008 May 10.

Apoptosis in the small intestine of neonatal rat using blue light-emitting diode 
devices and conventional halogen-quartz devices in phototherapy.

Tanaka K, Hashimoto H, Tachibana T, Ishikawa H, Ohki T.

Department of Surgery, Jikei University School of Medicine, 3-25-8,
Nishi-Shinbashi, Minato-ku, Tokyo 105-8461, Japan. keiichiro@jikei.ac.jp

Phototherapy is the most frequently used treatment for the neonatal jaundice.
However, recent papers report that phototherapy increased apoptosis in peripheral
mononuclear leukocytes in vivo and in mouse lymphoma cell line in vitro. We have 
investigated the cytotoxicity of phototherapy on the small intestine of neonatal 
rat using conventional halogen-quartz device (conventional device) and blue
light-emitting device (LED device) by measuring apoptotic cells. Four-day-old
male Wistar rats were divided into three groups as follows: group 1, exposure to 
conventional device for 72 h; group 2, exposure to LED device for 72 h; and group
3, control (without phototherapy). After light exposure, the small intestine was 
examined for apoptosis. Apoptotic cells were detected by the TUNEL (terminal
deoxynucleotidyl transferase-mediated dUTP nick end labeling) assay, by
immunohistochemistry for caspase-3 and by transmission electron microscopy. The
proportion of positive cells by the TUNEL method in the epithelium of the small
intestine was 6.2, 3.1 and 1.7% in the conventional device group, the LED device 
group and the control group, respectively. The apoptotic cells of the
conventional device group is significantly higher than the LED device group (P < 
0.01) and that of the LED device group was higher than that of the control group 
(P < 0.05). We suspected that phototherapy induced apoptosis in neonatal small
intestine and the conventional device introduces more apoptosis than the LED
device.

Publication Types: 
    Comparative Study
    Research Support, Non-U.S. Gov't

PMID: 18470518 [PubMed - indexed for MEDLINE]

43: Eur J Gastroenterol Hepatol. 2008 Jun;20(6):572-3.

Severe jaundice following treatment with ezetimibe.

Ritchie SR, Orr DW, Black PN.

Department of Medicine, University of Auckland, New Zealand.
sritchie@adhb.govt.nz

Ezetimibe is a cholesterol-lowering agent that modulates intestinal absorption of
sterols. It is well tolerated but hepatic toxicity has been reported when
ezetimibe is used in conjunction with a statin medication. In this case report,
we report severe isolated hyperbilirubinaemia occurring in a patient with occult 
cirrhosis, probably owing to nonalcoholic steatohepatitis, who was treated with
ezetimibe alone. The adverse event started after ezetimibe therapy was initiated 
and resolved when the drug was stopped. We propose a mechanism for this reaction 
and believe that liver function should be monitored in patients with abnormal
liver tests who are treated with ezetimibe, even if they are not on concomitant
treatment with a statin.

Publication Types: 
    Case Reports

PMID: 18467918 [PubMed - indexed for MEDLINE]

44: J Vasc Interv Radiol. 2008 May;19(5):748-54. Epub 2008 Mar 17.

Percutaneous metallic stents in patients with obstructive jaundice due to
hepatocellular carcinoma.

Hong HP, Kim SK, Seo TS.

Department of Radiology, Kangbuk Samsung Hospital, Sungkyunkwan University School
of Medicine, 108, Pyung-Dong, Jongro-ku, Seoul, 110-746 Korea.

PURPOSE: To evaluate the technical success and clinical efficacy of
percutaneously placed self-expandable metallic stents in patients with
obstructive jaundice due to hepatocellular carcinoma (HCC). MATERIALS AND
METHODS: Fifteen men (mean age, 59.3 years) with obstructive jaundice resulting
from HCC were treated with self-expandable metallic stents (28 stents in 19
sessions). The authors evaluated the technical success, clinical success
(decrease of 30% of total serum bilirubin level or <2 mg/dL [34.2 micromol/L]),
treatment efficacy according to lowest total serum bilirubin level,
complications, and duration of stent patency. RESULTS: Technical success was
achieved in all patients. Clinical success was achieved in 11 of the 15 patients 
(73%). After stent placement, seven patients (47%) had a low bilirubin level (<2 
mg/dL [34.2 micromol/L]), three (20%) had an intermediate bilirubin level (2-10
mg/dL [34.2-171 micromol/L]), and five (33%) had a high bilirubin level (>10
mg/dL [171 micromol/L]). A low bilirubin level was achieved in all patients with 
Child-Pugh A disease and stage T2 or T3 HCC. Major complications such as
hemobilia necessitating transfusion (n=1) or abscess formation (n=1) occurred in 
two of the 19 sessions (10%). The overall mean stent patency was 149.8 days
(range, 12-790 days). The mean stent patency in patients with Child-Pugh class A 
disease (257.8 days) was significantly longer than that of patients with
Child-Pugh class B and C disease (123.2 and 63 days, respectively) (P<.05).
CONCLUSIONS: The percutaneous placement of a self-expandable metallic stent is a 
feasible and effective palliative treatment for patients with obstructive
jaundice resulting from HCC, especially for those with Child-Pugh class A disease
and stage T2 or T3 HCC.

PMID: 18440465 [PubMed - indexed for MEDLINE]

45: J Hosp Med. 2008 Mar;3(2):117-23.

Fate of patients with obstructive jaundice.

Björnsson E, Gustafsson J, Borkman J, Kilander A.

Department of Internal Medicine, Sahlgrenska University Hospital, Gothenburg,
Sweden. einar.bjornsson@medic.gu.se

BACKGROUND/OBJECTIVE: Systematic data are limited on the etiology and prognosis
of unselected patients with obstructive jaundice (OJ). We aimed to review the
clinical features, etiology, and prognosis of patients with OJ. METHODS: All
adult patients with bilirubin >or= 5.85 mg/dL (100 micromol/L) at a university
hospital in Sweden in 2003-2004 were identified. Medical records from patients
with OJ were reviewed. RESULTS: Seven hundred and forty-nine patients were
identified, of whom 241 (32%) had OJ (median age 71 years, 129 women). No one was
lost to follow-up. The biliary obstruction of 154 patients (64%) was a result of 
a malignancy: 69 patients (46%) had pancreatic cancer, 44 (29%) had
cholangiocarcinoma (CC), 5 (3%) had papilla vateri cancers, and 36 patients (23%)
had other malignancies. Of the 87 patients with a benign obstruction, 57 (65%)
had choledocholithiasis, 7 (8%) had biliary strictures, 6% had PSC, and the
obstruction of 16 patients (20.7%) had other causes. A total of 115 of the 242
patients (48%) had abdominal pain associated with jaundice, whereas 52% had
painless jaundice. Thirty-four percent of patients with a malignant obstruction
had abdominal pain versus 71% of patients with a benign obstruction (P < .05). At
the end of follow-up, only 5% (8 patients) with a malignant obstruction were
alive versus 78% with a benign obstruction. CONCLUSIONS: Obstructive jaundice was
the cause of the severe jaundice of one third of patients. Most cases of OJ were 
a result of a malignancy, which carried a very poor prognosis, with a 2-year
mortality rate of 95%. (c) 2008 Society of Hospital Medicine.

Publication Types: 
    Comparative Study
    Research Support, Non-U.S. Gov't

PMID: 18438808 [PubMed - indexed for MEDLINE]

46: Am J Emerg Med. 2008 May;26(4):516.e1-2.

Erratum in:
    Am J Emerg Med. 2009 Jan;27(1):126.. Farmer, Michael C [corrected to Farner,
Michael C].

A rare incidental finding in a case of painless jaundice.

Patel SN, Baumann BM, Farner MC.

Department of Emergency Medicine, University of Medicine and Dentistry of New
Jersey, Robert Wood Johnson Medical School-Camden, Cooper University Hospital,
Camden, NJ 08103, USA.

Portal vein thrombosis secondary to protein C deficiency is a rare finding.
Diagnosing a portal vein thrombosis itself is difficult due to nonspecific
symptoms such as nausea, vomiting, anorexia, and weight loss. Proving that a
protein C deficiency is the cause of a portal vein thrombosis is even more
difficult as an extensive and thorough workup is required to rule out
malignancies, myeloproliferative disorders, and hypercoaguable states which can
all lead to thromboses. Patients require anticoagulation to prevent two dangerous
complications of portal vein thrombosis; portal hypertension leading to
esophageal varices with massive hemetemesis and extension of thrombus from the
portal vein into the mesenteric veins leading to intestinal ischemia and death.
In this case report, we present a patient with the complaint of painless jaundice
who was found to have an incidental finding of portal vein thrombosis secondary
to protein C deficiency. The different etiologies of portal vein thrombosis,
along with diagnosis and treatment options will be discussed and highlighted.

Publication Types: 
    Case Reports

PMID: 18410831 [PubMed - indexed for MEDLINE]

47: Endoscopy. 2008 Apr;40(4):340-2.

EUS-guided choledochoduodenostomy for palliative biliary drainage in patients
with malignant biliary obstruction: results of long-term follow-up.

Yamao K, Bhatia V, Mizuno N, Sawaki A, Ishikawa H, Tajika M, Hoki N, Shimizu Y,
Ashida R, Fukami N.

Department of Gastroenterology, Aichi Cancer Center Hospital, Japan.
kyamao@aichi-cc.jp

Five patients with obstructive jaundice caused by malignant periampullary biliary
stenosis underwent EUS-guided choledochoduodenostomy (EUS-CDS) from the first
portion of the duodenum using a convex echoendoscope and a needle knife. All the 
steps of the procedure including passage dilatation and the plastic stent
placement were performed through the accessory channel of the echoendoscope over 
the guide wire. Stent insertion was technically successful in all five patients. 
The procedure was also clinically effective in relieving jaundice in all cases.
One patient developed pneumoperitoneum, which resolved with conservative
management. Stent exchange was successful in seven of eight attempts in patients 
with stent occlusion. One failure was due to tumor invasion to the
choledochoduodenal fistula. Stent patency was maintained in the remaining
patients throughout their survival period. The average stent patency was 211.8
days. EUS-CDS from the first portion of the duodenum appears to be feasible and
safe in cases of obstructive jaundice caused by distal bile duct obstruction.

Publication Types: 
    Case Reports

PMID: 18389451 [PubMed - indexed for MEDLINE]

48: Am J Trop Med Hyg. 2008 Apr;78(4):556-9.

Pathophysiology of jaundice in amoebic liver abscess.

Singh V, Bhalla A, Sharma N, Mahi SK, Lal A, Singh P.

Department of Hepatology, Postgraduate Institute of Medical Education and
Research, Chandigarh, 160 022 India. virendrasingh100@hotmail.com

Jaundice in patients with amoebic liver abscess is a frequent occurrence.
However, the pathophysiology of jaundice in these patients is not fully
understood. Hepatic necrosis leads to damage to bile ducts as well as various
vascular structures, which in turn leads to biliovascular fistula and jaundice.
We studied the mechanism of jaundice in patients with amoebic liver abscess. We
prospectively evaluated 12 patients with amoebic liver abscess and jaundice from 
February 2002 to August 2007. All patients underwent various investigations,
including imaging studies. There were 11 males and 1 female patient with a mean
age of 41.3 years. Mean duration of illness before presentation was 13.8 days.
All patients had fever and jaundice. We detected damaged hepatic veins and bile
ducts in all patients with amoebic liver abscess causing biliovascular fistula
and hyperbilirubinemia, which reverted to normal after biliary diversion with
nasobiliary drainage. Jaundice in patients with amoebic liver abscess is caused
by biliovascular fistula resulting from hepatic necrosis leading to damage to
bile ducts and hepatic veins.

PMID: 18385348 [PubMed - indexed for MEDLINE]

49: Gastrointest Endosc. 2008 Sep;68(3):461-6. Epub 2008 Apr 2.

Comment in:
    Gastrointest Endosc. 2008 Sep;68(3):467-9.

Combined EUS with FNA and ERCP for the evaluation of patients with obstructive
jaundice from presumed pancreatic malignancy.

Ross WA, Wasan SM, Evans DB, Wolff RA, Trapani LV, Staerkel GA, Prindiville T,
Lee JH.

Departments of Gastroenterology, Hepatology and Nutrition, University of Texas
M.D. Anderson Cancer Center, Houston, Texas, USA.

BACKGROUND: An EUS-guided FNA (EUS-FNA) and a therapeutic ERCP are frequently
required for the evaluation of patients who were seen for an obstructing
periampullary lesion. OBJECTIVE: To determine the feasibility and outcomes of
combining an EUS-FNA and a therapeutic ERCP into a single session. DESIGN:
Retrospective single-center study. SETTING: Tertiary-referral cancer center.
PATIENTS: A total of 114 patients with a suspected malignant obstructing lesion
in the pancreatic head. INTERVENTIONS: An EUS with or without FNA plus an ERCP.
MAIN OUTCOME MEASUREMENTS: Duration, diagnostic yield, and complication rate of
the combined procedures. RESULTS: The mean (SD) total procedure time (EUS, with
or without FNA plus ERCP) was 73.6 +/- 30 minutes, with a median of 66 minutes
(range 25-148 minutes). In many cases, cytologic diagnosis from FNA became
available during an ERCP, which obviated the need for further sampling. EUS-FNA
had a sensitivity, specificity, positive predictive value, negative predictive
value, and overall accuracy of 84.6%, 100%, 100%, 62.9%, and 87.8%, respectively.
During an ERCP, endoscopic sphincterotomies were performed in 51 patients, and
biliary stents were placed in 96 patients. Twelve patients (10.5%) had a
complication, with 6 having postprocedural pancreatitis. LIMITATIONS:
Retrospective single-center experience. CONCLUSIONS: Combined EUS-FNA and
therapeutic ERCP is technically feasible, with a complication rate no higher than
the component procedures, while efficiently providing tissue diagnosis and
biliary drainage.

Publication Types: 
    Evaluation Studies

PMID: 18384788 [PubMed - indexed for MEDLINE]

50: Pancreas. 2008 Mar;36(2):187-91.

Transpancreatic precut sphincterotomy for cannulation of inaccessible common bile
duct: a safe and successful technique.

Weber A, Roesch T, Pointner S, Born P, Neu B, Meining A, Schmid RM, Prinz C.

Department of Internal Medicine II, Technical University of Munich, Munich,
Germany.

OBJECTIVE: Obstruction of the biliary tract can lead to severe complications. The
common treatment of patients with biliary tract obstruction is the decompression 
by endoscopic procedures. However, cannulation of the common bile duct can be
difficult under certain instances because of anatomical variations or obstruction
at the biliary entrance level. Needle-knife or precut sphincterotomy has been
described as technique to facilitate biliary access in patients with difficult
bile duct cannulation. In the current study, we evaluated success and
complication rates of a wire-guided transpancreatic precut technique at our
hospital. METHODS: Between January 2003 and June 2006, a total of 108 patients
with jaundice but with inaccessible bile ducts using classic techniques (failed
primary cannulation or failed needle-knife papillotomy) underwent a wire-guided
transpancreatic precut sphincterotomy. Precuts were performed using a soft guide 
wire placed in the pancreatic duct without injection of contrast fluid into the
pancreatic duct. RESULTS: We studied cannulation success and complications
associated with postprocedural hospitalization. Bile duct cannulation was
successful in 103 (95.4%) of the 108 patients. Five patients (4.6%) required a
percutaneous transhepatic biliary drainage. In 108 patients, there were 12
patients (11.1%) with procedure-related complications including acute
pancreatitis (n = 6) and bleeding (n=6). Four patients had a mild and transient
pancreatitis (pain improvement after 2 days), 2 had severe pancreatitis that was 
reversible after 7 days of conservative treatment. In 4 cases, a blood
transfusion (each with 2 erythrocyte concentrates) became necessary. Perforations
and other severe procedure-related deaths did not occur. CONCLUSIONS:
Transpancreatic precut sphincterotomy using a soft guide wire is a safe and
effective procedure in patients with difficult bile duct access where classic
sphincterotomy or needle-knife procedures fail.

PMID: 18376311 [PubMed - indexed for MEDLINE]

51: Surg Today. 2008;38(4):371-6. Epub 2008 Mar 27.

Pancreatobiliary fistula associated with an intraductal papillary-mucinous
pancreatic neoplasm manifesting as obstructive jaundice: report of a case.

Okada K, Furuuchi T, Tamada T, Sasaki T, Suwa T, Shatari T, Takenaka Y, Hori M,
Sakuma M.

Department of Surgery, Mito Red Cross Hospital, Sannomaru, Mito, Ibaraki
310-0011, Japan.

We report a pancreatobiliary fistula caused by an intraductal papillary-mucinous 
pancreatic neoplasm (IPMN), manifesting as obstructive jaundice. Computed
tomography showed dilatation of the bile duct and main pancreatic duct, with
multiple cystic masses in the head of the pancreas. Endoscopic retrograde
pancreatocholangiography showed a patulous papilla with mucin secretion. Contrast
enhancement outlined amorphous material obstructing the lower part of the common 
hepatic duct. Pancreatogram and magnetic resonance cholangiopancreatography
showed diffuse dilatation of the main pancreatic duct and side branches without
communication with the adjacent organs or duct. We performed
pancreaticoduodenectomy for IPMN of the pancreatic head and a tumor-like lesion
in the lower common bile duct (CBD). Macroscopically, impacted thick mucus
protruded into the CBD from the pancreas via a pancreatobiliary fistula.
Histologic examination revealed a pancreatobiliary fistula caused by intraductal 
papillary-mucinous carcinoma of the pancreas with mucin hypersecretion, an
adenoma without interstitial infiltration, and isolated implantation of an IPMN
in the bile duct mucosa around the fistula.

Publication Types: 
    Case Reports

PMID: 18368332 [PubMed - indexed for MEDLINE]

52: Clin Nucl Med. 2008 Apr;33(4):273-5.

Spontaneous biliary perforation in an infant: an unusual chronic presentation.

Vijay BB, Kumar R, Gupta DK, Ragavan M, Mohapatra T, Dhanpathi H, Sharma S,
Malhotra A.

Department of Nuclear Medicine, All India Institute of Medical Sciences, New
Delhi, India.

Spontaneous perforation of the biliary ducts is a rare disorder in infants. Early
diagnosis of this entity is important because it can be treated surgically. We
report on a 4-month-old child presenting with jaundice and progressive abdominal 
distention present since birth. Hepatobiliary scintigraphy, which was done to
rule out any obstructive pathology, showed a biliary leak from the porta hepatis 
region leading to biliary ascites and bilateral hydroceles. Surgical exploration 
and intraoperative cholangiogram confirmed cystic duct perforation.
Cholecystectomy and inguinal herniorrhaphy were performed. Follow-up
hepatobiliary scintigraphy demonstrated complete resolution of the bile leak and 
hydroceles.

Publication Types: 
    Case Reports

PMID: 18356667 [PubMed - indexed for MEDLINE]

53: Gastroenterology. 2008 Mar;134(3):781-92. Epub 2008 Jan 9.

Continuous cell injury promotes hepatic tumorigenesis in cdc42-deficient mouse
liver.

van Hengel J, D'Hooge P, Hooghe B, Wu X, Libbrecht L, De Vos R, Quondamatteo F,
Klempt M, Brakebusch C, van Roy F.

Molecular Cell Biology Unit, VIB, Ghent, Belgium; Department of Molecular
Biology, Ghent University, Ghent, Belgium.

BACKGROUND & AIMS: The Rho small guanosine triphosphatase Cdc42 is critical for
diverse cellular functions, including regulation of actin organization, cell
polarity, intracellular membrane trafficking, transcription, cell-cycle
progression, and cell transformation. This implies that Cdc42 might be required
for liver function. METHODS: Mice in which Cdc42 was ablated in hepatocytes and
bile duct cells were generated by Cre-loxP technology. Livers were examined by
histologic, immunohistochemical, ultrastructural, and serum analysis to define
the effect of loss of Cdc42 on liver structure. RESULTS: Mice lacking Cdc42 in
their hepatocytes were born at Mendelian ratios. They did not show increased
mortality but showed chronic jaundice. They developed hepatomegaly soon after
birth, and signs of liver transformation, such as formation of nodules and
tumors, became visible macroscopically at age 6 months. Hepatocellular carcinoma 
was observed 8 months after birth. Tumors grew slowly and lacked expression of
nuclear beta-catenin. Lung metastases were observed at the late stage of
carcinogenesis. Immunofluorescent examination and electron microscopy revealed
severe defects in the liver. At the age of 2 months, the canaliculi between
hepatocytes were greatly enlarged, although the tight junctions flanking the
canaliculi appeared normal. Regular liver plates were absent. E-cadherin
expression pattern and gap junction localization were distorted. Analysis of
serum samples indicated cholestasis. CONCLUSIONS: We describe a mouse model in
which chronic liver disease leads to hepatocarcinogenesis.

Publication Types: 
    Research Support, Non-U.S. Gov't

PMID: 18325391 [PubMed - indexed for MEDLINE]

54: Int J Gynaecol Obstet. 2008 Jun;101(3):277-80. Epub 2008 Mar 5.

Severe liver disease in pregnancy.

Chen H, Yuan L, Tan J, Liu Y, Zhang J.

Obstetrics and Gynecology Department, The Second Affiliated Hospital of Sun
Yat-Sen University, Guangdong, China.

OBJECTIVE: To determine the clinical characteristics of patients with fulminant
hepatitis of pregnancy (FHP) and acute fatty liver of pregnancy (AFLP) and
analyze their correlation with pregnancy outcome. METHODS: Of 55 pregnant women
with severe liver disease, 41 had FHP and 14 had AFLP. RESULTS: Jaundice was the 
primary manifestation for both FHP and AFLP and hepatic encephalopathy was the
most significant complication for both. Disseminated intravascular coagulation,
albuminuria, and prothrombin activity were found to be independent risk factors
of maternal mortality for both. However, the rates of preterm labor, fetal
demise, and neonatal asphyxia were lower in the FHP group. CONCLUSION: Women with
FHP or AFLP are at risk for severe complications and adverse pregnancy outcome.
Since the 2 conditions are managed differently, early diagnosis is essential.

PMID: 18321514 [PubMed - indexed for MEDLINE]

55: Surg Today. 2008;38(3):271-4. Epub 2008 Feb 29.

Liver cryptococcosis manifesting as obstructive jaundice in a young
immunocompetent man: report of a case.

Nara S, Sano T, Ojima H, Onaya H, Ikeda M, Morizane C, Esaki M, Sakamoto Y,
Shimada K, Kosuge T.

Hepatobiliary and Pancreatic Surgery Division, National Cancer Center Hospital,
5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan.

A 25-year-old immunocompetent Japanese man was referred to us for investigation
and treatment of obstructive jaundice. Computed tomography (CT) showed dilatation
of the bilateral intrahepatic bile ducts and a low-attenuated mass extending
along the portal tract, from the hepatic hilum to the periphery, suggestive of
cholangiocellular carcinoma (CCC) with periductal infiltration. However, the
culture of bile obtained by percutaneous transhepatic biliary drainage revealed
Cryptococcus neoformans. Microscopic examination of a biopsy specimen of the
mass-like lesion in the liver revealed fungal organisms encapsulated in
multinucleated giant cells. A small area of infiltration in the left lung was
also detected on chest CT, and a diagnosis of liver and lung cryptococcosis was
made. After 8 months of antifungal therapy, both the liver and lung lesions had
vanished and the biliary stricture resolved. Unnecessary surgical intervention
was avoided by an early and accurate diagnosis and effective antifungal therapy. 
The bile culture was the key to the definitive diagnosis in this case.

Publication Types: 
    Case Reports

PMID: 18307005 [PubMed - indexed for MEDLINE]

56: Eur J Surg Oncol. 2008 Mar;34(3):313-7. Epub 2008 Feb 13.

Endoscopic therapy in the management of malignant biliary obstruction.

Stern N, Sturgess R.

Department of Gastroenterology, University Hospital Aintree, Longmoor Lane,
Liverpool L9 7AL, UK.

Malignant biliary obstruction is often caused by tumour within the biliary tree, 
or extrinsic compression. This often results in patients becoming jaundiced
causing a significant associated morbidity. The majority of malignant biliary
obstruction is due to inoperable disease, and therefore the mainstay of
palliating jaundice is stent placement at endoscopic retrograde
cholangiopancreatography (ERCP). Cross-sectional imaging is necessary to
determine if stenting is appropriate and to guide stent placement. This is
especially important in patients with hilar cholangiocarcinoma, where drainage
should be undertaken in specialist centres. Self-expanding metal stents are
preferable to plastic stents and are cost effective if survival is likely to be
more than 6 months. With the exception of pancreatic carcinoma, traditional
non-operative disease modifying treatments for biliary malignancies have shown
only limited benefit. This particularly relates to radio and chemotherapy.
Photodynamic therapy is a relatively new modality of treatment that appears to be
effective in patients with local but inoperable cholangiocarcinoma and is capable
of prolonging survival.

Publication Types: 
    Review

PMID: 18276101 [PubMed - indexed for MEDLINE]

57: J Hepatobiliary Pancreat Surg. 2008;15(1):69-73. Epub 2008 Feb 16.

Stenting and interventional radiology for obstructive jaundice in patients with
unresectable biliary tract carcinomas.

Tsuyuguchi T, Takada T, Miyazaki M, Miyakawa S, Tsukada K, Nagino M, Kondo S,
Furuse J, Saito H, Suyama M, Kimura F, Yoshitomi H, Nozawa S, Yoshida M, Wada K, 
Amano H, Miura F; Japanese Association of Biliary Surgery; Japanese Society of
Hepato-Biliary-Pancreatic Surgery; Japan Society of Clinical Oncology.

Collaborators: Kai M, Kimura Y, Sawada S, Shimizu H, Nakagawara H, Nakachi K,
Yoshitome H, Saisyo H, Ryu M, Shikata S, Nimura Y.

Department of Medicine and Clinical Oncology, Chiba University Graduate School of
Medicine, Chiba, Japan.

Together with biliary drainage, which is an appropriate procedure for
unresectable biliary cancer, biliary stent placement is used to improve symptoms 
associated with jaundice. Owing to investigations comparing percutaneous
transhepatic biliary drainage (PTBD), surgical drainage, and endoscopic drainage,
many types of stents are now available that can be placed endoscopically. The
stents used are classified roughly as plastic stents and metal stents. Compared
with plastic stents, metal stents are of large diameter, and have long-term
patency (although they are expensive). For this reason, the use of metal stents
is preferred for patients who are expected to survive for more than 6 months,
whereas for patients who are likely to survive for less than 6 months, the use of
plastic stents is not considered to be improper. Obstruction in a metal stent is 
caused by a tumor that grows within the stent through the mesh interstices. To
overcome such problems, a covered metal stent was developed, and these stents are
now used in patients with malignant distal biliary obstruction. However, this
type of stent has been reported to have several shortcomings, such as being
associated with the development of acute cholecystitis and stent migration. In
spite of these shortcomings, evidence is expected to demonstrate its superiority 
over other types of stent.

Publication Types: 
    Practice Guideline
    Research Support, Non-U.S. Gov't

PMID: 18274846 [PubMed - indexed for MEDLINE]

58: Acta Chir Belg. 2007 Nov-Dec;107(6):716-9.

Solitary extra-hepatic hilar peribiliary cyst presenting with obstructive
jaundice: a case report.

Johnson MA, Ravichandran P, Surendran R.

Department of Surgical Gastro-enterology, Centre for G.I.Bleed and Division of
Hepato-biliary Pancreatic Diseases, Government Stanley Medical College Hospital, 
Chennai, India. roopikajohn@yahoo.co.in

Peribiliary cyst is a poorly recognized and under-reported clinico-pathologic
entity around the biliary tree. Peribiliary cysts are cystic dilatations of
obstructed peribiliary glands, which are normal elements of the biliary tract.
They are generally asymptomatic and rarely cause biliary obstruction. They are
usually discovered incidentally at autopsy or in explants following liver
transplantation. A 59-year-old male patient presenting with obstructive jaundice 
due to a large extra-hepatic hilar peribiliary cyst is reported here. We briefly 
discuss its differential diagnoses such as bile duct cyst, liver cyst or lymph
cyst, and its management. Radiological imaging demonstrated a solitary large (5
cm) well-defined, smooth, thin walled cystic lesion at the porta hepatis
paralleling but not communicating with the bile duct. A wide cyst de-roofing was 
performed and histological examination of the cystic wall revealed an
inflammatory cyst. The patient made an uneventful recovery and remained
asymptomatic with normal liver function tests 36 months postoperatively.

Publication Types: 
    Case Reports

PMID: 18274195 [PubMed - indexed for MEDLINE]

59: Clin Breast Cancer. 2007 Dec;7(11):890-1.

Delayed resolution of jaundice in the arm of a patient with impaired lymphatic
drainage: a case report.

Tsang RY, Mackey JR.

Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.

A 40-year-old woman, 6 years after mastectomy, lymph node dissection, and
locoregional radiation, presented with hepatic metastases, pruritus, and
jaundice. Physical examination revealed uniformly jaundiced skin and no arm
lymphedema. Ultrasonography confirmed progressive hepatic metastases with no
evidence of intrahepatic or extrahepatic biliary dilatation. Eight weeks after
starting chemotherapy, her pruritus and jaundice were markedly improved, but the 
jaundice on the skin of her left arm was substantially slower to clear than the
other skin areas. With further therapy, serum bilirubin normalized and her left
arm jaundice completely resolved. We hypothesize that the delayed resolution of
jaundice on her left arm resulted from impaired lymphatic drainage after left
axillary lymph node dissection and irradiation, and conclude that lymphatic
drainage might play a key role in the transport and clearance of bilirubin and
related pigments from peripheral tissues.

Publication Types: 
    Case Reports

PMID: 18269780 [PubMed - indexed for MEDLINE]

60: J Natl Med Assoc. 2007 Dec;99(12):1381-5.

Jaundice in African-American and Hispanic patients with AIDS.

Akhtar AJ, Shaheen M.

Charles R. Drew University of Medicine and Science, Los Angeles, CA, USA.
abbasiakhtar@cdrewu.edu

Although abnormalities in hepatic biochemical tests are common in patients with
acquired immunodeficiency syndrome (AIDS), overt jaundice is infrequent. The aim 
of this study was to investigate the etiology and outcome of jaundice in
African-American and Hispanic patients with AIDS. We retrospectively reviewed
medical records of 1,238 HIV-infected patients with abnormal liver chemistry over
a 10-year period. Data were abstracted and analyzed for demography, medications, 
laboratory tests, abdominal ultrasonography, computerized tomography (CT),
magnetic resonance imaging (MRI), endoscopic retrograde cholangiopancreatography 
(ERCP), percutaneous transhepatic cholangiography (PTC) and liver biopsy results.
Of 1,238 patients with abnormal liver chemistry and HIV infection, 1,040 (84%)
had AIDS. Of the 1,040 AIDS patients, 102 (10%) had jaundice (serum bilirubin >3 
mg/dL). Of the 198 HIV-positive patients without AIDS and with abnormal liver
chemistry, none had jaundice. The common causes of jaundice were drugs (29%) and 
infections (28%). Liver biopsy was performed in 20 AIDS patients, and the common 
findings included granulomas, Mycobacterium avium complex (25%) and Kaposi's
sarcoma (25%). Of 102 patients with AIDS and jaundice, 72 (70%) died. Of the 198 
patients without AIDS and without jaundice, 14 (7%) died. In conclusion,
liver-associated enzyme abnormality was common among our patients with AIDS;
however, jaundice was infrequent and associated with a high mortality; drugs,
infections and alcohol were the common culprits.

PMID: 18229774 [PubMed - indexed for MEDLINE]

61: Gastroenterology. 2008 Mar;134(3):706-15. Epub 2007 Dec 7.

Comment in:
    Gastroenterology. 2008 Jul;135(1):324-5; author reply 325.

Immunoglobulin G4-associated cholangitis: clinical profile and response to
therapy.

Ghazale A, Chari ST, Zhang L, Smyrk TC, Takahashi N, Levy MJ, Topazian MD, Clain 
JE, Pearson RK, Petersen BT, Vege SS, Lindor K, Farnell MB.

Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine,
Rochester, Minnesota, USA.

BACKGROUND & AIMS: Immunoglobulin (Ig)G4-associated cholangitis (IAC) is the
biliary manifestation of a steroid-responsive multisystem fibroinflammatory
disorder in which affected organs have a characteristic lymphoplasmacytic
infiltrate rich in IgG4-positive cells. We describe clinical features, treatment 
response, and predictors of relapse in IAC and compare relapse rates in IAC with 
intrapancreatic vs proximal bile duct strictures. METHODS: We reviewed clinical, 
serologic, and imaging characteristics and treatment response in 53 IAC patients.
RESULTS: IAC patients generally were older (mean age, 62 y) men (85%), presenting
with obstructive jaundice (77%) associated with autoimmune pancreatitis (92%),
increased serum IgG4 levels (74%), and abundant IgG4-positive cells in bile duct 
biopsy specimens (88%). At presentation, biliary strictures were confined to the 
intrapancreatic bile duct in 51%; the proximal extrahepatic/intrahepatic ducts
were involved in 49%. Initial presentation was treated with steroids (n = 30;
median follow-up period, 29.5 months), surgical resection (n = 18; median
follow-up period, 58 months), or was conservative (n = 5; median follow-up
period, 35 months). Relapses occurred in 53% after steroid withdrawal; 44%
relapsed after surgery and were treated with steroids. The presence of proximal
extrahepatic/intrahepatic strictures was predictive of relapse. Steroid therapy
normalized liver enzyme levels in 61%; biliary stents could be removed in 17 of
18 patients. Fifteen patients treated with steroids for relapse after steroid
withdrawal responded; 7 patients on additional immunomodulatory drugs remain in
steroid-free remission (median follow-up period, 6 months). CONCLUSIONS: IAC
should be suspected in unexplained biliary strictures associated with increased
serum IgG4 and unexplained pancreatic disease. Relapses are common after steroid 
withdrawal, especially with proximal strictures. The role of immunomodulatory
drugs for relapses needs further study.

Publication Types: 
    Comparative Study

PMID: 18222442 [PubMed - indexed for MEDLINE]

62: J Chin Med Assoc. 2008 Jan;71(1):45-8.

Cholestatic jaundice as the predominant presentation in a patient with autoimmune
hepatitis.

Tang CP, Shiau YT, Huang YH, Tsay SH, Huo TI, Wu JC, Lin HC, Lee SD.

Division of Gastroenterology, Buddhist Dalin Tzu Chi General Hospital, Chiayi,
Taiwan, Repblic of China.

Autoimmune hepatitis is a heterogeneous liver disease of unknown etiology. It is 
predominant in females and characterized by elevation of transaminase,
hypergammaglobulinemia and circulating autoantibodies. Interface hepatitis and
plasma cell infiltration are the main findings on liver biopsy. However, deep
cholestatic jaundice is rarely seen. We present here an unusual case of type 1
autoimmune hepatitis with hyperbilirubinemia as the initial and predominant
presentation. Although rare, autoimmune hepatitis should be considered in
patients with cholestasis without history of drug or viral hepatitis.

Publication Types: 
    Case Reports

PMID: 18218560 [PubMed - indexed for MEDLINE]

63: J Clin Gastroenterol. 2008 Feb;42(2):212.

Symptomatic stent cast.

Keohane J, Moore M, O'Mahony S, Crosbie O.

Department of Gastroenterology and Hepatology, Cork University Hospital, Cork,
Ireland. keohanejohn@gmail.com

Biliary stent occlusion is a major complication of endoscopic stent insertion and
results in repeat procedures. Various theories as to the etiology have been
proposed, the most frequently studied is the attachment of gram negative bacteria
within the stent. Several studies have shown prolongation of stent patency with
antibiotic prophylaxis. We report the case of stent occlusion from a cast of a
previously inserted straight biliary stent; a "stent cast" in an 86-year-old
woman with obstructive jaundice. This was retrieved with the lithotrypter and she
made an uneventful recovery. This is the first reported case of a biliary stent
cast.

Publication Types: 
    Case Reports

PMID: 18209595 [PubMed - indexed for MEDLINE]

64: Exp Clin Transplant. 2007 Dec;5(2):713-5.

Unusual presentation of recurrent hepatocellular carcinoma as obstructive
jaundice 15 years after liver transplant.

Camci C, Gurakar A, Kohli V, Sharma S, Jabbour N.

Nazih Zuhdi Transplant Institute, Integris Baptist Medical Center, Oklahoma City,
OK, USA.

Hepatocellular carcinoma recurrence is a known limitation of liver transplant.
Recurrence rates have been reported in 10% to 60% of patients within an average
of 1 to 2 years following liver transplant. We report a case of recurrent
hepatocellular carcinoma 15 years after orthotopic liver transplant, presenting
initially as obstructive bile duct compression as detected by cholangiogram.
Laparotomy revealed hepatocellular carcinoma invading the common bile duct
without any mass in the liver parenchyma. The main focus of the case is the
endoscopic retrograde cholangiopancreatography image, which is unique in the
setting of liver disease following liver transplant.

Publication Types: 
    Case Reports

PMID: 18194129 [PubMed - indexed for MEDLINE]

65: Eur J Gastroenterol Hepatol. 2008 Feb;20(2):145-7.

Severe jaundice, due to vanishing bile duct syndrome, as presenting symptom of
Hodgkin's lymphoma, fully reversible after chemotherapy.

Leeuwenburgh I, Lugtenburg EP, van Buuren HR, Zondervan PE, de Man RA.

Department of Gastroenterology and Hepatology, Erasmus University Medical Center 
Rotterdam, Rotterdam, The Netherlands.

Liver involvement in Hodgkin's lymphoma is common and is caused by hepatic
infiltration, biliary obstruction by lymphoma, hepatitis, sepsis or complications
of chemotherapeutic treatment. Jaundice caused by the vanishing bile duct
syndrome related to Hodgkin's lymphoma is very rare. The mechanism is poorly
understood but a paraneoplastic effect seems most likely as liver biopsy samples 
show cholestasis in the absence of lymphoma cells. Despite adequate treatment
almost all reported patients died of liver failure or disease progression.
Disease progression is explained partly by the difficulties encountered in the
administration of potential hepatotoxic chemotherapy in severely cholestatic
patients. We describe a 17-year-old man with vanishing bile duct syndrome and
Hodgkin's lymphoma who was treated successfully with chemotherapy. The markedly
elevated serum bilirubin levels completely normalized. Our case demonstrates that
although dosing of chemotherapy in this situation can be very difficult, a good
clinical outcome is possible, which makes the attempt at curative treatment
worthwhile.

Publication Types: 
    Case Reports

PMID: 18188038 [PubMed - indexed for MEDLINE]

66: Int J Immunopathol Pharmacol. 2007 Oct-Dec;20(4):855-60.

Anti-TNF-alpha treatment and bile duct drainage restore cellular immunity and
prevent tissue injury in experimental obstructive jaundice.

Padillo FJ, Cruz A, Segura-Jiménez I, Ruiz-Rabelo J, Vázquez-Ezquerra MR,
Perea-Alvarez MD, Peña J, Briceño J, Muntané J.

Department of General Surgery, Reina Sofia University Hospital, Ciberehd,
Córdoba, Spain.

Several experimental studies of obstructive jaundice (OJ) have shown the presence
of immunosuppressive state associated with the rise of tumor necrosis
factor-alpha (TNF-alpha) concentration in plasma. The present study evaluates the
impact of anti-TNF- alpha administration or bile duct drainage on the
inflammatory response, liver injury and renal insufficiency in obstructed rats.
OJ was induced by the ligation of bile duct in Wistar rats. The parameters were
determined at 14 and 21 days after OJ. Two additional groups of animals were
treated with anti-TNF-alpha antibodies or submitted to bile duct drainage at 14
days, and sacrificed 21 days after OJ. Cholestasis decreased glucose, and
enhanced urea, creatinin, bilirubin and transaminases. Cholestasis increased the 
number of different inflammatory cells (T and B lymphocytes, and
monocytes-macrophages) but reduced the expression of the corresponding cellular
activation markers. This low responsiveness of the inflammatory cells was related
to a decreased free radical production and phagocytic activity of cells.
Anti-TNF-alpha and bile duct drainage reduced tissue injury, and prevented the
reduction of the number and activity of T lymphocytes and phagocytic cells
observed at the advanced stages of cholestasis. In conclusion, anti-TNF- alpha
and bile duct drainage improved cell immunodeficiency, and reduced liver injury, 
cholestasis and renal insufficiency in experimental OJ.

Publication Types: 
    Research Support, Non-U.S. Gov't

PMID: 18179761 [PubMed - indexed for MEDLINE]

67: World J Gastroenterol. 2007 Dec 28;13(48):6458-64.

Pathophysiology of increased intestinal permeability in obstructive jaundice.

Assimakopoulos SF, Scopa CD, Vagianos CE.

Department of Internal Medicine, School of Medicine, University of Patras,
Vironos 18, Patras 26224, Greece. sassim@upatras.gr

Despite advances in preoperative evaluation and postoperative care, intervention,
especially surgery, for relief of obstructive jaundice still carries high
morbidity and mortality rates, mainly due to sepsis and renal dysfunction. The
key event in the pathophysiology of obstructive jaundice-associated complications
is endotoxemia of gut origin because of intestinal barrier failure. This breakage
of the gut barrier in obstructive jaundice is multi-factorial, involving
disruption of the immunologic, biological and mechanical barrier. Experimental
and clinical studies have shown that obstructive jaundice results in increased
intestinal permeability. The mechanisms implicated in this phenomenon remain
unresolved, but growing research interest during the last decade has shed light
in our knowledge in the field. This review summarizes the current concepts in the
pathophysiology of obstructive jaundice-induced gut barrier dysfunction,
analyzing pivotal factors, such as altered intestinal tight junctions expression,
oxidative stress and imbalance of enterocyte proliferation and apoptosis.
Clinicians handling patients with obstructive jaundice should not neglect
protecting the intestinal barrier function before, during and after intervention 
for the relief of this condition, which may improve their patients' outcome.

Publication Types: 
    Review

PMID: 18161914 [PubMed - indexed for MEDLINE]

68: Neurochem Res. 2008 Jun;33(6):1101-5. Epub 2007 Dec 20.

Quantification of superoxide radical in the brain of rats with experimentally
induced obstructive jaundice.

Konstantinou D, Mavrakis A, Grintzalis K, Papapostolou I, Assimakopoulos SF,
Chroni E, Georgiou C.

Department of Neurosurgery, School of Medicine, University of Patras, Rion,
Greece.

The study aimed to directly measure in vivo superoxide radical (O*2) a direct
indicator of oxidative stress, in the brain of rats with experimentally induced
obstructive jaundice by employing a new quantitative ultrasensitive fluorescent
assay requiring minimum sample. O*2 anion is specific for dihydroethidine (DHE)
and upon reaction gives a characteristic product, namely 2-OH-ethidium. Ten male 
rats underwent laparotomy and were divided into two groups: I, sham operated and 
II bile duct ligation. Ten days later, following injection with DHE (a O*2 trap),
all animals were killed and samples from cerebral cortex, midbrain and cerebellum
were removed for analysis. It was shown that compared to group I, in group II the
O*2 was increased by 67% in the cerebral cortex and by 37% in the midbrain as a
consequence of experimental obstructive jaundice, while its levels were
unaffected in the cerebellum. The data in this experimental obstructive jaundice 
model imply a region-specific increase of O*2 formation rate, being higher in
cerebral cortex, less so in the midbrain and not at all in cerebellum.

PMID: 18097750 [PubMed - indexed for MEDLINE]

69: Hepatobiliary Pancreat Dis Int. 2007 Dec;6(6):636-40.

Downregulation of AQP2 and AQP2 mRNA expression in kidney medulla of rats with
bile duct ligation.

Wang Y, Liu JG, Han JL.

Department of Hepatobiliary, Second Affiliated Hospital (Shengjing Hospital),
China Medical University, Shenyang 110004, China. wangy54321@hotmail.com

BACKGROUND: Obstructive jaundice is a common disease. Acute renal injury,
secondary to obstructive jaundice, is one of the main causes of postoperative
multiple system failure. This investigation evaluated renal function and renal
aquaporin 2 (AQP2) expression changes in obstructive jaundice. METHODS: Forty
male Wistar rats were equally randomized into two groups. Twenty in the
obstructive jaundice group were subjected to common bile duct ligation, and then 
were subdivided into 7- and 14-day obstruction groups, and the other 20
sham-operated rats were also subdivided into 7- and 14-day groups. At the end of 
each experiment, rats were sacrificed, venous blood was collected from the
inferior vena cava, and serum creatinine and urine nitrogen concentrations were
measured. At the same time, the medulla of the right kidney was separated and
AQP2 expression was assessed. The RT-PCR technique was used to detect AQP2 mRNA
expression. RESULTS: Ligation of the common bile duct caused significant rises in
serum bilirubin, creatinine clearance and urine nitrogen. AQP2 expression in the 
medulla decreased mere significantly (38.35+/-2.08) in the 7-day ligation group
than in the sham-operated group (41.06+/-1.04), as did that in the 14-day
ligation group, even more than (31.89+/-1.57). The expression of AQP2 mRNA also
decreased more significantly in the 14-day group (0.5429+/-0.1107) than in the
7-day group (0.6071+/-0.1328). CONCLUSION: AQP2 expression is inhibited in
obstructive jaundice, and so is its gene expression.

Publication Types: 
    Research Support, Non-U.S. Gov't

PMID: 18086632 [PubMed - indexed for MEDLINE]

70: Surg Today. 2008;38(1):76-80. Epub 2007 Dec 24.

Diffuse large B-cell lymphoma in the ampulla of vater causing obstructive
jaundice: report of a case.

Kondo N, Furuya H, Yamamoto S, Nakano A, Sakashita Y.

Department of Surgery, Oda Municipal Hospital, 1428-3 Yoshinaga, Oda-cho, Oda
694-0063, Japan.

We report a case of diffuse large B-cell lymphoma (DLBCL) in the ampulla of
Vater, causing painless obstructive jaundice in a 78-year-old woman. Duodenal
endoscopy revealed a mass in the ampulla of Vater and narrowing of the second
portion of the duodenum, although diagnosing DLBCL from an endoscopic biopsy was 
impossible because there were several kinds of leukocytes in the infiltrate. We
performed pylorus-preserving pancreatoduodenectomy to establish a histological
diagnosis, relieve the obstructive jaundice, and remove the narrowed second
portion of the duodenum. Histological and immunohistochemical examination of the 
surgically resected specimen confirmed a diagnosis of DLBCL. Chemotherapy is the 
mainstay of treatment for DLBCL; however, surgery still plays an important role
when the histological diagnosis cannot be established preoperatively and when
complications are not amenable to nonsurgical therapy.

Publication Types: 
    Case Reports

PMID: 18085371 [PubMed - indexed for MEDLINE]

71: World J Gastroenterol. 2007 Dec 21;13(47):6446-8.

Migrated endoclip and stone formation after cholecystectomy: a new danger of
acute pancreatitis.

Dolay K, Alis H, Soylu A, Altaca G, Aygun E.

Bakirkoy Egitim ve Arastirma Hastanesi Genel Cerrahi Klinigi Endoskopi Unitesi
Istanbul, Turkey. dolayk@yahoo.com

Endoclip migration into the common bile duct following laparoscopic
cholecystectomy (LC) is an extremely rare complication. Migrated endoclip into
the common bile duct can cause obstruction, serve as a nidus for stone formation,
and cause cholangitis. We report a case of obstructive jaundice and acute biliary
pancreatitis due to choledocholithiasis caused by a migrated endoclip 6 mo after 
LC. The patient underwent early endoscopic retrograde cholangiopancreatography
(ERCP) with endoscopic sphincterotomy and stone extraction.

Publication Types: 
    Case Reports

PMID: 18081240 [PubMed - indexed for MEDLINE]

72: Eur J Pediatr Surg. 2007 Dec;17(6):416-9.

Intestinal prostaglandin E2 expression in rats with obstructive jaundice.

Aslan A, Bulbul M, Elpek O, Karaveli C, Izgut-Uysal N.

Department of Pediatric Surgery, Akdeniz University School of Medicine, Antalya, 
Turkey. adaslan@yahoo.com

AIM: How obstructive jaundice causes the intestinal barrier to be injured is
still controversially discussed. In this study, we hypothesize that intestinal
prostaglandin E (2), a cytoprotective factor, may be affected by the bile duct
obstruction. MATERIALS AND METHODS: Four groups of Wistar-Albino rats were used: 
in Groups 1 and 3, the rats underwent a sham operation. In Groups 2 and 4, the
common bile duct was doubly ligated. Relaparotomy was performed after one week in
Groups 1 and 2, and after two weeks in Groups 3 and 4, and specimens of the
jejunum, ileum and liver were obtained for intestinal PGE (2) analysis and
histopathological evaluation. RESULTS: Jejunal and ileal PGE (2) levels had
significantly decreased in two-week bile duct-ligated rats compared to one-week
ligated rats and the sham group (p < 0.01). Tissue injury scores (Chiu score) of 
the ileum were significantly higher in the two-week and one-week ligated rats
than in the controls (p < 0.01 and p < 0.05, respectively). The jejunal injury
score was significantly higher in the two-week ligated rats compared to controls 
(p < 0.05). The ileal and jejunal injury scores were higher in the two-week
ligated rats than in the one-week ligated rats (p < 0.01 and p < 0.05,
respectively). Precirrhotic fibrosis was detected in all two-week ligated rats,
but in only 7 of 10 one-week ligated rats. CONCLUSIONS: Obstructive jaundice
associated with intestinal tissue injury and precirrhotic changes leads to
reduced intestinal PGE (2)-levels, suggesting an adverse effect on the intestinal
cytoprotective process.

Publication Types: 
    Research Support, Non-U.S. Gov't

PMID: 18072028 [PubMed - indexed for MEDLINE]

73: Cardiovasc Intervent Radiol. 2008 Mar-Apr;31(2):439-43. Epub 2007 Dec 7.

Pneumoperitoneum following percutaneous biliary intervention: not necessarily a
cause for alarm.

Amonkar SJ, Laasch HU, Valle JW.

Manchester Radiology Training Scheme, University of Manchester, Manchester, M13
9PL, UK. surajamonkar@hotmail.com

Percutaneous transhepatic cholangiography (PTC) is a well-established technique
for assessing and treating obstructive jaundice. Plastic and self-expanding metal
stents can be deployed as an alternative when ERCP is not feasible or hilar
strictures require an antegrade approach. Complication rates of percutaneous
procedures are low, and are usually related to bile leakage or hemorrhage;
pneumoperitoneum following PTC is rare and is usually taken to indicate bowel
perforation. We describe two cases of pneumoperitoneum without peritonitis
following PTC and stenting, both of which resolved spontaneously with
conservative management. The literature is reviewed and possible causes
discussed.

Publication Types: 
    Case Reports

PMID: 18066618 [PubMed - indexed for MEDLINE]

74: J Surg Res. 2008 May 15;146(2):262-70. Epub 2007 Dec 3.

Excessive inflammation but decreased immunological response renders liver
susceptible to infection in bile duct ligated mice.

Morita Y, Yoshidome H, Kimura F, Shimizu H, Ohtsuka M, Takeuchi D, Mitsuhashi N, 
Iida A, Miyazaki M.

Department of General Surgery, Chiba University Graduate School of Medicine,
Chiba, Japan.

BACKGROUND/AIMS: Obstructive jaundice (OJ) is associated with increased surgical 
morbidity and infectious complication. The aim of the current study was to
clarify the mechanism of excessive inflammation and susceptibility to infection
in OJ. METHODS: C57/BL6 mice were subjected to bile duct ligation (BDL) or sham
surgery. Expression tumor necrosis factor-alpha, macrophage inflammatory
protein-2, monocyte chemoattractant protein-1, inducible protein-10, and
interleukin (IL)-10, activation of nuclear factor kappa B, fluorescence activated
cell sorter analysis, serum alanine aminotransferase levels, and histology were
examined. Survival after lipopolysaccharide (LPS) administration or cecal
ligation and puncture 3 or 14 d after surgery was determined. IL-1beta and
interferon-gamma expression was examined after LPS administration. RESULTS: OJ
induced nuclear factor kappa B activation and increased expression of macrophage 
inflammatory protein-2, which caused significant increases in neutrophil
recruitment. Serum alanine aminotransferase levels increased consistent with
histological observations in OJ. Mononuclear cells were recruited in the liver
after BDL associated with monocyte chemoattractant protein-1 up-regulation. The
recruitment of NK and T cells was varied, consistent with IP-10 expression during
the time course of OJ. IL-10 expression was significantly up-regulated 14 d after
BDL. After LPS administration, the mice at 3 d after BDL and at 3 and 14 d after 
sham surgery were all still alive, but all mice at 14 d after BDL died. After LPS
administration, IL-1beta significantly increased in the mice at 14 d after BDL.
CONCLUSIONS: Immune response such as expression of pro- and anti-inflammatory
mediators and recruitment of immune cells may thus differ over the time course of
OJ. Prolonged OJ may cause excessive inflammation, thus result in susceptibility 
to infection.

Publication Types: 
    Research Support, Non-U.S. Gov't

PMID: 18061617 [PubMed - indexed for MEDLINE]

75: J Perinatol. 2008 Feb;28(2):129-35. Epub 2007 Dec 6.

Demographic and nutritional factors associated with prolonged cholestatic
jaundice in the premature infant.

Steinbach M, Clark RH, Kelleher AS, Flores C, White R, Chace DH, Spitzer AR;
Pediatrix Amino-Acid Study Group.

Collaborators: Bender D, Carr B, Flores C, Gierbolini J, Green DW, Harlan J,
Kamitsuka M, Kaushik S, Kelleher AS, Perez J, Sankar M, Singh B, Steinbach M,
White R, Wooldridge HH, Fulton K, Weng C, Fulmore E, Troyer D, Barcavage P, Reddy
RK, Hunt R, Bakewell C.

Pediatrix-Obstetrix Center for Research and Education and Pediatrix Analytical,
Sunrise, FL, USA.

OBJECTIVE: The primary aim of this study was to determine if an association
exists between amino-acid levels and development of cholestasis. The secondary
aim of our amino-acid dose comparison trial was to identify factors associated
with the development of prolonged cholestatic jaundice. STUDY DESIGN: We compared
demographic characteristics and amino-acid levels in neonates who developed
cholestasis with those who did not. Parenteral-associated cholestatic liver
disease was defined as a direct serum bilirubin above 5 mg per 100 ml any time
during the first 28 days after birth in neonates with no history of biliary
atresia or viral hepatitis. We obtained filter paper blood spots for amino acid
and acylcarnitine measurements on the day of randomization and days 7 and 28 of
age to identify a profile of values that could be used to identify neonates with 
evidence of abnormal liver function. RESULT: We enrolled 122 neonates in our
study; 13 (10.7%) developed cholestasis. Neonates who developed cholestasis were 
more immature, had lower birth weight, were exposed to parenteral nutrition for a
longer period, had a higher cumulative dose of amino acids, were less often on
enteral nutrition by day 7 of age, more often had a patent ductus arteriosus and 
severe intraventricular hemorrhage and were more commonly treated with steroids
by 28 days of age. Amino acid and acylcarnitine values were not different for the
two groups on the day of randomization. On day 7 (parenteral phase of nutrition),
blood urea nitrogen, citrulline, histidine, methionine and succinyl carnitine
were higher, and serine, glutamate and thyroxine levels were lower in the
neonates who developed cholestasis than in who did not. CONCLUSION: Cholestasis
remains an important complication of parenteral nutrition, and several clinical
and biochemical factors may be helpful in identifying high-risk patients.

Publication Types: 
    Comparative Study
    Multicenter Study
    Randomized Controlled Trial

PMID: 18059467 [PubMed - indexed for MEDLINE]

76: Eur J Gastroenterol Hepatol. 2007 Nov;19(11):1012-5.

Acute hepatitis E with severe jaundice: report of three cases.

Moucari R, Bernuau J, Nicand E, Cazals-hatem D, Valla D, Marcellin P, Asselah T.

Hepatology Department and INSERM U773, CRB3, University of Paris VII, Beaujon
Hospital, Clichy, France.

Hepatitis E virus (HEV) is the main cause of enterically transmitted non-A
hepatitis worldwide. Infection is endemic in developing countries. Disease course
is benign, and severe jaundice is rarely reported. Three patients presented to
our department with symptomatic acute hepatitis. Two of them had recently
travelled to endemic areas. Jaundice was very marked in all patients. HEV
infection was documented by HEV antibodies and by HEV-RNA detection in serum and 
stools. In the autochthonous case, immunoglobulin-M was absent, and diagnosis was
established on HEV-RNA amplification by real-time reverse transcriptase-PCR.
Comprehensive investigation for concomitant causes of liver disease was negative 
in all patients. Histological features showed marked cholestasis with multiple
bile plugs in dilated canaliculi. In conclusion, acute hepatitis E may be
autochthonous in developed countries and patients may present with severe
jaundice. HEV-RNA detection by real-time reverse transcriptase-PCR is a very
efficacious diagnostic tool in anti-HEV immunoglobulin-M-negative cases.

Publication Types: 
    Case Reports

PMID: 18049173 [PubMed - indexed for MEDLINE]

77: BMC Gastroenterol. 2007 Nov 28;7:44.

Peroxisome proliferators-activated alpha agonist treatment ameliorates hepatic
damage in rats with obstructive jaundice: an experimental study.

Cindoruk M, Kerem M, Karakan T, Salman B, Akin O, Alper M, Erdem O, Unal S.

Department of Gastroenterology, Gazi University Faculty of Medicine, Ankara,
Turkey. mcindoruk@gazi.edu.tr

BACKGROUND: Peroxisome proliferators-activated receptor alpha (PPARalpha)
activation modulates cholesterol metabolism and suppresses bile acid synthesis.
This study aims to evaluate the effect of short-term administration of
fenofibrate, a PPARalpha agonist, on proinflammatory cytokines, apoptosis, and
hepatocellular damage in cholestasis. METHODS: Forty male Wistar rats were
randomly divided into four groups: I = sham operated, II = bile duct ligation
(BDL), III = BDL + vehicle (gum Arabic), IV = BDL + fenofibrate (100 mg/kg/day). 
All rats were sacrificed on 7th day after obtaining blood samples and liver
tissue. Total bilirubin, aminotransferase (AST), alanine aminotransferase (ALT)
and alkaline phosphatase (ALP), gamma-glutamyl transferase, (GGT), tumor necrosis
factor alpha (TNF-alpha), interleukin 1 beta (IL-1 beta), and total bile acid
(TBA) in serum, and liver damage scores; portal inflammation, necrosis, bile duct
number, in liver tissue were evaluated. Apoptosis in liver was also assessed by
immunohistochemical staining. RESULTS: Fenofibrate administration significantly
reduced serum total bilirubin, AST, ALT, ALP, and GGT, TNF-alpha, IL-1 beta
levels, and TBA (P < 0.01). Hepatic portal inflammation, hepatic necrosis, number
of the bile ducts and apoptosis in rats with BDL were more prominent than the
sham-operated animals (P < 0.01). PPARalpha induction improved all
histopathologic parameters (P < 0.01), except for the number of the bile duct,
which was markedly increased by fenofibrate therapy (P < 0.01). CONCLUSION:
Short-term administration of fenofibrate to the BDL rats exerts beneficial
effects on hepatocellular damage and apoptosis.

PMID: 18045488 [PubMed - indexed for MEDLINE]

78: Cardiovasc Intervent Radiol. 2008 Jul;31 Suppl 2:S161-5.

Thrombosed mesocaval shunt: salvage by mechanical thrombolysis. Case report and
review of the literature.

Baijal SS, Mohan S, Singh JR, Verma A.

Department of Radiodiagnosis, Sanjay Gandhi Postgraduate Institute of Medical
Sciences, Raebareily Road, Lucknow, 226014 UP, India. ssbaijal@sgpgi.ac.in

We report the case of a 27-year-old male who presented with acute mesocaval shunt
thrombosis, which was successfully managed by mechanical thrombolysis. Shunt
thrombosis was suspected when the patient showed clinical signs and symptoms of
obstructive jaundice in the immediate postoperative period. Doppler sonography
showed absence of flow across the shunt, suggestive of thrombosis, which was
mechanically thrombolyzed by a percutaneous approach. The portocaval pressure
gradient noted at the end of procedure was <5 mm Hg. The shunt remained patent at
the end of 3 months' follow-up.

Publication Types: 
    Case Reports
    Review

PMID: 18026793 [PubMed - indexed for MEDLINE]

79: Dig Surg. 2007;24(6):452-5. Epub 2007 Nov 15.

Giant Brunner's hamartomas of the duodenum and obstructive jaundice. An overview 
of the literature and suspicion of malignancy in a case.

Hol JW, Stuifbergen WN, Teepen JL, van Laarhoven CJ.

Elisabeth Ziekenhuis, Tilburg, The Netherlands. jaapwhol@yahoo.com

BACKGROUND/AIMS: 150 cases of Brunner's gland hamartoma (BGH) have been reported 
in the literature. BGHs are benign and are thought not to cause bile obstruction.
METHODS: In this case report, a 60-year-old male is presented with unexplained
obstructive jaundice who was also known for over 17 years with diffuse
adenomatous hyperplasia of Brunner's glands in the duodenum. Despite the benign
preoperative diagnosis, the choice of treatment was Whipple's procedure due to
suspicion of a coexisting malignancy. RESULTS: Pathological analysis of the
resection specimen revealed multiple BGHs and an adenocarcinoma of the papilla of
Vater (PoV). Molecular pathology using loss of heterogeneity analysis was used to
confirm that both were different entities. CONCLUSION: It is likely that previous
reports of malignant degeneration of BGHs may actually have been cases involving 
the coexistence of a PoV adenocarcinoma. Physicians need to be alert when a
patient presents with BGH accompanied with obstructive jaundice for
simultaneously occurring PoV adenocarcinoma. Copyright (c) 2007 S. Karger AG,
Basel

Publication Types: 
    Case Reports

PMID: 18025786 [PubMed - indexed for MEDLINE]

80: Hepatogastroenterology. 2007 Sep;54(78):1844-6.

Successful emergency pancreatoduodenectomy in a non-trauma patient.

Vladov NN, Takorov IR, Mutafchiiski VM, Kjossev KT, Kazarov K, Mladenov N, Petrov
N.

Clinic of Hepato-Biliary and Pancreatic Surgery, Military Medical Academy, Sofia,
Bulgaria. vladovkoko@abv.bg

In the past decades considerable improvements in diagnostic imaging procedures,
surgical technique and perioperative intensive care treatment have lead to a
significant decrease in perioperative mortality and morbidity after pancreatic
resection. This lead to an expansion of the indications for
pancreatoduodenectomy. Little data exist in the literature on emergency
pancreatoduodenectomy in non-trauma patients. We present a 43-year-old woman with
extensive bleeding from papilla of Vater after endoscopic retrograde
cholangiopancreatography (ERCP) with papillosphincterotomy. During the surgical
exploration a tumor mass on the head of the pancreas was observed and a
pancreatoduodenectomy was performed. On day 7 after the operation pancreatic
leakage was observed and conservative therapy was administrated. Two weeks later 
the patient was released from the hospital in good health. Emergency
pancreatoduodenectomy may be considered in institutions with extensive experience
in these procedures, where cooperation of the invasive gastroenterologists and
the abdominal surgeons, long experience of the surgeon and intensive reanimation 
care are present.

Publication Types: 
    Case Reports

PMID: 18019731 [PubMed - indexed for MEDLINE]

81: Am J Geriatr Pharmacother. 2007 Sep;5(3):236-40.

Methimazole-induced cholestatic jaundice in an elderly hyperthyroid patient.

Ramos-Bonner LS, Goldberg TH, Moyer S, Anastasopoulou C.

Division of Geriatric Medicine, Albert Einstein Medical Center, Philadelphia,
Pennsylvania, USA. lsrbmd@verizon.net

BACKGROUND: Hyperthyroidism is a common disease in the elderly. Antithyroid
medications such as methimazole are one of the few treatment options. CASE
SUMMARY: A 76-year-old white woman presented to the clinic with a 1-week history 
of fatigue, sleepiness, 7-pound weight loss, and tachycardia. Her blood work
showed low levels of thyroid-stimulating hormone and high levels of free
thyroxine. Due to persistence of her symptoms, she was hospitalized and started
on methimazole 10 mg TID. Six weeks after receiving methimazole for the treatment
of hyperthyroidism, she had severe jaundice and itching. Results of her liver
function tests showed elevation of her alkaline phosphatase and liver
transaminase levels, as well as hyperbilirubinemia, formed mainly of the
conjugated fraction. Methimazole-induced cholestatic jaundice was diagnosed. Her 
symptoms gradually improved after discontinuation of the medication, and plasma
bilirubin levels were near normal after 8 weeks without methimazole. CONCLUSIONS:
We report here a probable association between methimazole use and severe
cholestatic jaundice in an elderly hyperthyroid patient. The patient's jaundice
was reversed after drug discontinuation.

Publication Types: 
    Case Reports

PMID: 17996663 [PubMed - indexed for MEDLINE]

82: JOP. 2007 Nov 9;8(6):790-4.

A benign cause of obstructive jaundice with von Hippel-Lindau disease. A case
report and review of the literature.

Boujaoude J, Samaha E, Honein K, Noun R, Abboud B, Ghorra C, Sayegh R.

Department of Gastroenterology, Hotel-Dieu de France Hospital, Saint-Joseph
University, Beirut, Lebanon. jbouj@hotmail.com

CONTEXT: Von Hippel-Lindau disease is a genetic disorder characterized by
neoplasms with multiple organ involvement, the pancreas being involved in about
half of the cases. Conservative treatment is indicated because the disease is
usually asymptomatic with long-term follow-up. CASE REPORT: We herein present the
case of a 64-year-old man with von Hippel-Lindau disease who presented with
obstructive jaundice which resulted as being caused by a fibro-cystic pancreatic 
nodule. In addition, we reviewed the literature concerning pancreatic involvement
in von Hippel-Lindau disease with emphasis on their presentation, type of lesions
and appropriate management, especially in cases with obstructive jaundice.
CONCLUSION: Conservative management is advocated in the majority of VHL disease
patients with pancreatic involvement, but surgery is sometimes required,
especially when patients are symptomatic (obstructive jaundice, upper
gastrointestinal bleed).

Publication Types: 
    Case Reports
    Review

PMID: 17993732 [PubMed - indexed for MEDLINE]

83: Trans R Soc Trop Med Hyg. 2008 Feb;102(2):117-22. Epub 2007 Nov 7.

Leptospirosis in the Andaman Islands, India.

Vijayachari P, Sugunan AP, Sharma S, Roy S, Natarajaseenivasan K, Sehgal SC.

Regional Medical Research Centre (Indian Council of Medical Research), WHO
Collaborating Centre for Diagnosis, Reference, Research & Training in
Leptospirosis, Port Blair 744 101, Andaman & Nicobar Islands.
vijayacharip@yahoo.com

Leptospirosis is an emerging zoonosis. In the Andaman Islands during the early
twentieth century, it occurred in the penal settlements of the British India
Administration, mostly as Weil's disease, an acute febrile illness with
hepato-renal complications. It was caused by leptospires belonging to groups
Akiamy A and Andamans A. After the 1930s nothing further is known regarding the
disease until the late 1980s, when Andaman haemorrhagic fever (AHF), a mysterious
illness with the majority of cases presenting pulmonary involvement, appeared.
AHF was later identified as leptospirosis and severe pulmonary haemorrhage was
shown for the first time as a complication of leptospirosis from India.
Leptospirosis continues to occur in the Islands annually. It generally presents
as two separate clinical syndromes: the hepato-renal form, and the pulmonary
form, which is associated with high case fatality rates ranging from 10 to 15%.
Infections are due to a variety of serovars, Valbuzzi being the commonest.
Leptospira interrogans sensu stricto has been the predominant infecting species. 
Doxycycline has been shown to confer a beneficial effect in reducing the clinical
illness and mortality during outbreaks. The history of leptospirosis in the
Islands, its epidemiology, clinical spectrum, characteristics of the isolates and
control are reviewed and discussed in this article.

Publication Types: 
    Review

PMID: 17991499 [PubMed - indexed for MEDLINE]

84: J Dig Dis. 2007 Nov;8(4):198-202.

Stent implantation through rendezvous technique of PTBD and ERCP: the treatment
of obstructive jaundice.

Liu YD, Wang ZQ, Wang XD, Yang YS, Linghu EQ, Wang WF, Li W, Cai FC.

Department of Gastroenterology of PLA General Hospital, Beijing, China.
liuyingdi301@sina.com

OBJECTIVE: To study the technical method and clinical value of stent implantation
through the rendezvous technique of percutaneous transhepatic biliary drainage
(PTBD) and endoscopic retrograde cholangiopancreatography (ERCP) in patients with
obstructive jaundice. METHODS: Thirty-six patients with obstructive jaundice
underwent the rendezvous technique of PTBD and ERCP after initially unsuccessful 
ERCP. RESULTS: The procedure of 36 cases were all successful. Sixteen cases
underwent PTBD drainage from the bile duct through the right lobe approach and in
20 cases the left lobe approach was used. The one-stage procedure involved in the
rendezvous technique of PTBD and ERCP was successful in 23 cases, while the other
13 cases underwent PTBD first and then rendezvous ERCP the next time. The serum
total bilirubin 4 days later had decreased by 44.75%, and direct bilirubin had
decreased by 45.61%. The main complication was infection of the bile duct.
CONCLUSION: Stent implantation using the rendezvous technique of PTBD and ERCP is
a new and feasible method to treat obstructive jaundice after initially
unsuccessful ERCP. This may be of considerable value in clinical practice.

Publication Types: 
    Evaluation Studies

PMID: 17970876 [PubMed - indexed for MEDLINE]

85: S Afr J Surg. 2007 Feb;45(1):12-6.

Palliation of malignant hilar obstruction at a single centre--review of operative
and non-operative techniques.

Clarke DL, Thomson SR, Anderson F, Moodley M, Buccimazza I, Moodley VV.

Department of General Surgery, Nelson R. Mandela School of Medicine, University
of KwaZulu-Natal, Durban.

INTRODUCTION: Jaundice secondary to a malignant hilar obstruction can be relieved
by operative bypass or percutaneous stenting. Comparative trials involving these 
techniques are scarce. We reviewed our experience with these competing techniques
in the palliation of malignant hilar obstruction. PATIENTS AND METHODS: All
patients with malignant hilar obstruction managed at our institution during the
period 1992-2002 were identified for review. RESULTS: A total of 36 deeply
jaundiced patients with hilar obstruction were identified. Twenty-two patients
underwent exploration with the intention of performing an operative bypass and 14
patients underwent percutaneous transhepatic cholangiography (PTC) with intention
to stent. Procedure-related mortality was similar in both groups. Morbidity was
much higher in the operative group. Effective symptom relief was achieved with
both techniques. In the PTC group recurrent biliary obstruction in 2 patients
necessitated salvage non-operative procedures. Although survival rates were
slightly longer in the operative group, this was not significant. There were no
long-term survivors. CONCLUSION: Operative bypass provides better sustained
relief of jaundice than PTC. However long-term survival in both groups is poor
and operative bypass is best reserved for younger patients with no technical
contraindications. Despite early and late procedural failures PTC is the method
of choice for patients with advanced-stage disease and those with significant
co-morbidities.

PMID: 17969772 [PubMed - indexed for MEDLINE]

86: J Med Assoc Thai. 2007 Sep;90(9):1803-8.

Transcutaneous bilirubin in the pre-term infants.

Sanpavat S, Nuchprayoon I.

Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok 
10330, Thailand. s_sanpavat@yahoo.com

OBJECTIVE: 1) To evaluate the accuracy of transcutaneous bilirubin (T(C)B)
measurement compared to total serum bilirubin level (TSB) in the pre-term infants
and 2) To establish cut-off values of T(C)B that indicated need for TSB. MATERIAL
AND METHOD: Premature infants whose birth weight was more than 1,000 grams and
gestational age less than 36 weeks had paired T(C)B-TSB assessment when jaundice 
was observed. T(C)B was done using JM 103 (Minolta AirShields Jaundice Meter) on 
the forehead. T(C)B, which corresponded to TSB level that required phototherapy, 
was chosen as the cut-off point that indicated blood sampling for TSB. RESULTS:
Two hundred and forty-nine paired T(CB)-TSB measurements from 196 premature
neonates were obtained. Birth weight was 1,887 +/- 344.4 grams. TSB ranged from
4.5-17.6 mg/dL (mean 9.4, SD 2.2 mg/dL), T(C)B 4.1-17.7 mg/dL (mean 9.7, SD 2.4
mg/dL). The correlation coefficient between T(C)B and TSB was significant (r
0.79, p < 0.0001). T(C)B had a tendency to overestimate TSB with the mean
difference of TSB- T(C)B = -0.3 +/- 1.5 mg/dL and 95% confidence interval of the 
mean -0.1 to -0.5 mg/dL. Of all the variables of birth weight, gestational age,
and postnatal age, only postnatal age significantly influenced the correlation of
T(C)B-TSB. In the early postnatal age of 1-4 days, the number of T(C)B reading
overestimated TSB more than underestimated. However, at > or = 5 days of age, the
number of underestimation was more than those of overestimation. The cut-off
points of T(C)B that indicated the need for blood sampling for TSB were chosen as
the same level of TSB of 6, 8, 10, 11, and 12 mg/dL when phototherapy was
recommended. Screening with T(C)B would eliminate painful procedure of blood
taking by 40%. CONCLUSION: Noninvasive T(C)B assessment demonstrated significant 
accuracy when compared to TSB. T(C)B can be adopted as a screening test to
identify the need for blood sampling of serum bilirubin in premature infants.

Publication Types: 
    Evaluation Studies

PMID: 17957922 [PubMed - indexed for MEDLINE]

87: World J Gastroenterol. 2007 Nov 7;13(41):5512-5.

Histological changes at an endosonography-guided biliary drainage site: a case
report.

Fujita N, Noda Y, Kobayashi G, Ito K, Obana T, Horaguchi J, Takasawa O, Nakahara 
K.

Department of Gastroenterology, Sendai City Medical Center, 5-22-1, Tsurugaya,
Sendai, Miyagi 983-0824, Japan. docfujita@gmail.com

Endosonography-guided biliary drainage (ESBD) is a new method enabling internal
drainage of an obstructed bile duct. However, the histological conditions
associated with fistula development via the duodenum to the bile duct have not
been reported. We performed ESBD 14 d preoperatively in a patient with an
ampullary carcinoma and histologically confirmed changes in and around the
fistula. The female patient developed no complications relevant to ESBD. Levels
of serum bilirubin and hepatobiliary enzymes declined quickly, and
pancreatoduodenectomy was carried out uneventfully. The resected specimen was
sliced and stained with hematoxylin-eosin. Histological evaluation of the
puncture site in the duodenum and bile-duct wall, and the sinus tract revealed no
hematoma, bile leakage, or abscess in or around the sinus tract. Little sign of
granulation, fibrosis, and inflammatory cell infiltration was observed. Although 
further large-scale confirmatory studies are needed, the findings here may
encourage more active use of ESBD as a substitute for percutaneous transhepatic
drainage in cases with failed/difficult endoscopic biliary stenting.

Publication Types: 
    Case Reports

PMID: 17907298 [PubMed - indexed for MEDLINE]

88: Pancreatology. 2007;7(5-6):540-3. Epub 2007 Sep 27.

Treatment, by insertion of multiple uncovered metallic stents, of intraductal
papillary mucinous neoplasm of the pancreas with biliary obstruction by mucus
impaction.

Seynaeve L, Van Steenbergen W.

Unit for Liver, Biliary and Pancreatic Diseases, Department of Internal Medicine,
University Hospital Gasthuisberg, Catholic University of Leuven, Leuven, Belgium.

BACKGROUND/AIMS: Biliary mucinous obstruction is a complication of intraductal
papillary mucinous neoplasms (IPMN). Surgery with resection of the tumour or with
biliary bypass is generally recommended. It is our aim to report a patient with
IPMN complicated by biliary mucinous impaction in whom surgery was not possible
because of extensive collateral circulation. Repeated insertions of plastic and
of single covered metallic stents were unsuccessful due to mucus-induced
migration of these stents. METHODS: Three metallic uncovered stents were inserted
in the bile duct alongside each other in order to fill the bile duct up with
stent material. RESULTS: Whereas previous insertions of single plastic or covered
metallic stents were invariably followed by recurrence of cholestasis by
spontaneous stent migration, insertion of three uncovered metallic stents was
followed by absence of any cholestatic symptoms during a follow-up period of at
least 4 years. CONCLUSION: In patients with IPMN complicated by biliary mucus
impaction, the insertion of multiple uncovered metallic stents seems the
endoscopic method of choice to prevent mucus-induced spontaneous stent
dislocation. (c) 2007 S. Karger AG, Basel and IAP.

Publication Types: 
    Case Reports

PMID: 17901716 [PubMed - indexed for MEDLINE]

89: J Gastrointest Surg. 2007 Dec;11(12):1728-31. Epub 2007 Sep 25.

Jaundice in the Hippocratic Corpus.

Papavramidou N, Fee E, Christopoulou-Aletra H.

History of Medicine Division, School of Medicine, Aristotle University of
Thessaloniki, P.O. Box 356, 54006 Thessaloniki, Greece. papavramidou@hotmail.com

The Hippocratic physicians were among the first who described jaundice (icterus).
The Hippocratic Corpus has numerous appearances of the condition, where its
etiology, description, prognosis, and treatment are provided. The connection made
between the liver and jaundice was remarkable, bearing in mind that the
Hippocratic physicians had not performed dissections and that their medical views
were based on observation. The Hippocratic doctors described five kinds of
jaundice. The etiology was, as in most cases of diseases mentioned in the
Hippocratic Corpus, "humoral" imbalance. The diagnosis and prognosis were based
on the color of the skin, the urine, the feces, and several other factors, such
as the season of the year during which the disease first appeared or the
coexisting diseases. The treatment, finally, consisted of herbal medications,
baths, diet, and blood-letting, depending on the type of jaundice in question.
Finally, an attempt is made to correlate modern diseases with the Hippocratic
types of jaundice.

Publication Types: 
    Historical Article

PMID: 17896166 [PubMed - indexed for MEDLINE]

90: World J Gastroenterol. 2007 Oct 21;13(39):5226-31.

Propolis reduces bacterial translocation and intestinal villus atrophy in
experimental obstructive jaundice.

Sabuncuoglu MZ, Kismet K, Kilicoglu SS, Kilicoglu B, Erel S, Muratoglu S, Sunay
AE, Erdemli E, Akkus MA.

4th General Surgery Department, Ankara Training and Research Hospital, S B Ankara
Egitim ve Arastirma Hastanesi 4th, Cerrahi Klinigi 06340, Ulucanlar, Ankara,
Turkey.

AIM: To investigate the effects of propolis on bacterial translocation and
ultrastructure of intestinal morphology in experimental obstructive jaundice.
METHODS: Thirty Wistar-Albino male rats were randomly divided into three groups, 
each including 10 animals: group I, sham-operated; group II, ligation and
division of the common bile duct (BDL); group III, BDL followed by oral
supplementation of propolis 100 mg/kg per day. Liver, blood, spleen, mesenteric
lymph nodes, and ileal samples were taken for microbiological, light and
transmission electron microscopic examination on postoperative 7th d after
sacrification. RESULTS: The mean number of villi per centimeter and mean mucosal 
height of the propolis group were significantly different in the BDL group (P =
0.001 and 0.012, respectively). The electron microscopic changes were also
different between these groups. Sham and BDL + propolis groups had similar
incidence of bacterial translocation (BT). The BDL group had significantly higher
rates of BT as compared with sham and BDL + propolis groups. BT was predominantly
detected in MLNs and the most commonly isolated bacteria was Escherichia coli.
CONCLUSION: Propolis showed a significant protective effect on ileal mucosa and
reduced bacterial translocation in the experimental obstructive jaundice model.
Further studies should be carried out to explain the mechanisms of these effects.

Publication Types: 
    Research Support, Non-U.S. Gov't

PMID: 17876893 [PubMed - indexed for MEDLINE]

91: Endocr Pract. 2007 Sep;13(5):476-80.

Two cases of thyroid storm-associated cholestatic jaundice.

Hull K, Horenstein R, Naglieri R, Munir K, Ghany M, Celi FS.

Division of Endocrinology, Diabetes and Nutrition, The University of Maryland
School of Medicine, Baltimore, Maryland, USA.

OBJECTIVE: To describe the association of the rare and serious complication of
jaundice with severe thyrotoxicosis, a potentially lethal endocrine disorder.
METHODS: We report the clinical, laboratory, and pathologic findings of 2 cases
of severe jaundice (total bilirubin levels: 35.2 mg/dL in case 1 and 42 mg/dL in 
case 2) associated with thyroid storm in the absence of a history of liver
disease, thionamide exposure, or congestive heart failure. We also present other 
relevant reports available in the literature. RESULTS: Case 1 was a 38-year-old
woman who presented with nausea, vomiting, fatigue, pruritus, and frequent
nonbloody diarrhea. She was transferred to our institution because of worsening
hyperbilirubinemia. Case 2 was a 35-year-old woman admitted to a community
hospital with thyroid storm and jaundice. Upon transfer to our institution, the
patient was unconscious, mechanically ventilated, and in atrial fibrillation. In 
case 2, liver biopsy results revealed diffuse hepatocellular ballooning with
intrahepatic cholestasis with mild portal lymphocytic infiltration. Both patients
presented with severe cholestatic jaundice in the absence of congestive heart
failure; underlying liver disease (infectious or autoimmune); or previous
exposure to thionamides, other hepatotoxic agents, or complementary and
alternative medications. In both cases, jaundice responded to therapy with
antithyroid medications. Both patients eventually underwent thyroidectomy with
complete resolution of the jaundice. CONCLUSION: The data strongly suggest that
in these patients, the hepatic dysfunction was primarily due to hyperthyroidism. 
These cases indicate that the mere presence of hyperbilirubinemia during severe
thyrotoxicosis should not per se delay the use of potentially life-saving
thionamides once a thorough evaluation for other causes of liver disease has been
completed.

Publication Types: 
    Case Reports
    Research Support, N.I.H., Intramural

PMID: 17872349 [PubMed - indexed for MEDLINE]

92: J Indian Med Assoc. 2007 Mar;105(3):133-4, 136.

Obstructive jaundice: a manifestation of pancreatic tuberculosis.

Pandya G, Dixit R, Shelat V, Dixit K, Shah N, Shah K.

Department of TB and Chest Diseases, BJ Medical College and Civil Hospital,
Ahmedabad 380016.

Tuberculosis of the pancreas is extremely rare and is most often associated with 
miliary tuberculosis or occurs in the immunocompromised patients. A case of
isolated pancreatic tuberculosis in an immunocompetent patient is presented with 
constitutional symptoms and obstructive jaundice. Ultrasonography and
computerised tomography showed a mass lesion in the head of pancreas.
Histological examination of the peripancreatic lymph node and fine needle
aspiration cytology from the head of pancreas confirmed the diagnosis following
laparotomy. Patient recovered following the administration of antituberculosis
chemotherapy.

Publication Types: 
    Case Reports

PMID: 17824465 [PubMed - indexed for MEDLINE]

93: J Gastrointest Surg. 2008 Jun;12(6):1149-50. Epub 2007 Sep 6.

Peripheral cholangiocarcinoma with endoluminal tumor thrombus in main bile duct
mimicking a Klatskin tumor.

Lucidi V, Van Laethem JL, Sersté T, Gelin M, Donckier V.

Medicosurgical Department of Hepatogastroenterology, Hôpital Erasme, Universite
Libre de Bruxelles, 808 route de Lennik, 1070 Brussels, Belgium.

BACKGROUND: Peripheral cholangiocarcinoma with endobiliary thrombus could be
confused with Klatskin tumor, eventually leading to inappropriate therapeutic
decision. CASE REPORT: A 56-year-old man presented with an obstructive jaundice. 
Preoperative magnetic resonance imaging (MRI) showed a segment 7 liver tumor
associated with a complete stop at the biliary bifurcation compatible with a
Klatskin tumor. Surgical exploration revealed that biliary obstruction was caused
by endobiliary tumor-related thrombus. A right hepatectomy was performed,
allowing complete endobiliary thrombus extraction. At pathology, a T2N0
intrahepatic cholangiocarcinoma was demonstrated. No adjuvant chemotherapy was
given and currently, 22 months after surgery, the patient remains disease free.
DISCUSSION: This case underlines the fact that intraductal growth of peripheral
cholangiocarcinoma does not represent a contraindication for surgical treatment. 
MRI could be useful to differentiate such presentation of peripheral
cholangiocracinoma from Klatskin tumor and orientate the surgical treatment.

Publication Types: 
    Case Reports

PMID: 17805934 [PubMed - indexed for MEDLINE]

94: J Pediatr Hematol Oncol. 2007 Sep;29(9):661-3.

Nonendemic Burkitt lymphoma presenting with an atypical clinical picture.

Papandreou E, Gentimi F, Baltogiannis N, Tzovaras A, Geroulanos-Christopoulos G, 
Karamolegou K, Stephanaki K, Moschovi M.

2nd Department of Pediatric Surgery, Hematology-Oncology Unit, Athens University 
Medical School, Pathology Department, Aghia Sophia Children's Hospital, Athens,
Greece. epapmed@yahoo.gr

Primary appendiceal Burkitt lymphomas are rare occurring in 0.015% of all
gastrointestinal lymphomas. Presentation of such lymphomas with peritonitis and
obstructive jaundice owing to its subhepatic location is even more unusual.
Burkitt lymphoma is very rare in children below 5 years old. We will present a
3-year-old boy with primary appendiceal lymphoma whose first symptom was
obstructive jaundice caused by a ruptured retrocecal subhepatic appendix which in
essence is a combination of all 3 mentioned occurrences complicated with acute
abdomen.

Publication Types: 
    Case Reports

PMID: 17805048 [PubMed - indexed for MEDLINE]

95: Acta Haematol. 2007;118(3):141-5. Epub 2007 Sep 5.

Safety of imatinib in chronic myeloid leukemia in blastic crisis presenting as
cholestatic jaundice.

Ramamoorthy SK, Pandita R, Prakash A, Ramaswamy NV, Al Bahar S.

Department of Hematology, Kuwait Cancer Control Center, Shuwaikh, Kuwait.
kannan_hemat@yahoo.com

Acute leukemia presenting as cholestatic jaundice is rare. It can occur due to
granulocytic sarcoma compressing the bile ducts in case of acute myeloid
leukemia. Rarely, diffuse infiltration of the liver sinusoids by the leukemic
blasts can present as cholestatic jaundice. We report a case of chronic myeloid
leukemia in lymphoid blast cell crisis presenting with severe cholestatic
jaundice due to diffuse infiltration of the liver sinusoids with lymphoblasts.
This patient tolerated imatinib well and, coinciding with the hematological
response, there was marked reduction in the cholestasis due to blast clearance
from the hepatic sinusoids. He was subsequently treated with combination
chemotherapy and achieved morphological and cytogenetic remission. 2007 S. Karger
AG, Basel

Publication Types: 
    Case Reports

PMID: 17804901 [PubMed - indexed for MEDLINE]

96: G Chir. 2007 Aug-Sep;28(8-9):312-4.

Erratum in:
    G Chir. 2007 Oct;28(10):408. Cupido, F [added].

Juxtapapillary duodenal diverticular bezor as an exceptional cause of biliary
stent obstruction. Case report.

Geraci G, Sciumè C, Pisello F, Facella T, Arnone E, Cupido F, Modica G.

Universitá degli Studi de Palermo, Azienda Ospedaliero Universitaria Policlinico 
Paolo Giaccone.

INTRODUCTION: we describe the first case in literature of biliary stent
obstruction by bezoar impaction in a iuxtapapillary duodenal diverticulum. CASE
REPORT: this case illustrates an juxtapapillary duodenal diverticulum and bezoar 
in it causing obstructive jaundice in subject with two biliary stents for
cholangiocarcinoma (Klatskin's tumor) in the absence of bile duct stones. RESULT:
successful treatment with endoscopic stent removal and diverticulum toilette.
Obstructive jaundice was cured after endoscopic removal of the bezoar and stent
substitution. DISCUSSION: the presence of a bezoar and its possible contribution 
to the pathogenesis of pancreatitis in the presence of periampullary extraluminal
duodenal diverticula makes endoscopic intervention for removal of the bezoar
necessary and effective. CONCLUSIONS: biliary bezoar is a very rare but treatable
cause of stents obstruction in patients with juxtapapillary duodenal diverticula.
Endoscopic retrograde cholangiopancreatografhy is helpful in making diagnosis and
for resolutive treatment.

Publication Types: 
    Case Reports

PMID: 17785042 [PubMed - indexed for MEDLINE]

97: Trop Doct. 2007 Jul;37(3):130-2.

A review of neonatal morbidity and mortality in Aminu Kano Teaching Hospital,
northern Nigeria.

Mukhtar-Yola M, Iliyasu Z.

Department of Paediatrics, Aminu Kano Teaching Hospital, Kano, Nigeria.
mariyamukhtar@hotmail.com

Neonatal morbidity and mortality still poses a serious challenge in developing
countries. Low level of obstetric care, unsupervised home deliveries and late
referrals lead to poor outcome even in special care baby units (SCBU). To
identify the common causes of neonatal morbidity and mortality among babies
admitted to the SCBU in Aminu Kano Teaching Hospital (AKTH) the case-notes of all
admitted neonates from January 1998 to December 2004 were retrospectively
reviewed. A total of 2963 (98.3%) babies had complete records. There were 1455
(49.1%) in-born (delivered in AKTH) and 1508 (50.9%) out-born (delivered
elsewhere) babies. The sex ratio was 1.25:1 in favour of males. A total of 1868
(63.0%) were of normal birth weight, while 951 (32.1%) and 134 (4.5%) were low
birth weight and macrocosmic, respectively. The leading diagnoses were birth
asphyxia (27%) (severe birth asphyxia 18.1%, moderate asphyxia 8.9%), neonatal
sepsis (25.3%) and prematurity (16.0%). Out of the 2963 babies, 501 (16.9%) died.
The risk of dying was significantly higher (20.5%) among out-born babies compared
with those delivered in AKTH (6.4%) (odds ratio = 1.71, 95% confidence interval =
1.4-2.1). In conclusion, the causes of neonatal morbidity and mortality at this
centre are similar to those reported from other units. They could be prevented
through effective antenatal care, supervised delivery and appropriate care and
early referral of sick neonates.

PMID: 17716492 [PubMed - indexed for MEDLINE]

98: Hepatogastroenterology. 2007 Jul-Aug;54(77):1331-4.

Predictors of mortality and morbidity in acute obstructive jaundice: implication 
of preventive measures.

Uslu A, Nart A, Colak T, Aykas A, Yüzbasioglu MF, Hidir K, Dogan M, Kanberler K.

Department of General Surgery and Organ Transplantation Center, Izmir Teaching
Hospital of The Ministry of Health, Turkey.

BACKGROUND/AIMS: The afferent events in acute obstructive jaundice (AOJ) are
characterized by endotoxemia-induced decrease in systemic vascular resistance and
bile salt mediated natriuresis and diuresis leading to diminished effective
plasma volume. METHODOLOGY: A prospective protocol aimed at preventing those
alterations was carried out in 104 consecutive patients with AOJ. The
preoperative risk factors that predict postoperative mortality and morbidity were
reevaluated and correctable factors were identified. RESULTS: The average
duration between the initiation of jaundice and surgery was 9.3 days. The
perioperative mortality was 0%. The essentials of the treatment protocol were
lactulose and cefazolin administration respectively for the prevention of portal 
endotoxemia and biliary sepsis and maintenance of body weight with adequately
replaced fluid and electrolytes. Clinically relevant nutritional deficit was not 
observed in any of the patients during the perioperative period. The unique
factor that predicted late mortality was the preoperative alanine transaminase
value. Renal hemodynamics and hematologic parameters were completely correctable 
before the operation and patients with malignant or benign biliary strictures
benefited and responded to the treatment similarly. CONCLUSIONS: Measures taken
to prevent the activation and progression of the afferent events in AOJ, have
resulted in excellent clinical outcomes.

PMID: 17708248 [PubMed - indexed for MEDLINE]

99: Urol J. 2007 Spring;4(2):91-4; discussion 94.

Urinary tract infection in term neonates with prolonged jaundice.

Pashapour N, Nikibahksh AA, Golmohammadlou S.

Department of Pediatrics, Imam Hospital, Urmia University of Medical Sciences,
Urmia, Iran. npashapor@yahoo.com

INTRODUCTION: The aim of this study was to evaluate the frequency of urinary
tract infection (UTI) in neonates with prolonged jaundice. MATERIALS AND METHODS:
Newborn infants with jaundice lasted more than 2 weeks were included in this
study. Patients who had other signs or symptoms were excluded. Workup of
prolonged hyperbilirubinemia was performed, including direct Coomb's test, blood 
group of the neonate and the mother, complete blood count, blood smear,
glucose-6-phosphate dehydrogenase (G6PD), reticulocyte count, serum level of
bilirubin (unconjugated and conjugated), thyroid function tests (serum thyroxine 
[T4] and thyroid-stimulating hormone), urinalysis, and suprapubic urine culture. 
Pediatric nephrologists carried out further investigation including kidney
function tests, renal ultrasonography, voiding cystourethrography, and Technetium
Tc 99m dimercaptosuccinic acid renal scintigraphy for patients with a positive
urine culture for microorganisms. RESULTS: Of 100 neonates who were evaluated, 43
were boys and 57 were girls. All of the neonates were breastfed. Six suffered
from UTI (4 boys and 2 girls). Reflux was detected on voiding cystourethrography 
in 1 and cortical defect in the kidney on renal scan in 2 boys. CONCLUSION: In
our region, with a high rate of breastfeeding, UTI remains as an important cause 
of prolonged jaundice. Despite the high rate of urogenital system abnormality
accompanied by neonatal UTI, there was not a significant difference between the
signs and symptoms of jaundice in patients with and without UTI. Performing urine
cultures should be considered as a routine procedure in the evaluation of every
infant with prolonged jaundice.

Publication Types: 
    Research Support, Non-U.S. Gov't

PMID: 17701928 [PubMed - indexed for MEDLINE]

100: World J Gastroenterol. 2007 Aug 14;13(30):4152-3.

Plasmapheresis and corticosteroid treatment for persistent jaundice after
successful drainage of common bile duct stones by endoscopic retrograde
cholangiography.

Saritas U, Aydin B, Ustundag Y.

Gastroneterology Department, Süleyman Demirel University, School of Medicine,
Turkey.

Prolonged cholestasis is a very rare complication of endoscopic retrograde
cholangiography (ERC). Only few cases with this complication are reported in the 
English literature. We report persisting cholestatic jaundice in a 73-year old
man after successful therapeutic ERC for choledocholithiasis. Serologic tests for
viral and autoimmune hepatitis were all negative. A second-look ERC was normal
also. He denied any medication except for prophylaxis given intravenous 1 g
ceftriaxone prior to the ERC procedure. After an unsuccessful trial with
ursodeoxycholic acid and cholestyramine for 2 wk, this case was efficiently
treated with corticosteroids and plasmapheresis. His cholestatic enzymes became
normal and intense pruritus quickly resolved after this treatment which lasted
during his follow-up period. We discussed the possible mechanisms and treatment
alternatives of intrahepatic cholestasis associated with the ERC procedure.

Publication Types: 
    Case Reports

PMID: 17696241 [PubMed - indexed for MEDLINE]

101: J Occup Health. 2007 Jul;49(4):268-72.

High pallidal T1 signal is rarely observed in obstructive jaundice, but is
frequently observed in liver cirrhosis.

Bang SJ, Choi SH, Park NH, Shin JW, Choy N, Kim SH, Kim Y.

Department of Internal Medicine, Ulsan University Hospital, University of Ulsan
College of Medicine, South Korea.

Although high signal intensities in the globus pallidus are frequently observed
in T1-weighted magnetic resonance images (MRI) of patients with liver cirrhosis, 
it is unclear whether these increases are due to portal-systemic shunt or
obstruction of biliary excretion. We therefore studied pallidal signals in 18
cancer patients with bile duct obstruction and marked jaundice (>10 mg/dl).
Patients who had fever, leukocytosis or liver cirrhosis were excluded to ensure
that jaundice was due to bile duct obstruction. All patients showed a dilated
intrahepatic duct on computed tomography (CT) scan. A high pallidal signal was
observed in one of 18 biliary obstructive patients whereas high signals were
highly prevalent in liver cirrhosis. A portal-systemic shunt rather than an
obstruction of biliary excretion may be responsible for the increased blood
manganese concentrations and pallidal T1 signals in chronic liver diseases.

Publication Types: 
    Comparative Study
    Research Support, Non-U.S. Gov't

PMID: 17690519 [PubMed - indexed for MEDLINE]

102: Hepatobiliary Pancreat Dis Int. 2007 Aug;6(4):435-7.

Amiodarone hepatotoxicity complicating obstructive jaundice due to ampullary
cancer.

Collins AM, Winter DC, McCormick AP, Cottell DC, Geoghegan JG.

Department of Surgery and Hepatology, St. Vincent's University Hospital, Dublin
4, Ireland.

BACKGROUND: The presence of dual pathology can cause diagnostic dilemmas. We
present a case of adenocarcinoma of the ampulla of Vater with concurrent
amiodarone hepatotoxicity. METHODS: Painless jaundice associated with a palpable 
gallbladder was investigated clinically, radiologically, endoscopically and via
liver biopsy. RESULTS: Liver biopsy showed amiodarone hepatotoxicity. Endoscopic 
biopsy identified an ampullary adenoma. However, the endoscopic ultrasound and
intra-operative findings suggested a malignancy, which was confirmed
postoperatively. CONCLUSIONS: While the classic findings of Courvoisier's Law are
borne out in this case, the etiology of jaundice is twofold. Although dual
pathology is uncommon it should always be considered.

Publication Types: 
    Case Reports

PMID: 17690045 [PubMed - indexed for MEDLINE]

103: Hepatobiliary Pancreat Dis Int. 2007 Aug;6(4):383-7.

Postoperative jaundice after cardiac surgery.

Mastoraki A, Karatzis E, Mastoraki S, Kriaras I, Sfirakis P, Geroulanos S.

Department of Surgical Intensive Care Unit, Onassis Cardiac Surgery Center, 356
Sygrou Ave, 17674 Athens, Greece. dr_kamast@yahoo.gr

BACKGROUND: The frequency and pattern of hyperbilirubinemia after open-heart
surgery and its severe perioperative complications are not well clarified. The
purpose of this study was to investigate the incidence and nature of
postoperative jaundice in patients undergoing cardiac operation, to analyze the
determinants, and to identify the clinical significance of this complication with
regard to the associated morbidity and mortality. METHODS: A prospective
observational study was made during the period of 2003-2004 in a Surgical
Intensive Care Unit of a Cardiac Surgery Center, Athens. One hundred twenty-eight
adult patients for open heart surgery were divided into three groups. Group A
included 50 patients who underwent coronary artery bypass crafting (CABG), group 
B 31 patients who were subjected to aortic valve replacement (AVR)+CABG and group
C 47 patients who underwent mitral valve replacement (MVR)+CABG.
Aminotransferases, alkaline phosphatase, gamma-glutamyl-transpeptidase and both
types of bilirubin were determined at admission, 24 hours after the operation and
thereafter according to clinical evolution. The presence of jaundice was
associated with elevated serum bilirubin above 3 mg/dl. RESULTS:
Hyperbilirubinemia developed in 34 patients (26.5%). The incidence of
postoperative jaundice was higher in patients who were subjected to MVR+CABG than
to CABG and AVR+CABG. Hyperbilirubinemia was correlated with prolonged
cardiopulmonary by-pass time (P<0.001), aortic cross-clamping time (P<0.001), the
use of intra aortic balloon pumping (P<0.001), the administration of inotrops and
the number of blood and plasma transfusions. Postoperative jaundice resulted
mainly from an increase in conjugated bilirubin. CONCLUSIONS: Although
hyperbilirubinemia seems to be multifactorial, the type of operation, the
preoperative hepatic dysfunction due to advanced heart failure (NYHA II-III) and 
the decreased hepatic flow during the operation seem to determine the incidence
of jaundice.

PMID: 17690034 [PubMed - indexed for MEDLINE]

104: J Neurosci Res. 2007 Dec;85(16):3652-6.

Melatonin prevents brain oxidative stress induced by obstructive jaundice in
rats.

Cruz A, Túnez I, Martínez R, Muñoz-Castañeda JR, Ramírez LM, Recio M, Ochoa L,
Arjona A, Montilla P, Muntané J, Padillo FJ.

Department of General Surgery, Reina Sofía University Hospital, Avenida Menendez 
Pidal s/n, Córdoba, Spain.

The aim of the study was to analyze the impact of melatonin on brain oxidative
stress in experimental biliary obstruction. Cholestasis was done by a double
ligature and section of the extrahepatic biliary duct. Melatonin was injected
intraperitoneally (500 microg/kg/day). Malondialdehyde (MDA), reduced glutathione
(GSH), catalase (CAT), superoxide dismutase (SOD), and glutathione peroxidase
(GPx) contents were determined in the brain tissue. Biliary obstruction raised
MDA and reduced GSH contents in the cortex, cerebellum, and hypothalamus areas.
Moreover, the scavenger enzyme activity significantly dropped in all areas of the
brain. Melatonin drastically reduced MDA concentration and enhanced GSH
concentration, as well as all antioxidant enzyme activity in all brain areas
obtained from the bile duct-ligated animals. In conclusion, the treatment with
melatonin decreased lipid peroxidation and recovered the antioxidant status in
the brain from cholestatic animals. (c) 2007 Wiley-Liss, Inc.

Publication Types: 
    Research Support, Non-U.S. Gov't

PMID: 17671989 [PubMed - indexed for MEDLINE]

105: World J Surg. 2007 Oct;31(10):2023-32.

Effect of antioxidant treatments on the gut-liver axis oxidative status and
function in bile duct-ligated rats.

Assimakopoulos SF, Maroulis I, Patsoukis N, Vagenas K, Scopa CD, Georgiou CD,
Vagianos CE.

Department of Internal Medicine, School of Medicine, University of Patras,
Patras, Greece.

BACKGROUND: Experimental and clinical studies have demonstrated the pivotal role 
of oxidative stress in the promotion of hepatic and intestinal injury in
obstructive jaundice. The present study was undertaken to investigate the effect 
of well known antioxidant treatments on the gut-liver axis oxidative status and
function in bile duct-ligated rats. METHODS: A total of 60 male Wistar rats were 
randomly divided into six groups of 10 animals each: controls, sham operated,
bile duct ligated (BDL), and BDL treated with either N-acetylcysteine (NAC),
allopurinol, or alpha-tocopherol (alpha-TC). Ten days after treatment, the
hepatic and intestinal oxidative status was estimated by measuring lipid
peroxidation and a battery of biochemical markers comprising the organ's thiol
redox state (i.e., glutathione, cysteine, protein thiols, oxidized glutathione,
nonprotein mixed disulfides, oxidized cysteine derivatives, protein symmetrical
disulfides, and protein mixed disulfides). Portal and aortic endotoxin
concentrations and alanine aminotransferase (ALT) levels were also determined.
RESULTS: All antioxidant treatments significantly improved intestinal barrier
function and protected from cholestatic liver injury, as evidenced by reduction
of the portal and aortic endotoxin concentration and ALT levels, respectively.
This effect accompanied their significant antioxidant action in both organs,
mediated by a certain influence profile on the thiol redox state by each
treatment. CONCLUSION: NAC, allopurinol, and alpha-TC, exerting a potent combined
antioxidant effect on the intestine and liver in experimental obstructive
jaundice, significantly prevented intestinal barrier dysfunction and liver
injury. The variety of results depending on the antioxidant agent that was
administered and the marker of oxidative stress that was estimated, indicates
that a battery of biomarkers would be more appropriate in assessing pharmacologic
responses to therapeutic interventions.

PMID: 17665241 [PubMed - indexed for MEDLINE]

106: Gastrointest Endosc Clin N Am. 2007 Jul;17(3):581-93, vii-viii.

Endoscopic ultrasonography (EUS)-guided access and therapy of pancreatico-biliary
disorders: EUS-guided cholangio and pancreatic drainage.

Shami VM, Kahaleh M.

University of Virginia Health System, Digestive Health Center of Excellence, Box 
800708, Charlottesville, VA 22908-0708, USA.

Endoscopic ultrasonography (EUS)-guided cholangio pancreatic drainage (ECPD) has 
been reported as an alternative to surgery or percutaneous transhepatic
cholangiography if endoscopic retrograde cholangiopancreatography (ERCP) is
unsuccessful. With the development of EUS and the ability to direct a puncture
within the field of vision, ECPD has been used increasingly in tertiary centers. 
Its concept includes EUS-guided access into a dilated biliary tree or main
pancreatic duct, creation of a transenteric fistula deployment of a stent across 
the fistula or the ampulla after a rendezvous-type procedure. EUS-guided
cholangio-drainage may be performed in a transhepatic or extrahepatic fashion,
whereas EUS-guided pancreatic drainage can be antegrade or retrograde. Their
respective efficacy can be measured by resolution of biliary obstruction or pain 
improvement in case of pancreatic drainage. The current literature, including our
own data, shows that ECPD has an acceptable success and complication rate and
might be considered as first-line therapy in centers offering expertise in EUS
and ERCP. The techniques, efficacy, and complication of ECPD are discussed.

Publication Types: 
    Review

PMID: 17640584 [PubMed - indexed for MEDLINE]

107: J Gastrointest Surg. 2007 Dec;11(12):1752-4. Epub 2007 Jul 17.

Gastroduodenal artery pseudoaneurysm associated with hemosuccus pancreaticus and 
obstructive jaundice.

Bohl JL, Dossett LA, Grau AM.

Department of Surgery, Vanderbilt University, Nashville, TN 37232-6860, USA.

A 42-year-old male was admitted with recurrent gastrointestinal bleeding and
new-onset jaundice. Computed tomography showed a persistent gastroduodenal artery
pseudoaneurysm and dilated intrahepatic and extrahepatic ducts consistent with
obstructive jaundice. This patient had two previous coil embolizations, which
failed to prevent recurrent bleeding. The patient underwent
pancreaticoduodenectomy for definitive treatment of his pseudoaneurysm. We report
this case and review the literature.

Publication Types: 
    Case Reports

PMID: 17634764 [PubMed - indexed for MEDLINE]

108: Ann Surg Oncol. 2007 Oct;14(10):2831-7. Epub 2007 Jul 14.

Biliary obstruction in gall bladder cancer is not sine qua non of inoperability.

Agarwal AK, Mandal S, Singh S, Bhojwani R, Sakhuja P, Uppal R.

Department of Gastrointestinal Surgery, GB Pant Hospital & Maulana Azad Medical
College, JLN Marg, New Delhi 110002, India. aka.gis@gmail.com

BACKGROUND: The presence of biliary obstruction in patients with gallbladder
cancer (GBC) is generally viewed as an indicator of advanced disease,
inoperability and poor prognosis. METHODS: Data was collected from patients with 
GBC with obstructive jaundice who underwent resection during the period January
2001 to October 2003. Systematic analysis of prospective data was undertaken;
patients were analyzed for resectability, post-operative morbidity, mortality and
disease-free survival. RESULTS: During this period 14 patients with GBC with
biliary obstruction underwent resection with curative intent. In these jaundiced 
patients, the resectability rate was 27.45% (14 of 51). In the jaundiced group
the mortality was 7.14% the morbidity rate 50%, the mean disease free survival
was 23.46 months (median 26 months and range of 2 to 62 months). Seven patients
(50%) survived more than two years. CONCLUSION: Biliary obstruction in gall
bladder cancer is not sine qua non of inoperability and resection results in
meaningful prolongation of survival.

PMID: 17632759 [PubMed - indexed for MEDLINE]

109: Clin Gastroenterol Hepatol. 2007 Jul;5(7):783-90.

Endoscopic retrograde cholangiopancreatography tissue sampling: when and how?

Papachristou GI, Smyrk TC, Baron TH.

Department of Medicine, Division of Gastroenterology, Hepatology & Nutrition,
University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.

A 69-year-old man presented with obstructive jaundice. Endoscopic retrograde
cholangiopancreatography was performed for biliary tree decompression and
diagnostic tissue acquisition. Techniques, indications, methodologic
considerations, and interpretation of tissue sampling at endoscopic retrograde
cholangiopancreatography in patients with biliary/pancreatic strictures are
discussed. This case-based educational presentation focuses on the importance of 
interdisciplinary communication between endoscopists and pathologists for optimal
tissue sampling, interpretation, and diagnostic accuracy.

Publication Types: 
    Case Reports

PMID: 17628333 [PubMed - indexed for MEDLINE]

110: Acta Cir Bras. 2007 Jul-Aug;22(4):251-4.

Obstructive jaundice induces early depression of mitochondrial respiration in rat
hepatocytes.

Younes RN, Poggetti RS, Fontes B, Itinoshe MM, Yoshida VM, Carvalho ME, Birolini 
D.

Trauma Division, SM, USP, São Paulo, Brazil.

INTRODUCTION: Oxidative phosphorylation dysfunction of hepatocyte mitochondria is
involved in the pathophysiology of organ dysfunction following obstructive
jaundice (OJ). However the time period from biliary occlusion to the occurrence
of the dysfunction has not been determined decisively. PURPOSE: To evaluate the
early effects (1 d and 7 d) of OJ on liver mitochondria respiratory function in
rats. METHODS: Male Wistar rats (200-250 g) were randomly divided into the
following 3 groups: laparotomy plus OJ for 24 h (1d group) (n = 10); laparotomy
plus OJ for 7 d (7d group) (n = 10); sham control procedure (CTR group) (n = 12).
At the end of OJ periods, total serum bilirubin level, hepatic enzyme activity
levels (GOT, GTP, Gama-GT, ALP), mitochondrial respiration phases S3 and S4, as
well as the respiratory control ratio (RC = S3/S4), and ADP consumption/oxygen
consumption (ADP/O) ratio, were determined. RESULTS: Total serum bilirubin,
activity of most hepatic enzymes, and O2 consumption during basal (S4)
respiration were increased in the 1d and 7d groups (ANOVA, p = 0.05 vs. CTR).
After ADP addition, the O2 consumption rate (S3) in the 1d group remained similar
to the CTR rate (ANOVA p > .05), while the RC rate was reduced (ANOVA, p = 0.001)
vs. CTR. The effects observed on mitochondrial respiration in the 1d group were
exacerbated in the 7d group. CONCLUSION: These results indicate that OJ induces
early (24 h) depression of liver mitochondria respiration, and thus may lead to
early reduction in the production of high energy bonds.

PMID: 17625661 [PubMed - indexed for MEDLINE]

111: JOP. 2007 Jul 9;8(4):438-43.

EUS-guided transduodenal biliary drainage in unresectable pancreatic cancer with 
obstructive jaundice.

Ang TL, Teo EK, Fock KM.

Division of Gastroenterology, Department of Medicine, Changi General Hospital,
Singapore, Singapore. tiing_leong_ang@cgh.com.sg

CONTEXT: Endoscopic transpapillary biliary drainage is the procedure of choice
for biliary decompression in patients with unresectable pancreatic cancer. When
ERCP is unsuccessful, the usual alternative is percutaneous transhepatic biliary 
drainage. Recently, the use of EUS-guided biliary drainage has been reported, but
it is not clear whether it is feasible for this technique to find more widespread
use as an alternative to failed ERCP. We herein describe our experience with two 
cases of unresectable pancreatic cancer associated with obstructive jaundice
treated by EUS-guided biliary drainage. CASE REPORT: Two men presented with
obstructive jaundice due to unresectable pancreatic cancer. ERCP was unsuccessful
in both cases because of complete tumor obstruction at the distal common bile
duct. Both patients rejected the standard option of percutaneous transhepatic
biliary drainage and EUS-guided biliary drainage was performed. The obstructed
biliary system was successfully decompressed by the creation of a
choledochoduodenal fistula and the insertion of a transduodenal biliary stent.
CONCLUSION: EUS-guided biliary drainage has the potential of replacing
percutaneous transhepatic biliary drainage in unresectable pancreatic cancer with
obstructive jaundice when ERCP is unsuccessful.

Publication Types: 
    Case Reports

PMID: 17625296 [PubMed - indexed for MEDLINE]

112: Korean J Intern Med. 2007 Jun;22(2):113-7.

Castleman disease presenting with jaundice: a case with the multicentric hyaline 
vascular variant.

Park JB, Hwang JH, Kim H, Choe HS, Kim YK, Kim HB, Bang SM.

Department of Internal Medicine, Seoul National University College of Medicine,
Seoul, Korea.

Castleman disease (CD) is a rare lymphoproliferative disorder of unknown etiology
with different clinical manifestations. A previous healthy 50 year-old man was
hospitalized for right upper quadrant (RUQ) abdominal pain. He had jaundice and a
1 cm-sized lymph node in the right supraclavicular area. Pancreas and biliary
computed tomography (CT) showed masses at the right renal hilum and
peripancreatic areas. Positron emission tomography (PET) showed widespread
systemic lymphadenopathy. Excisional biopsy of the right supraclavicular node
revealed a hyaline vascular variant of CD. Corticosteroid therapy was started and
the extent of disease decreased. We here report a case of multicentric CD, the
hyaline vascular variant, presenting with jaundice, diagnosed by excisional
biopsy and successfully treated with corticosteroids.

Publication Types: 
    Case Reports

PMID: 17616028 [PubMed - indexed for MEDLINE]

113: Pediatr Surg Int. 2007 Sep;23(9):845-9.

Definitive exclusion of biliary atresia in infants with cholestatic jaundice: the
role of percutaneous cholecysto-cholangiography.

Nwomeh BC, Caniano DA, Hogan M.

Division of Pediatric Surgery, Columbus Children's Hospital, The Ohio State
University College of Medicine & Public Health, 700 Children's Drive, Suite
ED379, Columbus, OH 43205, USA. nwomehbe@chi.osu.edu

Definitive exclusion of biliary atresia in the infant with cholestatic jaundice
usually requires operative cholangiography. This approach suffers from the
disadvantage that sick infants are subjected to a time-consuming and potentially 
negative surgical exploration. The purpose of this study was to determine if
percutaneous cholecystocholangiography (PCC) prevents unnecessary laparotomy in
infants whose cholestasis is caused by diseases other than biliary atresia. This 
study is a 10 year retrospective review of all infants with persistent direct
hyperbilirubinemia and inconclusive biliary nuclear scans who underwent further
evaluation for suspected biliary atresia. A gallbladder ultrasound (US) was
obtained in all patients. When the gallbladder was visualized, further imaging by
PCC was done under intravenous sedation; otherwise, the standard operative
cholangiogram (OCG) was performed, with liver biopsy as indicated. The primary
outcome was the diagnostic accuracy of PCC, especially with respect to preventing
a laparotomy. There were 35 infants with suspected biliary atresia, with a mean
age of 8 weeks (range 1-14 weeks). Nine infants whose gallbladder was visualized 
by ultrasound underwent PCC that definitively excluded biliary atresia. Of this
group, the most frequent diagnosis (five patients) was total parenteral
nutrition-associated cholestasis. The other 26 infants with absent or
decompressed gallbladder had laparotomy and OCG, which identified biliary atresia
in 16 patients (61%). Laparotomy was avoided in all 9 patients who underwent PCC,
thus reducing the negative laparotomy rate by 47%. There were no complications
associated with PCC. Several alternative techniques to operative cholangiogram
have been described for the definitive exclusion of biliary atresia, but many of 
these have distinct drawbacks. Advances in interventional radiology techniques
have permitted safe percutaneous contrast evaluation of the biliary tree.
Identification of a normal gall bladder on sonogram is highly predictive of the
absence of biliary atresia. Further confirmation can be accurately obtained by a 
combination of PCC and percutaneous liver biopsy.

Publication Types: 
    Evaluation Studies

PMID: 17605021 [PubMed - indexed for MEDLINE]

114: J Gastrointestin Liver Dis. 2007 Jun;16(2):177-86.

Haemostasis impairment in patients with obstructive jaundice.

Papadopoulos V, Filippou D, Manolis E, Mimidis K.

1st Department of Internal Medicine, Democritus University of Thrace Medical
School, Alexandroupoli.

As part of the multifactorial role of liver in protein synthesis, many
coagulation factors, natural anticoagulants, and compounds of the fibrinolytic
system are produced in the liver. A prolonged liver disease, either biliary
obstruction or parenchymal liver disease, is consecutively accompanied by
abnormal clotting. In the present paper we review the haemostasis impairment in
obstructive jaundice with special reference to the hepatic cirrhosis and failure,
to systemic inflammation and sepsis that develops in cholestatic diseases, and
finally in some other benign or malignant diseases including pancreatic
adenocarcinoma, acute pancreatitis, cholangiocarcinoma, and hepatocellular
carcinoma. Finally, a special reference to the possible therapeutic interventions
has been made. The aim of the present review is to collect the current concepts
concerning the haemostasis impairment in obstructive jaundice and provide
practical guidelines for the diagnostic and therapeutic strategies. Understanding
the pathophysiology of haemostatic changes in patients with cholestasis, and,
more generally, liver disease, is the hallmark of accurate diagnosis and
treatment.

Publication Types: 
    Review

PMID: 17592568 [PubMed - indexed for MEDLINE]

115: J Gastroenterol Hepatol. 2007 Oct;22(10):1615-20. Epub 2007 Jun 15.

Usefulness of transpapillary bile duct brushing cytology and forceps biopsy for
improved diagnosis in patients with biliary strictures.

Kitajima Y, Ohara H, Nakazawa T, Ando T, Hayashi K, Takada H, Tanaka H, Ogawa K, 
Sano H, Togawa S, Naito I, Hirai M, Ueno K, Ban T, Miyabe K, Yamashita H,
Yoshimura N, Akita S, Gotoh K, Joh T.

Department of Internal Medicine and Bioregulation, Nagoya City University
Graduate School of Medical Sciences, Nagoya, Japan. yasu-kita@nifty.com

BACKGROUND AND AIM: Transpapillary bile duct brushing cytology and/or forceps
biopsy was performed in the presence of an indwelling guidewire in patients with 
biliary stricture, and the treatment time, overall diagnosis rate, diagnosis rate
of each disease, complications, and influences on subsequent biliary drainage
were investigated. METHODS: After endoscopic retrograde cholangiography, brushing
cytology was performed, followed by forceps biopsy. In patients with obstructive 
jaundice, endoscopic biliary drainage (EBD) was subsequently performed. To
investigate the influences of bile duct brushing cytology and forceps biopsy on
EBD, patients who underwent subsequent EBD by plastic stent were compared with
patients who underwent EBD alone. RESULTS: The samples for cytology were
collected successfully in all cases, and the sensitivity for
malignancy/benignity, specificity, and accuracy were 71.6%, 100%, and 75.0%,
respectively. The biopsy sampling was successful in 51 patients, and samples
applicable to the evaluation were collected in all 51 patients. The sensitivity
for malignancy/benignity, specificity, and accuracy were 65.2%, 100%, and 68.6%, 
respectively. Combination of the two procedures increased the sensitivity and
accuracy to 73.5% and 76.6%, respectively. The time required for cytology and
biopsy was 11.7 min, which is relatively short. Cytology and biopsy did not
affect drainage. Regarding accidents, bile duct perforation occurred during
biopsy in one patient (1.9%), but was rapidly improved by endoscopic biliary
drainage. CONCLUSIONS: Transpapillary brushing cytology and forceps biopsy could 
be performed in a short time. The diagnosis rate was high, and the incidence of
complication was low, having no influence on subsequent biliary drainage.

PMID: 17573833 [PubMed - indexed for MEDLINE]

116: Neonatology. 2007;91(4):266-70. Epub 2006 Dec 22.

Ultrasound-guided percutaneous cholecystostomy for acute neonatal biliary
obstruction.

Helin R, Bhat R, Rao B.

Department of Pediatrics, University of Illinois Medical Center, Chicago, IL
60612, USA. rhelin1@uic.edu

Use of a percutaneously-inserted cholecystostomy drainage tube is an effective
therapeutic option for acute hyperbilirubinemia in severely-ill adult patients,
but to our knowledge has not been previously reported in infants. We describe an 
infant who developed acute extrahepatic biliary tract obstruction with marked
conjugated (direct) hyperbilirubinemia, and who was determined to be an
unsuitable surgical candidate. Ultrasound-guided percutaneous cholecystostomy was
performed and resulted in prompt, significant, and sustained decline in serum
bilirubin levels. Potential risks and benefits, as well as suggested indications 
for the procedure are discussed. Copyright (c) 2007 S. Karger AG, Basel.

Publication Types: 
    Case Reports

PMID: 17568158 [PubMed - indexed for MEDLINE]

117: Emerg Med Australas. 2007 Jun;19(3):276-8.

Abdominal pain and jaundice: appendiceal perforation an important differential.

Dawes T, Burrows C.

Department of Emergency Medicine, Royal Darwin Hospital, Darwin, Northern
Territory, Australia.

Clinicians must be aware of atypical presentations of common conditions.
Appendiceal perforation with peritonitis and sepsis presenting with cholestatic
jaundice is an important example, given the prevalence of the condition and the
mortality associated with delayed diagnosis. The authors describe a case seen at 
their hospital.

Publication Types: 
    Case Reports

PMID: 17564697 [PubMed - indexed for MEDLINE]

118: Neonatology. 2007;92(4):219-26. Epub 2007 Jun 8.

Minocycline blocks acute bilirubin-induced neurological dysfunction in jaundiced 
Gunn rats.

Geiger AS, Rice AC, Shapiro SM.

Department of Neurology and Physiology, Virginia Commonwealth University Medical 
Center, Virginia Commonwealth University, Richmond, VA, USA.

BACKGROUND: Extreme hyperbilirubinemia is treated with double volume exchange
transfusion, which may take hours to commence. A neuroprotective agent that could
be administered immediately might be clinically useful. Minocycline, an
anti-inflammatory and anti-apoptotic semisynthetic tetracycline, prevents
hyperbilirubinemia-induced cerebellar hypoplasia in Gunn rats. Acute brainstem
auditory evoked potential (BAEP) abnormalities occur after giving
sulfadimethoxine to 16-day-old jaundiced Gunn rats to displace bilirubin into
tissue including brain. OBJECTIVE: To assess whether minocycline is
neuroprotective in this model of acute bilirubin encephalopathy. METHODS: We
recorded BAEPs at baseline and 6 h after injecting sulfadimethoxine. Minocycline 
0.5 mg/kg (n = 4), 5 mg/kg (n = 9), 50 mg/kg (n = 9) or 500 mg/kg (n = 3, all
died) was administered 15 min before sulfadimethoxine (0 h). Controls received
saline followed by either sulfadimethoxine (n = 13) or saline (n = 7). RESULTS:
At 6 h total plasma bilirubin decreased from 10.84 +/- 0.88 mg/dl (mean +/- SD)
to 0.70 +/- 0.35 mg/dl (p <10(-9)) in all sulfadimethoxine-injected groups. At 6 
h, there was complete protection against decreased amplitudes of BAEP waves II
and III and increased I-II and I-III interwave intervals (brainstem conduction
times corresponding to I-III and I-V in humans) with 50 mg/kg minocycline, and
partial protection with lower doses. CONCLUSIONS: Minocycline 50 mg/kg 15 min
prior to an intervention that normally produces acute bilirubin neurotoxicity is 
neuroprotective in jaundiced Gunn rat pups. Further studies are needed to
investigate the temporal course and mechanism of neuroprotection. Minocycline,
administered immediately, may be clinically useful in treating extreme neonatal
hyperbilirubinemia and preventing kernicterus. We believe our model provides an
efficient in vivo model to screen and evaluate new agents that are
neuroprotective against bilirubin toxicity and kernicterus. (c) 2007 S. Karger
AG, Basel.

Publication Types: 
    Research Support, N.I.H., Extramural

PMID: 17556840 [PubMed - indexed for MEDLINE]

119: Am Surg. 2007 May;73(5):508-10.

Primary biliary B-cell lymphoma of the cystic duct causing obstructive jaundice.

Jho DH, Jho DJ, Chejfec G, Ahn M, Ong ES, Espat NJ.

Department of Surgery, University of Illinois, Chicago, Illinois, USA.

A distinctive case of primary biliary lymphoma occurring in the cystic duct
causing extrinsic compression of the porta hepatis in a 48-year-old woman is
presented. Imaging studies revealed stricture of the common hepatic duct with a
2.5-cm nonhomogeneous mass at the porta hepatis, mimicking a Klatskin tumor.
Exploratory laparotomy revealed a mass in the gallbladder neck with extension
into the cystic duct akin to Mirizzi's syndrome. A soft, tan-yellow 1.0-cm mass
was removed from the cystic duct, and infiltrating atypical lymphocytic nodules
were identified with a final diagnosis of an anaplastic variant of diffuse large 
B-cell lymphoma.

Publication Types: 
    Case Reports

PMID: 17521008 [PubMed - indexed for MEDLINE]

120: Cardiovasc Intervent Radiol. 2007 Sep-Oct;30(5):950-8. Epub 2007 May 17.

ePTFE/FEP-covered metallic stents for palliation of malignant biliary disease:
can tumor ingrowth be prevented?

Hatzidakis A, Krokidis M, Kalbakis K, Romanos J, Petrakis I, Gourtsoyiannis N.

Department of Radiology, University Hospital of Heraklion, Medical School of
Crete, 71110 Heraklion-Stavrakia, Crete, Greece. adamhatz@med.uoc.gr

PURPOSE: To determine the application and clinical effectiveness of
ePTFE/FEP-covered metallic stents for palliation of malignant biliary disease,
and to evaluate the efficiency of stent coverage in preventing tumor ingrowth.
METHODS: During a 3-year period, 36 patients with malignant obstructive jaundice 
were treated with ePTFE/FEP-covered stents, with or without proximal side holes. 
The stricture was located in the lower common bile duct (CBD) in 18 cases, the
upper CBD in 9, the lower common hepatic duct (CHD) in 6, and the upper CHD in 3 
patients. RESULTS: Thirty-seven covered stents were percutaneously implanted. The
technical success rate was 97%. Reintervention was required in 6 cases. The
30-day mortality rate was 40%, not procedure-related. Mean survival was 128 days.
Primary patency rates were 100%, 55.5%, and 25% at 3, 6, and 12 months,
respectively, while the assisted patency rate was 100% at 12 months. Stents
without side holes had higher primary patency rates compared with those with side
holes, where occlusion was always due to tumor ingrowth. Tumor ingrowth did not
occur in the completely covered stents. No stent dysfunction due to sludge
incrustation was found. Complications were 1 case of arterial laceration that
occurred during percutaneous transhepatic cholangiography, and a subcapsular
hematoma and 1 case of bile peritonitis, that both occurred during primary
stenting. No complications followed the secondary stenting technique. CONCLUSION:
ePTFE/FEP-covered metallic stents are safe and effective for palliation of
malignant biliary disease. The presence of the ePTFE/FEP coating is likely to
prevent from tumor ingrowth.

PMID: 17508236 [PubMed - indexed for MEDLINE]

121: Obes Surg. 2007 Feb;17(2):247-50.

Intermittent obstructive jaundice following gastric band placement.

Arkadopoulos N, Palamarou C, Koureas A, Sechopoulos P, Marinis A, Kostopanagiotou
C, Dafnios N, Smyrniotis V.

2nd Department of Surgery, University of Athens School of Medicine, Aretaieion
Hospital, Greece. narkado@otenet.gr

Complications of laparoscopic adjustable gastric banding occur in 10 - 20% of
patients. However, hepatobiliary complications of this procedure are very rare.
We report a unique case of gastric band misplacement around the hepato-duodenal
ligament. The patient developed obstructive jaundice several months after the
gastric band placement and suffered recurrent episodes of obstructive jaundice
and cholangitis that were initially erroneously attributed to fatty infiltration 
of the liver. Further diagnostic work-up demonstrated the presence of the gastric
band in the hepatic hilum. Exploratory laparotomy confirmed the diagnosis, and
the band was removed. Jaundice reversed and hepatic function was restored
following removal of the occluding band.

Publication Types: 
    Case Reports

PMID: 17476880 [PubMed - indexed for MEDLINE]

122: Clin Med Res. 2007 Mar;5(1):53-60.

Plastic biliary stent occlusion: factors involved and possible preventive
approaches.

Donelli G, Guaglianone E, Di Rosa R, Fiocca F, Basoli A.

Department of Technologies and Health, Istituto Superiore di Sanità, Viale Regina
Elena 299, 00161, Rome, Italy. donelli@iss.it

Endoscopic biliary stenting is today the most common palliative treatment for
patients suffering from obstructive jaundice associated with malignant
hepatobiliary tumors or benign strictures. However, recurrent jaundice, with or
without cholangitis, is a major complication of a biliary endoprosthesis
insertion. Thus, stent removal and replacement with a new one frequently occurs
as a consequence of device blockage caused by microbial biofilm growth and
biliary sludge accumulation in the lumen. Factors and mechanisms involved in
plastic stent clogging arising from epidemiological, clinical and experimental
data, as well as the possible strategies to prevent biliary stent failure, will
be reviewed and discussed.

Publication Types: 
    Review

PMID: 17456835 [PubMed - indexed for MEDLINE]

123: J Vasc Interv Radiol. 2007 Apr;18(4):567-71.

Portal hypertension and obstructive jaundice after hepatic interventions: report 
of two unusual complications.

Peynircioglu B, Cho KJ, Cwikiel W.

Department of Radiology, University of Hacettepe Hospitals, Ankara Tr-06700,
Turkey. borapeynir@gmail.com

We report two unusual complications after a transjugular intrahepatic
portosystemic shunt and a biliary stent placement, respectively. One patient with
cirrhosis and portal hypertension developed obstructive jaundice secondary to
compression of the right hepatic duct by a stent graft placed in the transjugular
intrahepatic portosystemic shunt. In another patient, biliary stents caused
obstruction of the portal vein, resulting in symptomatic portal hypertension. An 
awareness of these possible complications is important for early diagnosis and
appropriate treatment of such complications.

Publication Types: 
    Case Reports

PMID: 17446549 [PubMed - indexed for MEDLINE]

124: J Gastroenterol Hepatol. 2007 May;22(5):762-3.

Liver injury induced by a Japanese herbal medicine, sairei-to (TJ-114, Bupleurum 
and Hoelen Combination, Chai-Ling-Tang) R1.

Aiba T, Takahashi T, Suzuki K, Okoshi S, Nomoto M, Uno K, Aoyagi Y.

Division of Gastroenterology and Hepatology, Graduate School of Medical and
Dental Sciences, Niigata University, Niigata, Japan.

The case is reported of a man who showed acute hepatitis with jaundice after he
was given a Japanese herbal medicine, sairei-to (TJ-114, Bupleurum and Hoelen
Combination, Chai-Ling-Tang). Unusually, the component thought to be responsible 
for the observed drug-induced liver injury was able to be identified. Lymphocyte 
migration inhibition testing indicated that the tuber of the perennial herbage
Pinellia ternate was the causative agent.

Publication Types: 
    Case Reports

PMID: 17444872 [PubMed - indexed for MEDLINE]

125: J Gastroenterol Hepatol. 2007 May;22(5):724-8.

Clinical analysis of primary duodenal adenocarcinoma: an 11-year experience.

Hung FC, Kuo CM, Chuah SK, Kuo CH, Chen YS, Lu SN, Chang Chien CS.

Division of Hepatogastroenterology, Department of Internal Medicine, Chang Gung
Memorial Hospital, Kaohsiung Medical Center and Chang Gung University, College of
Medicine, Kaohsiung, Taiwan.

BACKGROUND AND AIM: The impact of obstructive jaundice (OJ) complicated by
primary duodenal adenocarcinoma (PDA) on survival, and its treatment options, has
rarely been mentioned in literature. The aim of the present study was to review
the clinical features of PDA patients in an attempt to determine the prognostic
factors and the influence of OJ on survival. METHODS: From May 1994 to February
2005, all duodenal malignancies treated at Kaohsiung Chang Gung Memorial Hospital
were reviewed. Preliminary findings were made on a total of 116 duodenal
adenocarcinoma (DA) cases. After excluding metastatic DA and the papilla of Vater
cancer, 23 patients (19.8%), confirmed as having PDA, were enrolled. RESULTS:
Among the 23 predominantly male patients with a mean age of 68 years, abdominal
pain was the most common symptom. Major tumor origin was the second portion, and 
the predominantly cytological feature was moderate differentiation.
Tumor-node-metastasis (TNM) cancer stage IV accounted for 47.8% of the patients, 
and cancer-directed surgeries (CDS) were performed on 11 patients. Seven patients
experienced complications due to OJ, which could be a sign of grave prognosis
predicting survival of less than 1 year. Four of the patients received internal
or external biliary drainage before CDS or palliative surgeries. Cigarette
smoking, cytology, TNM stage, aspartate aminotransferase (AST), OJ, and CDS were 
significant factors of overall survival in a univariate analysis. The independent
predictors of long-term survival were CDS, TNM stage, cytology, cigarette
smoking, and AST using the Cox proportional hazard model. CONCLUSION: PDA
patients who did not smoke and who were eligible for and received CDS had better 
prognostic outcomes.

PMID: 17444863 [PubMed - indexed for MEDLINE]

126: J Assoc Physicians India. 2007 Jan;55:76-7.

Primary duodenal lymphoma producing obstructive jaundice.

Bandyopadhyay SK, Moulick A, Dutta A.

Department of Medicine, Nil Ratan Sircar Medical College and Hospital, 138, A J C
Bose Road, Kolkata-14.

Primary lymphoma of the duodenum presenting with obstructive jaundice is a rare
entity. We report a case of primary non-Hodgkin's lymphoma of the duodenum
producing obstructive jaundice in a middle aged lady, where the concentric
thickening of the duodenal wall also gave rise to symptomatic partial high small 
bowel obstruction in due course. Guided aspiration and flowcytometry established 
a diagnosis of diffuse large B-cell lymphoma.

Publication Types: 
    Case Reports

PMID: 17444348 [PubMed - indexed for MEDLINE]

127: Dig Dis Sci. 2007 Sep;52(9):2312-6. Epub 2007 Apr 12.

X-linked hyper-IgM syndrome associated with poorly differentiated neuroendocrine 
tumor presenting as obstructive jaundice secondary to extensive adenopathy.

Nagaraj N, Egwim C, Adler DG.

Huntsman Cancer Center, University of Utah, Salt Lake City, Utah, USA.

X-Linked Hyper IgM Syndrome (XHIGM) is a rare B-cell immunodeficiency disease.
Patients with XHIGM are unable to switch immunoglobulin production from IgM to
IgG, IgA, and IgE. Patients with XHIGM require periodic intravenous immune
globulin to help prevent infections, and are also at risk for a variety of
neoplasms. We describe a young man with XHIGM who presented with obstructive
jaundice from malignant adenopathy from widespread, poorly differentiated
neuroendocrine tumor. This has not previously been reported and represents a new 
association with XHIGM.

Publication Types: 
    Case Reports

PMID: 17436099 [PubMed - indexed for MEDLINE]

128: Pediatr Res. 2007 Jun;61(6):727-31.

(TA)n UGT 1A1 promoter polymorphism: a crucial factor in the pathophysiology of
jaundice in G-6-PD deficient neonates.

Kaplan M, Renbaum P, Vreman HJ, Wong RJ, Levy-Lahad E, Hammerman C, Stevenson DK.

Department of Neonatology, Shaare Zedek Medical Center, Jerusalem 91031, Israel. 
kaplan@cc.huji.ac.il

Increased heme catabolism has been reported in glucose-6-phosphate dehydrogenase 
(G-6-PD)-normal neonates who were also homozygous for (TA)7/(TA)7 (UGT1A1*28)
uridine diphosphoglucuronate-glucuronosyltransferase 1A1 (UGT) promoter
polymorphism (Gilbert syndrome). As G-6-PD deficiency is associated with
increased hemolysis, we hypothesized that in G-6-PD-deficient neonates who also
have the (TA)7/(TA)7 UGT promoter genotype, steady-state hemolysis would be even 
further increased. Male G-6-PD-deficient neonates were sampled for plasma total
bilirubin (PTB), blood carboxyhemoglobin corrected for inhaled carbon monoxide in
ambient air (COHbc) (an index of heme catabolism), and UGT (TA)n promoter
genotype determination and compared with previously published G-6-PD-normal
neonates. Although COHbc values were higher in the G-6-PD-deficient than in the
G-6-PD-normal cohorts (0.97 +/- 0.32% of total Hb (tHb) versus 0.76 +/- 0.19% of 
tHb, p < 0.001), PTB values were similar (9.2 +/- 3.4 mg/dL versus 8.9 +/- 3.0
mg/dL, respectively, p = 0.3). Within the G-6-PD-deficient group, although COHbc 
values were alike between the three UGT promoter genotypes, PTB was higher in the
(TA)7/(TA)7 homozygotes (11.1 +/- 4.0 mg/dL) compared with (TA)6/(TA)7
heterozygotes (9.1 +/- 3.2 mg/dL, p = 0.03) and wild-type (TA)6/(TA)6 homozygotes
(8.8 +/- 3.4 mg/dL, p = 0.02). In the steady state, similar rates of hemolysis,
but increased PTB in the G-6-PD- deficient, (TA)7/(TA)7 homozygotes, imply that
(TA)7/(TA)7, homozygosity is central to increased PTB.

Publication Types: 
    Research Support, N.I.H., Extramural
    Research Support, Non-U.S. Gov't

PMID: 17426648 [PubMed - indexed for MEDLINE]

129: Hepatogastroenterology. 2007 Jan-Feb;54(73):229-33.

The effects of somatostatin and ursodeoxycholic acid in preventing the ischemic
injury of the liver following Pringle maneuver in obstructive jaundice-rat model.

Pergel A, Zengin K, Cercel A, Aki H, Kaya S.

Department of General Surgery, Istanbul University. Cerrahpasa Medical Faculty,
Istanbul, Turkey.

BACKGROUND/AIMS: In our study, the effects of somatostatin (SS) and
ursodeoxycholic acid (UDCA) on ischemic liver injury were studied in
(obstructive) jaundice-rat model. METHODOLOGY: For this purpose, jaundice was
produced in the first four groups by binding of their choleducts. We performed
just laparotomy to the other four groups of animals. To groups 1 and 5, SS was
given 15 mcg/kg/day intraperitoneally, and to groups 2 and 6, UDCA was given 20
mg/kg/day enterally. No drugs were given to any other group. At the end of one
week, a procedure with ischemia of the liver for 60 minutes followed by
reperfusion for 2 hours, was performed to each rat except for groups 4 and 8.
Following this procedure, they were sacrificed. The blood samples were taken to
measure SGOT, SGPT, ALP, LDH, total and direct bilirubin levels, while liver
biopsies were taken for histopathological evaluation. RESULTS: Under normothermic
conditions, following 60-minute liver ischemia period, no irreversible
histopathological changes were detected. However, increases in liver necrosis
parameters were noted biochemically. SS and UDCA were thought to be effective in 
preventing the injury by decreasing the liver enzymes levels to a significant
degree. The damage of the hepatic ischemic injury was found to be more meaningful
and prominent in liver with jaundice. CONCLUSIONS: In this study, it was noted
that SS and UDCA decrease the effects of cholestatic hepatic injury especially
and improve the condition.

PMID: 17419266 [PubMed - indexed for MEDLINE]

130: Can Assoc Radiol J. 2007 Feb;58(1):15-21.

Focal chronic pancreatitis mimicking pancreatic head carcinoma: are there
suggestive features on ultrasound?

Patlas M, Deitel W, Taylor B, Gallinger S, Wilson SR.

Department of Medical Imaging, Toronto General Hospital, University of Toronto,
Toronto, ON.

OBJECTIVE: Painless jaundice is one of the most common presentations of
pancreatic head cancer. Chronic pancreatitis can also occasionally present with a
mass or mass-like process in the pancreatic head, with the subsequent development
of jaundice. In this retrospective review, we evaluate the clinical and imaging
features of 22 patients presenting with painless jaundice, initially thought to
have pancreatic head cancer and ultimately proven to have chronic focal
pancreatitis, to determine whether there are any features on cross-sectional
imaging to suggest the correct diagnosis. METHODS: Patients (n = 22) were
identified from the medical and imaging records of more than 400 patients with an
original diagnosis of pancreatic cancer who were seen at our institution from
1995 to 2003. Of the patients, 17 were men and 5 were women (age range 25 to 82
years, mean age 54 years). RESULTS: Initial ultrasound showed a large,
hypoechoic, well-defined mass in the pancreatic head, varying in size from 3 to
7.5 cm; 14 of 22 masses were > 5 cm in maximal diameter. Diagnosis of focal
pancreatitis was proven by surgical pathology in 14 cases and suggested by
percutaneous biopsy in 3 cases; for all patients, prolonged imaging follow-up (at
least 1 year) showed no disease progression or evidence of malignancy. The mean
follow-up in our study group was 31 months (range 12 to 72 months). CONCLUSION:
Male sex, large size of the pancreatic head mass (mean diameter 5.5 cm), and lack
of atrophy of the pancreatic body and tail were the only features associated with
chronic inflammation rather than neoplasm as an explanation for a pancreatic head
mass. Chronic pancreatitis should be considered in the differential diagnosis of 
focal pancreatic masses, even in the absence of supporting clinical evidence.

PMID: 17408158 [PubMed - indexed for MEDLINE]

131: Dig Dis Sci. 2007 Sep;52(9):2317-22. Epub 2007 Apr 4.

Serum total sialic acid in differential diagnostics of jaundice caused by
malignant and nonmalignant diseases: a ROC curve analysis.

Cylwik B, Chrostek L, Zalewski B, Dabrowski A, Szmitkowski M.

Department of Biochemical Diagnostics, Medical University, Bialystok, Poland.

The purpose of this study was to evaluate the usefulness of serum total sialic
acid (SA) for discrimination of malignant and nonmalignant jaundice. Serum SA
concentration and its ratio with total protein (SA/TP) were determined in 55
patients with jaundice: 25 malignant and 30 nonmalignant. SA was estimated by
enzymatic method. Serum total SA and the ratio SA/TP were significantly higher in
malignant than in nonmalignant jaundice. Diagnostic sensitivity of SA and the
ratio of SA/TP in both types of jaundice reached the value of 95.8%. The
specificity, positive and negative predictive values, and efficiency of SA and
SA/TP were higher in malignant than in nonmalignant jaundice. Areas under ROC
curves for SA and the ratio of SA/TP in malignant jaundice were higher than in
nonmalignant, but there were not statistically significant differences. SA levels
and the ratio of SA/TP do not have the ability to discriminate between these
types of jaundice.

PMID: 17406834 [PubMed - indexed for MEDLINE]

132: Hepatobiliary Pancreat Dis Int. 2007 Apr;6(2):194-8.

Protective effects of pLNCX-SOD gene transfection on hepatocyte injury induced by
obstructive jaundice in rats.

Gong P, Wang ZY, Wang HJ.

Department of General Surgery, the First Affiliated Hospital, Dalian Medical
University, Dalian, China. gongp28@263.net

BACKGROUND: Hydrophobic bile acids lead to the generation of oxygen free radicals
in mitochondria. Accordingly, this study is to investigate if gene delivery of
superoxide dismutase (SOD) will reduce hepatocyte injury caused by experimental
cholestasis. METHODS: The recombinant of pLNCX-SOD gene packaged with lipofection
of AMINE was transfected into hepatocytes in vitro, which stably expressed the
SOD gene. RESULTS: After transfection, hepatocytes enhanced the protective effect
against injury to bile and the toxicity of serum in obstructive jaundice. The
inhibition of bile at the concentration of 2% (v:v, bile: DMEM 1:50) decreased
obviously from (78.80+/-12.35)% to (43.35+/-9.69)% in 12 hours, from
(82.55+/-11.27)% to (-26.64+/-7.66)% in 24 hours, and from (83.83+/-18.69)% to
(-19.27+/-14.38)% in 48 hours, compared with that of the untransfected cells
(P<0.01). The inhibition of serum at the obstructive jaudice concentration of
2.5% was obviously decreased from (89.72+/-1.52)% to (14.68+/-14.33)% in 12
hours, from (92.2+/-11.27)% to (41.39+/-7.66)% in 24 hours, and from
(94.25+/-8.96)% to (22.71+/-4.38)% in 48 hours (P<0.01). CONCLUSION: Hepatocytes 
transfected with the pLNCX-SOD gene could obviously be resistant to the toxicity 
of bile and serum from rat with obstructive jaundice.

Publication Types: 
    Research Support, Non-U.S. Gov't

PMID: 17374581 [PubMed - indexed for MEDLINE]

133: Arch Iran Med. 2007 Apr;10(2):264-7.

Extrahepatic bile duct neurilemmoma mimicking Klatskin tumor.

Kamani F, Dorudinia A, Goravanchi F, Rahimi F.

Department of Surgery, Taleghani Hospital, Shaheed Beheshti University of Medical
Sciences, Tehran, Iran.

Neurilemmoma rarely develops in the biliary tree. Here, we report a 39-year-old
Iranian woman with neurilemmoma in the extrahepatic bile duct presenting with
progressively deepening jaundice. On the basis of clinical and radiological
features, this tumor was initially suspected as Klatskin tumor. Histologically,
the tumor was a typical neurilemmoma. Immunostaining showed that tumor cells were
strongly and diffusely positive for S-100 protein, which supported the diagnosis 
of neurilemmoma. Neurilemmoma should be considered in the differential diagnosis 
of obstructive jaundice.

Publication Types: 
    Case Reports

PMID: 17367238 [PubMed - indexed for MEDLINE]

134: BMC Surg. 2007 Mar 12;7:3.

Preoperative biliary drainage for periampullary tumors causing obstructive
jaundice; DRainage vs. (direct) OPeration (DROP-trial).

van der Gaag NA, de Castro SM, Rauws EA, Bruno MJ, van Eijck CH, Kuipers EJ,
Gerritsen JJ, Rutten JP, Greve JW, Hesselink EJ, Klinkenbijl JH, Rinkes IH,
Boerma D, Bonsing BA, van Laarhoven CJ, Kubben FJ, van der Harst E, Sosef MN,
Bosscha K, de Hingh IH, Th de Wit L, van Delden OM, Busch OR, van Gulik TM,
Bossuyt PM, Gouma DJ.

Department of Surgery, Academic Medical Center Amsterdam, The Netherlands.
n.a.vandergaag@amc.uva.nl

BACKGROUND: Surgery in patients with obstructive jaundice caused by a
periampullary (pancreas, papilla, distal bile duct) tumor is associated with a
higher risk of postoperative complications than in non-jaundiced patients.
Preoperative biliary drainage was introduced in an attempt to improve the general
condition and thus reduce postoperative morbidity and mortality. Early studies
showed a reduction in morbidity. However, more recently the focus has shifted
towards the negative effects of drainage, such as an increase of infectious
complications. Whether biliary drainage should always be performed in jaundiced
patients remains controversial. The randomized controlled multicenter DROP-trial 
(DRainage vs. Operation) was conceived to compare the outcome of a 'preoperative 
biliary drainage strategy' (standard strategy) with that of an 'early-surgery'
strategy, with respect to the incidence of severe complications (primary-outcome 
measure), hospital stay, number of invasive diagnostic tests, costs, and quality 
of life. METHODS/DESIGN: Patients with obstructive jaundice due to a
periampullary tumor, eligible for exploration after staging with CT scan, and
scheduled to undergo a "curative" resection, will be randomized to either "early 
surgical treatment" (within one week) or "preoperative biliary drainage" (for 4
weeks) and subsequent surgical treatment (standard treatment). Primary outcome
measure is the percentage of severe complications up to 90 days after surgery.
The sample size calculation is based on the equivalence design for the primary
outcome measure. If equivalence is found, the comparison of the secondary
outcomes will be essential in selecting the preferred strategy. Based on a 40%
complication rate for early surgical treatment and 48% for preoperative drainage,
equivalence is taken to be demonstrated if the percentage of severe complications
with early surgical treatment is not more than 10% higher compared to standard
treatment: preoperative biliary drainage. Accounting for a 10% dropout, 105
patients are needed in each arm resulting in a study population of 210 (alpha =
0.95, beta = 0.8). DISCUSSION: The DROP-trial is a randomized controlled
multicenter trial that will provide evidence whether or not preoperative biliary 
drainage is to be performed in patients with obstructive jaundice due to a
periampullary tumor.

Publication Types: 
    Comparative Study
    Multicenter Study
    Randomized Controlled Trial
    Research Support, Non-U.S. Gov't

PMID: 17352805 [PubMed - indexed for MEDLINE]

135: Pediatr Allergy Immunol. 2007 Jun;18(4):313-9. Epub 2007 Mar 7.

Is neonatal phototherapy associated with an increased risk for hospitalized
childhood bronchial asthma?

Aspberg S, Dahlquist G, Kahan T, Källén B.

Division of Internal Medicine, Department of Clinical Sciences, Danderyd
Hospital, Karolinska Institutet, Stockholm, Sweden. sara.aspberg@ds.se

This population-based register study examined if factors during the fetal and
neonatal period influence the risk for the child to develop bronchial asthma
(asthma). From the Swedish Hospital Discharge Register we identified children,
born between 1987 and 1999, who had been hospitalized for asthma up to 2001.
Thus, the outcome measure contains only hospitalized cases, not all children with
asthma. Children younger than 2 yr at admission were excluded because of the
uncertainty about the diagnosis of asthma in younger children. The remaining
14,803 children were compared with all children born the same years, recorded in 
the Swedish Medical Birth Registry, for information on pre- and perinatal
characteristics. Odds ratios (ORs) were calculated with Mantel-Haenszel technique
and 95% confidence intervals (CIs) with Miettinen's test-based method. The
presence of various maternal and neonatal confounders were identified and
adjusted for in the analyses. The association between some known factors and
childhood asthma were confirmed: young maternal age, maternal smoking, period of 
unwanted childlessness, low maternal level of education, maternal diabetes,
preterm birth, low birth weight, small-for-gestational age, caesarean section,
and instrumental vaginal delivery. A number of neonatal characteristics were
shown to be independent risk factors: sepsis or pneumonia, neonatal respiratory
problems and treatments, neonatal icterus, and/or neonatal phototherapy. The
association with icterus and phototherapy remained after exclusion of cases
showing other neonatal risk factors and after adjustment for maternal factors (OR
1.27, 95% CI: 1.08-1.50), and increased to 1.5 if the children had been
hospitalized for asthma more than once. In conclusion, our results suggest an
association between neonatal icterus and/or treatment with neonatal phototherapy 
and hospitalized childhood asthma. This association needs further exploration.

Publication Types: 
    Research Support, Non-U.S. Gov't

PMID: 17346296 [PubMed - indexed for MEDLINE]

136: Ann Ital Chir. 2006 Nov-Dec;77(6):517-9.

A rare case of ectopic pancreas in the ampulla of Vater presented with
obstructive jaundice.

Filippou DK, Vezakis A, Filippou G, Condilis N, Rizos S, Skandalakis P.

First Surgical Department, Pireaus General Hospital "Tzaneio", Pireaus-Athens,
Greece. d_filippou@hotmail.com

A rare case of ectopic pancreas in the ampulla of Vater presented with
obstructive jaundice. Ectopic pancreas is a common congenital disorder which is
referred to as pancreatic rest. The incidence in autopsy series varies from 1 to 
2% (range 0.55 to 13%). Most common site of ectopic pancreatic tissue is the
stomach, although it can be found anywhere in the foregut and the proximal
midgut. Ectopic pancreatic tissue in the ampulla of Vater is a very rare
condition. Searching in the literature, using the terms "ectopic pancreas" and
"Ampulla of Vater", we found only 10 records. The authors report on a rare case
of a 69 years old female with ectopic pancreas in the ampulla of Vater, presented
with painless obstructive jaundice, and the diagnostic and therapeutic strategy
that followed.

Publication Types: 
    Case Reports

PMID: 17343237 [PubMed - indexed for MEDLINE]

137: J Am Coll Surg. 2007 Mar;204(3):409-15. Epub 2007 Jan 25.

Comment in:
    J Am Coll Surg. 2007 Sep;205(3):518-9.

Preoperative diagnosis and efficacy of laparoscopic procedures in the treatment
of Mirizzi syndrome.

Kwon AH, Inui H.

Department of Surgery, Kansai Medical University, Osaka, Japan.
kon@takii.kmu.ac.jp <kon@takii.kmu.ac.jp>

BACKGROUND: The role of laparoscopic procedures in the treatment of Mirizzi
syndrome (MS) is not well-defined and remains controversial. We evaluated the
preoperative diagnosis and efficacy of laparoscopic procedures in treatment of
MS. STUDY DESIGN: Preoperative diagnosis and cholecystectomy were attempted on
2,012 consecutive patients at a single center and 24 (1.2%) were finally
diagnosed with MS. Patients without preoperative endoscopic retrograde
cholangiography underwent preoperative spiral CT after IV infusion
cholangiography (IVC-SCT). RESULTS: Fourteen patients had McSherry type I MS (MS 
I) and 10 had type II MS (MS II). Open operation was performed on patients with
MS II or a preoperative suspicion of gallbladder cancer. Laparoscopic
cholecystectomy (LC) was performed successfully on 10 of 14 patients with MS I
and the remaining 4 patients with MS I were converted to open procedure. At
preoperative endoscopic retrograde cholangiography (n = 3) or IVC-SCT (n = 11) on
patients with MS I, 3 of 4 (75%) patients who were converted to open operation
had a nonvisualized cystic duct, and 9 of 10 (90%) patients with LC had a
visualized cystic duct. CONCLUSIONS: MS I with a visualized cystic duct can be
considered to be an indication for laparoscopic operation. IVC-SCT can be a
useful tool for correct preoperative diagnosis and assessment of the feasibility 
of LC in patients with MS I.

PMID: 17324774 [PubMed - indexed for MEDLINE]

138: Kurume Med J. 2006;53(3-4):89-94.

Endoscopic ultrasonography-guided cystogastrostomy for large pancreatic
pseudocyst with obstructive jaundice--a case report.

Okabe Y, Tsuruta O, Wada Y, Wada K, Suga H, Kudoh M, Kawahara R, Kodama T,
Kinoshita H, Toyonaga A, Sata M.

Department of Medicine, Kurume University School of Medicine, Kurume, Japan.
YIB01074@nifty.com

The patient was a 45-year-old man with a history of heavy drinking. A pseudocyst 
about 30 mm in diameter was found in the head of his pancreas. About four weeks
later an upper abdominal mass, abdominal pain and obstructive jaundice were
confirmed. Abdominal CT revealed that the cyst had increased in size to about 60 
mm, compressing the lower common bile duct and the surrounding digestive tract.
Therefore endoscopic ultrasonography-guided cystogastrostomy following
percutaneous transhepatic biliary drainage (PTBD) was performed. Postoperatively,
the cyst quickly decreased in size and jaundice improved. Because of persistent
common bile duct stenosis, an endoscopic retrograde biliary stent was implanted. 
There has been no recurrence at ten months after the endoscopic therapy. While
invasive surgery is generally employed in the treatment of pancreatic pseudocyst 
complicated by obstructive jaundice, EUS-guided cystogastrostomy appears to be a 
useful procedure, particularly when considering the relatively minor degree of
surgical invasion.

Publication Types: 
    Case Reports

PMID: 17317937 [PubMed - indexed for MEDLINE]

139: Dig Liver Dis. 2007 Apr;39(4):375-88. Epub 2007 Feb 20.

Endoscopic palliation of malignant obstructive jaundice: an evidence-based
review.

Cipolletta L, Rotondano G, Marmo R, Bianco MA; for the Italian Evidence-Based
Gastroenterology & Hepatology Club.

Department of Gastroenterology and Digestive Endoscopy, Hospital Maresca, Torre
del Greco, Naples, Italy.

Endoscopic stent insertion is considered the method of choice for palliative
treatment of malignant biliary obstruction. Nonetheless, relevant studies are
often underpowered or outdated and do not compare actual surgical outcomes with
latest stent technology. Purpose of this review was to assess, with an
evidence-based methodology, the role of endoscopic versus surgical palliation of 
patients with malignant obstructive jaundice with special reference to clinical
effectiveness, safety aspects and economic outcomes.

Publication Types: 
    Review

PMID: 17317347 [PubMed - indexed for MEDLINE]

140: World J Gastroenterol. 2007 Feb 7;13(5):813-5.

Metastatic melanoma to the common bile duct causing obstructive jaundice: a case 
report.

Colovic RB, Grubor NM, Jovanovic MD, Micev MT, Colovic NR.

Institute for Digestive Diseases, First Surgical Clinic, Clinical Center of
Serbia, Koste Todorovica 6, Belgrade 11000, Serbia. marcolov@eunet.yu

Metastatic melanoma to the common bile duct is very rare with only 18 cases
reported so far. We report a 46 year old women who, 18 mo after excision of a
skin melanoma, developed a painless progressive obstructive jaundice. At
operation a melanoma within the distal third of the common bile duct was found.
There were no other secondaries within the abdomen. The common bile duct,
including the tumor, was resected and anastomosed with Roux-en-Y jejunal limb.
The patient survived 31 mo without any sign of local recurrence and was submitted
to three other operations for axillar and brain secondaries, from which she
finally died. Radical resection of metastatic melanoma to the common bile duct
may result in lifelong relief of obstructive jaundice. It is safe and relatively 
easy to perform. In other cases, a less aggressive approach, stenting or bypass
procedures, should be adopted.

Publication Types: 
    Case Reports

PMID: 17278211 [PubMed - indexed for MEDLINE]

141: J Surg Oncol. 2007 Feb 1;95(2):142-7.

CEA, CA 19-9, and CA 125 in the differential diagnosis of benign and malignant
pancreatic diseases with or without jaundice.

Duraker N, Hot S, Polat Y, Höbek A, Gençler N, Urhan N.

Fifth Department of Surgery, SSK Okmeydani Training Hospital, Istanbul, Turkey.
nduraker@hotmail.com

BACKGROUND AND OBJECTIVES: In this study, the value of the serum tumor markers
carcinoembryonic antigen (CEA), CA 19-9, and CA 125 was assessed in the
differential diagnosis of benign and malignant pancreatic diseases with and
without obstructive jaundice. METHODS: Serum levels of CEA, CA 19-9, and CA 125
were measured by immunoradiometric assay before the treatment in 123 patients
with pancreatic carcinoma and 58 patients with a benign pancreatic disease.
RESULTS: The sensitivity of CEA, CA 19-9, and CA 125 in the diagnosis of
pancreatic carcinoma was 39.0%, 81.3%, and 56.9%; and specificity was 91.4%,
75.9%, and 77.6%, respectively. Although there was no significant difference
between the CA 19-9 positivity ratios of the jaundiced (84.3%) and nonjaundiced
(73.5%) patient subgroups of the pancreatic carcinoma, this ratio was
significantly higher in the jaundiced subgroup (64.7%) than the nonjaundiced
subgroup (7.3%) of the benign pancreatic diseases (P < 0.001). The CEA and CA 125
positivity ratios of jaundiced and nonjaundiced subgroups of patients with benign
and malignant pancreatic diseases were not significantly different. CONCLUSIONS: 
In the differential diagnosis of pancreatic carcinoma from benign pancreatic
diseases, CA 19-9 can be useful in the nonjaundiced patients, whereas CA 125
provides a limited contribution in jaundiced patients. (c) 2007 Wiley-Liss, Inc.

PMID: 17262731 [PubMed - indexed for MEDLINE]

142: Am J Surg. 2007 Feb;193(2):149-54.

Selective versus total biliary drainage for obstructive jaundice caused by a
hepatobiliary malignancy.

Ishizawa T, Hasegawa K, Sano K, Imamura H, Kokudo N, Makuuchi M.

Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate
School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, 
Japan.

BACKGROUND: Controversy exists regarding which approach is preferable among types
of biliary drainage for obstructive jaundice before major hepatectomy: selective 
biliary drainage (SBD) only on the future remnant liver (FRL) or total biliary
drainage (TBD). METHODS: There were 42 consecutive patients who underwent SBD (n 
= 15) or TBD (n = 27) for obstructive jaundice caused by a hepatobiliary
malignancy, and subsequent portal vein embolization (PVE) before extended
hemihepatectomy. The hypertrophy ratio, defined as the ratio of the FRL volume
after PVE to that before PVE, was evaluated. The bilirubin clearance also was
calculated. RESULTS: The hypertrophy ratio was higher in patients with SBD than
in those with TBD (median, 128%; range, 111-152% vs median, 121%; range,
102-138%; P = .013). The bilirubin clearance of FRL with SBD was markedly
improved after PVE compared with that in patients with TBD. CONCLUSIONS: SBD is
superior to TBD in promoting hypertrophy of the FRL induced by PVE and in
guaranteeing good liver function before major hepatectomy.

Publication Types: 
    Research Support, Non-U.S. Gov't

PMID: 17236839 [PubMed - indexed for MEDLINE]

143: Eur J Gastroenterol Hepatol. 2007 Jan;19(1):15-20.

Antibiotic therapy: a major cause of drug-induced jaundice in southwest England.

Hussaini SH, O'Brien CS, Despott EJ, Dalton HR.

Cornwall Gastrointestinal Unit, Royal Cornwall Hospital Truro, Cornwall, UK.
hyder.hussaini@rcht.cornwall.nhs.uk

OBJECTIVE: To determine the incidence and causes of drug-induced jaundice in a
rural community. METHODS: A retrospective analysis of 800 patients presenting to 
a single-centre jaundice referral system serving a community of 400 000 over a
period of 66 months (1998-2004). Standard criteria for drug-induced liver injury 
were applied to patients with a putative diagnosis of drug-induced jaundice. The 
incidence rates per prescription of drug-induced jaundice caused by co-amoxiclav 
and flucloxacillin were derived from local and national annual prescription
rates. RESULTS: The incidence of drug-induced jaundice was 1.27 (confidence
limits 0.85-1.8) per 100 000 per annum in a total of 28 patients (17 men, mean
age 69 years). Antibiotics were the commonest cause of jaundice (n=21). Of these,
co-amoxiclav (n=9) and flucloxacillin (n=7) caused the majority with an incidence
rate per 100 000 prescriptions of 9.91 (4.6-18.0) and 3.60 (1.5-7.2),
respectively. Co-amoxiclav-induced jaundice was observed more commonly in elderly
males (age 65 years, M : F 7 : 2). In those patients with flucloxacillin or
co-amoxiclav-induced jaundice, bilirubin ranged from 54 to 599 mumol/l (267
mumol/l) with a resolution of jaundice between 30 and 90 days. Counselling with
regard to potential drug-induced liver injury and reporting of the adverse
reaction had been performed in 1/28 patients. CONCLUSIONS: 8.1% patients with no 
biliary obstruction and jaundice had a drug-induced and predominantly
antibiotic-related aetiology particularly affecting an elderly population. We
recommend that all patients receiving co-amoxiclav and flucloxacillin should be
counselled before the therapy regarding the potential risk of jaundice and that
an alternative antibiotic to co-amoxiclav is used if possible in men over the age
of 60 years.

PMID: 17206072 [PubMed - indexed for MEDLINE]

144: Taiwan J Obstet Gynecol. 2006 Jun;45(2):180-2.

Acute viral hepatitis C-induced jaundice in pregnancy.

Hsieh TY, Yu CH, Kuo PL, Chang FM.

Department of Obstetrics and Gynecology, National Cheng Kung University Medical
College and Hospital, Tainan, Taiwan.

OBJECTIVE: Acute viral hepatitis C-induced jaundice in pregnancy is very rare and
may be fatal. Here, we report a complicated case with acute hepatitis C-induced
jaundice in pregnancy with successful management. CASE REPORT: A 27-year-old
pregnant woman, gravida 2, para 1, with gestational age of 36 weeks and 5 days,
was referred to our hospital due to jaundice and elevated liver enzymes of
undetermined cause. She had been suffering from general weakness, diarrhea and
vomiting for 1 week, and jaundice with tea-colored urine for 3 days. At our
medical center, acute viral hepatitis C-induced jaundice was suspected. Since her
general condition deteriorated at 36 weeks and 6 days of gestation, we decided to
induce labor. A male baby was born smoothly via the vaginal route, with birth
weight 2,857 g, birth length 48.6 cm, and 1- and 5-minute Apgar scores of 7 and
9, respectively. Maternal condition improved dramatically after delivery and her 
serum liver enzymes and bilirubin levels gradually approached normal ranges.
CONCLUSION: Mothers and fetuses with acute viral hepatitis C-induced jaundice
during pregnancy are at great risk of mortality and morbidity. Timely termination
may be one of the choices of treatment when fetal maturity has been reached and
the maternal condition has deteriorated.

Publication Types: 
    Case Reports

PMID: 17197365 [PubMed - indexed for MEDLINE]

145: Scand J Gastroenterol. 2007 Jan;42(1):94-102.

Inflammatory response in patients with malignant obstructive jaundice.

Ljungdahl M, Osterberg J, Ransjö U, Engstrand L, Haglund U.

Department of Surgery, University Hospital, Uppsala, Sweden.
mikael.ljungdahl@akademiska.se

OBJECTIVE: Surgery in patients with malignant obstructive jaundice is associated 
with increased risks for postoperative septic complications. The aim of this
study was to investigate the inflammatory and the local cellular immune response 
in patients accepted for surgery because of tumours in the
hepatic-pancreatic-biliary (HPB) tract. MATERIAL AND METHODS: Patients with
obstructive jaundice (group HPB(+)) were compared with those without (HPB(-)).
Patients undergoing surgery for benign abdominal disorders served as controls.
Obstructive jaundice was present in 18 out of 33 HPB patients. Preoperatively,
blood was analysed for bacteria, endotoxins and cytokines (TNF-alpha, IL-6 and
IL-10). At operation, mesenteric lymph nodes (MLNs) were excised for bacterial
cultures using standard microbiological techniques, and immunohistochemistry,
using antibodies CD4 and CD8 (mainly staining T lymphocytes), CD68 (macrophages),
and anti-caspase-3 (to determine the rate of apoptosis). RESULTS: Bacterial
translocation was not demonstrated in any of the patients. Increased preoperative
concentrations of endotoxins were found in group HPB(+). The number of
macrophages and the rate of apoptosis in MLNs were increased in jaundiced
patients, while the number of T lymphocytes was decreased. CONCLUSIONS: Malignant
obstructive jaundice causes increased blood concentrations of endotoxins and
cytokines, an increased number of macrophages in MLNs, a higher rate of apoptosis
in MLNs, but a decreased number of T lymphocytes in MLNs. The lymphocyte
depletion is probably due to the increased rate of apoptosis, and might reduce
the ability of jaundiced patients to eradicate infection.

Publication Types: 
    Research Support, Non-U.S. Gov't

PMID: 17190769 [PubMed - indexed for MEDLINE]

146: J Fish Dis. 2006 Dec;29(12):709-15.

Infectious haemolytic anaemia causes jaundice outbreaks in seawater-cultured coho
salmon, Oncorhynchus kisutch (Walbaum), in Chile.

Smith PA, Larenas J, Contreras J, Cassigoli J, Venegas C, Rojas ME, Guajardo A,
Pérez S, Díaz S.

Unit of Pathology of Aquatic Animals, Department of Animal Pathology, Faculty of 
Veterinary Sciences, University of Chile, Santiago de Chile, Chile.
psmith@uchile.cl

In the last 9 years, epizootics of an icterus condition has affected coho salmon,
Oncorhynchus kisutch (Walbaum), reared in seawater cages in southern regions of
Chile. At necropsy, fish from field cases exhibited signs of jaundice accompanied
by pale light-brown livers and dark spleens. Histopathological and haematological
results indicated that these fish presented haemolytic anaemia. After
microbiological examination no bacterial or viral agents could be identified as
aetiological agents of this disease. In an infectivity trial, coho salmon,
Atlantic salmon, Salmo salar L., and rainbow trout, Oncorhynchus mykiss
(Walbaum), were inoculated intraperitoneally with a filtrate of an organ
homogenate (0.45 microm) from a diseased coho salmon and held for 60 days in
tanks supplied with fresh water. The disease was only reproduced in coho salmon
in which mortalities, beginning at day 23 post-inoculation (p.i.), reached a
cumulative value of 24% at day 27 p.i. This condition was transmitted to
non-inoculated cohabiting coho salmon suggesting that it is a waterborne disease.
Thus, this icteric condition is caused by an infectious form of haemolytic
anaemia, probably of viral aetiology, and coho salmon are more susceptible than
either Atlantic salmon or rainbow trout.

Publication Types: 
    Research Support, Non-U.S. Gov't

PMID: 17169103 [PubMed - indexed for MEDLINE]

147: J Pediatr Surg. 2006 Dec;41(12):1987-91.

Idiopathic fibrosing pancreatitis in children--a single-center experience.

Deshpande AV, LaHei ER, Shun A, Martin HC, O'Loughlin EV.

Department of General Surgery, The Children's Hospital at Westmead, Westmead,
Sydney N.S.W. 2145, Australia. sushrudh@hotmail.com

PURPOSE: The experience of a single institution on idiopathic fibrosing
pancreatitis (IFP) is presented. METHODOLOGY: This is a retrospective review of
medical records of affected patients. RESULTS: There were 7 cases with a mean age
of 7 years. Upper abdominal pain followed by jaundice was the most common
presentation. One child had varicella and 1 developed Crohn's disease 3 years
later. In 5 cases, diagnosis was established intraoperatively, whereas 2 cases
were diagnosed preoperatively. Ultrasonography suggested the diagnosis in 2 of
the 7 cases, contrast computed tomography scan in 1 of the 3 cases, and magnetic 
resonance cholangiopancreatography in 1 of the 4 cases. Six patients were treated
by biliary enteric bypass surgery. Treatment by endoscopic biliary stenting was
successful in one. There were no postoperative complications. Pancreatic biopsies
showed fibrosis of exocrine elements with preservation of islets. Three patients 
have pancreatic atrophy, and none has diabetes at follow-up (mean, 62 months).
DISCUSSION: Idiopathic fibrosing pancreatitis presents as biliary obstruction in 
children. Precise preoperative diagnosis of IFP is difficult. Noninvasive imaging
has limited sensitivity. Surgery offers satisfactory long-term relief of biliary 
obstruction. Treatment using temporary endoscopic biliary drainage appears
promising in treatment of IFP. Patients should be followed up for pancreatic
insufficiency, long-term biliary obstruction, and inflammatory bowel disease.

PMID: 17161188 [PubMed - indexed for MEDLINE]

148: Am J Gastroenterol. 2007 Mar;102(3):558-62; quiz 693.

Etiology of new-onset jaundice: how often is it caused by idiosyncratic
drug-induced liver injury in the United States?

Vuppalanchi R, Liangpunsakul S, Chalasani N.

Department of Medicine, Indiana University School of Medicine, Indianapolis,
Indiana 46202, USA.

BACKGROUND AND AIM: The epidemiology of acute drug-induced liver injury (DILI) in
the United States has not been well studied. We conducted a study of adults with 
new-onset jaundice at a nonreferral community hospital to better understand the
epidemiology of acute DILI. METHODS: This is a retrospective study of adult
outpatients and inpatients (> or =18 yr) with new-onset jaundice over a 5-yr
period (1999-2003) at Wishard Memorial Hospital, Indiana. Patients with new-onset
jaundice were identified using our electronic medical record system and
individual medical records were reviewed to extract the required clinical data.
New-onset jaundice was defined as the presence of total serum bilirubin >3 mg/dL 
in patients without a prior total bilirubin >3 mg/dL. RESULTS: A total of 732
eligible adults constituted our study cohort. Sepsis or altered hemodynamic state
resulting in presumed ischemic liver injury is the single most common cause of
jaundice (22%). Acute liver disease as a result of nonalcoholic etiologies caused
new-onset jaundice in 97 patients (13%), with acute viral hepatitis in 66
patients (9%) and DILI in 29 patients (4%). Most cases of DILI were as a result
of acetaminophen toxicity with idiosyncratic DILI occurring in only five patients
(0.7%). No mortality was observed at 6 wk in patients who developed idiosyncratic
DILI. CONCLUSION: Idiosyncratic DILI appears to be a rare cause of new-onset
jaundice in a community hospital setting.

Publication Types: 
    Multicenter Study
    Research Support, N.I.H., Extramural

PMID: 17156142 [PubMed - indexed for MEDLINE]

149: Hepatogastroenterology. 2006 Nov-Dec;53(72):944-6.

Surgical outcome after pancreatoduodenectomy: effect of preoperative biliary
drainage.

Tomazic A, Pleskovic A.

Department of Abdominal Surgery, University Medical Center of Ljubljana,
Ljubljana, Slovenia. ales.tomazic@kclj.si

BACKGROUND/AIMS: Depth of jaundice has been associated with increased risk of
complications following operations. The value of preoperative biliary drainage
has already been studied with contradictory results. In the present analysis we
tried to determine the association between preoperative biliary drainage and
postoperative complications in a nonselected series of patients. METHODOLOGY:
Patients, who have undergone duodenopancreatectomy for periampullary
adenocarcinoma, were included in the study. Patient data consisted of age,
gender, diabetes mellitus, preoperative risk assessment according to ASA,
preoperative biliary drainage, preoperative bilirubin level, operative time, type
of duodenopancreatectomy, postoperative morbidity and mortality. Mann-Whitney
exact test, Fisher's exact test and logistic-regression model were used for
statistical analysis. RESULTS: Inclusion criteria for the study met 87 patients
operated on from January 1996 till January 2000. Preoperative biliary drainage
was not associated with mortality, rate of reoperation or length of hospital
stay. Morbidity in these patients was slightly higher comparing to patients, who 
were not preoperatively drained, but this difference was not statistically
important (p=0.3). In multivariate analysis, duration of operation was
statistically the most significant predictor for postoperative complications
(p=0.03). CONCLUSIONS: In patients with a resectable periampullary mass and
obstructive jaundice, preoperative biliary drainage is not warranted. It may even
be associated with increased risk of postoperative infectious complications.
Biliary drainage should be done only in patients, who are not candidates for
resection.

PMID: 17153458 [PubMed - indexed for MEDLINE]

150: Hepatogastroenterology. 2006 Nov-Dec;53(72):823-7.

Effect of preoperative biliary drainage on surgical outcome after
pancreaticoduodenectomy.

Tsai YF, Shyu JF, Chen TH, Shyr YM, Su CH.

Department of Surgery, Division of General Surgery, Taipei Veterans General
Hospital, Taiwan.

BACKGROUND/AIMS: Preoperative biliary drainage (PBD) in jaundiced patients
undergoing pancreaticoduodenectomy remains controversial. METHODOLOGY:
Retrospective analysis of 313 patients undergoing pancreaticoduodenectomy between
1991 and 2004 was performed. Patients were stratified into PBD and no
preoperative biliary drainage (NPBD) groups. Perioperative morbidity and
mortality were evaluated and surgical risks compared. Nine retrospective studies 
were also evaluated. RESULTS: PBD was performed in 210; 103 had NPBD. Common
indications for PBD were jaundice and cholangitis. Postoperative complications
occurred in 153; 20 died postoperatively. PBD patients were older and
predominantly male. Cholangitis, low albumin, and higher preoperative bilirubin
were increased in PBD. Pancreatic leakage and postoperative hospital days were
increased in NPBD. Wound infection occurred more frequently in PBD, but this was 
not significant. Perioperative mortality rate was 6.7% in PBD compared to 5.8% in
NPBD. Postoperative complication rate was 45.7% for PBD and 55.3% for NPBD.
Twelve PBD patients had procedure-related complications. Of 2391 patients pooled 
from the nine reviews and our study (1516 PBD and 875 NPBD), no significant
difference was observed in postoperative mortality and overall complications.
Wound infection was significantly increased in PBD (p<0.001). CONCLUSIONS:
Preoperative biliary drainage did not increase postoperative morbidity and
mortality rate in pancreaticoduodenectomy patients, but should be used
judiciously.

PMID: 17153432 [PubMed - indexed for MEDLINE]

151: Pediatr Surg Int. 2007 Feb;23(2):111-6. Epub 2006 Dec 6.

Diagnostic and therapeutic ERCP in the pediatric age group.

Issa H, Al-Haddad A, Al-Salem AH.

Department of Internal Medicine, Qatif Central Hospital, P. O. Box 61015, Qatif, 
31911, Saudi Arabia.

The role and value of endoscopic retrograde cholangiopancreatography (ERCP) in
the pediatric age group is not well established, because pancreatic and biliary
diseases are less common in children. This however is not the case in areas like 
the Eastern Province of Saudi Arabia where sickle cell disease (SCD) and other
hemoglobinopathies are common, with increased frequency of cholelithiasis and
choledocholithiasis. The purpose of this study was to evaluate the indications,
findings, safety and therapies of ERCP in children. One hundred and twenty five
children had diagnostic and/or therapeutic ERCP as part of their management at
our hospital. Their medical records were reviewed for: age at diagnosis, sex, Hb 
electrophoresis, indication for ERCP, findings, therapy and complications. There 
were 77 males and 48 females. Their age at presentation ranged from 5-18 year
(mean 13.25 year). The majority of them had sickle cell disease (77.6%). The
indications for ERCP were: obstructive jaundice (67.2%), recurrent biliary colic 
with or without jaundice (10.4%), acute and chronic pancreatitis (7.2%),
postoperative bile leak (2.4%), cholangitis with obstructive jaundice (2.4%),
hepatitis of unknown etiology (3.2%), cirrhosis of unknown etiology (4%),
thalassemia with jaundice (0.8%), hemobilia (0.8%), acute cholecystitis with
jaundice (0.8%), and sickle cell disease with ulcerative colitis and obstructive 
jaundice (0.8%). In six children, ERCP was done following laparoscopic
cholecystectomy. ERCP was carried out under sedation in 91 (72.8%) children and
under general anesthesia in 34. It was successful in 121 (96.8%) children while
cannulation of the Ampulla failed in four. ERCP was normal in 43 children, but
eight of them showed evidence of recent stone passage and in six, there were
gallstones. In the remaining children, ERCP revealed: normal CBD with stones (18 
patients), dilated CBD with stones (17 patients), dilated CBD without stones (19 
patients), dilated biliary tree with stones (10 patients), dilated biliary tree
without stones (six patients), bile leak (two patients), dilated biliary tree
with stones and choledocho-duodenal fistula (one patient), choledochal cyst (two 
patients), septate gallbladder (one patient), normal ERCP with multiple
pancreatic cysts (one patient) and biliary stricture (one patient). The following
procedures were carried out: 35 had endoscopic sphincterotomy and stone
extraction, 20 had endoscopic sphincterotomy, four had CBD stenting, one
underwent removal of a stent, two had insertion of a nasobiliary tube and one had
biliary endoprosethesis. There was no mortality. One had bleeding from the site
of sphincterotomy which stopped after adrenaline injection. Four patients (3.2%) 
developed transient mild pancreatitis which settled conservatively. ERCP in the
pediatric age group is safe both as a diagnostic and therapeutic procedure. ERCP 
can provide valuable information which aid in the diagnosis of biliary and
pancreatic diseases in children as well as therapy with the technical feasibility
of endoscopic sphincterotomy. This is specially so in the era of laparoscopic
cholecystectomy, where ERCP should be the treatment of choice in children with
CBD stones who are going or have previously undergone laparoscopic
cholecystectomy.

PMID: 17149628 [PubMed - indexed for MEDLINE]

152: Chin Med J (Engl). 2006 Nov 20;119(22):1856-60.

Enteral refeeding syndrome after long-term total parenteral nutrition.

Ren JA, Mao Y, Wang GF, Wang XB, Fan CG, Wang ZM, Li JS.

Department of Surgery, Jinling Hospital, Medical School of Nanjing University,
Nanjing 210002, China. jan@medmail.com.cn

BACKGROUND: Early enteral feeding (EF) may result in fever, elevated white blood 
cell count, increased serum levels of liver enzymes, and diarrhea. We name the
complications "enteral refeeding syndrome", as a subtype of refeeding syndrome,
because they are likely to result from long-term lack of lumen nutrition. The aim
of this study was to investigate the characteristics of enteral refeeding
syndrome after long-term total parenteral nutrition (TPN), and the solution for
the disease. METHODS: We collected the clinical data of 100 patients with
gastrointestinal fistula, who were cured from Apirl 2001 to July 2002. Their
fasting time, daily stool frequency, body temperature, heart rate, respiratory
rate, levels of transaminases, alkaline phosphatase (AKP), and
gamma-glutamylcyclotransferase (gamma-GT), white blood cell count, and systemic
inflammatory reaction syndrome (SIRS) score were recorded before and 1, 3, 5, 10,
and 15 days after EF. Student's t test and analysis of variance were used to
analyze the data. RESULTS: Of the 100 patients, 56 were cured after selective
resection of intestinal fistula, 15 were cured by emergency operation, and 29
recovered spontaneously. The levels of AKP and gamma-GT increased significantly
on the 3rd day after EF [On the 3rd day after EF, (243.0 +/- 121.6) U/L and
(177.2 +/- 109.9) U/L vs. before EF (181.5 +/- 127.5) U/L and (118.4 +/- 94.2)
U/L, P < 0.05], and decreased gradually afterwards. The SIRS scores on the 1st
day (1.05 +/- 1.08) and 3rd day (0.96 +/- 1.11) after EF were significantly
higher than that before EF (0.72 +/- 0.84), then decreased to 0.83 +/- 0.91, 0.49
+/- 0.73 and 0.32 +/- 0.60 on the 5th, 10th and 15th days after EF. The number of
patients with diarrhea at 1, 3, 5, 10 and 15 days post-EF were 31, 26, 12, 13,
and 7, respectively. CONCLUSIONS: The longer the TPN lasts, the more severe the
enteral refeeding syndrome becomes. Continuous EF is effective for the syndrome. 
Early enteral nutrition is useful in preventing it.

PMID: 17134582 [PubMed - indexed for MEDLINE]

153: Ann R Coll Surg Engl. 2006 Nov;88(7):610-6.

The current standard of care in the periprocedural management of the patient with
obstructive jaundice.

Clarke DL, Pillay Y, Anderson F, Thomson SR.

Department of General Surgery, Nelson R Mandela School of Medicine, University of
KwaZulu Natal, Durban, South Africa.

This review provides a literature-based guide to the optimal management of the
patient with obstructive jaundice with emphasis placed on prevention of
complications.

Publication Types: 
    Review

PMID: 17132306 [PubMed - indexed for MEDLINE]

154: Surg Clin North Am. 2006 Dec;86(6):1495-502.

Jaundice in the intensive care unit.

Bansal V, Schuchert VD.

Department of Surgery, University of California at San Diego, San Diego, CA, USA.

Hyperbilirubinemia, or jaundice, is common in the ICU, with incidence up to 40%
among critically ill patients. Unfortunately, it is poorly understood in the
critically ill, and too often presents a diagnostic dilemma to the ICU physician.
Causes of jaundice in the ICU are multiple; the etiology in any given patient,
multifactorial. Acute jaundice can be a harbinger or marker of sepsis,
multisystem organ failure (MSOF), or a reflection of transient hypotension (shock
liver), right-sided heart failure, the metabolic breakdown of red blood cells, or
pharmacologic toxicity. Acute ICU jaundice is best divided into obstructive and
nonobstructive. This stratification directs subsequent management and therapeutic
decisions.

Publication Types: 
    Review

PMID: 17116459 [PubMed - indexed for MEDLINE]

155: World J Surg. 2006 Dec;30(12):2217-26.

Effect of glucocorticoid pretreatment on oxidative liver injury and survival in
jaundiced rats with endotoxin cholangitis.

Lee CW, Chuang JH, Wang PW, Chang NK, Wang HC, Huang CC, Tiao MM, Lo SK.

Department of Emergency Medicine, E-Da Hospital, I-Shou University, 1 E-Da Road, 
Jiau-shu Tsuen, Yan-chau Shiang, 824, Kaohsiung, Taiwan.

INTRODUCTION: Biliary tract infection is associated with high mortality. This
study investigated the effect of glucocorticoid pretreatment on
lipopolysaccharide (LPS)-induced cholangitis. METHODS: Rats undergoing either
sham operation or ligation of the extrahepatic bile duct (BDL) for 2 weeks were
randomly assigned to receive intravenous injections of dexamethasone (DX) or
normal saline (NS) prior to infusing LPS into the biliary tract. The plasma
levels of tumor necrosis factor-alpha (TNFalpha), chemokines monocyte
chemoattractant protein-1 (MCP-1) and macrophage inflammatory protein-2 (MIP-2)
as well as liver mRNA expression of MCP-1 and MIP-2 were determined. Infiltration
of monocytes, Kupffer cells, and neutrophils in rat liver were studied with
immunohistochemistry. Oxidative liver injury was measured by the malondialdehyde 
(MDA) content. RESULTS: Dexamethasone pretreatment resulted in significantly
decreased plasma levels of TNFalpha at 1 hour, MCP-1 and MIP-2 at 2 and 3 hours, 
and decreased liver MCP-1 mRNA expression at 3 hours following LPS infusion in
BDL-DX rats than in BDL-NS rats. The number of inflammatory cells in the liver
was significantly different between sham- and BDL-treated rats but was not
affected by DX pretreatment. Pretreatment with DX resulted in significantly
decreased liver MDA contents in the BDL-DX group than that in the BDL-NS group.
Jaundiced rats pretreated with 5 mg DX prior to infusion of 1 g of LPS were 6.8
times more likely to survive than those that were not pretreated. CONCLUSIONS:
Pretreatment of jaundiced, LPS-treated rats with a supraphysiological dose of
dexamethasone may rescue their lives by suppression of chemokine expression and
alleviation of oxidative liver injury.

Publication Types: 
    Research Support, Non-U.S. Gov't

PMID: 17102917 [PubMed - indexed for MEDLINE]

156: Clin Imaging. 2006 Nov-Dec;30(6):413-5.

Atypical MRI features of a biliary cystadenoma revealed by jaundice.

Baudin G, Novellas S, Buratti MS, Saint-Paul MC, Chevallier P, Gugenheim J,
Bruneton JN.

Service d'Imagerie Médicale, Centre Hospitalier Régional et Universitaire de
Nice, Hôpital Archet 2, F-06202 Nice Cedex 3, France. baudin.guillaume@gmail.com

We report on the case of a patient admitted for epigastric pain. An abdominal
ultrasound revealed a voluminous cystic lesion of the left hepatic lobe. In
magnetic resonance imaging, the mass had a liquid-liquid level that was
spontaneously hyperintense on T(1)-weighted images and hypointense on
T(2)-weighted images. Magnetic resonance cholangiography identified bilateral
intrahepatic bile duct dilatation. A left hepatectomy finally revealed a mucinous
cystadenoma with pseudo-ovarian stroma that had a pedunculated intraductal
extension to the biliary convergence.

Publication Types: 
    Case Reports

PMID: 17101411 [PubMed - indexed for MEDLINE]

157: Eur J Gastroenterol Hepatol. 2006 Dec;18(12):1289-92.

Endoscopic ultrasound in patients with obstructive jaundice and inconclusive
ultrasound and computer tomography findings.

Craanen ME, van Waesberghe JH, van der Peet DL, Loffeld RJ, Cuesta MA, Mulder CJ.

Department of Gastroenterology, VU University Medical Center, Amsterdam, The
Netherlands. me.craanen@vumc.nl

The clinical work-up of patients with presumed pancreaticobiliary obstruction is 
usually straightforward including laboratory investigation, abdominal ultrasound 
and computer tomography. Ultrasound and computer tomography may, however, yield
inconclusive findings regarding underlying cause. We report a case series (n =
10) demonstrating the usefulness of endoscopic ultrasound in the work-up of
patients with inconclusive ultrasound and computer tomography findings,
clinically suspected of pancreaticobiliary cancer.

Publication Types: 
    Case Reports
    Evaluation Studies

PMID: 17099378 [PubMed - indexed for MEDLINE]

158: Nat Clin Pract Gastroenterol Hepatol. 2006 Nov;3(11):645-8.

Virchow's node, jaundice, and weight loss--lymphoma mimicking gastrointestinal
malignancy.

Anastassiades CP, Poterucha TH.

Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905,
USA. anastassiades.constantinos@mayo.edu

BACKGROUND: A 46-year-old white male with a history of well-controlled paranoid
schizophrenia presented with painless jaundice, progressive anorexia, weight
loss, and dyspnea of 3 months' duration. His only medication at presentation was 
the antipsychotic olanzapine, taken orally. INVESTIGATIONS: Physical examination 
and laboratory tests, including a complete blood cell count, electrolyte, lactate
dehydrogenase and haptoglobin levels, liver function tests, and a Coombs' test;
CT scan of the chest and abdomen; invasive investigations, including
thoracentesis and pleural fluid analysis, bone-marrow biopsy, and left
supraclavicular lymph-node biopsy. DIAGNOSIS: Diffuse large B-cell lymphoma.
MANAGEMENT: Large-volume thoracentesis. Rituximab, cyclophosphamide, doxorubicin,
vincristine, and prednisolone chemotherapy followed by dexamethasone, cytarabine,
and cisplatin chemotherapy, and autologous stem-cell transplantation.

Publication Types: 
    Case Reports

PMID: 17068502 [PubMed - indexed for MEDLINE]

159: J Surg Oncol. 2006 Dec 1;94(7):614-8.

Is metallic stenting worthwhile for biliary obstruction due to lymph node
metastases?

Okamoto T, Yanagisawa S, Fujioka S, Gocho T, Yanaga K, Kakutani H, Tajiri H.

Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan.
tomoka@jikei.ac.jp

BACKGROUND: The indications for metallic stents have widened from primary
hepatobiliary cancers to the other diseases such as lymph node metastases from
distant organs. The present study aimed to evaluate the results and establish the
efficacy of metallic stenting in patients with obstructive jaundice due to
metastatic lymph nodes. METHODS: Stent patency, survival and cost per patient
until death were retrospectively compared between patients with primary carcinoma
of the biliary tract (PC group; n = 71) and lymph node metastases from the
gastric and colorectal carcinomas. (LN group; n = 26). RESULTS: Stent occlusion
occurred in 17 patients in the PC group (24%). In contrast, stent occlusion was
significantly more frequent in the LN group (P = 0.0293), occurring in 13
patients (50%). Cumulative stent patency was also significantly shorter in the LN
group than that in the PC group (P = 0.0016). However, survival was almost the
same between the two groups. The mean medical fee was 27% higher for the LN group
than for the PC group, which was attributable to additional treatment for stent
occlusion. DISCUSSION: The indications for metallic stent placement for biliary
obstruction caused by lymph node metastases from the gastrointestinal tract seem 
limited. Further investigation of the treatments alternative to metallic stents
would be required. (c) 2006 Wiley-Liss, Inc.

PMID: 17048236 [PubMed - indexed for MEDLINE]

160: J Surg Res. 2006 Dec;136(2):280-7. Epub 2006 Oct 13.

Single dose of anti-transforming growth factor-beta1 monoclonal antibody enhances
liver regeneration after partial hepatectomy in biliary-obstructed rats.

Deneme MA, Ok E, Akcan A, Akyildiz H, Soyuer I, Muhtaroglu S.

Department of Surgery, Erciyes University School of Medicine, Kayseri, Turkey.

BACKGROUND: Transforming growth factor (TGF) beta is a potent inhibitor of
hepatocyte DNA synthesis and liver regeneration. TGF-beta(1) expression
progressively increases in obstructive jaundice. We investigated the effect of
TGF-beta(1) blockage on liver regeneration in rats induced with obstructive
jaundice. MATERIALS AND METHODS: Male Wistar-albino rats were divided into three 
groups: sham, control, and study groups. In the study and control groups, the
common bile duct was ligated and divided, and 7 days later a partial hepatectomy 
was performed. In the study group, anti-TGF-beta(1) monoclonal antibody
(10-microg single dose) was administered immediately after the 70% hepatectomy.
In the control group, those rats in which obstructive jaundice was induced
received normal saline after the 70% hepatectomy, and nonjaundiced rats received 
anti-TGF-beta(1) monoclonal antibody after the 70% hepatectomy. Rats were
sacrificed after 48 or 72 h. Relative liver weight, AST, ALT, total and
conjugated bilirubin, and TGF-beta(1) levels were measured. The mitotic index and
proliferating cell nuclear antigen (PCNA) labeling index were evaluated as
histopathologic parameters. RESULTS: At 72 h, the TGF-beta(1) level in the study 
group was similar to that in the sham group, whereas TGF-beta(1) in the study
group was significantly lower than that of the jaundiced control group at 48 or
72 h (P < 0.001). The relative liver weight, mitotic index, and PCNA labeling
index were significantly higher in the study group than in the jaundiced control 
group at 48 and 72 h (P < 0.001). The AST, ALT, and TGF-beta(1) levels were
significantly higher in the jaundiced control group compared to the study group
after 48 and 72 h, whereas these values were significantly lower in the
nonjaundiced control group (P < 0.001). CONCLUSIONS: In obstructive jaundiced
rats, TGF-beta(1) blockage with anti-TGF-beta(1) monoclonal antibody after liver 
resection improved liver regeneration both morphologically and functionally.

Publication Types: 
    Research Support, Non-U.S. Gov't

PMID: 17046790 [PubMed - indexed for MEDLINE]

161: Dig Surg. 2006;23(4):262-4. Epub 2006 Oct 10.

Ectopic pancreas in the ampulla of vater with obstructive jaundice. A case report
and review of literature.

Chou SJ, Chou YW, Jan HC, Chen VT, Chen TH.

Division of General Surgery, Department of Surgery, Cardinal Tien Hospital,
College of Medicine, Fu Jen Catholic University, 362 Chung Cheng Road, Hsintien
Taipei Hsien 23237, Taiwan/ROC. surgery6711@sina.com.tw

Ectopic pancreas is an uncommon condition and is usually found in the
gastrointestinal tract, such as stomach, duodenum and jejunum. However, ectopic
pancreas in the ampulla of Vater is rare and its clinical presentations may be
similar to periampullary cancer. It is difficult to diagnose preoperatively. We
present such a case where the diagnosis was proven postoperatively. Our patient, 
a 51-year-old man, presented with epigastric pain, jaundice, weight loss and
abnormal laboratory data. Imaging study, including abdominal sonography,
abdominal computerized tomography with contrast and endoscopic retrograde
cholangiopancreatography, showed a mass protruding into the ampulla of Vater. The
mass was resected and histological examination revealed an ectopic pancreas. The 
patient presented with symptoms of periampullary tumor but the imaging study did 
not reveal an obvious lesion for us consider the possibility of ectopic pancreas.
Surgical excision is indicated for symptomatic cases. Copyright (c) 2006 S.
Karger AG, Basel

Publication Types: 
    Case Reports
    Review

PMID: 17035700 [PubMed - indexed for MEDLINE]

162: Pediatr Transplant. 2006 Nov;10(7):835-7.

Obstructive jaundice caused by biliary stone formation around the stent after
liver transplantation.

Kawagishi N, Matsuo C, Takeda I, Miyagi S, Satoh K, Akamatsu Y, Sekiguchi S,
Fujimori K, Satomi S.

Division of Advanced Surgical Science and Technology, Graduate School of
Medicine, Tohoku University, Sendai, Japan. kawan@mail.tains.tohoku.ac.jp

We report an unusual case of obstructive jaundice caused by a biliary stone,
which developed in the stump of a Roux-en-Y hepaticojejunostomy after undergoing 
LT. The patient was a 13-yr-old male. At 74 days after birth, a
hepaticojejunostomy (Kasai's procedure) was performed for the treatment of
biliary atresia. He underwent a reduced size deceased donor LT in the left
subphrenic space twice at the age of one and three years in Australia. Eleven
years after his second LT, he developed liver dysfunction and jaundice with a low
grade fever. Computed tomography showed a marked jejunal loop enlargement by a
rugby ball-shaped stone and the bile duct in the graft was thus dilated. A
surgical exploration revealed the jejunal loop to be bent sharply while its stump
side was dilated by stagnated bile including a biliary stone. The stone included 
a stent that had been previously used for the hepaticojejunostomy. This case
suggests that a retained stent used for hepaticojejunostomy had thus caused
biliary stone formation because of a combination of various conditions in the
jejunal loop.

Publication Types: 
    Case Reports

PMID: 17032432 [PubMed - indexed for MEDLINE]

163: J Vector Borne Dis. 2006 Sep;43(3):123-9.

A comparative study of regression of jaundice in patients of malaria and acute
viral hepatitis.

Kochar DK, Kaswan K, Kochar SK, Sirohi P, Pal M, Kochar A, Agrawal RP, Das A.

Department of Medicine, S.P Medical College, Bikaner, India. drdkkochar@yahoo.com

BACKGROUND & OBJECTIVES: Jaundice is one of the common manifestations of severe
malaria in adults. The purpose of this study is to compare the pattern of
clinical and biochemical parameters such as serum bilirubin and liver enzyme
levels in patients of malaria with jaundice and acute viral hepatitis.
METHODOLOGY: The present study was conducted on 34 patients of malaria with
jaundice and 15 patients of acute viral hepatitis. Estimation of serum bilirubin,
aspartate amino transferase (AST), alanine amino transferase (ALT) and alkaline
phosphatase was done daily using standard procedures in malaria patients and
weekly in acute viral hepatitis patients. RESULTS: Mean level of serum bilirubin 
on first day in malaria and acute viral hepatitis patients was 7.07 +/- 3.94 and 
10.38 +/- 7.87 mg%, whereas on Day 8 it was 1.19 +/- 1.43 and 7.88 +/- 7.02 mg%
respectively. Mean level of AST on Day 1 in malaria and acute viral hepatitis
patients was 158.47 +/- 120.35 and 1418.6 +/- 834.11 IU/L, whereas on Day 8 it
was 41 +/- 28.33 and 775.3 +/- 399.01 IU/L respectively. Mean level of ALT on Day
1 in malaria and acute viral hepatitis patients was 220.14 +/- 145.61 and 1666.67
+/- 1112.77 IU/L, whereas on Day 8 it was 50.85 +/- 37.31 and 823.8 +/- 475.06
IU/L respectively. Mean level of serum alkaline phosphatase on Day 1 in malaria
and acute viral hepatitis patients was 394.74 +/- 267.78 and 513.4 +/- 324.7
IU/L, whereas on Day 8 it was 84.76 +/- 68.50 and 369.27 +/- 207.75 IU/L
respectively. INTERPRETATION & CONCLUSION: We observed that resolution of
jaundice in malaria took 1-2 weeks in contrast 6 to 8 weeks in viral hepatitis.
This difference in duration was statistically significant. Thus, jaundice not
resolving in 1-2 weeks time in a patient of malaria requires serious
consideration for presence of other concomitant diseases including viral
hepatitis.

Publication Types: 
    Comparative Study

PMID: 17024861 [PubMed - indexed for MEDLINE]

164: Acta Cytol. 2006 Sep-Oct;50(5):531-3.

Diagnosis of icteric-type hepatocellular carcinoma by fine needle aspiration: a
case report.

Huang JF, Chen SC, Wang LY, Yu ML, Dai CY, Chuang WL, Chang WY.

Department of Internal Medicine, Fooyin University Hospital, Pingtung, Taiwan,
ROC. jeefuhuang@yahoo.com.tw

BACKGROUND: Bile duct invasion is very rare in patients with hepatocellular
carcinoma (HCC). It usually presents difficult problems with the clinical
differential diagnosis. Moreover, another difficulty might arise when an
obstructive jaundice patient is found to have past history of 2 separate
malignancies. Fine needle aspiration (FNA) becomes the method of choice for
clarification of the bile duct tumor thrombus. CASE: A 72-year-old man presented 
with progressive obstructive jaundice for 1 month. Past history revealed the
occurrence of 2 distinct malignancies during the previous 3 years; they had been 
resected successfully. Initial imaging studies, including abdominal sonography
and computed tomography, were negative for the liver. However, FNA demonstrated
clusters of pleomorphic and hyperchromatic cancer cells with an increased
nuclear/cytoplasmic ratio proliferating in a vague trabecular pattern with some
appearance of sinusoids. Multinucleated giant cells were seen. No bile duct
epithelial cells were seen. The diagnosis of the third separate malignancy,
moderately differentiated HCC, was made. CONCLUSION: To our knowledge, this is
the first report of icteric-type HCC diagnosed by FNA although the primary lesion
was undetectable on routine, noninvasive examinations. FNA cytology is an
accurate and minimally invasive method for early confirmation of biliary HCC
thrombi.

Publication Types: 
    Case Reports

PMID: 17017439 [PubMed - indexed for MEDLINE]

165: World J Gastroenterol. 2006 Sep 21;12(35):5735-8.

Obstructive jaundice due to hepatobiliary cystadenoma or cystadenocarcinoma.

Erdogan D, Busch OR, Rauws EA, van Delden OM, Gouma DJ, van-Gulik TM.

Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ
Amsterdam, The Netherlands.

Hepatobiliary cystadenomas (HBC) and cystadenocarcinomas are rare cystic lesions.
Most patients with these lesions are asymptomatic, but presentation with
obstructive jaundice may occur. The first patient presented with intermittent
colicky pain and recurrent obstructive jaundice. Imaging studies revealed a
polypoid lesion in the left hepatic duct. The second patient had recurrent
jaundice and cholangitis. Endoscopic retrograde cholangiopancreatography (ERCP)
showed a cystic lesion at the confluence of the hepatic duct. In the third
patient with intermittent jaundice and cholangitis, cholangioscopy revealed a
papillomatous structure protruding into the left bile duct system. In the fourth 
patient with obstructive jaundice, CT-scan showed slight dilatation of the
intrahepatic bile ducts and dilatation of the common bile duct of 3 cm. ERCP
showed filling of a cystic lesion. All patients underwent partial liver
resection, revealing HBC in the specimen. In the fifth patient presenting with
obstructive jaundice, ultrasound examination showed a hyperechogenic cystic
lesion centrally in the liver. The resection specimen revealed a hepatobiliary
cystadenocarcinoma. HBC and cystadenocarcinoma may give rise to obstructive
jaundice. Evaluation with cross-sectional imaging techniques is useful. ERCP is a
useful tool to differentiate extraductal from intraductal obstruction.

Publication Types: 
    Case Reports

PMID: 17007033 [PubMed - indexed for MEDLINE]

166: World J Gastroenterol. 2006 Sep 14;12(34):5579-81.

An alternative surgical approach to a difficult case of Mirizzi syndrome: a case 
report and review of the literature.

Safioleas M, Stamatakos M, Revenas C, Chatziconstantinou C, Safioleas C, Kostakis
A.

2nd Department of Propeudeutic Surgery, Athens University School of Medicine,
Laiko Hospital, Athens, Greece.

Mirizzi syndrome (MS) is an uncommon complication of gallstone disease and occurs
in approximately 1% of all patients suffering from cholelithiasis. The syndrome
is characterized by extrinsic compression of the common hepatic duct frequently
resulting in clinical presentation of intermittent or constant jaundice. Most
cases are not identified preoperatively. Surgery is the indicated treatment for
patients with MS. We report here a 71-year-old male patient referred to the
surgical outpatient department for diffuse upper abdominal pain and mild jaundice
(bilirubin rate: 4.2 mg/dL). Ultrasound examination revealed a stone in the
cystic duct compressing the common hepatic duct. The patient had a history of
gastrectomy for gastric ulcer 30 years ago. MRCP revealed a stone impacted in the
cystic duct causing obstruction of the common hepatic duct by extrinsic
compression. With these findings the preoperative diagnosis was indicative of MS.
At laparotomy a moderately shrunken gallbladder was found embedded in adhesions
containing a large stone which was palpable in the common bile duct. The anterior
wall of the body of the gallbladder was opened by an incision which extended
longitudinally along the gallbladder towards the common bile duct. The stone
measuring 3.0 cm in diameter, was then removed setting astride a large
communication with the common bile duct. A Roux-en-Y
cholecysto-choledocho-jejunostomy was performed. The subhepatic region was
drained. The patient had an uneventful recovery. He was discharged eleven days
after operation and remained well after a 30-mo follow-up.

Publication Types: 
    Case Reports
    Review

PMID: 17007006 [PubMed - indexed for MEDLINE]

167: Pancreas. 2006 Oct;33(3):246-9.

Preoperative carbohydrate antigen 19-9 is most predictive of malignancy in older 
jaundiced patients undergoing pancreatic resection.

Bloomston M, Bekaii-Saab TS, Kosuri K, Cowgill SM, Melvin WS, Ellison EC,
Muscarella P 2nd.

Department of Surgery, Ohio State University, Columbus, OH 43210, USA.

OBJECTIVES: Given the increased detection of occult pancreatic neoplasms with
modern imaging modalities, it is often difficult to determine the risk of
malignancy before curative pancreatectomy. We reviewed patients who underwent
pancreatectomy to determine factors predictive of malignancy with particular
attention to the serum marker carbohydrate antigen 19-9 (CA19-9). METHODS: One
hundred eighteen patients underwent radical pancreatectomy for malignant (n = 59)
or benign (n = 59) pancreatic lesions. Demographic data, preoperative CA19-9
levels (normal, <37 U/mL), and follow-up were obtained from patient charts.
Logistic regression analysis was used to determine univariate and multivariate
predictors of malignancy. RESULTS: Significant multivariate predictors of
malignancy were increased CA19-9, age older than 50 years, and preoperative
jaundice. The sensitivity and specificity of increased preoperative CA19-9 alone 
were 71% and 83%, respectively. The combination of age older than 50 years and
jaundice was a more accurate predictor than CA19-9 (sensitivity, 76%;
specificity, 92%). Increased CA19-9 was highly specific (97%) for malignancy in
older jaundiced patients or when the preoperative level was greater than 150
U/mL. CONCLUSIONS: Age and preoperative jaundice are more predictive of
malignancy than CA19-9 alone unless levels are greater than 150 U/mL.
Preoperative CA19-9 levels should be interpreted within the context of these
other clinical factors.

PMID: 17003645 [PubMed - indexed for MEDLINE]

168: JBR-BTR. 2006 Jul-Aug;89(4):201-3.

Giant splenic artery aneurysm presenting as unusual cause of obstructive
jaundice.

Coulier B, Mairy Y, Broze B, Ramboux A.

Department of Radiology, Clinique St Luc, Bouge (Namur), Belgium.
bcoulier@skynet.be

Giant splenic aneurysms larger than 8 cm (GSAA) are rare and often asymptomatic
but present an increased risk of dramatic rupture, a life-threatening
complication. The management of these aneurysms is especially challenging. We
probably report the first case of GSAA revealed by clinical mechanical jaundice
due to direct compression of the biliary tree.The lesion was diagnosed during
abdominal ultrasound in a 68-year-old patient but determination of the specific
splenic origin and extensive anatomic preoperative evaluation were achieved by
MDCT. The case illustrates the new high quality performances of MDCT in the
evaluation of complex vascular abdominal situations and is presented with a brief
review of the relevant literature.

Publication Types: 
    Case Reports

PMID: 16999322 [PubMed - indexed for MEDLINE]

169: JOP. 2006 Sep 10;7(5):496-501.

Pediatric pancreatic hemangioma: a case report and literature review.

England RJ, Woodley H, Cullinane C, McClean P, Walker J, Stringer MD.

Children's Liver and GI Unit, St. James's University Hospital, Leeds, United
Kingdom. r.england@doctors.org.uk

CONTEXT: The pancreas is an unusual site for a hemangioma in an infant. A child
with obstructive jaundice caused by a pancreatic hemangioma is presented and
management strategies for this benign tumor are discussed. CASE REPORT: A
5-month-old girl presented with a 2-week history of jaundice, pale stools and
dark urine. Liver function tests confirmed obstructive jaundice. An abdominal
ultrasound scan and magnetic resonance imaging showed an enhancing mass in the
head of the pancreas. At laparotomy, a wedge biopsy of the pancreatic tumor was
taken and a tube cholecystostomy inserted. Histological examination of the
specimen revealed a pancreatic hemangioma with sclerotic features. The high
volume of bile loss from the cholecystostomy proved problematic and biliary
diversion with a Roux-en-y hepaticojejunostomy was therefore performed. The tumor
subsequently regressed spontaneously and was no longer visible on follow-up
imaging two years later. The child has since thrived. CONCLUSIONS: Pancreatic
hemangiomas are rare and may cause diagnostic confusion. Pancreatic resection
should be avoided since the natural history of these benign tumors is that of
spontaneous involution. Various strategies can be used to manage any associated
obstructive jaundice.

Publication Types: 
    Case Reports
    Review

PMID: 16998249 [PubMed - indexed for MEDLINE]

170: Hepatogastroenterology. 2006 Jul-Aug;53(70):491-6.

Effect of percutaneous biliary drainage on serum levels of tumor markers in
patients with obstructive jaundice.

Koroglu M, Koroglu BK, Akhan O, Coskun HS, Yildizz H, Yesildag A, Oyar O.

Department of Radiology, Suleyman Demirel University School of Medicine, Isparta,
Turkey. mertkoroglu@hotmail.com

BACKGROUND/AIMS: Some tumor markers such as CA 19-9 are shown to be increased in 
obstructive jaundice due to either benign or malignant causes. In this study the 
clinical importance of raised serum levels of tumor markers have been evaluated, 
with particular reference to obstructive jaundice and percutaneous biliary
drainage. METHODOLOGY: We conducted a prospective longitudinal before-after
trial. Twenty-one patients with obstructive jaundice were investigated, 5 with
benign obstruction and 16 with malignant disease. All patients were examined with
abdominal CT prior to biliary drainage. All patients underwent percutaneous
transhepatic cholangiography, and 20 of 21 patients underwent percutaneous
biliary drainage within 3 days after the CT examination. RESULTS: The mean CA
19-9 at presentation was lower in the group with benign disease (95 +/- 60.9
IU/mL) than those with malignancy (461.9 +/- 331.4 IU/mL). The mean CA 19-9 level
in the benign group 1 week after drainage was 12 +/- 11.8 IU/mL. The mean CA 19-9
level in the malignant group after drainage was 249.7 +/- 279.5 IU/mL.
CONCLUSIONS: A prominently high serum CA 19-9 level at the presentation and a
high serum CA 19-9 level after successful biliary drainage should prompt
investigation for a malignant etiology of obstructive jaundice.

Publication Types: 
    Clinical Trial

PMID: 16995447 [PubMed - indexed for MEDLINE]

171: Intern Med. 2006;45(16):953-6. Epub 2006 Sep 15.

A patient with early syphilis complicated by fatty liver who showed an
alleviation of hepatopathy accompanied by jaundice after receiving
anti-syphilitic therapy.

Ishikawa M, Shimizu I, Uehara K, Fujiwara S, Shiraishi T, Yamamoto H, Horie T,
Iuchi A, Ito S.

Department of Internal Medicine, Miyoshi Prefectural Hospital.

A 42-year-old male with visceral obesity and a fatty liver presented with
hepatopathy accompanied by jaundice and was diagnosed to have early syphilis
based on the results of standard serologic tests and clinical findings. Both the 
subjective and objective findings including hepatopathy were rapidly alleviated
by anti-syphilitic therapy. Severe hepatopathy accompanied by jaundice used to be
considered a rare complication. However, due to contemporary unhealthy lifestyle 
patterns characterized by hypernutrition and a lack of exercise the occurrence of
fatty liver is now dramatically increasing. Our findings suggest that the
occurrence of fatty liver can exacerbate the damage to the hepatic parenchyma due
to a Treponema pallidum infection.

Publication Types: 
    Case Reports

PMID: 16974057 [PubMed - indexed for MEDLINE]

172: J Pak Med Assoc. 2006 Aug;56(8):379-81.

Pleomorphic rhabdomyosarcoma within a choledochal cyst; a rare cause of
obstructive jaundice.

Tufail M, Rizwan MM, Majid HJ.

Department of General Surgery, Shaikh Zayed Federal Post Graduate Medical
Institute, Lahore, Pakistan.

Bile duct cysts are rare and of uncertain origin. Most have been reported in
young females of Asian Descent. The long term complication of choledochal cysts
includes malignant transformation in the epithelial lining of biliary tree.
Histopathologically it is Cholangiocarcinoma in the majority of cases with poor
long-term prognosis. However, Rhabdomyosarcoma associated with choledochal cyst
in an adult is rarely reported before. The authors report one such case in an
adult female patient who presented to us with features of obstructive jaundice.

Publication Types: 
    Case Reports

PMID: 16967793 [PubMed - indexed for MEDLINE]

173: Abdom Imaging. 2007 Mar-Apr;32(2):243-7. Epub 2006 Sep 12.

Biliary atresia in infants with prolonged cholestatic jaundice: diagnostic
accuracy of hepatobiliary scintigraphy.

Esmaili J, Izadyar S, Karegar I, Gholamrezanezhad A.

Department of Nuclear Medicine, Imam Khomeini Hospitals Complex, Tehran
University of Medical Sciences, Keshavarz Blvd., Tehran, Iran.

BACKGROUND: Cholestatic jaundice during infancy is one of the most problematic
challenges for pediatricians. Biliary atresia (BA) and neonatal hepatitis
syndrome (NHS) are major causes of cholestatic jaundices. Our aim was to compare 
the diagnostic accuracy of hepatobiliary scintigraphy with liver biopsy and
ultrasonography in excluding BA. METHODS: Seventy consecutive patients, all
suffering from prolonged cholestatic jaundice (>1 month), were included.
Laparotomy with surgical cholangiography was considered as the gold standard;
however, in nine patients, based on the patient's recovery from jaundice and the 
normalization of laboratory values during the clinical follow-up period (=6-12
months), the diagnosis of NHS was verified and performing laparotomy was
unnecessary. All patients underwent hepatobiliary scintigraphy, liver biopsy and 
ultrasonography and their results were compared. RESULTS: Based on the gold
standards mentioned above, 46 patients (46/70 = 65.7%) had BA. The sensitivity,
specificity, PPV, NPV, and accuracy of the hepatobiliary scintigraphy in
diagnosis of BA were 90%, 80%, 91.8%, 76.2%, and 84.5%, respectively. The
respective values for liver biopsy were 92.5%, 88.9%, 94.9%, 84.2%, and 90.1% and
for ultrasonographic analysis were 41.7%, 90.9%, 90.9%, 41.7%, and 66.3%.
CONCLUSION: Hepatobiliary scintigraphy is an important imaging technique in the
diagnostic evaluation of infants with prolonged cholestatic jaundice. It is a
convenient and reliable method of differentiating BA from NHS, with a diagnostic 
accuracy superior to that of US but slightly inferior to that of liver biopsy.
Ultrasonography is the least sensitive and specific available modality and its
findings should be confirmed by scintigraphy or liver biopsy.

PMID: 16967250 [PubMed - indexed for MEDLINE]

174: Pediatr Res. 2006 Nov;60(5):602-6. Epub 2006 Sep 11.

Impaired T-lymphocyte proliferation function in biliary atresia patients with
chronic cholestatic jaundice after a Kasai operation.

Wu JF, Chiang BL, Chen HL, Lai HS, Chang MH, Ni YH.

Department of Pediatrics, National Taiwan University Hospital, National Taiwan
University, Taipei, Taiwan.

To investigate the association between chronic cholestatic jaundice, systemic
immunity, and various infectious complications in patients with biliary atresia
(BA), we performed a survey of the systemic immune function in 30 children with
BA. Patients were divided into a jaundice group (total serum bilirubin > or = 2
mg/dL for >6 mo) and control group (total serum bilirubin <2 mg/dL for >6 mo)
with comparable age. Patients were tested for serum immunoglobulin and complement
levels, mitogen response, interleukin (IL)-4, IL-5, and interferon-gamma
production after phytohemagglutinin (PHA) stimulation, blood cell and lymphocyte 
subpopulation counts, phagocytic function, and leukocyte adhesion complex. They
were then followed prospectively for 6 mo, and severe infectious complications
requiring hospitalization were recorded. Compared with jaundice-free patients,
T-lymphocyte proliferation function, determined by PHA mitogen test was
significantly lower (p = 0.02) in BA patients with chronic cholestatic jaundice
after a Kasai operation. During the study period, patients with chronic
cholestatic jaundice had a higher risk of severe infectious complications than
their jaundice-free counterparts (risk ratio = 5.87; p = 0.001). In conclusion,
BA patients with chronic cholestatic jaundice are associated with impairment of
T-lymphocyte proliferation and increased incidence of severe infectious
complications.

PMID: 16966356 [PubMed - indexed for MEDLINE]

175: J Invest Surg. 2006 Sep-Oct;19(5):283-9.

Prostaglandin E1 maintains structural integrity of intestinal mucosa and prevents
bacterial translocation during experimental obstructive jaundice.

Gurleyik E, Coskun O, Ustundag N, Ozturk E.

Department of Surgery, Abant Izzet Baysal University, Duzce Medical Faculty,
Duzce, Turkey. egurleyik@yahoo.com

The absence of bile in the gut lumen induces mucosal injury and promotes
bacterial translocation (BT). Prostaglandin E (PGE) has a protective effect on
the mucosal layer of the alimentary tract. We hypothesize that PGE1 may prevent
BT by its beneficial action on the mucosa of the small bowel. Thirty Wistar
albino rats were divided equally into 3 groups; Group 1 (control) underwent sham 
laparotomy, group 2 obstructive jaundice (OJ) and group 3 (OJ + PGE1) underwent
common bile duct (CBD) ligation and transection. Groups 1 and 2 received; 1 mL
normal saline and group 3 received 40 mg of the PGE1 analogue misoprostol
dissolved in 1 mL normal saline administered by orogastric tube once daily. After
7 days, laparotomy and collection of samples for laboratory analyses were
performed, including bacteriological analysis of intestine, mesenteric lymph
nodes (MLNs), and blood, and histopathologic examination of intestinal mucosa to 
determine mucosal thickness and structural damage. Serum bilirubin and alkaline
phosphatase levels confirmed OJ in all animals with CBD transection. The mucosal 
damage score was significantly reduced in jaundiced animals receiving PGE1
compared to jaundiced controls (2.15 +/- 0.74 vs 5.3 +/- 0.59; p < .00001) and
mucosal thickness was greater (607 +/- 59.1 microm vs. 393 +/- 40.3 microm; p <
.00001). The incidence of BT to MLNs decreased from 90% to 30% (p < .02) when
jaundiced rats received PGE1. PGE1 treatment reduced the detection rate of viable
enteric bacteria in the blood from 60% to 10% (p < .057). We conclude that
administration of PGE1 provides protection against OJ-induced atrophy and damage 
of intestinal mucosa, and thereby prevents translocation of enteric bacteria to
underlying tissues.

PMID: 16966206 [PubMed - indexed for MEDLINE]

176: Am J Gastroenterol. 2006 Nov;101(11):2659-62. Epub 2006 Sep 4.

Cholestatic jaundice and IgA nephropathy induced by OTC muscle building agent
superdrol.

Jasiurkowski B, Raj J, Wisinger D, Carlson R, Zou L, Nadir A.

Maricopa Medical Center, Phoenix, Arizona, USA.

Over the counter (OTC) medicines are commonly used in the United States despite a
lack of scientific evidence for clinical utility and toxicity associated with
their use. A case of jaundice and IgA nephropathy as a consequence of use of a
muscle enhancing OTC supplement that was advertised as innocuous with no hormonal
activity is described. IgA nephropathy has not been described previously in
association with the use of testosterone. The case highlights that, besides
adulteration, the misrepresentation of chemicals present in OTC medications and
supplements can create confusion and a false sense of security with their use.

Publication Types: 
    Case Reports

PMID: 16952289 [PubMed - indexed for MEDLINE]

177: Early Hum Dev. 2007 May;83(5):313-7. Epub 2006 Sep 1.

Using BiliCheck for preterm neonates in a sub-intensive unit: diagnostic
usefulness and suitability.

De Luca D, Zecca E, de Turris P, Barbato G, Marras M, Romagnoli C.

Division of Neonatology, A. Gemelli University Hospital, Catholic University of
the Sacred Heart, Rome, Italy. dm.deluca@fastwebnet.it <dm.deluca@fastwebnet.it>

BACKGROUND: BiliCheck (BC), a new transcutaneous bilirubinometer is thought to be
lacking in the disadvantages of old devices and could be potentially useful for
diagnosing jaundice in preterm babies. Although its accuracy is well known in
healthy term babies, there is a lack of knowledge about its usefulness in preterm
infants. AIMS: To investigate BC usefulness in preterm babies and its suitability
in a sub-intensive neonatal unit. STUDY DESIGN: In 340 preterm infants between 30
and 36 weeks of gestational age, transcutaneous and serum bilirubin measurement
were performed. Hematocrit, pH, postnatal age, gestational age, and sex were also
studied to clarify their influence on BC accuracy. For a subset of 100 neonates
transcutaneous measurement, blood collection and serum analysis were timed and
costs were considered. RESULTS: Correlation coefficient is 0.795 (p<0.001) and
this is not affected by factors previously supposed to be important. Overall
sensitivity was 100% and specificity were comprised between 40% and 72%. BC has a
tendency to overestimate serum bilirubin, at high values. Considering the whole
time for serum bilirubin measurement, transcutaneous bilirubinometry is a faster 
(p<0.0001), but more expensive technique with a cost of about 5 euro/measurement.
Nevertheless, using BC as a screening-device we could safely avoid 58-79% of
blood samples, since its positive predictive values is about 21-42%. This would
allow to a cost reduction of 1555-2120 euro/year. CONCLUSIONS: BC has a good
reliability in preterm infants although not as good as in healthy term babies. BC
is a time-sparing tool and can improve the management of neonatal jaundice in
preterm infants; however, its tendency to overestimate suggests its use only for 
screening purposes.

Publication Types: 
    Clinical Trial

PMID: 16949773 [PubMed - indexed for MEDLINE]

178: APMIS. 2006 Sep;114(9):666-8.

Myeloid sarcoma of the extrahepatic bile ducts presenting as obstructive
jaundice.

González-Vela MC, Val-Bernal JF, Mayorga M, Cagigal ML, Fernández F, Mazorra F.

Department of Anatomical Pathology, Marqués de Valdecilla University Hospital,
Medical Faculty, University of Cantabria, Avda. Valdecilla s/n, ES-39008
Santander, Spain.

We report a rare case of myeloid sarcoma (MS) of the extrahepatic bile ducts
presenting as obstructive jaundice in a patient without leukemia at time of
diagnosis. A 75-year-old female presented with a one-month history of abdominal
pain and jaundice. Computerized tomography scan of the abdomen showed stenosis of
the extrahepatic bile ducts. Endoscopic retrograde cholangiography disclosed an
irregular narrowing of the common biliary duct, suggestive of a
cholangiocarcinoma, and resection was performed. Histologic examination showed
diffuse transmural infiltration of malignant cells. These cells exhibited
medium-sized round nuclei with central nucleoli and eosinophilic cytoplasm, and
were strongly positive for myeloperoxidase, CD68, lysozyme, CD45, CD117 (c-kit
protein) and CD43. Eight months following surgery the patient presented with
multiple cutaneous nodules and bone marrow trephine biopsy showed acute
myelomonocytic leukemia. A literature search identified two previously reported
cases of MS of the extrahepatic biliary duct. MS should be taken into
consideration in the differential diagnosis of a patient with obstructive
jaundice. Immunohistochemistry is essential for a correct diagnosis.

Publication Types: 
    Case Reports

PMID: 16948823 [PubMed - indexed for MEDLINE]

179: World J Gastroenterol. 2006 Aug 21;12(31):5094-5.

Obstructive jaundice leads to accumulation of oxidized low density lipoprotein in
human liver tissue.

Comert M, Ustundag Y, Tekin IO, Gun BD, Barut F.

Oxidized low density lipoprotein (ox-LDL) molecule is one of the most important
modified lipoproteins produced during the oxidative stress. Modified lipoproteins
have been defined as being part of the immune inflammatory mechanisms in
association with oxidant stress. We have reported the accumulation of ox-LDL in
Balb/c mice liver after bile duct ligation previously. Here, we investigated this
finding in human beings with obstructive jaundice. Our study demonstrates that
obstructive jaundice results in tremendous accumulation of ox-LDL in the liver
tissue of patients.

Publication Types: 
    Letter

PMID: 16937517 [PubMed - indexed for MEDLINE]

180: World J Gastroenterol. 2006 Aug 14;12(30):4922-6.

Obstructive jaundice caused by secondary pancreatic tumor from malignant solitary
fibrous tumor of pleura: a case report.

Yamada N, Okuse C, Nomoto M, Orita M, Katakura Y, Ishii T, Shinmyo T, Osada H,
Maeda I, Yotsuyanagi H, Suzuki M, Itoh F.

Division of Gastroenterology and Hepatology, Department of Internal Medicine, St.
Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki
216-8511, Japan.

A 77-year-old man on systemic chemotherapy against postoperative bilateral
multiple lung metastases of malignant solitary fibrous tumor of the pleura
suffered from pruritus and jaundice. Blood examination showed elevated levels of 
hepatobiliary enzymes. Abdominal computed tomography showed a tumor with
peripheral enhancement in the pancreatic head, accompanied with the dilatation of
intra- and extra-hepatic bile ducts. He was diagnosed as having obstructive
jaundice caused by a pancreatic head tumor. The pancreatic head tumor was
presumably diagnosed as the metastasis of malignant solitary fibrous tumor of the
pleura, because the findings on the pancreatic head tumor on abdominal CT were
similar to those on the primary lung lesion of malignant solitary fibrous tumor
of the pleura. The pancreatic tumor grew rapidly after the implantation of
metallic stent in the inferior part of the common bile duct. The patient died of 
lymphangitis carcinomatosa of the lungs. Autopsy revealed a tumor that spread
from the pancreatic head to the hepatic hilum. Microscopically, spindle-shaped
cells exhibiting nuclear atypicality or division together with collagen
deposition were observed. Immunohistochemically the pancreatic head tumor cells
were negative for staining of alpha-smooth muscle actin (alpha-SMA) or CD117, but
positive for vimentin, CD34 and CD99. These findings are consistent with those on
malignant solitary fibrous tumor of the pleura. We report the first case of
obstructive jaundice caused by a secondary pancreatic tumor from malignant
solitary fibrous tumor of the pleura.

Publication Types: 
    Case Reports

PMID: 16937484 [PubMed - indexed for MEDLINE]

181: J Clin Gastroenterol. 2006 Aug;40(7):623-5.

Eosinophilic gastroenteritis of the pancreas: an unusual cause of obstructive
jaundice.

Sheth A, Palmer R, Jordan PA, Manas K, Bhalodia A.

Department of Internal Medicine, Louisiana State University Health Sciences
Center, Shreveport, USA. drankursheth@yahoo.com

Eosinophilic gastroenteritis (EG) is a rare gastrointestinal disorder of
undetermined etiology and is manifest by eosinophilic infiltration of any area of
gastrointestinal tract, most frequently stomach and small intestine. Peripheral
eosinophilia is present in about 80% of patients. Definitive diagnosis requires
histologic evidence of eosinophilic infiltration; which is usually patchy in
distribution. Steroids are the mainstay of treatment. We present a case of
47-year-old man with abdominal pain, jaundice, and marked eosinophilia.
Endoscopic retrograde cholangio-pancreatogram revealed a dilated common bile
duct. There was biopsy proven eosinophilic infiltration in stomach, duodenum,
gall bladder, and pancreas. Obstructive jaundice is an extremely rare
manifestation of EG. This unusual case illustrates the wide variety of
gastrointestinal manifestations caused by EG and emphasizes the importance of
clinical suspicion and endoscopic mucosal biopsies in diagnosis of EG. This
entity should be considered in the patients with chronic and relapsing
gastrointestinal symptoms.

Publication Types: 
    Case Reports

PMID: 16917405 [PubMed - indexed for MEDLINE]

182: Korean J Intern Med. 2006 Jun;21(2):132-5.

Pancreatic metastasis and obstructive jaundice in small cell lung carcinoma.

Jeong IB, Kim SM, Lee TH, Im EH, Huh KC, Kang YW, Choi YW.

Department of Internal Medicine, College of Medicine, Konyang University,
Daejeon, Korea.

Primary lung cancer frequently metastasizes to distant organs. The pancreas is a 
relatively infrequent site of metastasis. Furthermore, obstructive jaundice
resulting from pancreatic metastasis is extremely rare. This paper examines the
case of a 65-year-old woman with small cell lung cancer initially presenting with
extrahepatic biliary obstruction. The patient underwent percutaneous transhepatic
biliary drainage. The obstruction was relieved with a stent placement, then the
woman was treated with combination chemotherapy (irinotecan, cisplatin) and a
complete remission achieved in six months.

Publication Types: 
    Case Reports

PMID: 16913445 [PubMed - indexed for MEDLINE]

183: Hepatobiliary Pancreat Dis Int. 2006 Aug;5(3):432-5.

Effect of L-arginine on calcium in hepatic mitochondrion in rats with obstructive
jaundice.

Lin MS, Miao HL, Gong XG, Bao ST.

Department of Hepatobiliary Surgery, Affiliated Hospital of Guangdong Medical
College, Zhanjiang 524023, China. linmusheng@gdmc.edu.cn

BACKGROUND: There is much debate over the regulation of mitochondrial calcium
overload and reducing the impairment of energy metabolism in hepatic cells. It
has not been reported whether L-arginine (L-Arg) can affect hepatic mitochondrial
calcium overload. This study was undertaken to investigate the protective effect 
of L-Arg on Ca2+ handling of hepatic mitochondrion in rats with obstructive
jaundice and to clarify its possible mechanism. METHODS: Seventy-two male SD rats
were randomly divided into 3 groups: sham operation+normal saline group (SO
group), common bile duct ligation+normal saline group (BDL group), and common
bile duct ligation+ L-Arg group (L-Arg group). The levels of malondialdehyde
(MDA), superoxide dismutase (SOD) and Ca2+ in rat hepatic mitochondrion were
examined at the 7th, 14th and 21st day after operation. RESULTS: The Ca2+ and MDA
levels of hepatic mitochondrion increased significantly but their SOD content
decreased markedly at each time point in the BDL group. Except at the 21st day,
the Ca2+ and MDA, contents of hepatic mitochondrion were significantly lower, and
SOD concentrations were higher in the L-Arg group than those in the BDL group at 
the 7th and 14th day (P<0.01). CONCLUSION: L-Arg has a protective effect on
mitochondrion in the early and mid stages of obstructive jaundice.

Publication Types: 
    Research Support, Non-U.S. Gov't

PMID: 16911945 [PubMed - indexed for MEDLINE]

184: Trop Gastroenterol. 2006 Jan-Mar;27(1):50-1.

Schwannoma of bile duct--a case report.

Vyas FL, Jesudason MR, Samuel R, Govil S, Jesudason SR.

Department of General Surgery, Christian Medical College and Hospital, Vellore,
India. sur4@cmcvellore.ac.in

This is a case report of a 29 year old woman who presented with painless and
progressive obstructive jaundice. Imaging investigations of the abdomen revealed 
a tumour of the common bile duct. She was treated by complete excision of the
bile duct and hepaticojejunostomy. The histopathology report of the tumour read
as benign schwannoma.

Publication Types: 
    Case Reports

PMID: 16910064 [PubMed - indexed for MEDLINE]

185: J Assoc Physicians India. 2006 Jun;54:483-4.

Portal biliopathy.

Sumathi B, Randhir J, Sekhar KS, Malathi S, Reddy DN, Jayanthi V.

Department of Gastroenterology, Stanley Medical College Hospital, Chennai.

A young male with portal venous thrombosis presented with obstructive jaundice,
due to common bile duct stricture secondary to portal biliopathy.

Publication Types: 
    Case Reports

PMID: 16909698 [PubMed - indexed for MEDLINE]

186: Med Princ Pract. 2006;15(5):379-81.

Agenesis of the gallbladder with primary choledochal stones.

Afifi el-SM, Atef H, Wael B.

Department of Surgery, Al-Sabah Hospital, Kuwait. graa7_no1@hotmail.com

OBJECTIVE: To report a case of true agenesis of the gallbladder (GB) with
obstructive jaundice due to primary choledochal stone. CLINICAL PRESENTATION AND 
INTERVENTION: A 66-year-old woman presented with a full picture of obstructive
jaundice, both clinically and biochemically. Ultrasound and endoscopic retrograde
cholangiopancreatography failed to show the GB but showed dilatation of
extrahepatic ducts with a stone in the common bile duct (CBD). Upon exploration, 
the GB was found to be absent and through a choledochotomy, the stone in the CBD 
was removed. CONCLUSION: This case shows that proper exploratory laparotomy and
intraoperative cholangiography may be required to confirm absence of the GB.

Publication Types: 
    Case Reports

PMID: 16888397 [PubMed - indexed for MEDLINE]

187: Brain Res. 2006 Sep 21;1111(1):203-12. Epub 2006 Aug 1.

Effect of N-acetylcysteine, allopurinol and vitamin E on jaundice-induced brain
oxidative stress in rats.

Karageorgos N, Patsoukis N, Chroni E, Konstantinou D, Assimakopoulos SF, Georgiou
C.

Department of Neurosurgery, School of Medicine, University of Patras, Greece.

We examined the possible protective effect of certain antioxidants
(N-acetylcysteine, allopurinol and vitamin E) against the oxidative stress of
brain tissue induced by experimental obstructive jaundice in rats. Thirty-six
male Wistar rats were randomly divided into six groups; group I control, group II
sham operated, group III bile duct ligated and groups IV, V, and VI in which the 
rats, after bile duct ligation, were given every day an intraperitoneal injection
with N-acetylcysteine, allopurinol and Vit-E respectively. All rats were
sacrificed on the tenth day by exsanguination and the oxidative state in samples 
from cortex, midbrain and cerebellum was assessed by measuring the thiol redox
state and lipid peroxidation quantified by MDA measurements. The main finding was
that all three antioxidants decrease lipid peroxidation in the three brain areas.
Cysteine levels increased and protein thiol levels were reserved only in the
group treated with N-acetylcysteine, whereas oxidized glutathione increased
dramatically in the group treated with allopurinol, suggesting that each
antioxidant agent had a certain influence profile on the different antioxidant
defense systems. The observed effects of the antioxidants in this experimental
model could also provide insight into some aspects of jaundice-induced hepatic
encephalopathy in humans.

PMID: 16884703 [PubMed - indexed for MEDLINE]

188: World J Gastroenterol. 2006 Jul 21;12(27):4428-30.

Xanthogranulomatous cholangitis causing obstructive jaundice: a case report.

Kawate S, Ohwada S, Ikota H, Hamada K, Kashiwabara K, Morishita Y.

Department of Surgery, Gunma University Graduate School of Medicine, 3-39-22,
Maebashi, Gunma 371-8511, Japan.

This article reports the case of a 34-year-old woman with xanthogranulomatous
cholangitis who developed obstructive jaundice. Microscopically, the bile duct
was surrounded and narrowed by a xanthogranulomatous lesion, but no
xanthogranulomatous cholecystitis was seen. Although percutaneous cholangiograms 
done via the transhepatic biliary drainage showed smooth narrowing of the upper
to middle bile duct, the cytology of bile was diagnosed as class V
adenocarcinoma. Therefore, right extended hepatectomy and extrahepatic bile duct 
resection were performed. The differentiation of benign and malignant strictures 
at the hepatic hilum is often difficult. Xanthogranulomatous cholangitis is one
possible diagnosis of a bile duct stricture. Precise review of all the
preoperative information is required to make a correct diagnosis.

Publication Types: 
    Case Reports

PMID: 16865792 [PubMed - indexed for MEDLINE]

189: Surg Endosc. 2006 Sep;20(9):1477-81. Epub 2006 Jul 24.

Mirizzi syndrome: laparoscopic management by subtotal cholecystectomy.

Rohatgi A, Singh KK.

Hospital Worthing Hospital, Lyndhurst Road, Worthing, West Sussex, BN11 2HR, UK.

BACKGROUND: The authors present their experience with laparoscopic subtotal
cholecystectomy for the management of Mirizzi's syndrome and their review of the 
literature. METHODS: Over a period of 24 months, five cases of Mirizzi's syndrome
were encountered, representing 1.5% of all the laparoscopic cholecystectomies
performed in the authors' unit. The sex ratio was 4 females to 1 male, and the
mean age of the patients was 66 years. All underwent a subtotal cholecystectomy. 
RESULTS: All procedures were completed laparoscopically. Morbidities involved one
case of biliary peritonitis and a one case of biliary leak requiring endoscopic
stenting. CONCLUSION: Mirizzi's syndrome cannot always be anticipated on the
basis of preoperative staging, and often is encountered during the procedure. The
"anatomic scenario" of this condition should be suspected for patients presenting
with conditions such as empyema or mucocoele when there is a likelihood of stone 
impaction in the infundibulum of the gallbladder. Subtotal cholecystectomy with
secure intraperitoneal biliary drainage appears to be a safe option for these
patients.

Publication Types: 
    Case Reports
    Review

PMID: 16865619 [PubMed - indexed for MEDLINE]

190: J Postgrad Med. 2006 Jul-Sep;52(3):204-6.

Malignant gastrointestinal stromal tumor of the ampulla of Vater presenting with 
obstructive jaundice.

Filippou DK, Pashalidis N, Skandalakis P, Rizos S.

First Department of General Surgery, Pireaus General Hospital "Tzaneio",
Afentouli and Tzani str, Pireaus-Athens, Greece. d_filippou@hotmail.com

Malignant gastrointestinal stromal tumor (GIST) consists a rare neoplasm,
developing in small intestine and stomach. The presenting manifastations include 
weakness, weight loss, nausea, melena and anaemia. The present case refers to a
65 years old female patient with a GIST of the ampulla of Vater presenting with
obstructive jaundice. Diagnosis was achieved pre-operatively by biopsies
collected through diagnostic ERCP. The tumour was locally excised, with
preservation of the ampulla. The histological analysis suggested low grade GIST
positive for both CD 117 (c-kit) and CD34. Two years after the surgery the
patient remains free of disease. Malignant GIST of the ampulla of the Vater is
extremely rare as only few similar cases have been described in the literature.
This is the first time a GIST being presented as obstructive jaundice ever
reported. Despite the unavailability of EUS-FNA, the diagnosis was set
preoperatively and the tumor was resected.

Publication Types: 
    Case Reports

PMID: 16855323 [PubMed - indexed for MEDLINE]

191: Brain Res. 2006 Aug 30;1107(1):215-21. Epub 2006 Jul 7.

Biliverdin-induced brainstem auditory evoked potential abnormalities in the
jaundiced Gunn rat.

Rice AC, Shapiro SM.

Department of Neurology, Box 980599, Virginia Commonwealth University, Richmond, 
VA 23298-0599, USA. acrice@mail2.vcu.edu

Brainstem auditory evoked potential (BAEP) abnormalities occur in jaundiced Gunn 
rats given sulfadimethoxine to displace bilirubin bound to serum albumin,
releasing it into the tissues. One problem with the model is that after
displacement, plasma bilirubin levels drop and do not correlate with neurological
dysfunction. In this report, we administered biliverdin, the immediate precursor 
of bilirubin, in 15- to 17-day-old Gunn rat pups to create an improved model of
bilirubin-induced neurological dysfunction. Total plasma bilirubin (TB) levels
were measured with a Leica bilirubinometer. Biliverdin (40 mg/kg) or
phosphate-buffered saline (PBS) was administered either once and BAEPs recorded 8
h later or twice, 12 h apart, and BAEPs recorded 24 h after the initial
injection. A single biliverdin injection produced a significantly decreased
amplitude of BAEP wave III, 1.21+/-0.25 vs. 0.49+/-0.27 microV (control vs.
biliverdin). The two-injection paradigm resulted in a significantly elevated TB
(9.9+/-1.2 vs. 14.9+/-3.1 mg/dl; control vs. biliverdin), significant increases
in I-II (1.15+/-0.08 vs. 1.42+/-0.09 ms) and I-III (2.17+/-0.08 vs. 2.5+/-0.13
ms) interwave intervals and a decrease in the amplitude of wave III (1.36+/-0.30 
vs. 0.38+/-0.26 microV). Additionally, there were significant correlations
between TB and the amplitude of wave III (r2=0.74) and TB and the I-III interwave
interval (r2=0.51). In summary, biliverdin administration in jaundiced Gunn rat
pups produces BAEP abnormalities consistent with those observed in the
sulfadimethoxine model and human newborn hyperbilirubinemia and resulted in
increased plasma bilirubin levels that correlate with the degree of neurological 
dysfunction.

Publication Types: 
    Comparative Study
    Research Support, N.I.H., Extramural

PMID: 16828065 [PubMed - indexed for MEDLINE]

192: Ann Ital Chir. 2005 Nov-Dec;76(6):579-81.

An uncommon complication of liver biopsy: obstructive jaundice from blood clots.

Sciumè C, Geraci G, Pisello F, Facella T, Licata A, Modica G.

Dipartimento di Chirurgia Generale d'Urgenza e dei Trapianti d'Organo, UO di
Chirurgia Generale ad indirizzo Toracico, Università degli Studi di Palermo.
carmesci@hotmail.com

INTRODUCTION: The AA. report on a case of one young woman who developed
obstructive jaundice induced by hemobilia after percutaneous liver biopsy,
successfully treated with endoscopic retrograde cholangiopancreatography (ERCP)
METHODS: An endoscopic sphincterotomy was performed with extraction of the clots 
OBSERVATIONS: Four weeks after ERCP the patient was healthy and asymptomatic,
valuated as outpatient CONCLUSIONS: The role of ERCP in managing biliary sequelae
of hemobilia is well established: biliary decompression is required if and
intrabiliary lot causes obstructive jaundice and/or biliary colic. ERCP is
feasible and leads to relief of symptoms in most cases, without the need of
surgery.

Publication Types: 
    Case Reports

PMID: 16821524 [PubMed - indexed for MEDLINE]

193: J Pediatr Surg. 2006 Jul;41(7):e1-3.

Successful revision of portoenterostomy in an infant with biliary atresia.

Haber BA, Erlichman J, Thayu M, Flake AW, Rand EB.

Division of Gastroenterology and Nutrition, The Children's Hospital of
Philadelphia, Philadelphia, PA 19104, USA. haber@email.chop.edu

We present a case report of a boy with biliary atresia who, after
hepatoportoenterostomy performed on day 21 of life, had immediate resolution of
cholestasis and remained anicteric until 3.5 months of age. He then abruptly
developed acholic stools. Nuclear medicine imaging study showed no excretion.
Broad-spectrum antibiotics and corticosteroids were administered but did not lead
to clinical improvement; a surgical revision of the original anastomosis was
undertaken at 4 months of age. At 14 months of age, the child is anicteric and
growing well. In this case, successful revision of hepatoportoenterostomy averted
the need for liver transplantation.

Publication Types: 
    Case Reports

PMID: 16818040 [PubMed - indexed for MEDLINE]

194: ANZ J Surg. 2006 Jul;76(7):631-6.

Hepatocellular carcinoma presenting with obstructive jaundice.

Lai EC, Lau WY.

Department of Surgery, The Chinese University of Hong Kong, Prince of Wales
Hospital, Hong Kong, China.

BACKGROUND: Jaundice occurs in 5-44% of patients with hepatocellular carcinoma
(HCC). It is an important clinical presentation as the different aetiological
causes of jaundice in HCC determine the therapeutic approach and the prognosis.
This article aims to review the classification, management and prognosis of
patients with jaundice associated with HCC. METHODS: A Medline search was
undertaken to identify articles using the key words 'hepatocellular carcinoma',
'jaundice' and 'tumour thrombus'. Additional articles were identified by a manual
search of the references from the key articles. RESULTS: Patients with jaundice
due to hepatic parenchymal insufficiency (hepatocellular type) have a very dismal
prognosis. For patients with biliary obstruction due to HCC (icteric type), the
reported 1-, 3- and 5-year survival rates after curative resection were
57.1-100%, 20-47% and 6.7-45%, respectively. The mean survival after palliative
biliary drainage alone was less than 6 months but when biliary drainage was
combined with other palliative treatment, the mean survival could be up to 1
year. CONCLUSIONS: It is important to differentiate the hepatocellular type from 
the icteric type of HCC. For patients with the icteric type of HCC, curative
liver resection can achieve a survival comparable to that in patients without
jaundice. For patients with unresectable icteric type of HCC, treatment can
provide improvement in patient's quality of life and survival.

Publication Types: 
    Review

PMID: 16813631 [PubMed - indexed for MEDLINE]

195: J Invest Surg. 2006 May-Jun;19(3):175-84.

Effect of N-acetylcysteine on blood and tissue lipid peroxidation in
lipopolysaccharide-induced obstructive jaundice.

Caglikulekci M, Dirlik M, Pata C, Plasse M, Tamer L, Ogetman Z, Ercan B.

Department of General Surgery, Mersin University Medical School, Mersin, Turkey. 
mcaglikulecki@yahoo.com

In obstructive jaundice, free radical production is increased and antioxidative
activity is reduced. N-Acetylcysteine (NAC) has a beneficial effect with
anti-inflammatory and antioxidant activity, acting as a free radical scavenger.
NAC inhibits inducible nitric oxide synthase, suppresses cytokine
expression/release, and inhibits adhesion molecule expression and nuclear factor 
kappa B. The aim of this study was to investigate the effects of NAC on
liver/renal tissue and serum lipid peroxidation in lipopolysaccharide
(LPS)-induced obstructive jaundice. We randomized 60 rats into 6 groups: group 1,
Sham; group 2, obstructive jaundice (OJ) induced after bile-duct ligation; group 
3, OJ + NAC (100 mg kg- 1 subcutaneously); group 4, OJ + LPS (10 mg kg-1); group 
5, OJ + NAC + LPS; and group 6, OJ + LPS + NAC. For each group, the biochemical
markers of lipid peroxidation and the antioxidant products were measured in serum
and liver/renal tissue after sacrifice. Almost all lipid peroxidation products
levels were increased and antioxidant products levels were decreased in groups
who received LPS (groups 4, 5, and 6), but the effect was less remarkable when
NAC was administered before LPS (group 5). The same trend was seen for groups
with OJ +/- LPS who did not received NAC or received it after induced toxemia
(groups 2, 4, and 6) as compared to groups 1 and 3. Moreover, in the case of OJ +
LPS, rats treated with NAC before LPS (group 5) had lower lipid peroxidation
products levels and higher antioxidant products levels as compared to those who
did not received NAC (group 4). This phenomenon was not reproducible with NAC
administered after LPS (group 6). Thus, results of this study showed that NAC
prevents the deleterious effects of LPS in obstructive jaundice by reducing lipid
peroxidation in serum and liver/renal tissue if administered before LPS.
Nonetheless, NAC failed to prevent the lipid peroxidation in the case of
established endotoxemia in obstructive jaundice.

PMID: 16809227 [PubMed - indexed for MEDLINE]

196: J Gen Intern Med. 2006 Jul;21(7):C11-3.

Stauffer's syndrome variant with cholestatic jaundice: a case report.

Morla D, Alazemi S, Lichtstein D.

Department of Medicine, Division of Pulmonary/Critical Care, University of
Miami-Miller School of Medicine, Miami, FL, USA. dmorla@med.miami.edu

Cholestasis is a common feature of several malignant diseases, including
pancreatic, hepatic, gallbladder, and ampullary carcinomas. It is usually
secondary to main bile duct obstruction or widespread hepatic metastasis, but it 
can also be a paraneoplastic syndrome of other underlying malignancies.
Stauffer's syndrome is a rare paraneoplastic manifestation of renal cell
carcinoma (RCC) that is characterized by elevated alkaline phosphatase,
erythrocyte sedimentation rate, alpha-2-globulin, and gamma-glutamyl transferase,
thrombocytosis, prolongation of prothrombin time, and hepatosplenomegaly, in the 
absence of hepatic metastasis and jaundice. A rare variant of this syndrome with 
jaundice has recently been described in 3 cases in the literature. We report a
patient who presented with abdominal pain and cholestatic jaundice in whom RCC
was incidentally found during initial workup. Jaundice and liver dysfunction
resolved completely after surgical resection of the tumor. This case illustrates 
the protean manifestations of RCC, and the importance of considering Stauffer's
syndrome and its variant in the differential diagnosis of anicteric and icteric
cholestasis, which may allow early recognition and treatment of an underlying
malignancy.

Publication Types: 
    Case Reports

PMID: 16808761 [PubMed - indexed for MEDLINE]

197: Peptides. 2006 Nov;27(11):2592-9. Epub 2006 Jun 27.

Effects of the antimicrobial peptide BMAP-27 in a mouse model of obstructive
jaundice stimulated by lipopolysaccharide.

Ghiselli R, Cirioni O, Giacometti A, Mocchegiani F, Orlando F, Bergnach C,
Skerlavaj B, Silvestri C, Vittoria AD, Zanetti M, Rocchi M, Scalise G, Saba V.

Department of General Surgery, I.N.R.C.A. I.R.R.C.S., Università Politecnica
delle Marche, Ancona, Italy.

An experimental study was designed to investigate the efficacy of BMAP-27, a
compound of the cathelicidin family, in neutralizing Escherichia coli 0111:B4
lipopolysaccharide (LPS) in bile duct-ligated mice. Main outcome measures were:
endotoxin and TNF-alpha concentrations in plasma, evidence of bacterial
translocation in blood and peritoneum, and lethality. Adult male BALB/c mice were
injected intraperitoneally with 2 mg/kg E. coli 0111:B4 LPS 1 week after sham
operation or bile duct ligation (BDL). Six groups were studied: sham with
placebo, sham with 120 mg/kg tazobactam-piperacillin (TZP), sham with 1 mg/kg
BMAP-27, BDL with placebo, BDL with 120 mg/kg TZP, and BDL with 1mg/kg BMAP-27.
After LPS, TNF-alpha plasma levels were significantly higher in BDL mice compared
to sham-operated animals. BMAP-27 achieved a significant reduction of plasma
endotoxin and TNF-alpha concentration when compared with placebo- and TZP-treated
groups. On the other hand, both TZP and BMAP-27 significantly reduced the
bacterial growth compared with saline treatment. Finally, LPS induced 60% and 55%
lethality in BDL placebo- and TZP-treated treated mice and no lethality in
sham-operated mice, while only BMAP-27 significantly reduced the lethality to
10%. In light of its dual antimicrobial and anti-endotoxin properties, BMAP-27
could be an interesting compound to inhibit bacterial translocation and endotoxin
release in obstructive jaundice.

Publication Types: 
    Research Support, Non-U.S. Gov't

PMID: 16806583 [PubMed - indexed for MEDLINE]

198: Eur Surg Res. 2006;38(3):347-52. Epub 2006 Jun 23.

Effect of vitamin A on the CD44 expression in the small intestine of rats with
obstructive jaundice.

Sen M, Inan A, Yenidunya S, Ergin M, Dener C.

Department of General Surgery, Fatih University School of Medicine, Ankara,
Turkey. drmeralsen@yahoo.com

HYPOTHESIS: In this study, the influence of obstructive jaundice on the CD44
expression in the rat small intestine and the alterations of this CD44 expression
by vitamin A given intraperitoneally (200 IU/g/day) are evaluated. MATERIALS AND 
METHODS: In a prospective animal model study, 32 Sprague-Dawley rats were
randomized into four groups: group A rats (n = 8) underwent sham operation and
were given daily saline intraperitoneally for 2 weeks (sham + saline); group B
animals (n = 8) underwent sham operation and were given daily vitamin A
intraperitoneally for 2 weeks (sham + vitamin A); group C rats (n = 8) underwent 
common bile duct ligation and were given daily saline intraperitoneally for 2
weeks (obstructive jaundice + saline), and group D animals (n = 8) underwent
common bile duct ligation and were given daily vitamin A intraperitoneally for 2 
weeks (obstructive jaundice + vitamin A). After 2 weeks, standardized jejunum and
ileum segments were harvested from all animals. The expression of CD44 on the
cell surface was evaluated immunohistochemically. Comparisons among the four
groups were done. RESULTS: The plasma bilirubin, aspartate transaminase, alanine 
transaminase, alkaline phospatase, and gamma-glutamyltransferase levels in groups
C and D (obstructive jaundice groups) were higher than those in groups A and B
(sham groups; p < 0.05). There was no difference between groups A and B (sham
groups) with regard to the number of cells expressing surface CD44 in jejunum and
ileum. When groups A and B were compared with group C (obstructive jaundice +
saline) animals, the number of cells expressing surface CD44 was significantly
decreased in both jejunum and ileum in group C. The difference between sham
groups (A and B) and group C was found to be significant (p < 0.05). When group D
(obstructive jaundice + vitamin A) was compared with group C (obstructive
jaundice + saline), the number of cells expressing surface CD44 was significantly
increased in jejunum and ileum in group D animals (p < 0.05), higher than in the 
sham groups (A and B). The difference between group D and sham groups (A and B)
was found to be significant (p < 0.05). CONCLUSION: Obstructive jaundice for 2
weeks significantly decreased the CD44 expression in the rat small intestine. We 
found that daily intraperitoneal administration of vitamin A in rats with
obstructive jaundice for 2 weeks significantly restored the impaired CD44
expression.

Publication Types: 
    Research Support, Non-U.S. Gov't

PMID: 16804311 [PubMed - indexed for MEDLINE]

199: Lipids Health Dis. 2006 Jun 23;5:16.

Effects of dietary calcium on atherosclerosis, aortic calcification, and icterus 
in rabbits fed a supplemental cholesterol diet.

Hsu HH, Culley NC.

Department of Pathology and Laboratory Medicine, Cardiovascular Research
Division, University of Kansas Medical Center, Kansas City, KS 66160, USA.
hhsu@kumc.edu

BACKGROUND: Vascular calcification is implicated in myocardial infarction,
instability and rigidity of the aortic wall, and bioprosthetic failures. Although
an increase in the calcium (Ca) content in atherogenic diets has been shown to
decrease atherosclerosis in rabbits, whether Ca supplementation and deficiency
can affect atherosclerosis-related aortic calcification remains unknown. RESULTS:
New Zealand White male rabbit littermates were fed an atherogenic diet containing
0.5% cholesterol and 2% peanut oil. The Ca content of the diet, which normally
contains 1%, was adjusted to 0.5 or 3%. Segments of thoracic aortas were
dissected from rabbits for histological evaluations and Ca and Pi determinations.
Rabbits with calcium supplementation were maintained for 4 months, whereas those 
with calcium deficiency were maintained for 2 1/2 months due to severe icterus
beyond this stage. The ratios of intimal to medial areas and calcified to intimal
areas were used to semi-quantify lesion accumulation and calcification,
respectively. Icterus was estimated from the extent of yellowing of the skin,
sclera, and mucous membranes along with gross evidence of hepatic lipidosis
and/or biliary obstructions. Statistical analysis of 16 matched littermates shows
that Ca supplementation significantly decreased the lesions by 41% (p < 0.05) and
markedly inhibited calcification by 62% (p < 0.05). Statistical analysis of 11
matched littermates shows that Ca deficiency significantly increased the lesions 
by 2.7-fold (p < 0.05) and that the diet caused a small but significant
calcification not seen in the sibling groups with normal dietary Ca. Ca
supplementation caused a significant 30% decrease in serum cholesterol (p <
0.05). Calcium deficiency increased serum cholesterol by 57% (p < 0.001). Serum
cholesterol and LDL-cholesterol levels in Ca deficient rabbits were 2-fold higher
than those with high Ca diets. Ca supplementation decreased soluble Ca and Pi
content in aortas, suggesting that this effect may underlie the effects of Ca
supplementation on calcification. Calcium deficiency increased icterus by 33% (p 
< 0.05), which may affect hepatic clearance of cholesterol, while calcium
supplementation decreased it by 43% (p < 0.001). CONCLUSION: Ca supplementation
to an atherogenic diet inhibits atherosclerosis, aortic calcification, and
icterus, whereas a Ca deficient-diet promotes them.

Publication Types: 
    Research Support, N.I.H., Extramural

PMID: 16796746 [PubMed - indexed for MEDLINE]

200: Surg Today. 2006;36(7):633-7.

An icteric type hepatocellular carcinoma with no detectable tumor in the liver:
report of a case.

Makino T, Nakamori S, Kashiwazaki M, Masuda N, Ikenaga M, Hirao M, Fujitani K,
Mishima H, Sawamura T, Takeda M, Mano M, Tsujinaka T.

Department of Surgery, National Hospital Organization, Osaka National Hospital,
2-1-14 Hoenzaka, Osaka, Japan.

A 70-year-old man was admitted to our hospital with obstructive jaundice.
Computed tomography revealed a tumor in the left intrahepatic bile duct extending
to the common bile duct without any significant lesions in the liver.
Cholangiography showed a filling defect due to an intraductal tumor. Cytology of 
the bile juice was negative and tumor markers were carcinoembryonic antigen 5.7
ng/ml, carbohydrate antigen 19-9 49 U/ml, alpha-fetoprotein 9 ng/dl, and PIVKA-II
19 200 AU/ml. With a preoperative diagnosis of hilar bile duct carcinoma, a
laparotomy was performed. The common bile duct was filled with a tumor and it
extended into the bilateral intrahepatic bile ducts. The intraductal tumor was
removed together with the extrahepatic bile ducts. An intraoperative histological
examination of the tumor showed a well-differentiated hepatocellular carcinoma.
No lesions were detected in the liver by ultrasonography, palpation during the
operation, or a computed tomography scan after the operation. At 1 year
postoperatively, no recurrence has been seen in this patient.

Publication Types: 
    Case Reports

PMID: 16794800 [PubMed - indexed for MEDLINE]

201: Crit Care Med. 2006 Sep;34(9):2415-20.

Comment on:
    Crit Care Med. 2006 Sep;34(9):2503-4.

Amphibian peptides prevent endotoxemia and bacterial translocation in bile
duct-ligated rats.

Giacometti A, Cirioni O, Ghiselli R, Mocchegiani F, Silvestri C, Orlando F,
Kamysz W, Licci A, Kamysz E, Lukasiak J, Saba V, Scalise G.

Institute of Infectious Diseases and Public Health, Università Politecnica delle 
Marche, Ancona, Italy.

OBJECTIVE: To investigate the efficacy of amphibian antimicrobial peptides in
preventing bacterial translocation and neutralizing endotoxins in bile
duct-ligated rats. DESIGN: Prospective, randomized, controlled animal study.
SETTING: Research laboratory in a university hospital. SUBJECTS: Adult male
Wistar rats. INTERVENTIONS: Adult male Wistar rats underwent sham operation or
bile duct ligation (BDL). Eight groups were studied: sham operation with saline
treatment, sham operation with 120 mg/kg tazobactam-piperacillin, sham operation 
with 2 mg/kg uperin 3.6, sham operation with 2 mg/kg magainin2, BDL with saline
treatment, BDL with 120 mg/kg tazobactam-piperacillin, BDL with 2 mg/kg uperin
3.6, and BDL with 2 mg/kg magainin2. MEASUREMENTS AND MAIN RESULTS: Main outcome 
measures were: endotoxin and tumor necrosis factor-alpha concentrations in plasma
and evidence of bacterial translocation in blood, peritoneum, liver, and
mesenteric lymph nodes. Endotoxin and tumor necrosis factor-alpha plasma levels
were significantly higher in BDL rats compared with sham-operated animals. All
amphibian peptides achieved a significant reduction of plasma endotoxin and tumor
necrosis factor-alpha concentration when compared with saline- and
tazobactam-piperacillin-treated groups. On the other hand, both
tazobactam-piperacillin and peptides significantly reduced bacterial growth
compared with the control. Tazobactam-piperacillin and magainin2 exerted the
maximal inhibition of bacterial growth. CONCLUSION: In conclusion, because of
their multifunctional properties, amphibian peptides could be interesting
compounds to inhibit bacterial translocation and endotoxin release in obstructive
jaundice.

Publication Types: 
    Comment
    Research Support, Non-U.S. Gov't

PMID: 16791114 [PubMed - indexed for MEDLINE]

202: J Clin Monit Comput. 2006 Jun;20(3):159-64. Epub 2006 Jun 10.

A dose-response model for the conventional phototherapy of the newborn.

Osaku NO, Lopes HS.

Hospital Universitário Universidade Estadual do Oeste do Paraná - UNIOESTE, R. da
Bandeira, 668, 85812-270, Cascavel, Brazil.

Jaundice of the newborn is a common problem as a consequence of the rapid
increment of blood bilirubin in the first days of live. In most cases, it is
considered a physiological transient situation, but unmanaged hyperbilirubinemia 
can lead to death or serious injuries for the survivors. For decades,
phototherapy has been used as the main method for prevention and treatment of
hyperbilirubinaemia of the newborn. This work aims at finding a predictive model 
for the decrement of blood bilirubin for patients submitted to conventional
phototherapy. Data from the phototherapy of 90 term newborns were collected and
used in a multiple regression method. A rigorous statistical analysis was done in
order to guarantee a correct and valid model. The obtained model was able to
explain 78% of the variation of the dependent variable. We show that it is
possible to predict the total serum bilirubin of the patient under conventional
phototherapy by knowing its birth weight, bilirubin level at the beginning of
treatment and the radiant energy density (dose). Besides, it is possible to infer
the time necessary for a given decrement of bilirubin, under approximately
constant irradiance. Statistical analysis of the obtained model shows that it is 
valid for several ranges of birth weight, initial bilirubin level, and radiant
energy density. It is expected that the proposed model can be useful in the
clinical management of hyperbilirubinemia of the newborn.

Publication Types: 
    Clinical Trial
    Research Support, Non-U.S. Gov't

PMID: 16767500 [PubMed - indexed for MEDLINE]

203: Indian J Gastroenterol. 2006 Mar-Apr;25(2):93-4.

Acute myeloid leukemia presenting as obstructive jaundice.

Rajesh G, Sadasivan S, Hiran KR, Nandakumar R, Balakrishnan V.

Department of Gastroenterology, Amritha Institute of Medical Sciences and
Research Center, Cochin, India. grajesh@aimshospital.org

We report a 32-year-old man with acute myeloid leukemia presenting as obstructive
jaundice. Imaging revealed dilated common bile duct with abrupt narrowing at the 
lower end, distended gall bladder, and dilated intrahepatic biliary radicles. In 
addition he had a mass lesion in the urinary bladder. On evaluation he was found 
to have the eosinophilic variant of M4 subtype acute myeloid leukemia. He expired
before chemotherapy could be instituted.

Publication Types: 
    Case Reports

PMID: 16763341 [PubMed - indexed for MEDLINE]

204: Acta Chir Belg. 2006 Mar-Apr;106(2):202-5.

The effects of nitric oxide supplementation and inhibition on bacterial
translocation in bile duct ligated rats.

Demirkiran AE, Balkaya M, Tuncyurek P, Cevikel MH, Culhaci N, Iyigor M, Ozgun H, 
Aydin N, Boylu S.

Department of Surgery, Adnan Menderes University, Faculty of Medicine, Istanbul, 
Turkey. aedemirkiran@yahoo.com

Obstructive jaundice promotes bacterial translocation from the gut, but the role 
of nitric oxide is controversial in this process. We studied the effects of
nitric oxide synthase substrate, L-arginine, and nitric oxide synthase inhibitor,
N(G)-nitro-L-arginine methyl ester, on bacterial translocation in bile duct
ligated rats. The animals were randomized into five groups; control, sham, common
bile duct ligation alone, nitric oxide inhibition, and nitric oxide
supplementation. Obstructive jaundice was performed with common bile duct
ligation. L-arginine or N(G)-nitro-L-arginine methyl ester was injected once
daily for 14 days. Blood bilirubin level, liver histology, and bacterial
translocation to the mesenteric lymph nodes as well as to the liver were
assessed. The L-arginine supplemented group had the lowest bacterial
translocation rate, but the most prominent hepatic fibrosis. Nitric oxide
inhibition increased bacterial translocation to the mesenteric lymph nodes.
Therefore, the administration of nitric oxide donor or inhibitor acts as a
significant regulatory factor for bacterial translocation in obstructive
jaundice.

Publication Types: 
    Evaluation Studies
    Research Support, Non-U.S. Gov't

PMID: 16761478 [PubMed - indexed for MEDLINE]

205: Pediatr Radiol. 2006 Aug;36(8):877-80. Epub 2006 Jun 7.

Biliary cryptococcosis in a child: MR imaging findings.

Das CJ, Pangtey GS, Hari S, Hari P, Das AK.

Department of Radiology, All India Institute of Medical Science, New Delhi,
India. dascj@yahoo.com

Cryptococcosis is a systemic mycosis with a worldwide distribution. It frequently
occurs in patients who are immunologically compromised or chronically ill.
Clinical manifestations are usually confined to the central nervous system, lungs
and skin. Involvement of the hepatobiliary system is very rare. We describe the
MR imaging appearance of a rare case of disseminated cryptococcosis in an
immunocompetent child in whom the clinical presentation was dominated by biliary 
and lymph nodal involvement.

Publication Types: 
    Case Reports

PMID: 16758185 [PubMed - indexed for MEDLINE]

206: Intern Med. 2006;45(9):621-5. Epub 2006 Jun 1.

Nonparasitic solitary giant hepatic cyst causing obstructive jaundice was
successfully treated with monoethanolamine oleate.

Miyamoto M, Oka M, Izumiya T, Nagaoka T, Ishihara Y, Ueda K, Enomoto S, Yanaoka
K, Arii K, Tamai H, Shimizu Y, Ichinose M.

Division of Internal Medicine, Nagayama Hospital, Osaka.

A 77-year-old man hospitalized for epigastric pain showed jaundice of the skin
and conjunctivae. Laboratory tests revealed elevated hepatobiliary enzymes and
inflammatory markers, and imaging studies demonstrated a 12 cm hepatic cyst
compressing the common bile duct. The diagnosis was a giant hepatic cyst causing 
obstructive jaundice. Cyst drainage and sclerotherapy with 5% monoethanolamine
oleate was performed twice, resulting in almost complete disappearance of the
cyst. Obstructive jaundice due to a hepatic cyst, as seen in this case, is
relatively rare and this report includes a review of other similar cases in
Japan.

Publication Types: 
    Case Reports
    Review

PMID: 16755093 [PubMed - indexed for MEDLINE]

207: Pediatr Radiol. 2006 Sep;36(9):980-2. Epub 2006 Jun 3.

MRCP diagnosis of Mirizzi syndrome in a paediatric patient: importance of
T1-weighted gradient echo images for diagnosis.

Kaya D, Karcaaltincaba M, Akhan O, Uslu N, Haliloglu M.

Department of Radiology, Hacettepe University School of Medicine, Sihhiye,
Ankara, 06100, Turkey.

We report a 15-year-old boy with Mirizzi syndrome diagnosed by MR
cholangiopancreatography (MRCP). Respiratory-triggered 3D MRCP was performed
during free breathing. An impacted gallstone was noted in the infundibulum; this 
was not visible on T2-weighted images, but was hyperintense on T1-weighted
gradient-echo images. This case illustrates the utility of 3D MRCP with parallel 
imaging in paediatric patients and the importance of T1-weighted gradient-echo
images for the diagnosis of impacted gallstones.

Publication Types: 
    Case Reports

PMID: 16752132 [PubMed - indexed for MEDLINE]

208: Trop Gastroenterol. 2005 Oct-Dec;26(4):203-4.

Hepatic tuberculosis presenting as cholestatic jaundice. A case report.

Ghoda MK.

Rajasthan Hospital and Sterling Hospital, Ahmedabad. mkghoda@yahoo.com

We report three cases of hepatic tuberculosis with cholestatic jaundice. All
three patients presented with cholestatic jaundice, anorexia, fever and weight
loss. All had hepatomegaly. No biliary obstruction was detected. Two patients had
evidence of extra hepatic tuberculosis but one had no such evidence. Diagnosis of
hepatic tuberculosis was confirmed by liver biopsy. Little is known about
tuberculous affecting the liver and the general belief is that it is a
histopathological entity only, but these cases are a reminder of the unusual
manifestation of a very common condition. All the cases recovered with
anti-tuberculous treatment.

Publication Types: 
    Case Reports

PMID: 16737053 [PubMed - indexed for MEDLINE]

209: J Nephrol. 2006 Mar-Apr;19(2):229-33.

The pathology of jaundice-related renal insufficiency: cholemic nephrosis
revisited.

Betjes MG, Bajema I.

Division of Nephrology, Department of Internal Medicine, Erasmus Medical Center, 
Rotterdam, The Netherlands. M.G.H.Betjes@erasmusmc.nl

The spectrum of jaundice-related nephropathy can range from limited proximal
tubulopathy to renal failure. The latter condition was known as cholemic
nephrosis in the early literature on this subject. Elevated plasma concentrations
of bile salts and bilirubin conjugated or not, putatively mediate the
nephrotoxicity. A functional derangement of renal tubule cells is considered to
underlie the nephropathy, but published data on renal histology are scarce. In
this report, we describe the renal biopsies of two jaundiced patients with
reduced creatinine clearance, and we critically review the literature on the
pathogenesis of jaundice-related nephropathy. Normal renal architecture,
indicating functional renal impairment, and extensive renal tubule necrosis were 
both observed in jaundice-related renal failure. The findings fit the original
description of cholemic nephrosis. Both bilirubin and bile salts are potential
nephrotoxins in animal models, but their precise role in the pathogenesis of
jaundice-related nephropathy is not known. Patients with bilirubin plasma
concentrations >20 mg/dL, a low serum albumin concentration or endo-toxemia,
could be more prone to develop renal failure due to jaundice-related tubulopathy.
In conclusion, jaundice-related nephropathy is essentially a tubulopathy, but the
exact nature of the Pathogenesis is still uncertain.

Publication Types: 
    Case Reports

PMID: 16736428 [PubMed - indexed for MEDLINE]

210: Egypt J Immunol. 2004;11(2):149-55.

Role of some viral infections in neonatal cholestasis.

Amer OT, Abd El-Rahma HA, Sherief LM, Hussein HF, Zeid AF, Abd El-Aziz AM.

Pediatric Department, Faculty of Medicine, Zagazig University, Egypt.

Viral infection is one of the postulated causes of neonatal cholestasis. In
addition to earlier reports on the association of viral infection and
intrahepatic cholestasis (IH), recent studies have suggested a similar link to
extra hepatic biliary atresia (EHBA). The aim of this work was to evaluate the
role of some viral infections in neonates presenting with cholestasis to the
Neonatology Ward of Zagazig University Hospitals. Sixty-two neonates were
included in the study (44 cholestatic neonates and 18 apparently healthy neonates
as the control group). All neonates were subjected to full history taking and
complete physical examination. Laboratory investigations included CBC, liver
function tests, bleeding profile, blood cultures, abdominal ultrasound and
detection of HBsAg and serum IgM antibodies against certain viruses (CMV,
Reovirus III, HSV I, HSV II, Rubella virus) using ELISA. Radionuclide
cholescintigraphy was performed for patients only. The study revealed that
cholestatic neonates were significantly associated with dark urine, pale stool
and hepatomegaly compared with the control (P<0.004, P<0.001, P<0.008,
respectively). Quantitation of IgM antibody titre using ELISA revealed
significantly higher levels of serum anti-CMV IgM and anti-Reovirus III IgM in
cholestatic than in the control groups. No significant differences were found in 
levels of anti-HSV I, anti-HSV II or anti-rubella antibodies between cholestatic 
and control groups. HBsAg was negative for all neonates; cholestatic and control.
Lastly, no significant differences were found between neonates with EHBA (7
cases) and Intrahepatic cholestasis (37 cases) regarding anti -CMV IgM or anti
-Reo III IgM. It can be concluded that CMV and Reovirus type 3 infections of the 
neonates are associated with the development of cholestatic disorder, not only
due to IH cholestasis but also due to the production of EHBA.

PMID: 16734127 [PubMed - indexed for MEDLINE]

211: World J Gastroenterol. 2006 Jun 7;12(21):3410-5.

Experimental obstructive jaundice alters claudin-4 expression in intestinal
mucosa: effect of bombesin and neurotensin.

Assimakopoulos SF, Vagianos CE, Charonis AS, Alexandris IH, Spiliopoulou I,
Thomopoulos KC, Nikolopoulou VN, Scopa CD.

Department of Internal Medicine, School of Medicine, University of Patras,
Greece. sassim@upatras.gr

AIM: To investigate the influence of experimental obstructive jaundice and
exogenous bombesin (BBS) and neurotensin (NT) administration on the expression of
the tight junction (TJ)-protein claudin-4 in intestinal epithelium of rats.
METHODS: Forty male Wistar rats were randomly divided into five groups: I =
controls, II = sham operated, III = bile duct ligation (BDL), IV = BDL+BBS (30
microg/kg per d), V = BDL+NT (300 microg/kg per d). At the end of the experiment 
on d 10, endotoxin was measured in portal and aortic blood. Tissue sections of
the terminal ileum were examined histologically and immunohistochemically for
evaluation of claudin-4 expression in intestinal epithelium. RESULTS: Obstructive
jaundice led to intestinal barrier failure demonstrated by significant portal and
aortic endotoxemia. Claudin-4 expression was significantly increased in the upper
third of the villi in jaundiced rats and an upregulation of its lateral
distribution was noted. Administration of BBS or NT restored claudin-4 expression
to the control state and significantly reduced portal and aortic endotoxemia.
CONCLUSION: Experimental obstructive jaundice increases claudin-4 expression in
intestinal epithelium, which may be a key factor contributing to the disruption
of the mucosal barrier. Gut regulatory peptides BBS and NT can prevent this
alteration and reduce portal and systemic endotoxemia.

Publication Types: 
    Research Support, Non-U.S. Gov't

PMID: 16733860 [PubMed - indexed for MEDLINE]

212: Gastrointest Endosc. 2006 Jun;63(7):996-1000.

Comment in:
    Gastrointest Endosc. 2006 Jun;63(7):1001-3.

A comparison of covered and uncovered Wallstents for the management of distal
malignant biliary obstruction.

Yoon WJ, Lee JK, Lee KH, Lee WJ, Ryu JK, Kim YT, Yoon YB.

Department of Internal Medicine, Seoul National University College of Medicine,
28 Yeongeon-dong, Jongno-gu, Seoul 110-744, Korea.

BACKGROUND: The efficacy and complications of covered self-expandable metal
stents (SEMS) remain controversial. OBJECTIVE: We conducted this study to compare
the efficacies and complication rates of covered and uncovered SEMS in malignant 
biliary obstruction. DESIGN: Data on patients who underwent endoscopic retrograde
biliary drainage with covered or uncovered Wallstents for the palliation of
unresectable distal malignant biliary obstruction were collected. Stent patency, 
complications, and causes of stent occlusion were analyzed. SETTING: We collected
the data retrospectively. PATIENTS: A total of 77 patients received Wallstents
for unresectable distal malignant biliary obstruction. INTERVENTIONS: Endoscopic 
sphincterotomy was performed, and a Wallstent was deployed after guidewire
passage. Polyurethane-covered Wallstents were used in 36 patients and uncovered
Wallstents in 41 patients. RESULTS: Stent migration occurred in 3 of the covered 
Wallstent group and in 1 of the uncovered Wallstent group. Cholecystitis occurred
in 1 of the covered Wallstent group but in none of the uncovered Wallstent group.
Stent occlusion occurred after a mean of 398 days in the covered group and after 
319 days in the uncovered Wallstent group (P > .05). Stent patency rates were
83%, 78%, 67%, and 54% at 100, 200, 300, and 400 days, respectively, in covered
group and 83%, 66%, 54%, and 36% in the uncovered group, which was not
significantly different. LIMITATIONS: This study is not a prospective randomized 
study and sample size is not large. CONCLUSIONS: Covered Wallstents are safe with
acceptable complication rates. However, we found no significant difference
between the stent patencies of covered and uncovered Wallstents.

Publication Types: 
    Comparative Study

PMID: 16733115 [PubMed - indexed for MEDLINE]

213: Gastrointest Endosc. 2006 Jun;63(7):986-95.

Comment in:
    Gastrointest Endosc. 2006 Jun;63(7):1001-3.

Covered metal versus plastic stents for malignant common bile duct stenosis: a
prospective, randomized, controlled trial.

Soderlund C, Linder S.

Karolinska Institutet, Upper GI Surgery, Department of Surgery, South Hospital,
SE 118-83 Stockholm, Sweden.

BACKGROUND: Most patients with malignant common bile duct strictures are suited
only for palliation of jaundice by placement of a polyethylene (PE) stent using
an endoscopic retrograde cholangiographic technique. Occlusion of these stents
occurs after 3 to 4 months, whereas uncovered self-expanding metal stents (SEMS) 
remain open twice as long. The initial higher cost of the latter might be
balanced by a decreased need for repeat intervention. OBJECTIVE: To compare the
patency of 10F PE stents and covered 30F steel SEMS (Wallstent; Boston Scientific
Nordic AB, Helsingborg, Sweden). DESIGN: Single-center, prospective, randomized, 
controlled trial. SETTING: General hospital in Stockholm, Sweden, which has a
catchment area of 0.6 million people. PATIENTS: Non-referred, unresectable
malignant common bile duct strictures. INTERVENTIONS: Endoscopic retrograde
cholangiography with plastic stents or covered SEMS. MAIN OUTCOME MEASUREMENTS:
Time to stent failure, requiring a new stent. LIMITATIONS: Similar setting and
patients, and costs in Scandinavia. RESULTS: Fifty-one and 49 patients were
allocated to the PE stent and SEMS groups, respectively. Fifty-six patients died 
without stent failure within 10 months (median, 2.6 months). Twenty-two PE stent 
and 9 SEMS patients (P = .009) developed failure after a median of 1.1 and 3.5
months, respectively (P = .007). Median patency times were 1.8 and 3.6 months in 
the PE and SEMS groups, respectively (P = .002). Median survival was 4.5 months; 
in 35 patients with distant metastases, the median survival was 2.5 months (P =
.002)(PE group, 1.9 months). CONCLUSIONS: The more-effective SEMS are recommended
in unresectable patients with malignant common bile duct strictures, who survive 
a median of 4.5 months. Less costly plastic stents are preferable in the one
third of patients who have distant metastases. In our study, the cost was equal.

Publication Types: 
    Comparative Study
    Randomized Controlled Trial
    Research Support, Non-U.S. Gov't

PMID: 16733114 [PubMed - indexed for MEDLINE]

214: Pediatr Res. 2006 Jul;60(1):44-9. Epub 2006 May 11.

Calculated in vivo free bilirubin levels in the central nervous system of Gunn
rat pups.

Daood MJ, Watchko JF.

Department of Pediatrics, Division of Newborn Medicine, University of Pittsburgh 
School of Medicine, Magee-Womens Research Institute, Pittsburgh, Pennsylvania
15213, USA.

In vitro studies suggest a free bilirubin (B(F)) concentration in the range of
71-770 nmol/L can induce neurotoxicity. In vivo data regarding central nervous
system (CNS) B(F) levels have not been determined. We calculated in vivo CNS B(F)
levels in Gunn rat pups (15-19 d old; heterozygous nonjaundiced Gunn rats (J/j)
and homozygous jaundiced Gunn rats (j/j); saline or sulfadimethoxine treated)
based on 1) total brain bilirubin (TBB) content, 2) brain albumin level, 3) CNS
bilirubin binding capacity attributable to brain albumin determined using an
ultrafiltration technique, and 4) published Gunn rat albumin-bilirubin binding
constants (k). Gunn rat brain bilirubin binding capacity was approximately 22 x
10(-3) micromol/g, of which two thirds was accounted for by brain albumin. Using 
a Gunn rat pup in vivo, k of 9.2 L/micromol, calculated CNS B(F) levels ranged
from 72 to 112 nmol/L [95% confidence interval (CI)] in saline and from 59 to 156
nmol/L (95% CI) in sulfadimethoxine-treated J/j pups. These animals demonstrated 
no neurobehavioral abnormalities and normal cerebellar weight. Calculated CNS
B(F) levels were severalfold higher (p < 0.001) in saline (95% CI: 556-1110
nmol/L) and sulfadimethoxine-treated (95% CI: 3461-8985 nmol/L) j/j pups; the
former evidenced reduced cerebellar weight; the latter both reduced cerebellar
weight and acute neurobehavioral abnormalities. We conclude that calculated CNS
B(F) values in j/j pups are substantially higher than those in J/j animals. Given
the absence of CNS abnormalities in J/j pups, the presence of such in j/j
animals, and the CNS B(F) levels in these groups, we speculate that the CNS B(F) 
neurotoxicity threshold in vivo is subsumed within the range (71-770 nmol/L)
reported in vitro.

Publication Types: 
    Research Support, N.I.H., Extramural
    Research Support, Non-U.S. Gov't

PMID: 16690957 [PubMed - indexed for MEDLINE]

215: World J Gastroenterol. 2006 Apr 21;12(15):2423-6.

One-step palliative treatment method for obstructive jaundice caused by
unresectable malignancies by percutaneous transhepatic insertion of an expandable
metallic stent.

Yoshida H, Mamada Y, Taniai N, Mizuguchi Y, Shimizu T, Yokomuro S, Aimoto T,
Nakamura Y, Uchida E, Arima Y, Watanabe M, Uchida E, Tajiri T.

Department of Surgery 1, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo
113-8603, Japan. hiroshiy@nms.ac.jp

AIM: To describe a simple one-step method involving percutaneous transhepatic
insertion of an expandable metal stent (EMS) used in the treatment of obstructive
jaundice caused by unresectable malignancies. METHODS: Fourteen patients
diagnosed with obstructive jaundice due to unresectable malignancies were
included in the study. The malignancies in these patients were a result of very
advanced carcinoma or old age. Percutaneous transhepatic cholangiography was
performed under ultrasonographic guidance. After a catheter with an inner
metallic guide was advanced into the duodenum, an EMS was placed in the common
bile duct, between a point 1 cm beyond the papilla of Vater and the entrance to
the hepatic hilum. In cases where it was difficult to span the distance using
just a single EMS, an additional stent was positioned. A drainage catheter was
left in place to act as a hemostat. The catheter was removed after resolution of 
cholestasis and stent patency was confirmed 2 or 3 d post-procedure. RESULTS:
One-step insertion of the EMS was achieved in all patients with a procedure mean 
time of 24.4 min. Out of the patients who required 2 EMS, 4 needed a procedure
time exceeding 30 min. The mean time for removal of the catheter post-procedure
was 2.3 d. All patients died of malignancy with a mean follow-up time of 7.8 mo. 
No stent-related complication or stent obstruction was encountered. CONCLUSIONS: 
One-step percutaneous transhepatic insertion of EMS is a simple procedure for
resolving biliary obstruction and can effectively improve the patient's quality
of life.

PMID: 16688837 [PubMed - indexed for MEDLINE]

216: Clin Nutr. 2006 Dec;25(6):949-54. Epub 2006 May 3.

Nutritional risk index predicts a high-risk population in patients with
obstructive jaundice.

Clugston A, Paterson HM, Yuill K, Garden OJ, Parks RW.

Clinical and Surgical Sciences (Surgery), Royal Infirmary of Edinburgh, Little
France Crescent, Edinburgh EH16 4SA, UK.

BACKGROUND: Malnutrition is common in obstructive jaundice but is difficult to
define. The aim of this study was to compare definitions of malnutrition in
patients with obstructive jaundice to identify correlation with mortality,
complications and length of hospital stay after intervention. METHODS:
Prospective case-control study comparing 39 inpatients with obstructive jaundice 
with 21 controls. Body mass index (BMI), skin-fold thickness (TSF), mid-arm
muscle circumference (MAMC), percentage weight loss, nutritional risk index (NRI)
and malnutrition universal screening tool (MUST) were measured and compared.
Duration of admission, interventions, complications and outcome were recorded
prospectively. RESULTS: Patients with obstructive jaundice were significantly
malnourished compared to controls. Severe malnutrition was equally prevalent in
benign and malignant disease. Malnourished patients had higher mortality and
longer duration of stay after intervention compared to non-malnourished patients.
NRI<83.5 was significantly associated with mortality and longer duration of
hospital admission but not complication rate. CONCLUSION: NRI is simple to use
and defines a high-risk sub-group of patients with obstructive jaundice.

PMID: 16675070 [PubMed - indexed for MEDLINE]

217: Pancreatology. 2006;6(4):273-8. Epub 2006 Apr 19.

Phagocytosis and production of H2O2 by human peripheral blood mononuclear cells
from patients with obstructive jaundice.

Treglia-Dal Lago M, Jukemura J, Machado MC, da Cunha JE, Barbuto JA.

Department of Immunology, Institute of Biomedical Sciences, University of São
Paulo, São Paulo, Brazil.

BACKGROUND: The immune function is altered in jaundiced patients; here, the
ability of their peripheral blood mononuclear cells to perform phagocytosis and
to release H2O2 was analyzed. METHODS: Cells from 53 patients before surgery for 
relief of cholestasis, from 38 patients 1 week and from 15 patients 2 weeks after
surgery were separated and cultured for 1 h in the presence of phorbol myristate 
acetate. H2O2 release was evaluated colorimetrically and phagocytosis by the
ingestion of Escherichia coli in vitro. RESULTS: Before surgery for relief of
cholestasis, the cells of the patients were unable to release H2O2, but, after
surgery, an increasing percentage of patients had cells that were able to produce
H2O2 (13% after 1 week; 33% after 2 weeks). This recovery did not correlate with 
bilirubinemia. When cultured for 1 week in the presence of normal or jaundiced
plasma, regardless of collection time, cells of 12/12 patients released H2O2, but
in lower levels if in the presence of jaundiced plasma. In contrast, H2O2 release
by normal donor cells was enhanced in the presence of jaundiced plasma.
Phagocytosis by cells of the patients was lower, but when present was associated 
with a significantly higher bactericidal activity. CONCLUSION: These significant,
but reversible alterations of monocyte function in jaundiced patients might
contribute to their enhanced susceptibility to surgical complications. (c) 2006
S. Karger AG, Basel and IAP.

Publication Types: 
    Research Support, Non-U.S. Gov't

PMID: 16636599 [PubMed - indexed for MEDLINE]

218: Scand J Gastroenterol. 2006 Apr;41(4):505-8.

Jaundice of unknown origin: Remember zoonoses!

Pappas G, Christou L, Akritidis NK, Tsianos EV.

1st Department of Internal Medicine and Hepato-Gastroenterology Unit, University 
Hospital of Ioannina, Greece. gpele@otenet.gr

Zoonotic diseases are randomly remembered in the differential diagnosis of
jaundice of unknown origin. We present four characteristic cases of jaundice
attributed to brucellosis and Coxiella burnetii infection and discuss the various
pathogenetic pathways implicated in each case. We present a brief review of the
relevant literature and, in an era of increasing subspecialization, underline the
importance of viewing the "whole picture".

Publication Types: 
    Case Reports
    Review

PMID: 16635923 [PubMed - indexed for MEDLINE]

219: J Gastrointest Surg. 2006 Apr;10(4):523-31.

Influence of bactibilia after preoperative biliary stenting on postoperative
infectious complications.

Howard TJ, Yu J, Greene RB, George V, Wairiuko GM, Moore SA, Madura JA.

Department of Surgery, Indiana University School of Medicine, Indianapolis, USA. 
tjhoward@iupui.edu

The aim of this study was to correlate the bactibilia found after preoperative
biliary stenting with that of the bacteriology of postoperative infectious
complications in patients with obstructive jaundice. One hundred thirty-eight
patients (83% malignant and 17% benign etiologies) with obstructive jaundice had 
both their bile and all postoperative infectious complications cultured.
Eighty-six (62%) had preoperative biliary stents (stent group) and 52 (38%) did
not (no-stent group). There were no differences for age, sex, incidence of
malignancy, type of operation, estimated blood loss, transfusion requirements,
hospital length of stay, morbidity, or mortality rates between the two groups. Of
31 infectious complications, 23 were in the stent group and eight were in the
no-stent group (P > 0.05), but only 13 (42%) infectious complications had
bacteria that were also cultured from the bile. Only wound infection (P = 0.03)
and bacteremia (P = 0.04) were more likely to occur in stented patients. Taken
together, these data show that preoperative biliary stenting increases the
incidence of bactibilia, bacteremia, and wound infection rates but does not
increase morbidity, mortality, or hospital length of stay. Jaundiced patients can
undergo preoperative biliary stenting while maintaining an acceptable
postoperative morbidity rate.

PMID: 16627218 [PubMed - indexed for MEDLINE]

220: Cochrane Database Syst Rev. 2006 Apr 19;(2):CD004200.

Update of:
    Cochrane Database Syst Rev. 2006;(1):CD004200.

Palliative biliary stents for obstructing pancreatic carcinoma.

Moss AC, Morris E, Mac Mathuna P.

BACKGROUND: Palliative endoscopic stents or surgical by-pass are often required
for inoperable pancreatic carcinoma to relieve symptomatic obstruction of the
distal biliary tree. The optimal method of intervention remains unknown.
OBJECTIVES: To compare surgery, metal endoscopic stents and plastic endoscopic
stents in the relief of distal biliary obstruction in patients with inoperable
pancreatic carcinoma. SEARCH STRATEGY: We searched the databases of the Cochrane 
Upper Gastrointestinal and Pancreatic Group specialised register, Cochrane
Central Register of Controlled Trials, MEDLINE, EMBASE, CancerLit, Current
Concepts Database and BIDS (September 2002 to September 2004). The searches were 
re-run in December 2005 and we are awaiting further details on two trials.
Reference lists of articles and published abstracts from UEGW and DDW were
hand-searched. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing 
surgery to endoscopic stenting, endoscopic metal stents to plastic stents, and
different types of endoscopic plastic and metal stents, used to relieve
obstruction of the distal bile duct in patients with inoperable pancreatic
carcinoma. DATA COLLECTION AND ANALYSIS: Two authors independently assessed trial
quality and extracted data. Adverse effects information was collected from the
trials. MAIN RESULTS: Twenty-one trials involving 1,454 people were included.
Based on meta-analysis, endoscopic stenting with plastic stents appears to be
associated with a reduced risk of complications (RR 0.60, 95% CI 0.45 - 0.81),
but with higher risk of recurrent biliary obstruction prior to death (RR 18.59,
95% CI 5.33 - 64.86) when compared with surgery. There was a trend towards higher
30-day mortality in the surgical group (p=0.07, RR 0.58, 95% CI 0.32, 1.04).
There was no evidence of a difference in technical or therapeutic success. Other 
outcomes were not suitable for meta-analysis. No trials comparing endoscopic
metal stents to surgery were identified.In endoscopic stent comparisons, metal
biliary stents appear to have a lower risk of recurrent biliary obstruction than 
plastic stents (RR 0.52, 95% CI 0.39 - 0.69). There was no significant
statistical difference in technical success, therapeutic success, complications
or 30-day mortality using meta-analysis. A narrative review of studies of the
cost-effectiveness of metal stents drew conflicting conclusions, but results may 
be dependent on the patients' length of survival.Neither Teflon, hydrourethane,
or hydrophilic coating appear to improve the patency of plastic stents above
polyethylene in the trials reviewed. Only perflouro alkoxy plastic stents had
superior outcome to polyethylene stents in one trial. The single eligible trial
comparing types of metal stents reported higher patency with covered stents, but 
also a higher risk of complications. These results are based on review of the
trials individual results only. AUTHORS' CONCLUSIONS: Endoscopic metal stents are
the intervention of choice at present in patients with malignant distal
obstructive jaundice due to pancreatic carcinoma. In patients with short
predicted survival, their patency benefits over plastic stents may not be
realised. Further RCTs are needed to determine the optimal stent type for these
patients.

Publication Types: 
    Meta-Analysis
    Review

PMID: 16625598 [PubMed - indexed for MEDLINE]

221: Eur J Gastroenterol Hepatol. 2006 May;18(5):537-40.

Primary pancreatic Burkitt's lymphoma mimicking carcinoma with obstructive
jaundice and very high CA19-9.

Wang YJ, Jeng CM, Wang YC, Chang PP, Wang TH.

Department of Radiology, Cathay General Hospital, 18 Hsinhai Road, Pan Chiao
City, Taipei Hsien 220, Taiwan, ROC. ab0506@ms35.hinet.net

Primary pancreatic lymphoma is a rare neoplasm. We report the case of a
49-year-old man who presented with biliary obstruction due to a neoplasm
involving the pancreatic head. Initial computed tomography revealed a suspicious 
periampullary mass. Consequently, magnetic resonance imaging was performed 16
days later, showing a relatively clearly defined and homogeneous signal mass in
the pancreatic head with biliary dilatation on enhanced study. In combination
with high tumour marker associated antigen CA19-9 levels (1872 and 2110 U/ml),
these findings were highly suggestive of a pancreatic carcinoma. He underwent
Whipple's procedure. Examination of the surgical specimen revealed a Burkitt's
lymphoma. This case demonstrates that lymphoma can present with features
mimicking pancreatic head carcinoma on imaging, clinical and laboratory studies. 
Neither clinical nor imaging nor laboratory methods indicate correct diagnosis,
but a relatively clearly defined and homogeneous mass should prompt the physician
to include lymphoma in a differential diagnosis of a pancreatic mass.

Publication Types: 
    Case Reports

PMID: 16607151 [PubMed - indexed for MEDLINE]

222: South Med J. 2006 Mar;99(3):306-8.

Comment in:
    South Med J. 2006 Mar;99(3):205.

Patient with markedly elevated CA 19-9 not associated with malignancy.

Lowe D, Lee J, Schade R, Chaudhary A.

Department of Internal Medicine, Section of Gastroenterology/ Hepatology, Medical
College of Georgia and Veterans Administration Medical Center, Augusta, GA 30912,
USA.

A 66-year-old white male presented with jaundice, pruritus, and a 30-pound weight
loss over two months. Physical examination revealed scleral icterus. Laboratory
evaluation revealed ALT 161 U/L, AST 290 U/L, alkaline phosphatase 2004 U/L, GGT 
2,552 U/L, total bilirubin 10.2 mg/dL, and a carbohydrate antigen 19-9 (CA 19-9) 
level of 4,374 U/mL. Initial endoscopic retrograde cholangiopancreatography
(ERCP) was unsuccessful due to ulceration in the duodenum healed with
esomeprazole therapy. Subsequent ERCP showed a possible filling defect in the
common bile duct treated with sphincterotomy and balloon sweeping of the common
bile duct. Symptoms and jaundice resolved five months after initial presentation 
with normal labs and studies. While elevated CA 19-9 levels occur in most
patients with carcinoma of the pancreas, it can also be elevated in patients with
extrapancreatic malignancies and acute cholangitis. This case illustrates the
fact that a markedly elevated CA 19-9 can be secondary to causes other than
carcinoma.

Publication Types: 
    Case Reports

PMID: 16553110 [PubMed - indexed for MEDLINE]

223: Ann R Coll Surg Engl. 2006 Mar;88(2):176-80.

The effects of Saccharomyces boulardii on bacterial translocation in rats with
obstructive jaundice.

Geyik MF, Aldemir M, Hosoglu S, Ayaz C, Satilmis S, Buyukbayram H, Kokoglu OF.

Department of Clinical Microbiology and Infectious Diseases, Dicle University
Medical Faculty, Diyarbakir, Turkey. mefgeyik@dicle.edu.tr

INTRODUCTION: The aim of this study was to investigate the effect of
Saccharomyces boulardii treatment on preventing bacterial translocation in an
obstructive jaundice animal model. MATERIALS AND METHODS: Sixty adult rats were
divided into five groups: group 1 - the sham-operated group; group 2 - the common
bile duct ligation group; group 3 - the S. boulardii group; group 4 - the
ampicillin-sulbaktam group; and group 5 - the S. boulardii plus
ampicillin-sulbaktam group. The saline, antibiotics and S. boulardii were given, 
respectively, for a 7-day period as a single dose per day via temporary
orogastric intubation. Seven days following the obstructive jaundice, the animal 
had laparatomy under sterile conditions. Segments of ileum were removed for
histopathological examination. Blood, liver, spleen and mesenteric lymph nodes
were taken for microbiological culture. RESULTS: Bacterial translocation rates
were 0% in the sham-operated group, 83% in group 2, 42% in group 3, 42% in group 
4 and 33% in group 5. Bacterial translocation significantly increased in group 2 
compared to groups 3, 4 and 5 (P = 0.001). The bacterial counts (CFU/g) of group 
2 were significantly higher than those of groups 3, 4 and 5 (P =
0.001).Histopathological examination of ileum specimens revealed a significant
decrease in the heights of villi in groups 2-5 compared to the sham-operated
group (P = 0.001). The mean villus height in groups 3 and 5 was significantly
higher than that of group 4 (P = 0.001). CONCLUSIONS: S. boulardii was found to
be effective in the successful control of translocation and improvement of
intestinal barrier function.

PMID: 16551414 [PubMed - indexed for MEDLINE]

224: J Hepatobiliary Pancreat Surg. 2006;13(2):172-3.

Obstructive jaundice due to a textiloma mimicking a common bile duct stone.

Cimsit B, Keskin M, Ozden I, Alper A.

Department of General Surgery, Hepatopancreatobiliary Unit, Istanbul University, 
Istanbul Faculty of Medicine, Istanbul, Turkey.

A foreign body is a rare cause of obstructive jaundice. We report a 19-year-old
woman with jaundice caused by a surgical gauze in the common bile duct (CBD).
Four yours earlier, she had undergone a cholecystectomy and drainage for hydatid 
disease of the liver. Her postoperative course was complicated by a biliary
fistula that healed after 50 days. She now presented with obstructive jaundice of
2 weeks' duration. Magnetic resonance cholangiopancreatography (MRCP) showed a
signal-void mass, consistent with a CBD stone. Surgical exploration of the CBD
revealed a surgical gauze as the cause of the obstruction. To the best of our
knowledge, this is the first case of a surgical gauze obstructing the CBD
requiring surgical removal.

Publication Types: 
    Case Reports

PMID: 16547681 [PubMed - indexed for MEDLINE]

225: J Invest Surg. 2006 Jan-Feb;19(1):19-30.

The effect of aminoguanidine on blood and tissue lipid peroxidation in jaundiced 
rats with endotoxemia induced with LPS.

Ogetman Z, Dirlik M, Caglikulekci M, Canbaz H, Karabacak T, Yaylak F, Tamer L,
Kanik A, Aydin S.

Department of General Surgery, Mersin University Medical School, Mersin, Turkey.

Obstructive jaundice (OJ) is a severe condition that leads to several
complications. One of the important problems in OJ is the increased incidence of 
endotoxemia, which is the result of bacterial translocation (BT) and defective
host immune response. Lipid peroxidation (LP) is an important problem in OJ and
sepsis in which nitric oxide (NO) production and inducible nitric oxide synthase 
(iNOS) activity are increased and antioxidative activity is decreased. Formation 
of peroxynitrite (ONOO(-)) anion leads to cellular damage and apoptosis. In this 
experimental study, we explore the effect of specific iNOS inhibitor
aminoguanidine (AG) on blood and tissue (liver and renal) LP and iNOS levels in
jaundiced rats with endotoxemia induced with lipopolysaccharide (LPS). Rats were 
randomized into six groups; group A, sham; group B, obstructive jaundice (OJ);
group C, OJ + LPS; group D, OJ + AG; group E, OJ + LPS + AG; group F, OJ + AG +
LPS. Serum malondialdehyde (MDA) and serum myeloperoxidase (MPO) activity and
liver and renal tissue MDA, MPO, and Na(+)/K(+)-ATPase activity levels were
detected in biochemical methods. Liver and renal tissue iNOS levels were examined
immunohistopathologically. Serum and tissue MDA and MPO levels and tissue iNOS
expression were increased significantly in groups B, C, and E, while tissue
ATPase levels were decreased significantly in the same groups. In the group
treated with AG (group D), serum and tissue MDA and MPO levels and tissue iNOS
expression were decreased while tissue ATPase levels were increased
significantly. In group F, if AG was administrated before LPS, we observed that
serum and tissue MDA and MPO levels and tissue iNOS expression were decreased
while tissue ATPase levels were increased significantly. Thus, our study showed
that AG had a protective effect when it was administrated before LPS, but it
failed to prevent tissue iNOS expression and LP if there was established
endotoxemia in OJ.

PMID: 16546926 [PubMed - indexed for MEDLINE]

226: Indian J Exp Biol. 2006 Mar;44(3):254-5.

Limitation of glucose oxidase method of glucose estimation in jaundiced neonates.

Chaudhuri RK, Mukherjee M, Sengupta D, Mazumder S.

Department of Biochemistry, University College of Science, University of
Calcutta, 35, Ballygunge Circular Road, Kolkata 700 019, India.

The most widely used method for estimation of plasma glucose is that adopted by
Trinder's using glucose oxidase-peroxidase (GOD-POD) system. This method gives
much lower blood glucose values with blood samples of neonatal jaundice (plasma
bilirubin level > 10 mg/dL) of age 10 +/- 5 daysthan with samples of neonates of 
the same age group without jaundice or older children suffering from other
diseases like acute respiratory distress, septicemia.

Publication Types: 
    Evaluation Studies

PMID: 16538867 [PubMed - indexed for MEDLINE]

227: Gastroenterol Clin North Am. 2006 Mar;35(1):113-23.

Medical palliation of the jaundiced patient with pruritus.

Bergasa NV.

Department of Medicine, State University of New York at Downstate, 451 Clarkson
Avenue, Brooklyn, NY 11203, USA. Bergasa@downstate.edu

Cholestasis secondary to infiltration of the liver by malignant tumors or by
obstruction of the biliary tree can be complicated by pruritus. The clinician and
ancillary personal must recognize how debilitating pruritus is and identify the
treatment of this symptom as a priority. Because robust clinical trials have not 
been conducted in patients who have pruritus with cholestasis, a network
connecting the services that provide care for these patients (eg, hospices) may
be useful for disseminating information.

Publication Types: 
    Review

PMID: 16530114 [PubMed - indexed for MEDLINE]

228: Gastroenterol Clin North Am. 2006 Mar;35(1):101-12.

Palliation of malignant obstructive jaundice.

Baron TH.

Division of Gastroenterology & Hepatology, Mayo Clinic College of Medicine, 200
First Street Southwest, Charlton 8A, Rochester, MN 55905, USA.
baron.todd@mayo.edu

Palliation of obstructive jaundice can be achieved in most patients using various
approaches. The method chosen should be individualized to the patient and based
upon performance status, patient preferences, and available expertise.The best
approach ideally should be determined by a multi-discipline approach with
endoscopists, interventional radiologists, oncologists, and surgeons.

Publication Types: 
    Review

PMID: 16530113 [PubMed - indexed for MEDLINE]

229: Rays. 2005 Jul-Sep;30(3):263-7.

Obstructive jaundice.

Scialpi M, Baraldi R, Campioni P, Mannella P.

Dipartimento di Scienze Chirurgiche, Anestesiologiche e Radiologiche Sezione di
Diagnostica per Immagini, Università di Ferrara, Italy.

The case of a 67-year-old male patient affected by ingravescent obstructive
jaundice, calcific choledocholithiasis and cardiopathic hypertension, is
presented. On sonography, marked dilatation of intra- and extrahepatic bile ducts
with a hyperechoic round neoformation was visualized. CT was performed to
ascertain the nature of the lesion. However, it did not confirm the lithiasic
nature of the stenosis. Sampling for ERCP was inadequate.
Cholangiopancreatography was therefore necessary to establish a correct diagnosis
and the subsequent therapeutic approach. Distal choledochal obstruction was
evidenced, suspicious for lithiasis obstruction. A definitive diagnosis could not
be established on exclusive imaging findings. Surgery was performed with the
diagnosis of cholangiocarcinoma with lithiasis.

Publication Types: 
    Case Reports

PMID: 16512074 [PubMed - indexed for MEDLINE]

230: Eur J Clin Invest. 2006 Mar;36(3):181-7.

Evidence for intestinal oxidative stress in patients with obstructive jaundice.

Assimakopoulos SF, Thomopoulos KC, Patsoukis N, Georgiou CD, Scopa CD,
Nikolopoulou VN, Vagianos CE.

Department of Internal Medicine, School of Medicine, University of Patras, 261 10
Patras, Greece. sassim@upatras.gr

BACKGROUND: Obstructive jaundice results in failure of the intestinal barrier
with consequent systemic endotoxemia associated with septic complications. We
have recently shown that gut barrier failure in experimental obstructive jaundice
is associated with high intestinal oxidative stress. This study was undertaken to
investigate whether oxidative alterations occur in the intestinal mucosa of
patients with obstructive jaundice. PATIENTS AND METHODS: Fifteen patients with
malignant biliary obstruction and no signs of cholangitis and 15 control patients
were subjected to duodenal biopsy to assess intestinal oxidative stress,
estimated by lipid peroxidation (malondialdehyde - MDA) and glutathione redox
state [reduced glutathione (GSH), glutathione disulphide (GSSG) and GSH/GSSG
ratio]. In addition, mucosal biopsies were examined histologically and intestinal
mucosal protein content was determined biochemically as an index of intestinal
trophic state. RESULTS: Patients with obstructive jaundice presented high levels 
of intestinal oxidative stress, with significantly increased lipid peroxidation
(P < 0.001). Glutathione redox state was also suggestive of high intestinal
oxidative stress in jaundiced patients, indicated by significantly decreased GSH 
(P = 0.001) and GSH/GSSG ratio (P = 0.006) and increased GSSG (P = 0.026).
Histological examination showed a mild infiltration of the lamina propria by
chronic inflammatory cells in obstructive jaundice, whereas duodenal architecture
remained intact and epithelial continuity was retained. Duodenal mucosa was
atrophic in jaundiced patients as indicated by a significant reduction of mucosal
protein content compared with controls (P = 0.001). Among oxidative stress
parameters, intestinal GSH exhibited a significant positive correlation with
mucosal protein content (r = 0.588, P = 0.021). CONCLUSIONS: Obstructive jaundice
in humans induces intestinal oxidative stress, which may be a key factor
contributing to intestinal barrier failure and the development of septic
complications in this patient population.

PMID: 16506963 [PubMed - indexed for MEDLINE]

231: World J Gastroenterol. 2006 Jan 14;12(2):331-5.

Treatment of malignant biliary obstruction by combined percutaneous transhepatic 
biliary drainage with local tumor treatment.

Qian XJ, Zhai RY, Dai DK, Yu P, Gao L.

Department of Interventional Radiology, Beijing Chaoyang Hospital, Capital
University of Medical Sciences, 8 Baijiazhuang lu, Chaoyang District, Beijing
100020, China. qian_xj_70@yahoo.com.cn

AIM: To evaluate the utility of local tumor therapy combined with percutaneous
transhepatic biliary drainage (PTBD) for malignant obstructive biliary disease.
METHODS: A total of 233 patients with malignant biliary obstruction were treated 
in our hospital with PTBD by placement of metallic stents and/or plastic tubes.
After PTBD, 49 patients accepted brachytherapy or extra-radiation therapy or
arterial infusion chemotherapy. The patients were followed up with clinical and
radiographic evaluation. The survival and stent patency rate were calculated by
Kaplan-Meier survival analysis. RESULTS: Twenty-two patients underwent
chemotherapy (11 cases of hepatic carcinoma, 7 cases of pancreatic carcinoma, 4
cases of metastatic lymphadenopathy), and 14 patients received radiotherapy (10
cases of cholangiocarcinoma, 4 cases of pancreatic carcinoma), and 13 patients
accepted brachytherapy (7 cases of cholangiocarcinoma, 3 cases of pancreatic
carcinoma, 4 cases of metastatic lymphadenopathy). The survival rate of the local
tumor treatment group at 1, 3, 6, and 12 months was 97.96%, 95.92%, 89.80%, and
32.59% respectively, longer than that of the non treatment group. The patency
rate at 1, 3, 6, and 12 months was 97.96%, 93.86%, 80.93%, and 56.52%
respectively. The difference of patency rate was not significant between
treatment group and non treatment group. CONCLUSION: Our results suggest that
local tumor therapy could prolong the survival time of patients with malignant
biliary obstruction, and may improve stent patency.

Publication Types: 
    Research Support, Non-U.S. Gov't

PMID: 16482640 [PubMed - indexed for MEDLINE]

232: J Neuropathol Exp Neurol. 2006 Feb;65(2):193-8.

Brain oxidative stress induced by obstructive jaundice in rats.

Chroni E, Patsoukis N, Karageorgos N, Konstantinou D, Georgiou C.

Department of Neurology, School of Medicine, University of Patras, PO Box 1045,
26504 Rion-Patras, Greece. echroni@yahoo.com

The effect of experimental obstructive jaundice on the oxidative status of brain 
tissues in rats was examined. Twenty-four male Wistar rats were divided into 4
groups: Group I was the control, group II was the sham operated, and groups III
and IV were bile duct ligated and killed on the 5th and the 10th day,
respectively. Oxidative stress was assessed by measuring the thiol redox state
(protein and nonprotein components) and lipid peroxidation level variations in
samples from the cerebral cortex, midbrain, and cerebellar tissue in all animals.
Results indicated the presence of oxidative stress in the jaundiced animals that 
was more pronounced on the 10th day as indicated by a decrease in reduced
glutathione and protein thiol and an increase in protein disulphide and lipid
peroxidation. A dramatic elevation of the level of total nonprotein mixed
disulphide level was found specifically in the midbrain in the 10th day group.
This suggests an accumulation of nonprotein disulfides other than oxidized
glutathione, which remained unchanged, in this particular brain area. This study 
showed a correlation between experimental obstructive jaundice and the oxidative 
stress in the rats' brain, implying that a similar pathogenetic mechanism may
play a key role in cholestatic liver disease, resulting in hepatic encephalopathy
in humans.

PMID: 16462210 [PubMed - indexed for MEDLINE]

233: Intensive Care Med. 2006 Feb;32(2):267-74. Epub 2006 Feb 1.

Jaundice in critical illness: promoting factors of a concealed reality.

Brienza N, Dalfino L, Cinnella G, Diele C, Bruno F, Fiore T.

Emergency and Organ Transplantation Department, Anaesthesia and Intensive Care
Unit, University of Bari, P.zza G. Cesare 11, 70124, Bari, Italy.
nbrienza@rianima.uniba.it

OBJECTIVE: In critical illness, liver dysfunction (LD) is associated with a poor 
outcome independently of other organ dysfunctions. Since strategies to support
liver function are not available, a timely and accurate identification of factors
promoting LD may lead to prevention or attenuation of its consequences. The aim
of this study was to assess risk factors for LD in critically ill patients.
DESIGN: Prospective, observational study. SETTING: A multidisciplinary intensive 
care unit (ICU) of a university hospital. PATIENTS: All patients consecutively
admitted over a 6-month period. INTERVENTION: None. MEASUREMENTS AND RESULTS: LD 
was defined as serum bilirubin levels >or=2 mg/dl and lasting for at least 48 h. 
Out of 283 patients, 141 matched inclusion criteria. Forty-four patients (31.2%) 
showed LD (LD group), while 97 (68.8%) were included in control group (C group). 
A binomial analysis showed that LD occurrence was associated with moderate (odds 
ratio [OR] 3.11; p=0.04) and severe shock (OR 3.46; p= 0.05), sepsis (OR 3.03;
p=0.04), PEEP ventilation (OR 4.25; p=0.006), major surgery (OR 4.03; p=0.03),
and gram-negative infections (OR 3.94; p=0.002). In stepwise multivariate
analysis, the single independent predictive factors of LD resulted in severe
shock (p=0.002), sepsis (p=0.03), PEEP ventilation (p=0.04), and major surgery
(p=0.05). CONCLUSIONS: In critically ill patients jaundice is common, and severe 
shock states, sepsis, mechanical ventilation with PEEP and major surgery are
critical risk factors for its onset. Since there is no specific treatment, prompt
resuscitation, treatment of sepsis and meticulous supportive care will likely
reduce its incidence and severity.

PMID: 16450099 [PubMed - indexed for MEDLINE]

234: Pediatr Res. 2006 Feb;59(2):203-9.

Transcutaneous bilirubinometry: a noninvasive tool for studying newborn jaundiced
rats before and after exposure to light.

Vreman HJ, Wong RJ, Chan ML, Young BW, Stevenson DK.

Department of Pediatrics, Stanford University School of Medicine, CA 94305, USA. 
henk.vreman@stanford.edu

The homozygous Gunn rat is the most frequently used animal model for the study of
neonatal jaundice. We evaluated the applicability of noninvasive transcutaneous
bilirubin (TcB) measurements as an index of serum total bilirubin (STB) levels in
neonatal rats by comparison to invasive STB measurements. TcB measurements were
made during the first 96 h of life with the Model 101 Minolta/Air-Shields
Jaundice Meter (JM) and SpectRx BiliCheck System (BC). Measurements with both
devices displayed parallel TcB profiles, rapidly rising within 24 h, increasing
during the next 6 h, then leveling off after 30 h. Linear regressions for the JM 
(n = 60) were as follows: STB (mg/dL) = 0.79 (JM) - 0.01 (units, r = 0.95, head);
STB (mg/dL) = 0.82 (JM) + 1.51 (units, r = 0.95, upper back); and STB (mg/dL) =
0.74 (JM) + 1.60 (units, r = 0.91, lower back). Mean bias +/- imprecision were as
follows: -0.02 +/- 3.99 mg/dL, -0.01 +/- 3.90, and 0.01 +/- 4.28 at the head,
upper back, and lower back, respectively. For the BC, only lower back
measurements were taken, and the regression was as follows: STB (mg/dL) = 0.77
(BC) + 1.65 mg/dL, (r = 0.93, n = 29) with a mean bias +/- imprecision of -1.08
+/- 3.08 mg/dL. When pups were exposed to light, correlations remained strong but
intercepts increased. These results demonstrate that noninvasive TcB measurements
correlate highly with STB in the Gunn rat during the first 96 h of life and after
exposure to light. We conclude that JM measurements at the head and BC at the
lower back reflect STB most reliably and consistently. Thus, in addition to being
a useful tool for evaluating jaundice in human neonates, TcB methodology can be
used successfully for the noninvasive monitoring of jaundice in neonatal Gunn
rats pre- and postlight exposure.

Publication Types: 
    Research Support, N.I.H., Extramural
    Research Support, Non-U.S. Gov't

PMID: 16439579 [PubMed - indexed for MEDLINE]

235: Cochrane Database Syst Rev. 2006 Jan 25;(1):CD004200.

Update in:
    Cochrane Database Syst Rev. 2006;(2):CD004200.

Palliative biliary stents for obstructing pancreatic carcinoma.

Moss AC, Morris E, Mac Mathuna P.

BACKGROUND: Palliative endoscopic stents or surgical by-pass are often required
for inoperable pancreatic carcinoma to relieve symptomatic obstruction of the
distal biliary tree. The optimal method of intervention remains unknown.
OBJECTIVES: To compare surgery, metal endoscopic stents and plastic endoscopic
stents in the relief of distal biliary obstruction in patients with inoperable
pancreatic carcinoma. SEARCH STRATEGY: We searched the databases of the Cochrane 
Upper Gastrointestinal and Pancreatic Group specialised register, Cochrane
Central Register of Controlled Trials , MEDLINE, EMBASE, CancerLit, Current
Concepts Database and BIDS (September 2002 to September 2004). Reference lists of
articles and published abstracts from UEGW and DDW were hand-searched. SELECTION 
CRITERIA: Randomised controlled trials (RCTs) comparing surgery to endoscopic
stenting, endoscopic metal stents to plastic stents, and different types of
endoscopic plastic and metal stents, used to relieve obstruction of the distal
bile duct in patients with inoperable pancreatic carcinoma. DATA COLLECTION AND
ANALYSIS: Two authors independently assessed trial quality and extracted data.
Adverse effects information was collected from the trials. MAIN RESULTS:
Twenty-one trials involving 1,454 people were included. Based on meta-analysis,
endoscopic stenting with plastic stents appears to be associated with a reduced
risk of complications (RR 0.60, 95% CI 0.45 - 0.81), but with higher risk of
recurrent biliary obstruction prior to death (RR 18.59, 95% CI 5.33 - 64.86) when
compared with surgery. There was a trend towards higher 30-day mortality in the
surgical group (p=0.07, RR 0.58, 95% CI 0.32, 1.04). There was no evidence of a
difference in technical or therapeutic success. Other outcomes were not suitable 
for meta-analysis. No trials comparing endoscopic metal stents to surgery were
identified.In endoscopic stent comparisons, metal biliary stents appear to have a
lower risk of recurrent biliary obstruction than plastic stents (RR 0.52, 95% CI 
0.39 - 0.69). There was no significant statistical difference in technical
success, therapeutic success, complications or 30-day mortality using
meta-analysis. A narrative review of studies of the cost-effectiveness of metal
stents drew conflicting conclusions, but results may be dependent on the
patients' length of survival.Neither Teflon, hydrourethane, or hydrophilic
coating appear to improve the patency of plastic stents above polyethylene in the
trials reviewed. Only perflouro alkoxy plastic stents had superior outcome to
polyethylene stents in one trial. The single eligible trial comparing types of
metal stents reported higher patency with covered stents, but also a higher risk 
of complications. These results are based on review of the trials individual
results only. AUTHORS' CONCLUSIONS: Endoscopic metal stents are the intervention 
of choice at present in patients with malignant distal obstructive jaundice due
to pancreatic carcinoma. In patients with short predicted survival, their patency
benefits over plastic stents may not be realised. Further RCTs are needed to
determine the optimal stent type for these patients.

Publication Types: 
    Meta-Analysis
    Review

PMID: 16437477 [PubMed - indexed for MEDLINE]

236: Endoscopy. 2006 Jan;38(1):90-2.

Obstructive jaundice due to isolated tuberculosis of the pancreas: endoscopic
treatment instead of surgery?

Rolny P, Falk A, Olofsson J.

Department of Medicine, Division of Gastroenterology and Hepatology, Surgery and 
Respiratory Diseases, Sahlgrenska University Hospital/Ostra and Sahlgrenska,
Göteborg, Sweden. peter.rolny@vgregion.se

The optimal treatment for relieving biliary obstruction due to isolated
pancreatic tuberculosis has not so far been defined, and most previously reported
patients were treated surgically. We describe a 17-year-old, immunocompetent girl
who was admitted with obstructive jaundice caused by a tuberculous mass in the
head of the pancreas. Antituberculous therapy alone failed to alleviate the
jaundice, and she was therefore treated by stent insertion and, subsequently,
balloon dilation of the common bile duct stricture. At follow-up 5 years later,
magnetic resonance cholangiopancreatography showed no evidence of stricture in
the common bile duct.

Publication Types: 
    Case Reports

PMID: 16429362 [PubMed - indexed for MEDLINE]

237: Gastrointest Endosc. 2006 Feb;63(2):317-20.

Biliary drainage by using stents without a central lumen: a pilot study.

Raju GS, Sud R, Elfert AA, Enaba M, Kalloo A, Pasricha PJ.

Center for Endoscopic Research, Training, and Innovation (CERTAIN), Department of
Medicine, University of Texas Medical Branch, University of Texas, Galveston,
Texas, USA.

BACKGROUND: Despite several attempts to make the conventional tubular stents with
a central lumen for flow less susceptible to a biofilm buildup and thereby
prevent clogging, this goal has remained elusive. We hypothesized that the
creation of pathways for fluid flow around the stent instead of through it would 
avoid this problem. The aim of our study was to report the development and the
evaluation of a novel lumen-less stent. METHODS: By using a software computer
modeling, a 10F "winged" stent was designed. A pilot feasibility study was
performed by using a prototype of this stent for endoscopic biliary drainage in 5
patients with malignant biliary obstruction. OBSERVATIONS: Modeling data revealed
that the winged stent offers a larger surface area for flow, higher velocity of
flow, and increased flow rates compared with the conventional tubular stent. In
the clinical trial, there was a significant decrease of serum bilirubin after the
placement of this stent (serum bilirubin before and 2 weeks after stent
placement, 14.94 +/- 5.7 mg/dL vs. 2.86 +/- 1.4 [p < 0.004]), accompanied by
radiologic evidence of decompression of the biliary system. CONCLUSIONS: We have 
shown that it is possible to provide adequate biliary drainage by using a stent
without a lumen. Such a design may have potential clinical advantages over
existing designs.

Publication Types: 
    Comparative Study

PMID: 16427942 [PubMed - indexed for MEDLINE]

238: Neth J Med. 2006 Jan;64(1):17-9.

Fascioliasis: a report of five cases presenting with common bile duct
obstruction.

Gulsen MT, Savas MC, Koruk M, Kadayifci A, Demirci F.

Division of Gastroenterology, Department of Internal Medicine, Faculty of
Medicine, University of Gaziantep, Gaziantep, Turkey.

Fascioliasis is a zoonotic infection caused by Fasciola hepatica. It is rarely
seen with icterus caused by obstruction of the common bile duct. We report five
patients with obstructive jaundice due to Fasciola hepatica, who were diagnosed
and managed with endoscopic retrograde cholangiopancreatography (ERCP). All cases
were admitted to hospital with complaints of icterus and pain in the right upper 
quadrant of the abdomen; their biochemical values were interpreted as obstructive
jaundice. Ultrasound and computer tomography (CT) revealed biliary dilatation in 
the common bile duct, but did not help to clarify the differential diagnosis.
ERCP showed the presence of Fasciola hepatica in the common bile duct. After
removing the flukes, the symptoms disappeared and the biochemical values returned
to normal. Biliary fascioliasis should be considered in the differential
diagnosis of obstructive jaundice. This report confirms the diagnostic and
therapeutic role of ERCP in patients with obstructive jaundice caused by biliary 
fascioliasis.

PMID: 16421437 [PubMed - indexed for MEDLINE]

239: Biochim Biophys Acta. 2006 Feb;1760(2):227-32. Epub 2005 Dec 19.

PLGA-microsphere mediated clearance of bilirubin in temporarily
hyperbilirubinemic rats: an alternate strategy for the treatment of experimental 
jaundice.

Ahmad N, Arif K, Faisal SM, Neyaz MK, Tayyab S, Owais M.

Inter-Disciplinary Biotechnology Unit, Aligarh Muslim University, India.

In the present study, we have demonstrated the suitability of microspheres in
removal of plasma bilirubin from systemic circulation of hyperbilirubinemic rats.
Poly (lactide co-glycolide) microspheres (PLGA microspheres) have been shown to
bind with bilirubin in both a concentration and time dependent manner. The
binding affinity of bilirubin to microspheres was enhanced when rat serum albumin
(RSA) was loaded into the microspheres. On evaluating the potential of
microspheres in elimination of bilirubin from the systemic circulation, RSA
bearing microspheres were found to be competent in both removing bilirubin from
the systemic circulation and controlling elevated plasma levels of liver function
enzymes in temporarily hyperbilirubinemic rats. On the basis of results of the
present study, we suggest that microsphere-based delivery system may help in
development of safe, effective and alternate strategy for the treatment of
hyperbilirubinemic conditions in model animals.

Publication Types: 
    Research Support, Non-U.S. Gov't

PMID: 16388906 [PubMed - indexed for MEDLINE]

240: Surg Today. 2006;36(1):89-93.

Successful cystic fenestration for a macrocystic serous cystadenoma of the
pancreas causing obstructive jaundice: report of a case.

Watanabe H, Ohtsubo K, Yamaguchi Y, Mouri H, Motoo Y, Noto M, Kitagawa H,
Kayahara M, Ohta T, Gabata T, Sakamoto S, Sawabu N.

Department of Internal Medicine and Medical Oncology, Cancer Research Institute, 
Kanazawa University, Graduate School of Medical Science, Takaramachi 13-1,
Kanazawa 920-8641, Japan.

A 72-year-old man was admitted to our hospital for investigation of jaundice. We 
made a preoperative diagnosis of macrocystic serous cystadenoma (SCA) of the
pancreas, but did not perform palliative choledochojejunostomy because aspiration
of the pancreatic cystic fluid caused the cysts to shrink and relieved the
compressive stenosis of the common bile duct (CBD) during the operation. Frozen
sections of the cyst wall taken by incision biopsy showed no signs of malignancy.
Therefore, we performed fenestration of the cystic wall after fixing the inner
epithelium of the cyst with 100% ethanol and aspirating the cystic fluid.
Cholangiography after the cystic fenestration showed resolution of the CBD
stenosis and abdominal computed tomography (CT) confirmed the disappearance of
the pancreatic cysts. No recurrence of cystic swelling or obstructive jaundice
has been detected by abdominal CT or laboratory data for more than 2 years since 
the cystic fenestration. Thus, cystic fenestration may be a better palliative
option for treating benign compressive tumors such as macrocystic SCA of the
pancreas causing obstructive jaundice.

Publication Types: 
    Case Reports

PMID: 16378203 [PubMed - indexed for MEDLINE]

241: Laryngoscope. 2005 Dec;115(12):2167-73.

The jaundiced gunn rat model of auditory neuropathy/dyssynchrony.

Shaia WT, Shapiro SM, Spencer RF.

Michigan Ear Institute, Providence Hospital, Farmington Hills, Michigan, USA.

OBJECTIVE: High levels of bilirubin are neurotoxic and may result in deafness or 
auditory neuropathy/auditory dyssynchrony (AN/AD). The jaundiced (jj) Gunn rat
animal model of kernicterus has electrophysiologic and neuroanatomic
abnormalities of brainstem auditory nuclei with normal cochlear microphonic
recordings. We examined morphologic changes in the cochlea, spiral ganglion, and 
auditory nerve and relate these findings to current understanding of AN/AD.
METHODS: At 15 days of age, jj and nonjaundiced (Nj) littermates were injected
with sulfadimethoxine (sulfa) and killed 3 days later by transcardial perfusion. 
Sections were cut through decalcified temporal bones, cochlear nerves, and
auditory brainstem and processed for light and electron microscopy and
immunohistochemical localization of calbindin-D and parvalbumin. RESULTS: Spiral 
ganglion neurons were severely degenerated with a paucity of myelinated axons in 
jj animals. Electron microscopy of the intramodilar auditory nerve revealed a
lack of large caliber axons in jj-sulfa versus Nj-sulfa controls. Large diameter 
degenerating axons were characterized by an electron-dense atrophied axis
cylinder resembling an axonopathy. CONCLUSIONS: Our findings of abnormal spiral
ganglion cells and selective loss of large, myelinated auditory nerve fibers with
no abnormalities in cochlear hair cells, support the sulfa-treated jj Gunn rat as
a model for bilirubin induced AN/AD. The paucity of large caliber neurons
undermines temporal coding of auditory information and neural synchrony and
demonstrates that in addition to brainstem auditory nuclei, spiral ganglion
neurons are selectively vulnerable to bilirubin toxicity.

Publication Types: 
    Comparative Study
    Research Support, N.I.H., Extramural

PMID: 16369161 [PubMed - indexed for MEDLINE]

242: J Gastroenterol Hepatol. 2005 Dec;20(12):1859-66.

Obstructive jaundice increases sensitivity to lipopolysaccharide via TLR4
upregulation: possible involvement in gut-derived hepatocyte growth
factor-protection of hepatocytes.

Miyaso H, Morimoto Y, Ozaki M, Haga S, Shinoura S, Choda Y, Iwagaki H, Tanaka N.

Department of Gastroenterological Surgery, Okayama University Graduate School of 
Medicine and Dentistry, Okayama, Japan.

BACKGROUND: Patients with obstructive jaundice are prone to sepsis after biliary 
tract surgery. The present study was designed to determine the effect of biliary 
obstruction on cytokine responses to lipopolysaccharide (LPS). METHODS: Wister
rats were allocated into two groups; the BDL group underwent bile duct ligation, 
followed 2 weeks later by administration of LPS into the duodenum. The control
group underwent sham operation, and similarly received enteral LPS. Specimens
were collected serially, and applied for the assays. RESULTS: Serum aspartate
aminotransferase and alanine aminotransferase levels were significantly increased
in BDL rats. High tumor necrosis factor alpha (TNF-alpha) and interleukin (IL)-6 
levels in peripheral blood were observed 2 h after LPS administration in BDL
rats. In contrast, no increases in both cytokines were noted in peripheral and
portal blood in control rats. Baseline HGF levels in portal and peripheral blood 
in BDL rats were significantly higher than in control rats. LPS significantly
increased hepatocyte growth factor (HGF) levels in portal blood and decreased in 
peripheral blood in BDL rats, but not in control rats. Immunohistochemical
analysis revealed that BDL increased expressions of Toll-like receptor (TLR)4,
CD14 and CD68 both in the small intestine and liver. Both TLR4 and CD14 mRNAs
were upregulated in the small intestine and liver after LPS administration in BDL
rats. CONCLUSION: Obstructive jaundice and LPS stimulation induced TLR4
upregulation both in the liver and small intestine, which led to increased
TNF-alpha and IL-6 production in liver and HGF production in the small intestine.
The upregulation of TLR4 may lead to pathological and host defense reactions in
obstructive jaundice complicated with Gram-negative bacterial infection.

PMID: 16336445 [PubMed - indexed for MEDLINE]

243: Pediatr Hematol Oncol. 2006 Jan-Feb;23(1):87-90.

Obstructive jaundice: an unusual initial manifestation of intra-abdominal
non-Hodgkin lymphoma in a child.

Ugur H, Tacyildiz N, Yavuz G, Unal E, Sayili A, Emir S, Kansu A, Kuloglu Z, Bahar
K.

Pediatrics Department, Ankara University School of Medicine, Ankara, Turkey.
handanprl@hotmail.com

Obstructive jaundice is an unusual manifestation of non-Hodgkin lymphomas in
children. Although surgical drainage is one of the initial treatment choices in
some cases, usually lymphomatous masses rapidly response to chemotherapy and
jaundice decreases due to regression of the mass, without any surgical procedure.
The authors report the case of a 16-year-old girl who presented with biliary
obstruction due to a neoplasm involving the duodenum. Histological examination of
the specimen, which was taken from the mass by endoscopic biopsy, revealed
Burkitt lymphoma infiltrating the duodenum. Chemotherapy including
cyclophosphamide was started immediately. In a few days, jaundice decreased
rapidly by the shrinkage of the mass. Neither surgery nor percutaneous drainage
were needed. In conclusion, biliary tract obstruction due to non-Hodgkin lymphoma
can be effectively treated with chemotherapy alone without any surgical
procedure.

Publication Types: 
    Case Reports

PMID: 16326418 [PubMed - indexed for MEDLINE]

244: Clin Chim Acta. 2006 Apr;366(1-2):357-60. Epub 2005 Nov 14.

Pseudohyponatraemia in a patient with obstructive jaundice.

le Riche M, Burgess LJ, Marais AD.

Department of Chemical Pathology, National Health Laboratory Service (NHLS),
Tygerberg Hospital, University of Stellenbosch, P.O. Box 19113, Tygerberg 7505,
Parow, South Africa. mleriche@sun.ac.za

INTRODUCTION: Pseudohyponatraemia is uncommonly associated with severe
hypercholesterolaemia. Severe hypercholesterolaemia encountered in obstructive
jaundice due to an abnormal lipoprotein, lipoprotein X (LpX), may result in
pseudohyponatraemia. CASE REPORT: We report a case of falsely low sodium
measurements in a patient with severe hypercholesterolaemia due to obstructive
liver disease. The pathophysiology, complications and analytical effects of LpX
are briefly discussed. CONCLUSION: The possibility of pseudohyponatraemia should 
be considered in severely hypercholesterolaemic samples.

Publication Types: 
    Case Reports

PMID: 16289427 [PubMed - indexed for MEDLINE]

245: Hepatobiliary Pancreat Dis Int. 2005 Nov;4(4):577-81.

Hepatic injury in rats with obstructive jaundice: roles of the protein kinase C
signal pathway and cytoprotection of fructose.

Wang JM, Wang H, Xu LN, Zou SQ.

Department of General Surgery, Tongji Hospital,Tongji Medical College, Huazhong
University of Science and Technology, Wuhan 430030, China.
wangjm18@tjh.tjmu.edu.cn

BACKGROUND: Fructose is cytoprotective during bile salt-induced apoptosis of
hepatocytes by regulating protein kinase C (PKC). This study was undertaken to
explore the regulating mechanism of hepatic injury in rats with obstructive
jaundice, and to detect the PKC signal pathway. METHODS: Rat hepatocytes were
isolated by in situ collagenase perfusion and primary culture, and pretreated
with various concentrations of PKC agonist phorbol myristate acetale (PMA) and
inhibitor chelerythrine for 20 minutes. After pretreatment, 50 mumol/L
glycochenodeoxycholate (GCDC) was added for additional 24 hours. Subsequently,
the cells were detected by FCM and TUNEL. After adding with different
concentrations of fructose and 100 mumol GCDC, the hepatocytes were evaluated by 
FCM and TUNEL. Experimental obstructive jaundice was induced with fructose and
without fructose via double ligation of the bile duct for 3, 7, 14, and 21 days. 
Apoptotic status in the liver of all rats was detected with TUNEL, and PKC
protein in the liver of obstructive jaundice (OJ) with the immunohistochemistry
method. RESULTS: PMA increased GCDC-induced apoptosis and chelerythrine decreased
GCDC-induced apoptosis in a concentration-dependent manner. Adding with different
concentration of fructose and 100 mumol GCDC, the decreased apoptotic rate was
related to the concentration of fructose. The apoptotic rate of the liver was
related to times of OJ. PKC and apoptosis index (AI) were the highest after a
14-day ligation of the bile duct without use of fructose. AI and PKC were
decreasing from a 14-day ligation of the bile duct with fructose. CONCLUSIONS:
PKC takes part in the regulation, occurrence, and progression of hepatic injury
in OJ. Fructose is cytoprotective during bile salt-induced apoptosis of
hepatocytes by regulating PKC.

PMID: 16286266 [PubMed - indexed for MEDLINE]

246: Nat Clin Pract Gastroenterol Hepatol. 2004 Nov;1(1):53-7; quiz 1 p following
57.

Cholestatic jaundice and bone lesions in an elderly woman.

Papachristou GI, Demetris AJ, Craig F, Lee KK, Rabinovitz M.

University of Pittsburgh Medical Center, PA, USA.

BACKGROUND: A 74-year-old Caucasian female presented with jaundice, clay-colored 
stools, diarrhea, and fatigue of 3 months' duration, accompanied by a weight loss
of 6.8 kg. Physical examination demonstrated mild hepatomegaly. Initial blood
work revealed abnormal liver biochemistries with a cholestatic pattern. An
abdominal CT scan showed intrahepatic bile-duct dilatation without masses but
with multiple lytic and blastic bone lesions. A sacral bone biopsy established
the diagnosis. INVESTIGATIONS: Endoscopic ultrasound, endoscopic retrograde
cholangiopancreatography, CT scan, bone biopsy and liver biopsy. DIAGNOSIS:
Systemic mastocytosis affecting the biliary system resulting in a
primary-sclerosing-cholangitis-like picture combined with diffuse blastic and
lytic bone lesions. MANAGEMENT: Biliary stenting, histamine 1- and 2-receptor
blockers, and chemotherapy (cladribine).

Publication Types: 
    Case Reports

PMID: 16265045 [PubMed - indexed for MEDLINE]

247: Abdom Imaging. 2005 Nov-Dec;30(6):748-9.

Biliary obstruction secondary to combat-related foreign bodies: report of two
cases.

Kamona A, Mansour A, Qandeel M, Al-Eshaiker M.

Department of Radiology, King Hussein Cancer Center, AL-Jubeiha, Amman, Jordan.
akamona@khcc.jo

We present two cases with combat-related hepatic injury. These patients presented
later with obstructive jaundice as seen on the percutaneous transhepatic
cholangiography. Combat-related injuries are a rare cause of obstructive
jaundice.

Publication Types: 
    Case Reports

PMID: 16252146 [PubMed - indexed for MEDLINE]

248: J Invest Surg. 2005 Sep-Oct;18(5):247-56.

The effect of platelet activating factor antagonist BN 52021 on bacterial
translocation and ICAM-I expression in experimental obstructive jaundice.

Akyürek N, Salman B, Irkörücü O, Tezcaner T, Azili C, Erdem O, Akca G, Akin O,
Tatlicioglu E.

Department of General Surgery, Gazi University School of Medicine, Ankara,
Turkey.

Expression of intracellular adhesion molecule-1 (ICAM-1) in an obstructive
jaundice model and the potential protective role of platelet activating factor
antagonist over small intestine and liver together with its effects on bacterial 
translocation are examined in this study. Forty-eight male Wistar albino rats
were assigned into four equal groups of 12. In groups I and II, animals were sham
operated. In groups III and IV, common bile duct ligation and division were
performed. In group I and group III, 0.5 ml/day normal saline was applied
intraperitoneally daily from day 2 to 6 of the study; in group II and group IV, 1
mg/kg/day BN 52021 was applied intraperitoneally daily from day 2 to 6 of the
study. All animals were sacrificed on postoperative day 7. ICAM-1 expression
(CD54 positivity) was analyzed in the liver and ileum tissue by
immunohistochemical method. Samples from blood, liver mesenteric lymph nodes, and
spleen were cultured under aerobic conditions. It is revealed that ICAM-1
expression was statistically higher in group III, with highest bacterial
translocation and liver and spleen injury when compared to other groups. Serum
alanine transaminase (ALT), aspartate transaminase (AST), alkaline phosphatase
(ALP), gamma-glutamyltranspeptidase (GGT), bilirubin, tumor necrosis factor alpha
(TNFalpha), and interleukin 1beta(IL-1beta) values were at the highest level in
group III, and there was a statistical decrease in group IV compared to group
III. The administration of BN52021 in experimental obstructive jaundice is a
useful way to reduce liver and intestinal mucosal villi damage by inhibiting
bacterial translocation and systemic inflammatory response.

PMID: 16249168 [PubMed - indexed for MEDLINE]

249: Eur J Surg Oncol. 2006 Mar;32(2):197-200. Epub 2005 Oct 24.

The effect of jaundice on the generation of anti-gastrin antibodies in G17DT
immunized patients with advanced pancreatic cancer.

Takhar AS, Gilliam AD, Watson SA, Henwood M, Rowlands BJ, Broome P, Beckingham
IJ.

Academic Unit of Cancer Studies, D Floor, West Block, Queen's Medical Centre,
University Hospital, Nottingham NG7 2UH, UK. arjun.takhar@nottingham.ac.uk

AIM: The aim of this study was to determine the ability of G17DT to generate
anti-gastrin antibodies in jaundiced patients with biliary obstruction due to
advanced pancreatic cancer. METHODS: G17DT was administered to 41 patients with
advanced pancreatic adenocarcinoma by intramuscular (i.m.) injection at a dose of
250mcg at weeks 0, 1 and 3 of the study. RESULTS: Thirty-five of 41 patients
participating in the study were categorized as responders in terms of their
gastrin-17 antibody response. There was no correlation between the maximum G17
antibody response and the bilirubin level at either week 0 or week 12. The median
survival of patients from the time of the first injection of G17DT was 204 days
with 25% of patients surviving for <or=97 days and 25% of patients surviving for 
>or=305 days. CONCLUSION: This study shows that G17DT administered to jaundiced
patients with advanced pancreatic cancer is immunogenic and well tolerated.

Publication Types: 
    Clinical Trial, Phase II

PMID: 16246519 [PubMed - indexed for MEDLINE]

250: J Surg Res. 2005 Nov;129(1):38-45.

The effect of N-acetylcysteine on pulmonary lipid peroxidation and tissue damage.

Akca T, Canbaz H, Tataroglu C, Caglikulekci M, Tamer L, Colak T, Kanik A, Bilgin 
O, Aydin S.

Department of Surgery, Mersin University Medical Faculty, Mersin, Turkey.
tacka@mersin.edu.tr

BACKGROUND: We aimed to investigate the effect of N-acetylcysteine (NAC) on
pulmonary lipid peroxidation and tissue damage in experimental obstructive
jaundice (OJ) stimulated by lipopolysaccharide (LPS) in this study. MATERIALS AND
METHODS: We randomized 40 rats into five groups. Group A: Sham (n = 8); group B: 
OJ (n = 8); group C: OJ + lipopolysaccharide (LPS; n = 8); group D: OJ + NAC +
LPS (n = 8); group E: OJ + LPS + NAC (n = 8). OJ was performed by common bile
duct ligation and division in all groups except the sham group. At the fifth day,
the rats were jaundiced. At the fifth day of OJ, LPS was injected 10 mg/kg
intraperitoneally to the rats and at the tenth day, the rats were sacrificed in
group C. In group D; at the fifth day of OJ, NAC was started 100 mg/kg
subcutaneously and the same dose NAC injection repeated every day for 5 days. At 
the tenth day of OJ, LPS was injected 10 mg/kg intraperitoneally to the rats and 
then after 6 h they were sacrificed. In group E; 10 mg/kg LPS was administered
intraperitoneally at fifth day of OJ and after then NAC was started 100 mg/kg
subcutaneously and the same dose NAC injection repeated every day for 5 days and 
at the tenth day, the rats were sacrificed. Tissue samples were harvested through
a midline incision, and lungs were resected and examined histopathologically and 
immunohistochemically for tissue damage scoring. The blood was taken by cardiac
puncture and malondialdehyde (MDA), myeloperoxidase (MPO), and levels of total
antioxidant status were detected with biochemical methods to evaluate lung tissue
damage. RESULTS: Increase in lung and serum MDA and MPO levels, as well as
decrease in total antioxidant status, were observed in groups B and C when
compared with the sham group (P = 0.0001, for each comparison). Furthermore, the 
lung tissue damage was observed in the same groups by histopathological
examination when compared with sham group. There was significant decrease at
serum and lung MPO and MDA levels after the NAC application in groups D and E,
when compared with group C (P = 0.0001, for each comparison). Antioxidant status 
in groups D and E were increased in the presence of NAC (P = 0.0001, for each
comparison). Lung histology was prevented relatively in group D when compared
with groups B and C. CONCLUSION: Results of the study indicate that NAC has
protective effect on pulmonary lipid peroxidation and tissue damage before and
after LPS administration.

PMID: 16243047 [PubMed - indexed for MEDLINE]

251: Dig Liver Dis. 2006 Oct;38(10):768-71. Epub 2005 Oct 19.

Extra-hepatic hepatocellular carcinoma presenting as obstructive jaundice.

Batsis JA, Halfdanarson TR, Pitot H.

Department of Medicine, Mayo School of Graduate Medical Education, Mayo Clinic
College of Medicine, 200 First Street SW, Rochester, MN 55905, USA.
batsis.john@mayo.edu

Hepatocellular carcinoma is a neoplasm with a uniformly poor prognosis. Risk
factors for its development include chronic hepatitis B or C infection,
haemochromatosis and alpha-1-antitrypsin deficiency, but individuals with any
type of chronic liver disease are predisposed. The incidence is significantly
higher in Asia and Africa although it has been noted to be increasing in the
United States. We present a patient with notable atypical clinical features for
hepatocellular carcinoma. The patient had neither predisposing risk factors nor a
primary liver lesion causing obstructive jaundice. After multiple tissue
specimens were obtained, the final pathological diagnosis was established.
Hepatocellular carcinoma generally requires a surgical cure, but patients who are
icteric often portend poorer prognoses. For those at high risk, screening may be 
indicated to identify early curative treatment.

Publication Types: 
    Case Reports

PMID: 16243009 [PubMed - indexed for MEDLINE]

252: Asian J Surg. 2005 Oct;28(4):301-4.

Burkitt's lymphoma: an unusual cause of obstructive jaundice.

Kessel B, Moisseiev E, Korin A, Soimu U, Ashkenazi I, Asquenasi A, Groissman G,
Alfici R.

Department of Surgery B, Hillel Yaffe Medical Center, Hadera, Israel.
trauma@hillel-yaffe.health.gov.il

Biliary obstruction secondary to malignancy is a common clinical problem. Rarely,
biliary obstruction is due to non-Hodgkin's lymphoma. Obstructive jaundice in
these patients usually presents late in the course of the disease. Burkitt's
lymphoma is a subtype of non-Hodgkin's lymphoma. Unlike other forms of
non-Hodgkin's lymphoma, Burkitt's lymphoma presents as an extranodal disease. We 
present the case of a patient suffering from non-endemic Burkitt's lymphoma whose
initial presenting symptom was obstructive jaundice.

Publication Types: 
    Case Reports

PMID: 16234085 [PubMed - indexed for MEDLINE]

253: Singapore Med J. 2005 Nov;46(11):621-6.

Endoscopic retrograde cholangiopancreatography in the elderly: outcomes, safety
and complications.

Chong VH, Yim HB, Lim CC.

Gastroenterology Unit, Department of Medicine, RIPAS Hospital, Bandar Seri
Begawan BA1710, Negara Brunei Darussalam. chongvuih@yahoo.co.uk

INTRODUCTION: As the population ages, the incidence of biliary tract pathologies 
also increases, leading to an increase in the demand for endoscopic retrograde
cholangiopancreatography (ERCP) interventions. Our aims are to assess the
outcomes, safety and complications associated with ERCP performed in an elderly
population. METHODS: Patients aged 80 years or over referred for ERCP from
January 1999 to September 2002, were identified and retrospectively reviewed.
RESULTS: 103 patients (68 females, mean age 84.6 +/- 3.9 years old) underwent 144
procedures (1-6 procedures/patient). The main indications were cholangitis (51.4 
percent), choledocholithiasis (19.4 percent) and blocked stents (14.6 percent).
Malignancies represented 5.6 percent of indications. The mean procedure time was 
38 +/- 16 minutes. The overall success rate was 80.5 percent. Minor events
occurred in 23 percent (tachycardia 13, desaturation six, transient hypotension
six, self-limiting bleed four, extravasations three, and mild pancreatitis one). 
Major events were post sphincterotomy bleeding (five days post-procedure) one,
duodenal perforation one (Billroth-II gastrectomy, survived after surgery),
cholangitis two, and one death was probably procedure-related (acute myocardial
event five days post-stenting in a patient with Klatskin tumour). Seven deaths
occurred within one month of ERCP, due to advanced malignancies (four), sepsis
(two) and acute myocardial infarction (one). Patients who died within one month
had significantly higher serum urea (p-value equals 0.001), and creatinine
(p-value equals 0.007) levels, and lower haemoglobin (p-value equals 0.014)
level. More patients had an underlying malignancy (p-value less than 0.001). In
addition, they were given significantly less conscious sedation (midazolam
[p-value equals 0.002] and fentanyl [p-value equals 0.018]). CONCLUSION: Our
study showed that ERCP is safe in an elderly Asian population. Minor
complications are usually transient and related to sedation, and mortality is
usually related to severity of illness and underlying malignancies.

PMID: 16228093 [PubMed - indexed for MEDLINE]

254: J Surg Res. 2006 Jan;130(1):119-23. Epub 2005 Oct 13.

Phenylalanine breath test as a method to evaluate hepatic dysfunction in
obstructive jaundice.

Aoki M, Ishii Y, Ito A, Khono T, Takayama T.

Department of Digestive Surgery, Nihon University School of Medicine, Tokyo,
Japan.

BACKGROUND: The purpose of this study was to investigate whether the hepatic
dysfunction associated with obstructive jaundice can be measured from changes in 
expiratory 13CO2 levels after intravenous administration of
l-[1-(13)C]phenylalanine, using a rat model of obstructive jaundice. MATERIALS
AND METHODS: Under pentobarbital anesthesia, bile duct ligation (BDL) was
performed (n=12). In the control group, simple laparotomy was performed (n=12).
On postoperative day 7, 20 mg/kg l-[1-(13)C]phenylalanine was administered via
the femoral vein. Phenylalanine breath test (PBT) was performed for 30 min. We
compared single point of 13CO2 level (SPT: T: min) and sum of 13CO2 output (ST)
values between BDL and control rats. We examined the correlation of SPT or ST
with phenylalanine hydroxylase activity (PHA) and blood chemical parameters.
RESULTS: Both SPT and ST values decreased in BDL compared to control 3 min after 
the start of PBT (SP10; 103+/-12 (per thousand) versus 84+/-16 (per thousand)
P=0.025). PHA/g liver in BDL was significantly decreased compared to control
(40.81+/-4.80 (U) versus 28.93+/-9.60 (U) P=0.008). PHA/g liver was correlated
with SPT with correlation coefficient of more than 0.715, 10 min after the start 
of PBT, and the maximum correlation was at SP20 (r=0.801). Blood chemical
parameters were correlated with S15 (total bilirubin, r=-0.717; alkaline
phosphatase, r=-0.841; gamma-glutamyl transpeptidase, r=-0.759; alanine
aminotransferase, r=-0.776; albumin, r=0.819). CONCLUSIONS: In the breath test
with intravenously l-[1-(13)C]phenylalanine, hepatic dysfunction associated with 
obstructive jaundice could be measured in a short period.

PMID: 16226276 [PubMed - indexed for MEDLINE]

255: Eur J Gastroenterol Hepatol. 2005 Nov;17(11):1229-32.

Obstructive jaundice secondary to neuroendocrine tumour in a patient with von
Recklinghausen's disease.

Samonakis DN, Quaglia A, Joshi NM, Tibballs JM, Nagree A, Triantos CK, Davies N, 
Standish R, Dhillon AP, Davidson BR, Burroughs AK, Caplin ME.

Liver Transplantation and Hepatobiliary Unit, Royal Free Hospital, London, UK.

Neurofibromatosis type 1 (NF1) is an autosomal dominant genetic disorder, with
variable clinical manifestations and unpredictable course, associated with an
increased incidence of various tumours. Plexiform neurofibromas are hallmark
lesions of NF1; they are slow-growing tumours, which account for substantial
morbidity, including disfigurement and functional impairment, and may even be
life-threatening. Neuroendocrine tumours (NETs), a rare diverse group of
neoplasms, are occasionally associated with neurofibromatosis. Pancreatic NETs
are tumours with an incidence of less than 1/100 000 population/year and complex 
patterns of behaviour, which often need complicated strategies for optimal
management. We present the case of a young adult with NF1, having a unique
concurrence of plexiform neurofibroma involving the liver with an ampullary NET, 
and we discuss step by step the management in a specialist centre.

Publication Types: 
    Case Reports

PMID: 16215436 [PubMed - indexed for MEDLINE]

256: Surg Infect (Larchmt). 2005 Fall;6(3):323-8.

Risk of postoperative infection in patients with bactibilia undergoing surgery
for obstructive jaundice.

Namias N, Demoya M, Sleeman D, Reever CM, Raskin JB, Ginzburg E, Minhaj M, Pappas
PA, Padron I, Levi JU.

Miller School of Medicine Department of Surgery, University of Miami, Miami,
Florida 33101, USA. nnamias@miami.edu

BACKGROUND: This study was performed to investigate the relationship between
bactibilia and postoperative infection in patients undergoing surgery for
obstructive jaundice. METHODS: With IRB approval, we prospectively examined 76
patients undergoing surgery for obstructive jaundice. It was the routine practice
of the surgeons performing the operations to culture the common bile duct bile
(CBDB). Rates of postoperative infection were analyzed with regard to the effect 
of positive bile cultures and biliary instrumentation preoperatively. RESULTS:
Seventy-one patients had CBDB cultures, 16 of whom had bactibilia. Bactibilia was
present in 15 of 47 (33%) who had preoperative ERCP versus one of 24 (4%) of
those without preoperative ERCP (p = 0.0075). Postoperative infection, including 
pneumonia, bloodstream, central venous catheter, surgical site, intraabdominal,
and urinary tract infection, occurred in six of 16 (38%) of those with bactibilia
versus four of 55 (7%) of those without bactibilia (p = 0.0071). CONCLUSIONS:
Preoperative ERCP was associated with an approximately eightfold increase in the 
likelihood of having culture-positive bile at the time of surgery for obstructive
jaundice. Additionally, culture-positive bile at the time of surgery was
associated with a greater than fivefold incidence of postoperative infection.

PMID: 16201942 [PubMed - indexed for MEDLINE]

257: Zhonghua Wai Ke Za Zhi. 2001 Dec;39(12):897-900.

The relationship between protein kinase C signal pathway and the immunologic
evaluation in patients with obstructive jaundice.

Zou S, Wang J.

Department of Surgery, Tongji Hospital, Tongji Medical College, Huazhong
University of Science and Technology, Wuhan, 430030, China.

OBJECTS: To explore the roles of the protein kinase C (PKC) signal pathway in
immunologic evaluation of patients with obstructive jaundice. METHODS: PKC from
cytosolic and membrane fractions of peripheral blood lymphocytes (PBL) was
isolated and purified, then its activities were determined by radioactive isotope
gamma-32P-ATP-catalyzing assay. RESULTS: Total PKC activities in PBL in patients 
with obstructive jaundice were significantly (r = 0.64, P < 0.01) increased as
compared to those in normal subjects. Moreover, the membrane PKC activities and
their percentages of the total PKC activities were higher in the patients with
obstructive jaundice than in normal subjects (r = 0.63, P < 0.05). The total PKC 
activities in PBL were significantly correlated with the levels of soluble IL-2
receptor (sIL-2R) (r = 0.67, P < 0.01) and the degree of jaundice (T-BIL) (r =
0.58, P < 0.01) in serum. CONCLUSIONS: The activities of the PKC signal pathway
is related to the degree of T-BIL. PKC may be implicated in the activation of
T-lymphocytes in patients with obstructive jaundice. It is suggested that the
role of the PKC signal pathway may be important in the immune regulation and the 
assessment of pathosis in patients with obstructive jaundice.

PMID: 16201164 [PubMed - indexed for MEDLINE]

258: J Huazhong Univ Sci Technolog Med Sci. 2005;25(4):435-8.

Roles of protein kinase C and fructose in hepatic injury caused by obstructive
jaundice.

Wang J, Wang H, Xiao B, Zou S.

Department of General Surgery, Tongji Hospital, Tongji Medical College, Huazhong 
University of Science and Technology, Wuhan 430030, China.

The regulating mechanism in hepatic injury caused by obstructive jaundice (OJ)
was examined in this study. Rat hepatocytes were harvested by in situ collagenase
perfusion and subjected to primary culture. The heptocytes were pre-treated with 
various concentrations of protein kinase C (PKC) agonist PMA and its inhibitor
chelerythrine and cultured for 20 min. After the treatment, 50 micromol/L
glycochenodeoxycholate (GCDC) was added and the cells were cultured for an
additional 24 h. Cells were then detected by flow cytometry (FCM) and TUNEL.
After hepatocytes were treated with different concentrations of fructose and 100 
microM GCDC, the cells were examined by FCM and TUNEL. Experimental obstructive
jaundice (BDL) was induced by double ligation of the bile duct. After BDL, the
rats were fed with or without fructos and sacrificed 3, 7, 14 and 21 days after
the ligation. The apoptotic status was observed in liver of all rats with TUNEL
and PKC protein in liver of OJ was studied by immunohistochemical method. Our
results showed that PMA increased GCDC-induced apoptosis and chelerythrine
decreased GCDC-induced apoptosis in a concentration-dependent manner. After the
treatment with fructose of different concentrations, 100 microM GCDC decreased
the apoptotic rate and the apoptotic rate decreased with the increase of fructose
concentration. The apoptotic rate of liver was related to the time of OJ. Without
the treatment of fructose, PKC and apoptosis index (AI) were highest 14 days
after the bile duct ligation. With the treatment of fructose, apoptosis index
(AI) and PKC were decreased from the 14th day after the bile duct ligation. It is
concluded that PKC is involved in the regulation of apoptosis in the liver cells 
with OJ and plays important roles in the development and progression of liver
injury caused by OJ. Fructose can protect hepatocytes in the bile salt-induced
apoptosis by regulating PKC.

Publication Types: 
    Research Support, Non-U.S. Gov't

PMID: 16196296 [PubMed - indexed for MEDLINE]

259: Dig Surg. 2005;22(5):295-304; discussion 305. Epub 2005 Sep 28.

Role of palliative endoscopic drainage in patients with malignant biliary
obstruction.

Hammarstrom LE.

Department of Surgery, Angelholms Sjukhus, Angelholm, Sweden.
le.hammarstrom@lund.mail.telia.com

BACKGROUND: Endoscopic biliary drainage for malignant obstructive jaundice is a
viable palliative alternative, but its role and cost-effectiveness compared to
percutaneous drainage or surgical bypass are subject to debate. AIM: To review
the evidence in the literature with regard to the settings in which endoscopic
drainage favorably compares with and affords palliation and quality of life
comparable to percutaneous drainage or surgical bypass in malignant obstructive
jaundice patients. METHOD: Using PubMed, Embase, Current Contents, and Medline, a
literature search was performed for papers published from 1979 to April 2004. All
retrieved papers comparing endoscopic drainage with percutaneous or surgical
drainage, with special reference to the level of obstruction, were rated
according to the strength of evidence and carefully analyzed. RESULTS AND
CONCLUSIONS: Palliative drainage affords improved quality of life. The outcome of
endoscopic and percutaneous drainage was similar, but data were few and
inconsistent. Due to fewer late complications, surgical bypass is an alternative 
to metal stents (Wallstenttrade mark) which remain patent longer than plastic
stents (large-bore polyethylene), with an overall median of 180 and 109 days,
respectively, in patients who survive longer than about 6 months, which cannot be
accurately predicted though. Overall early and late morbidity, stent patency, and
survival were similar in patients treated for hilar compared to distal
obstruction. Copyright (c) 2005 S. Karger AG, Basel

Publication Types: 
    Review

PMID: 16192728 [PubMed - indexed for MEDLINE]

260: Int J Urol. 2005 Aug;12(8):757-9.

Stauffer's syndrome variant associated with renal cell carcinoma.

Giannakos G, Papanicolaou X, Trafalis D, Michaelidis I, Margaritis G,
Christofilakis C.

1st Department of Internal Medicine, 401 General Army Hospital of Athens, Athens,
Greece.

Cholestasis, as a paraneoplastic syndrome, has been well described in patients
with malignant lymphohyperplastic diseases and renal cell cancer. Non-metastatic 
nephrogenic hepatic dysfunction syndrome without jaundice has often been
described in patients with Stauffer's syndrome. Paraneoplastic cholestatic
jaundice is extremely uncommon. We report, a patient who presented with pruritus 
and cholestatic jaundice and was diagnosed with renal cell carcinoma (RCC) in the
right kidney. Liver malfunction and cholestatic icterus was attributed to RCC.
Jaundice and liver dysfunction gradually restored to normal after surgical
resection of the tumor. Malignancies may cause cholestatic jaundice through
well-recognized mechanisms. Paraneoplastic syndromes associated with malignancy, 
can induce a reversible form of cholestasis through an unclear pathogenetic
mechanism.

Publication Types: 
    Case Reports

PMID: 16174051 [PubMed - indexed for MEDLINE]

261: East Afr Med J. 2005 Jul;82(7):379-81.

Validity of ultrasonography in diagnosing obstructive jaundice.

Admassie D, H/Yesus A, Denke A.

Department of Radiology, Faculty of Medicine, Addis Ababa University, P.O. Box
9086, Addis Ababa, Ethiopia.

OBJECTIVE: To evaluate the validity of ultrasonography in patients who have
obstructive jaundice. DESIGN: A descriptive retrospective study. SETTING:
Surgical Department, Tikur Anbessa Teaching Hospital, Addis-Ababa, Ethiopia.
SUBJECTS: A total of 49 patients; 15 male and 34 female underwent operation for
obstructive jaundice. RESULTS: The cause of obstructive jaundice identified by
ultrasonography with reasonable sensitivity of 90% and specificity of 79% for
choledocholithiasis and sensitivity of 50% and specificity of 90% for pancreatic 
head tumours. The degree of common bile duct enlargement was significantly higher
when the cause for obstruction was malignant, originating from the head of
pancreas or distal end of the common bile duct. CONCLUSION: Ultrasonography
should be the first and best initial imaging procedure in patients who have
obstructive jaundice and shows reasonable sensitivity and specificity to identify
causes of obstruction in obstructive jaundice. These findings may act also as a
base for which further studies on validity of ultrasonography in the diagnosis of
obstructive jaundice could be carried out.

Publication Types: 
    Clinical Trial
    Validation Studies

PMID: 16167714 [PubMed - indexed for MEDLINE]

262: Pediatr Hematol Oncol. 2005 Oct-Nov;22(7):561-6.

Glucose-6-phosphate dehydrogenase deficiency and Gilbert syndrome: a gene
interaction underlies severe jaundice without severe hemolysis.

Nicolaidou P, Kostaridou S, Mavri A, Galla A, Kitsiou S, Stamoulakatou A.

Third Department of Pediatrics, University of Athens, Attikon Hospital, Athens,
Greece.

The authors describe the paradoxical clinical phenotype of an undetected severe
hemolysis in parallel with the development of severe jaundice in a 13-year-old
male suffering from a confirmed interaction of glucose-6-phosphate dehydrogenase 
deficiency (Mediterranean variant, 563 C/T) and Gilbert syndrome [variant
(TA)7/(TA)7]. The child had 2 acute hemolytic episodes at the age of 10 and 13
years following infections of unknown origin. Both episodes were characterized by
considerably high bilirubin levels (1st episode: 10.8 mg/dL, 2nd episode: 17.8
mg/dL) associated with unexpectably mild hemolysis indices (1st episode
hemoglobin levels, 11.1 g/dL; reticulocyte counts, 2.5%; 2nd episode hemoglobin
values, 12.7 g/dL; reticulocyte counts, 2.5%). During the steady-state condition 
of the child, hemoglobin values were within the normal ranges for his age (14.2
g/dL) and bilirubin levels were slightly elevated (1.70 mg/dL, indirect 1.5
mg/dL). The interaction of the two genetic abnormalities in the causation of this
odd clinical phenotype is discussed.

Publication Types: 
    Case Reports

PMID: 16166048 [PubMed - indexed for MEDLINE]

263: World J Surg. 2005 Oct;29(10):1329-34.

Effect of oral glutamine administration on bacterial tanslocation, endotoxemia,
liver and ileal morphology, and apoptosis in rats with obstructive jaundice.

Margaritis VG, Filos KS, Michalaki MA, Scopa CD, Spiliopoulou I, Nikolopoulou VN,
Vagianos CE.

Department of Gastroenterology, University of Patras, School of Medicine, Patras 
26500, Greece.

Postoperative complications in patients with obstructive jaundice remain
increased when associated with endotoxemia and the inflammatory response due to
gut barrier failure. Administration of glutamine has been proposed to maintain
the integrity of the gut mucosa and thus reduce bacterial translocation (BT), but
the effects of this pretreatment on apoptosis and histologic morphology of
various organs affected by BT in obstructive jaundice have not been studied. We
therefore studied the effects of oral glutamine supplementation on endotoxemia,
BT, liver and terminal ileal morphology, and apoptosis in an experimental model
of obstructive jaundice. A total of 60 male Wistar rats were randomly divided
into four groups of 15 each: I, controls; II, sham-operated; III, bile duct
ligation (BDL); IV, BDL + glutamine (4.5 g/kg/day in drinking water). Ileal
samples for histology, DNA and protein content, liver biopsies, mesenteric lymph 
nodes (MLNs) for culture, and portal and systemic blood samples for endotoxin
measurements were obtained 10 days later. Compared to the controls, a significant
increase in contaminated MLN and liver samples and increased endotoxemia were
noted in group III (p < 0.01) but were significantly reduced in group IV (p <
0.05). Group IV also had a significantly higher number of mitoses per crypt (M/c)
(p < 0.05), less apoptotic body counts (ABCs) (p < 0.05), and a higher DNA
content than did group III (p < 0.05). Liver biopsies from group III displayed
typical changes of large duct obstruction that significantly improved after
glutamine treatment, with decreased ductular proliferation.We concluded that
supplementation of oral glutamine in the presence of obstructive jaundice
ameliorates BT, endotoxemia, and apoptosis and improves the ileal and liver
histology.

Publication Types: 
    Evaluation Studies

PMID: 16136290 [PubMed - indexed for MEDLINE]

264: Hepatobiliary Pancreat Dis Int. 2005 Aug;4(3):445-9.

Effects of recombinant human growth hormone on intestinal translocation of
bacteria and endotoxin in rats with obstructive jaundice.

Yang ZW, Li JG, Mao XG, Sun B, Tong ZS, Sun HY, Li XR, Cong YP.

Department of General Surgery, Heilongjiang Provincial Hospital, Harbin 150036,
China. Zhaoliangyan2003@163.com

BACKGROUND: Extrahepatic biliary obstruction promotes intestinal translocation of
bacteria and endotoxin and this process is an important cause of morbidity and
mortality in patients with jaundice. This study was undertaken to investigate the
effect and mechanism of recombinant human growth hormone(rhGH) and to alleviate
intestinal translocation of bacteria and endotoxin in murine obstructive
jaundice. METHODS: A group of 42 Wistar rats were divided into 3 groups:sham
operation(SO), bile duct ligation (BDL), and BDL and rhGH treatment(rhGH). By the
end of the experiment, on day 7, the animals were killed, and their liver
function and serum endotoxin were measured, bacterial cultures of the liver,
kidney and mesenchymal lymph were made. Terminal ileum mucosa was observed under 
an electron microscope. RESULTS: Liver function was improved more significantly
in the rhGH group than in the BDL group. The value of endotoxin in the rhGH group
was 0.38+/-0.03 EU/ml, significantly lower than that in the BDL group(0.65+/-0.04
EU/ml, P < 0.01), and similar to that in the SO group (0.30+/-0.02 EU/ml, P >
0.05). The rate of bacteria translocation in the liver, kidney and mesenteric
lymph was much higher in the BDL group than in other two groups. The rate of
bacteria translocation in mesenteric lymph was 64.29%, significantly higher than 
that in the SO group and the rhGH group (P < 0.05). There was no significant
difference in bacteria translocation rate between the SO group and the rhGH group
(P > 0.05). Under an electron microscope, ileum mucosa epithelial cells in the
BDL group were necrotic, and organelle were markedly metamorphic. In the rhGH
group, ultrastructural changes were less evident or similar to those in the SO
group. CONCLUSION: rhGH has significant protective effects on intestinal mucosa
barrier in obstructive jaundice, and reduces intestinal translocation of bacteria
and endotoxin.

Publication Types: 
    Research Support, Non-U.S. Gov't

PMID: 16109534 [PubMed - indexed for MEDLINE]

265: J Gastroenterol Hepatol. 2005 Sep;20(9):1322-32.

Jaundice in malaria.

Anand AC, Puri P.

Department of Medicine, Armed Forces Medical College, Pune, India.
anilcanand@sify.com

Jaundice is not an unusual accompaniment of malaria. It can occur due to
intravascular hemolysis, disseminated intravascular coagulation, and, rarely,
'malarial hepatitis'. Although the primary schizogony of the malarial parasite
always leads to the rupture of the infected hepatocyte, alteration of the hepatic
functions is uncommonly recorded due to this event. Histologically, the hepatitis
or the actual inflammation in the liver has never been demonstrated. Nonetheless,
the term 'malarial hepatitis' (MH) has been used in the literature to describe
the occurrence of hepatocellular jaundice in patients with Plasmodium falciparum 
infection. The authors' own data and review of the literature indicate that it is
not an uncommon entity. In endemic areas, jaundice is seen in approximately 2.5% 
of patients with falciparum malaria. It also appears to be a heterogeneous
syndrome and one can recognize two clinical subsets. In one group there was an
acute, virulent presentation with coma, renal failure and in some cases even
hemorrhagic manifestations. It is only in this setting that jaundice signified a 
'severe' disease as noted by the World Health Organization action program. This
presentation is often confused with acute viral hepatitis and acute hepatic
failure in non-endemic areas, but can be clinically differentiated. Copyright
2005 Blackwell Publishing Asia Pty Ltd.

Publication Types: 
    Review

PMID: 16105116 [PubMed - indexed for MEDLINE]

266: Ir J Med Sci. 2005 Apr-Jun;174(2):60-2.

Giant solitary non-parasitic cyst of the liver.

Tucker ON, Smith J, Fenlon HM, McEntee GP.

Department of Surgery, Mater Misericordiae Hospital, Eccles St., Dublin 7.
otucker@rcsi.ie

BACKGROUND: Cystic diseases of the liver and intrahepatic biliary tree are
uncommon. The majority of cases are detected only when patients become
symptomatic, or as an incidental finding on radiological imaging. METHODS: We
discuss the case of a 25-yr-old female with a centrally located giant liver cyst 
causing obstructive jaundice, and briefly discuss the management options in the
treatment of this uncommon problem. RESULTS AND CONCLUSIONS: Intervention is
recommended in patients with symptomatic simple cysts of the liver. Surgical
cystectomy is the treatment of choice for large deep seated cysts.

Publication Types: 
    Case Reports

PMID: 16094916 [PubMed - indexed for MEDLINE]

267: Br J Surg. 2005 Nov;92(11):1388-92.

Multivariate analysis of factors associated with renal dysfunction in patients
with obstructive jaundice.

Padillo FJ, Cruz A, Briceño J, Martin-Malo A, Pera-Madrazo C, Sitges-Serra A.

Department of Surgery, Hospital Reina Sofía, Córdoba, Barcelona, Spain.

BACKGROUND: The aim was to evaluate the factors determining preoperative renal
dysfunction in patients with obstructive jaundice. METHODS: In a prospective
cross-sectional observational study, 63 patients, 27 with benign and 36 with
malignant obstructive jaundice, were investigated at admission and compared with 
25 healthy control subjects. Variables analysed included extracellular body water
(ECW) compartment, plasma levels of aldosterone, renin, atrial natriuretic
peptide, vasopressin, nitric oxide, endothelin (ET) 1 and prostaglandin E2
(PGE2), urinary nitric oxide and PGE2, serum albumin and renal function. RESULTS:
The metabolic profile of obstructive jaundice was characterized by a depletion of
the ECW (P = 0.004), and increased plasma levels of atrial natriuretic peptide (P
< 0.001), ET-1 (P = 0.044), vasopressin (P = 0.017), aldosterone (P = 0.005) and 
renin (P = 0.001). Increased plasma (P < 0.001) and urinary (P = 0.001) PGE2
levels were also found. Fifty-four per cent of patients had a creatinine
clearance of less than 70 ml/min. In multivariate analysis, serum bilirubin,
renin, ET-1, PGE2, decreased urinary sodium excretion and age were identified as 
predictors of renal dysfunction. CONCLUSIONS: Renal dysfunction in patients with 
obstructive jaundice was associated with the degree of biliary obstruction, age
of the patient and reduced urinary sodium excretion. These alterations were
closely related to derangements in sodium- and water-regulating hormones.

Publication Types: 
    Research Support, Non-U.S. Gov't

PMID: 16078295 [PubMed - indexed for MEDLINE]

268: J R Soc Med. 2005 Aug;98(8):357-9.

Comment in:
    J R Soc Med. 2005 Dec;98(12):532.

Jaundice as a presentation of heart failure.

van Lingen R, Warshow U, Dalton HR, Hussaini SH.

Cornwall Gastrointestinal Unit, Royal Cornwall Hospital Trust, Truro TR1 3LJ, UK.

On rare occasions the first manifestation of heart disease is jaundice, caused by
passive congestion of the liver or acute ischaemic hepatitis. We looked for this 
presentation retrospectively in 661 patients referred over fifty-six months to a 
'jaundice hotline' (rapid access) service. The protocol included a full clinical 
history, examination and abdominal ultrasound. Those with no evidence of biliary 
obstruction had a non-invasive liver screen for parenchymal liver disease and
those with suspected heart disease had an electrocardiogram, chest X-ray and
echocardiogram. 8 patients (1.2%), bilirubin 31-79 micromol/L, mean 46
micromol/L, had a primary cardiac cause for their jaundice. All had dyspnoea, an 
increased cardiothoracic ratio on chest X-ray and an abnormal electrocardiogram. 
The jugular venous pressure was raised in the 3 in whom it was recorded. In 6
patients the jaundice was attributed to hepatic congestion and in 2 to ischaemic 
hepatitis. All patients had severe cardiac dysfunction. Jaundice due to heart
disease tends to be mild, and a key feature is breathlessness. The most common
mechanism is hepatic venous congestion; ischaemic hepatitis is suggested by a
high aminotransferase.

PMID: 16055900 [PubMed - indexed for MEDLINE]

269: Pediatr Surg Int. 2005 Sep;21(9):752-4. Epub 2005 Oct 20.

Obstructive jaundice in a child with pancreatic hemangioma.

Hibi M, Tokiwa K, Fukata R, Nakajima F.

Department of Pediatric Surgery and Maizuru Medical Center, National Hospital
Organization, Maizuru-city, Kyoto, Japan. mhibi@fujita-hu.ac.jp

We report the case of a 2-year-old boy who presented with obstructive jaundice by
pancreatic hemangioma. In this case, a minimal operation for obstructive jaundice
without resection of the tumor was performed. Three years after the operation,
the pancreatic hemangioma almost disappeared. We discuss treatment of the
pancreatic hemangioma in children.

Publication Types: 
    Case Reports

PMID: 16047179 [PubMed - indexed for MEDLINE]

270: J Invest Surg. 2005 May-Jun;18(3):107-13.

Evaluation of Pringle maneuver during liver resection in a rat model of surgical 
obstructive jaundice.

Chinnakotla S, Pande GK, Sahni P, Gupta SD, Maulik M, Kumari R, Nundy S,
Chattopadhyay TK.

Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, 
New Delhi, India. srinathc@baylorhealth.edu

Temporary portal triad clamping (Pringle maneuver) during liver resection reduces
intraoperative blood loss. A normal liver can safely tolerate normothermic
ischemia for up to 60 min. However, its safety in patients with surgical
obstructive jaundice (SOJ) is not known. Therefore, we investigated the effect of
hepatic ischemia in an experimental rat model of SOJ created by ligating the bile
duct. Four groups of rats were created: Group I (sham operation, 10 days later,
liver resection); Group II (sham operation, 10 days later, liver resection with 5
min of hepatic ischemia); Group III (bile duct ligation, 10 days later, liver
resection); and Group IV (bile duct ligation, 10 days later, liver resection with
5 min of hepatic ischemia). The ischemic injury was assessed by the survival of
rats, liver tissue malondialdehyde and total glutathione (markers of free radical
injury), serum alanine aminotransferase, aspartate aminotransferase, and liver
histology. The results showed decreased survival (47.6% vs. 90% [p = .046]),
increased liver tissue malondialdehyde (161 +/- 35 vs. 129 +/- 33 microg/gm liver
tissue [p = .05]), and decreased liver tissue total glutathione (565 +/- 169 vs. 
1075 +/- 276 nmol/gm liver tissue [p = .05]) in rats with SOJ subjected to
hepatic ischemia when compared to nonjaundiced rats. The changes in serum
aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline
phosphatase showed an increasing trend in the SOJ group but were not
statistically significant. Ischemic changes in liver histology were seen more
often in the SOJ group but were not statistically significant. These data suggest
that temporary portal triad clamping in an experimental model of SOJ is
detrimental to the outcome of liver resection.

Publication Types: 
    Evaluation Studies

PMID: 16036781 [PubMed - indexed for MEDLINE]

271: Acta Chir Belg. 2005 May-Jun;105(3):309-12.

Inflammatory pseudotumour of the liver presenting with obstructive jaundice.

Alimoglu O, Sahin M, Eryilmaz R, Turgut H, Kurtulmus N, Igci A.

Department of General Surgery, Vakif Gureba Training Hospital, 34080 Istanbul,
Turkey. oalimoglu@yahoo.com

Inflammatory pseudotumours are rare benign tumours characterized by an
inflammatory process and can occur in any system. We present a case of
inflammatory pseudotumours of the liver presenting with obstructive jaundice due 
to a mass forming lesion in the left lobe of the liver which was treated by left 
hepatic lobectomy. Inflammatory pseudotumour of the liver is a benign lesion and 
diagnosis with an image examination is difficult. Surgical management depends on 
the location of the lesion. Peripheral hepatic pseudotumours may be treated with 
simple observation or conservative therapy. In contrast to this, those involving 
the porta hepatis require treatment for obstructive jaundice.

Publication Types: 
    Case Reports

PMID: 16018527 [PubMed - indexed for MEDLINE]

272: Gastroenterology. 2005 Jul;129(1):315-20.

Dual hereditary jaundice: simultaneous occurrence of mutations causing Gilbert's 
and Dubin-Johnson syndrome.

Cebecauerova D, Jirasek T, Budisova L, Mandys V, Volf V, Novotna Z, Subhanova I, 
Hrebicek M, Elleder M, Jirsa M.

Institute for Clinical and Experimental Medicine, Prague, Czech Republic.

BACKGROUND & AIMS: Dubin-Johnson syndrome is recessively inherited, conjugated
hyperbilirubinemia induced by mutations in the ABCC2/MRP2 gene encoding the
canalicular transporter for conjugated bilirubin. Gilbert's syndrome is
recessively inherited, unconjugated hyperbilirubinemia caused by decreased
conjugation rate of bilirubin associated mostly with homozygous A(TA) 7 TAA
variant of the TATAA-box in the UGT1A1 gene promoter. Our aim was to establish
the molecular diagnosis in a 3-year-old male with atypical, intermittent,
predominantly unconjugated, hyperbilirubinemia. METHODS: 99m Tc-HIDA
cholescintigraphy was used for imaging the biliary tree. Expression of ABCC2/MRP2
protein in hepatocytes was investigated immunohistochemically. UGT1A1 and
ABCC2/MRP2 genes were sequenced from genomic DNA, and the mutations were verified
by fragment analysis, sequencing the cloned exons, and restriction fragment
length polymorphism. RESULTS: Cholescintigraphy revealed delayed visualization of
the gallbladder. A brown granular lipopigment differing from melanin-like pigment
reported in Dubin-Johnson syndrome was present in hepatocytes, but, otherwise,
liver histology was normal. ABCC2/MRP2 protein was not detected on the
canalicular membrane of hepatocytes, and 2 novel mutations were found in the
ABCC2/MRP2 gene: a heterozygous in-frame insertion-deletion mutation
1256insCT/delAAACAGTGAACCTGATG in exon 10 inherited from the father and a
heterozygous deletion 4292delCA in exon 30 inherited from the mother. In
addition, the patient was homozygous for -3279T>G and A(TA) 7 TAA mutations in
the UGT1A1 gene promoter. CONCLUSIONS: Our patient represents a case of digenic
mixed hyperbilirubinemia-a distinct type of constitutive jaundice resulting from 
coinherited defects in ABCC2/MRP2 and UGT1A1 genes.

Publication Types: 
    Case Reports
    Research Support, Non-U.S. Gov't

PMID: 16012956 [PubMed - indexed for MEDLINE]

273: Hepatogastroenterology. 2005 Jul-Aug;52(64):1274-7.

Alcoholic chronic pancreatitis with simultaneous multiple severe
complications--extrahepatic portal obliteration, obstructive jaundice and
duodenal stricture.

Kakizaki S, Hamada T, Yoshinaga T, Higuchi T, Kashiwabara K, Takagi H, Mori M.

Department of Internal Medicine, Saiseikai Maebashi Hospital, Maebashi, Gunma,
Japan. kakizaki@showa.gunma-u.ac.jp

The major complications of chronic pancreatitis are malabsorption, diabetes
mellitus, pancreatic calcification and pseudocysts. Sinistral portal hypertension
due to splenic vein thrombosis, obstructive jaundice and duodenal stricture have 
also been reported as complications of chronic pancreatitis. However, a case
having all these three complications at the same time is relatively rare. We
present a case of chronic alcoholic pancreatitis complicated with simultaneous
multiple severe complications. Although biliary drainage is usually a useful
treatment for reducing the bilirubin level in the patients with obstructive
jaundice, jaundice was hardly improved by the percutaneous transhepatic
cholangio-drainage (PTCD) in this case. We discussed the cause of the failure in 
reducing the jaundice and reviewed the previous reports of complications of
pancreatitis.

Publication Types: 
    Case Reports
    Review

PMID: 16001677 [PubMed - indexed for MEDLINE]

274: Hepatogastroenterology. 2005 May-Jun;52(63):742-4.

Hepato-pancreaticoduodenectomy with preservation of the collateral arterial
arcade in the head of the pancreas in a patient with celiac axis stenosis.

Hasegawa K, Sano K, Ishida T, Shin N, Ikeda M, Kokudo N, Makuuchi M.

Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Graduate
School of Medicine University of Tokyo, Tokyo, Japan. kihase-tky@umin.ac.jp

Hepato-pancreaticoduodenectomy was performed for common bile duct carcinoma
associated with celiac axis stenosis. To secure arterial blood flow to the upper 
abdominal organs, we preserved the anterior arcade in the pancreas head acting as
a collateral pathway between the superior mesenteric artery and the celiac
artery. This is another valid alternative procedure for pancreaticoduodenectomy
in a patient with celiac axis stenosis.

Publication Types: 
    Case Reports

PMID: 15966195 [PubMed - indexed for MEDLINE]

275: Hepatogastroenterology. 2005 May-Jun;52(63):672-7.

Collagen IV is a predictor for clinical course in patients with malignant
obstructive jaundice.

Mizuguchi Y, Yoshida H, Yokomuro S, Arima Y, Mamada Y, Taniai N, Akimaru K,
Tajiri T.

First Department of Surgery, Nippon Medical School, Tokyo, Japan.

BACKGROUND/AIMS: Increases in the serum extracellular matrix proteins (ECMPs)
have been described in studies on cholestasis, therefore we investigated the
serum levels of collagen IV, aminoterminal propeptide of type III procollagen,
and hyaluronic acid prior to percutaneous transhepatic biliary drainage (PTBD) to
evaluate its potential as a predictor for prolonged bilirubin clearance and
clinical course in patients with malignant obstructive jaundice (MOJ).
METHODOLOGY: Serum levels of ECMPs were prospectively investigated in 42 patients
with MOJ prior to PTBD. The study group was subdivided according to the bilirubin
clearance, and was also subdivided according to the determined level of collagen 
IV (cut-off point of 260 ng/mL). RESULTS: Serum collagen IV was identified as an 
independent risk factor for prolonged bilirubin clearance (P=0.006).
Receiver-operating-characteristic curve analysis revealed that serum collagen IV 
had a diagnostic accuracy of 79% at the cut-off point of 260 ng/mL. Furthermore, 
these results indicated that the level of collagen IV is a reliable marker of
postoperative liver failure (P=0.029) and predictor of death from liver failure
(P=0.02). CONCLUSIONS: Elevated serum collagen IV is a feature of MOJ commonly
associated with prolonged bilirubin clearance, and a useful indicator of clinical
course, postoperative morbidity, and mortality in patients with MOJ.

Publication Types: 
    Research Support, Non-U.S. Gov't

PMID: 15966179 [PubMed - indexed for MEDLINE]

276: Clin Nephrol. 2005 Jun;63(6):493-5.

Obstructive icterus directly related to visceral artery aneurysm in a CAPD
patient.

Sipahioglu MH, Tokgöz B, Karahan OI, Ok E, Sav T, Oymak O, Utas C.

Department of Nephrology, Erciyes University Medical School, Kayseri, Turkey.
murathsipahioglu@yahoo.com

Visceral artery aneurysms (VAA) are uncommon pathologies. We report a case of the
first CAPD patient with obstructive jaundice directly related to VAA. A
25-year-old man with a four-year history of hemodialysis followed by two years of
CAPD was admitted due to jaundice. He had two episodes of peritonitis. An
abdominal ultrasonogram and a selective common hepatic arteriogram confirmed the 
presence of a 5 cm saccular aneurysm supplied from the gastroduodenal artery and 
a 4 cm fusiform aneurysm supplied from the proximal part of the common hepatic
artery. The gastroduodenal artery was responsible for the impression of the
common bile duct. In the operation, the gastroduodenal artery aneurysm was
completely excised after its proximal and distal ends were ligated. The proximal 
and distal ends of the hepatic artery were also ligated. A prosthetic graft
(PTFE), which extended from the splenic artery to the distal portion of the
hepatic artery, was placed. In this way, the arterial blood flow of the liver was
re-established. Patients with VAAs present with a constellation of symptoms
including abdominal pain, jaundice and shock (due to rupture of aneurysm).
Pancreatitis, and atherosclerosis have been reported to be the most common causes
of VAAs. In conclusion, when CAPD patients present with jaundice or hemorrhagic
shock with abdominal pain, VAA should be considered in differential diagnosis,
especially if patients have a history of frequent pancreatitis episodes, and
severe risk factors for atherosclerosis.

Publication Types: 
    Case Reports

PMID: 15960153 [PubMed - indexed for MEDLINE]

277: J Surg Res. 2005 Jun 1;126(1):19-26.

The activity of ornithine transcarbamoylase and arginase during mechanical
jaundice in the rat model.

Beck B, Ciszek M, Polaniak R, Beyga Z, Król W, Drozdz M, Shani J.

Department of Biochemistry, Medical University of Silesia, Zabrze, Poland.
bbeck@slam.katowice.pl

BACKGROUND: The pathogenesis of morbidity and mortality associated with
intervention of the biliary system in patients with obstructive jaundice is
unknown. Mechanical jaundice initiates the development of morphological changes
in hepatocytes with concomitant disturbances in metabolism. These are followed by
changes in enzyme activity in hepatocytes and peripheral blood. MATERIAL AND
METHODS: Wistar rats were divided into three groups: group 1, sham-operated
controls; group 2, rats with permanent jaundice; and group 3, rats with temporary
mechanical jaundice. The animals were examined at 2 weeks (groups A), 4 weeks
(groups B) and 6 weeks (groups C) after surgery. We explored the impact of
induced mechanical jaundice on the activity of selected urea cycle enzymes
(arginase [E.C.3.5.3.1] and ornithine transcarbamoylase (OTC) [E.C.2.1.3.3]).
RESULTS: Mechanical jaundice was found to induce changes in hepatocytic
metabolism, which in turn led to disturbances in the urea cycle and the process
of transamination. After relief of the mechanical jaundice (recanalization of the
common bile duct), the urea cycle activity in the liver was greatly increased
despite the normalization of the basic biochemical indices. CONCLUSION: The
results of the experiment confirmed the hypothesis that long-term mechanical
jaundice causes lasting disturbances in hepatocytic metabolism. We conclude that 
the rate of nitrogen metabolism is higher after recanalization of the bile duct.

PMID: 15916970 [PubMed - indexed for MEDLINE]

278: World J Gastroenterol. 2005 May 21;11(19):3008-9.

The right hepatic artery syndrome.

Miyashita K, Shiraki K, Ito T, Taoka H, Nakano T.

First Department of Internal Medicine, Mie University School of Medicine, 2-174
Edobashi, Tsu, Mie 514-8507, Japan.

Various benign and malignant conditions could cause biliary obstruction.
Compression of extrahepatic bile duct (EBD) by right hepatic artery was reported 
as a right hepatic artery syndrome but all cases were compressed EBD from stomach
side. Our case compressed from dorsum was not yet reported, so it was thought to 
be a very rare case. We present here the first case of bile duct obstruction due 
to the compression of EBD from dorsum by right hepatic artery.

Publication Types: 
    Case Reports

PMID: 15902748 [PubMed - indexed for MEDLINE]

279: Pediatr Surg Int. 2005 Jul;21(7):560-2. Epub 2005 May 18.

Herniation through the foramen of Winslow presenting as obstructive jaundice.

Antao B, Hamill J, Samuel M, Hiorns M, Pierro A.

Department of Paediatric Surgery, Institute of Child Health and Great Ormond
Street Hospital for Children, London, WC1N 1EH, UK.

Herniation through the foramen of Winslow is a rare variety of paraduodenal
hernia. We report a 19-month-old child with obstructive jaundice due to midgut
herniation through the foramen of Winslow with associated volvulus. The
herniation and volvulus were precipitated by intestinal malrotation. The patient 
underwent extraamniotic silo repair of exomphalos major in the neonatal period.
Investigation for malrotation is recommended after extraamniotic closure of
exomphalos.

Publication Types: 
    Case Reports

PMID: 15902477 [PubMed - indexed for MEDLINE]

280: Indian J Gastroenterol. 2005 Mar-Apr;24(2):52-4.

Comment in:
    Indian J Gastroenterol. 2005 Mar-Apr;24(2):47-8.

Cholestatic jaundice during infancy: experience at a tertiary-care center in
Bangladesh.

Bazlul Karim AS, Kamal M.

Department of Pediatric Gastroenterology and Nutrition, B S M Medical University,
Shabagh, Dhaka, Bangladesh. karimb@bangla.net

BACKGROUND AND OBJECTIVE: Cholestatic jaundice in early infancy is a difficult
diagnostic problem. Early diagnosis is important for proper management. This
retrospective study was conducted to find out the etiology and clinical profile
of neonatal cholestatic disorders in Bangladesh. SETTING: Tertiary-care hospital 
in a developing country. METHODS: Clinical profile and cause of cholestatic
illness were studied in 62 infants with cholestatic jaundice developing before
three months of age and persisting for more than two weeks. RESULTS: Neonatal
hepatitis (22; 35.5%--17 with TORCH, 5 with urinary infection), followed by
biliary atresia (16; 25.8%) and idiopathic neonatal hepatitis (15; 24.2%), were
the commonest causes of cholestasis. Mean age at presentation was 3.5 months. Ten
(62.5%) of 16 biliary atresia cases were male and jaundice appeared before 14
days in 14 (87.5%) cases. CONCLUSIONS: Neonatal hepatitis, biliary atresia and
idiopathic neonatal hepatitis were the common causes of neonatal cholestasis in
infancy. Though cholestatic jaundice developed early, most of the cases presented
late.

PMID: 15879649 [PubMed - indexed for MEDLINE]

281: Sao Paulo Med J. 2005 Jan 2;123(1):30-2. Epub 2005 Mar 31.

Obstructive jaundice secondary to bile duct involvement with Hodgkin's disease: a
case report.

Di Sena V, Thuler FP, Macedo EP, Paulo GA, Della Libera E, Ferrari AP.

Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo,
Brazil.

CONTEXT: Obstructive jaundice due to lymphoma is very rare. It may be difficult
to distinguish between this condition and a large number of causes of
extrahepatic bile duct obstruction, even by endoscopic retrograde
cholangiography. Its prognosis is poor. Combined chemotherapy and/or radiotherapy
with bile duct drainage is a therapeutic option. CASE REPORT: We describe a case 
of obstructive jaundice as the initial presentation of Hodgkin's disease. After
chemotherapy and endoscopic bile duct stenting, it was noted that the enlarged
lymph nodes, jaundice and bile duct dilation disappeared.

Publication Types: 
    Case Reports

PMID: 15821813 [PubMed - indexed for MEDLINE]

282: J Surg Res. 2005 Apr;124(2):237-43.

Effect of jaundice and its resolution on wound re-epithelization, skin collagen
synthesis, and serum collagen propeptide levels in patients with neoplastic
pancreaticobiliary obstruction.

Koivukangas V, Oikarinen A, Risteli J, Haukipuro K.

Department of Surgery, Oulu University Hospital, University of Oulu, Oulu,
Finland. vesa.koivukangas@oulu.fi

BACKGROUND: Wound and anastomotic healing is considered to be delayed in patients
with obstructive jaundice. The study was designed to find out whether the healing
of experimental suction blister wounds, skin collagen synthesis, and serum
procollagen levels are affected by obstructive jaundice, and if biliary drainage 
may cause any alterations in these processes. PATIENTS AND METHODS: Suction
blisters were induced on 24 patients with obstructive jaundice caused by
neoplastic pancreaticobiliary obstruction and 17 control patients with the
corresponding condition without jaundice, to compare healing parameters and
collagen synthesis between the groups. A second set of suction blisters were
induced on 13 formerly jaundiced patients after the resolution of jaundice and on
14 control patients, to find out whether drainage or time modifies healing or
collagen synthesis. By using this model, it is possible to evaluate the
re-epithelization and inflammation on wound healing and to assess the baseline
skin collagen synthesis. The healing of suction blisters was followed up by
measuring water evaporation and blood flow in the wound. Blister fluids and serum
samples were collected to study collagen propeptides. RESULTS: Healing of the
blister wound was unaffected by obstructive jaundice. Drainage had no effect on
healing. The baseline synthesis of type I and type III collagen in the skin was
decreased in jaundiced patients. Biliary drainage improved the synthesis. Serum
type III procollagen propeptide levels were elevated in jaundiced patients, but
began to normalize after drainage. CONCLUSION: Healing of an experimental blister
wound is not disturbed by obstructive jaundice. The decreased baseline skin
collagen synthesis is partly restored by the resolution of jaundice. The results 
indicate that cell protein synthesis is disturbed earlier than cell dynamics in
obstructive jaundice. The elevated serum PIIINP levels, which are most likely to 
be related to early fibrosis in liver, decreased after drainage.

PMID: 15820253 [PubMed - indexed for MEDLINE]

283: Osaka City Med J. 2004 Dec;50(2):95-9.

Nonoprerative management of obstructive jaundice caused by a benign hepatic cyst.

Ogawa M, Kubo S, Uenishi T, Hirohashi K, Tanaka H, Shuto T, Yamamoto T, Takemura 
S.

Department of Gastroenterological and Hepato-Biliary-Pancreatic Surgery, Osaka
City University, Graduate School of Medicine, Japan.
m0035881@msic.med.osaka-cu.ac.jp

A 64-year-old man with a 9.0 cm benign hepatic cyst near the hepatic hilum
presented with obstructive jaundice caused by the compression of the hepatic
ducts. The cyst was aspirated percutaneously, and minocycline hydrochloride was
instilled as a sclerosant through a catheter inserted into the cyst. The cyst
gradually became smaller, relieving the obstructive jaundice. There were no
complications or side-effects. The instillation of minocycline hydrochloride is a
useful alternative to ethanol instillation for treating benign hepatic cysts,
even when the cyst is causing obstructive jaundice.

Publication Types: 
    Case Reports

PMID: 15819304 [PubMed - indexed for MEDLINE]

284: J Formos Med Assoc. 2005 Mar;104(3):194-7.

Hyperemesis gravidarum presenting as jaundice and transient hyperthyroidism
complicated with acute pancreatitis.

Weng MT, Wei SC, Wong JM, Chang TC.

Department of Internal Medicine, National Taiwan University Hospital, College of 
Medicine, National Taiwan University, Taipei, Taiwan.

Hyperemesis gravidarum is an extreme form of nausea and vomiting during
pregnancy. Its presenting symptoms include vomiting, disturbed nutrition,
electrolyte imbalance, ketosis, extreme weight loss, renal and/or liver damage.
It is rare for a hyperemesis gravidarum patient to present with jaundice,
hyperthyroidism and idiopathic acute pancreatitis during the same hospitalization
period. Here, we report such a case. A 25-year-old pregnant woman without
underlying liver or thyroid disease was admitted due to jaundice noted for 2 days
at 8 weeks of gestational age. Hyperthyroidism symptoms of tachycardia and finger
tremor also bothered her. After treatment with parenteral fluid and antithyroid
agents, her clinical condition improved. However, an episode of idiopathic
pancreatitis occurred after nausea and vomiting subsided. Bowel rest with
parenteral fluid and nutrition supplement was given and the increased pancreatic 
enzyme level gradually subsided. Follow-up liver and thyroid function were normal
after gestational age of 26 weeks. She delivered a healthy female baby without
low birth body weight at gestational age of 39 weeks. Rapid diagnosis and
supportive care are important for the hyperemesis gravidarum patient with the
complication of acute pancreatitis.

Publication Types: 
    Case Reports

PMID: 15818435 [PubMed - indexed for MEDLINE]

285: Hepatogastroenterology. 2005 Mar-Apr;52(62):537-40.

Evaluation of functional liver reserve in patients with obstructive jaundice
undergoing hepatectomy.

Higuchi R, Otsubo T, Takasaki K.

Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical
University, Tokyo, Japan. ryotahig@yahoo.co.jp

BACKGROUND/AIMS: In hepatectomy in patients with obstructive jaundice, correct
evaluation of the functional liver reserve is sometimes difficult. This study
examined whether the preoperative level of total bilirubin in the bile from a
predicted remnant liver can be used as a predictor for safe hepatectomy in such
patients. METHODOLOGY: Twenty consecutive patients with jaundice who underwent
major hepatectomy and in whom all bile from the predicted remnant liver could be 
collected were included in this study. The level of total bilirubin in the bile
was calculated by multiplying bile volume and density obtained by percutaneous
transhepatic biliary drainage. Patients were divided into two groups, with (group
1) and without postoperative death due to liver failure (group 2). RESULTS: The
level of total bilirubin in the bile from the predicted remnant liver was lower
in group 1 than in group 2. Patients did not die of postoperative liver failure
if the level of total bilirubin in the bile was maintained, even if the bile
volume or density were low. CONCLUSIONS: The preoperative level of total
bilirubin in the bile from the predicted remnant liver can be used as a predictor
for safe hepatectomy in patients with obstructive jaundice.

PMID: 15816473 [PubMed - indexed for MEDLINE]

286: J Clin Gastroenterol. 2005 May-Jun;39(5):413-21.

Endobiliary stents for palliation in patients with malignant obstructive
jaundice.

Hammarström LE.

Department of Surgery, Angelholms Sjukhus, Angelholm, Sweden.
le.hammarstrom@lund.mail.telia.com

BACKGROUND: Endobiliary drainage for malignant obstructive jaundice presents a
viable palliative alternative. Its role and efficacy depend on factors related to
the stent, procedure, and patient. GOALS: To review the evidence in the
literature in which settings plastic or metal stents are cost-effective, and
whether adjuvant measures or patient-related factors affect duration of stent
patency. STUDY: Using databases a literature search was performed for papers
published from 1979 to April 2004. All retrieved papers reporting experimental or
clinical observations were rated according to strength of evidence, and carefully
analyzed. RESULTS AND CONCLUSIONS: Metal stents (Wallstent) stay patent longer
than plastic stents (large-bore polyethylene with side-holes), overall median 250
and 110 days, respectively, and seem cost-effective in patients with longer than 
about 6 months survival, which cannot be accurately predicted. Antibiotics or
choleretic agents do not prolong stent patency in clinical settings. In case of
stent occlusion, indicated stent exchanges and insertion of a plastic stent,
respectively, seem cost-effective in patients initially treated with plastic and 
metal stents.

Publication Types: 
    Comparative Study

PMID: 15815210 [PubMed - indexed for MEDLINE]

287: J Paediatr Child Health. 2005 Mar;41(3):143-6.

Anterior abdominal wall defects and biliary obstruction.

Teoh L, Wong CK, Martin H, O'Loughlin EV.

Department of Gastroenterology, The Children's Hospital at Westmead, Westmead,
New South Wales, Australia. laurelt@cyllene.uwa.edu.au
<laurelt@cyllene.uwa.edu.au>

Three infants with anterior abdominal wall defects (gastroschisis and exomphalos)
who presented with obstructive jaundice secondary to biliary obstruction, are
described. All three infants had abnormal biliary systems, with mechanical
distortion of the biliary tree. Biliary obstruction secondary to structural
biliary anomalies should be considered in patients with abdominal wall defects
and cholestasis, as prolonged unrelieved biliary obstruction may lead to biliary 
cirrhosis and portal hypertension.

Publication Types: 
    Case Reports

PMID: 15790327 [PubMed - indexed for MEDLINE]

288: Acta Chir Belg. 2005 Feb;105(1):74-8.

Strictures of the terminal bile duct--who profits from the surgery?

Leffler J, Simsa J, Poloucek P, Krejci T, Grabec P.

Department of Surgery University Hospital Motol, Prague, Czech Republic.
jan.leffler@lfmotol.cuni.cz

BACKGROUND: Elucidation of the etiology of terminal bile duct strictures is
oftentimes challenging. In choosing the optimal treatment method, a
multidisciplinary approach is necessary. AIMS AND METHODS: To demonstrate the
advantages and indications of surgical management, 153 patients with terminal
bile duct strictures were retrospectively analysed. All patients had been treated
during a period of eight years (1st January 1995 - 31st December 2002) in same
department. The principal datas studied were surgical morbidity, thirty-days'
mortality rates and recurrence of jaundice. RESULTS: During a period of eight
years, 153 patients (100%) underwent laparotomy. Radical surgery
(duodenopancreatectomy) was performed in 79 patients (51.6%), while 74 others
(48.4%) benefited from bypass procedures. Postoperative morbidity reached 13.1%; 
nine patients (5.9%) died within the thirty days of surgery. Recurrence of
jaundice was observed in three patients (1.9%). CONCLUSION: Surgical management
of terminal bile duct strictures is indicated in most patients with benign
strictures, strictures of unknown origin and with malignant strictures, where the
patients are in a reasonably satisfactory clinical condition. The surgical
approach provides the potential advantage to obtain a definite histological
diagnosiscare and to remove the tumour in many patients. Patients with non
resectable tumours could benefit from bypass procedures ensuring long-term and
effective drainage of the bile.

Publication Types: 
    Research Support, Non-U.S. Gov't

PMID: 15790207 [PubMed - indexed for MEDLINE]

289: Surgeon. 2005 Feb;3(1):43-4.

Jaundice as a presentation of phenol induced hepatotoxocity following injection
sclerotherapy for haemorrhoids.

Suppiah A, Perry EP.

Department of Surgery, Scarborough General Hospital, Scarborough, Y012 6QL.
aravindsuppiah@hotmail.com

A 43-year-old man was admitted with jaundice six days following phenol injection 
sclerotherapy for haemorrhoids. He was diagnosed with a phenol-induced hepatitis.
Although he remained well, liver function tests only returned to normal after six
months. Systemic absorption of phenol has been reported with ingestion, upper
airway and excessive cutaneous exposure but not as a complication of
haemorrhoidal injection sclerotherapy. Hepatic involvement is also rare and
usually the result of ongoing sepsis. We report the unique case of a patient
presenting with jaundice secondary to chemical hepatitis, following systemic
absorption of phenol at injection sclerotherapy. This case highlights the
importance of clinical awareness of not only the infective complications of
injection sclerotherapy but also the potential for phenol to be absorbed
systemically with severe consequences. A brief overview of symptoms of phenol
toxicity is included.

Publication Types: 
    Case Reports

PMID: 15789794 [PubMed - indexed for MEDLINE]

290: Minerva Gastroenterol Dietol. 2004 Dec;50(4):339-43.

Intrahepatic cholestatic jaundice related to administration of ranitidine. A case
report with histologic and ultramicroscopic study.

Varriale M, Salvio A, Giannattasio F, d'Errico T, Montone L, Borgia F, Gentile I,
Reynaud L, Borgia G, Rossiello R, Visconti M.

Unit of Hepatology D.H., Department of Internal Medicine Ospedale degli
Incurabili, ASL NA 1, Naples, Italy.

Ranitidine may cause liver injuries ranging from transient, subclinical serum
transaminases increase every 100-1,000 treated patients to cholestatic hepatitis 
in less than 1/100,000. Other H2-receptor antagonists are more dangerous: 11
toxic hepatitis cases have been reported as adverse effect after 1 year of
marketed ebrotidine. A 75-year-old male with ischemic cardiopathy history was
started on an 8 days treatment of oral ranitidine due to pirosis, without any
other changes of therapy; 48 h after drug withdrawal, light-coloured stools, dark
urine and icteric scleras developed. On hospital admission, 10 days later,
physical examination showed slight hepatomegaly and severe jaundice with skin
excoriations followed by serum mixed bilirubin further increase and
aminotransferases activities mild rise. Total bilirubin peaked at 381.33 mmol/l
(5.1-17.1) and progressively returned to normal, after discharge home, in 3
months and now, 1 year later, there is no sign of liver disease. Ultrasonographic
biliary anomalies and the most frequent causes of liver damage were excluded.
Liver biopsy confirmed ranitidine as the most likely cause of liver toxicity
since histological and ultramicroscopical study revealed a drug-induced picture. 
We report a rare case of intrahepatic cholestasis jaundice related to ranitidine,
a widely used drug. Diagnosis would need an ethically unacceptable rechallange
test.

Publication Types: 
    Case Reports
    Review

PMID: 15788990 [PubMed - indexed for MEDLINE]

291: Hepatogastroenterology. 2005 Jan-Feb;52(61):220-2.

Repeated obstructive jaundice and acute pancreatitis caused by metastatic liver
tumor: an unusual case.

Kobayashi T, Makuuchi M, Sano K, Koyama K, Motoi T.

Department of Surgery, Showa General Hospital, Tokyo, Japan.
ta-koba@mb.kcom.ne.jp

A case of repeated obstructive jaundice and acute pancreatitis caused by mucus
plug produced by metastatic liver tumor is reported. A 74-year-old woman, who had
a past history of curative resection of mucinous rectal cancer, showed repeated
obstructive jaundice and acute pancreatitis during the follow-up period. Neither 
computed tomographic scan nor abdominal ultrasound could detect the recurrent
lesion, however, cholangioscopy detected mucin and tumor projection into the left
hepatic duct. Since the biopsy specimen of the tumor revealed adenocarcinoma,
left hepatectomy was performed. The tumor was mucinous adenocarcinoma having the 
same histology as the primary rectal cancer, with partly mucosal replacement and 
formation of intraluminal mucus plaque. This case indicates that repeated
obstructive jaundice and acute pancreatitis should be considered one of the
manifestations of liver metastasis of mucinous cancer.

Publication Types: 
    Case Reports

PMID: 15783035 [PubMed - indexed for MEDLINE]

292: Hepatogastroenterology. 2005 Jan-Feb;52(61):128-34.

Endo-laparoscopic approach in the management of obstructive jaundice and
malignant gastric outflow obstruction.

Tang CN, Siu WT, Ha JP, Li MK.

Department of Surgery, Pamela Youde Nethersole Eastern Hospital, Hong Kong.
cntang@netvigator.com

BACKGROUND/AIMS: Only a minority of patients with tumor at the
pancreaticoduodenal junction is suitable for resection, palliation is however
often required relieving the obstructive jaundice and gastric outflow obstruction
(GOO). This study evaluates endo-laparoscopic approach as a palliative treatment 
of obstructive jaundice and malignant gastric outflow obstruction. METHODOLOGY: A
retrospective review of a prospectively maintained database. During the period
from 1992-2002, patients with diagnosis of unresectable tumor at the
pancreaticoduodenal junction were evaluated. If the tumor was confirmed to be
unresectable, patients would be offered either open double bypass or laparoscopic
gastrojejunostomy (LGJ) +/- endoscopic or percutaneous transhepatic stenting for 
any obstructive jaundice, the choice of approach would depend on whether the
endoscopic access was still maintained. RESULTS: Out of 942 patients with tumors 
around the pancreaticoduodenal junction during the study period from 1992-2002,
there were 34 patients (13 male & 21 female) with median age 69 years (range,
48-87) selected for LGJ. Of these 34 patients, 3 of them underwent endoscopic
biliary stenting whereas 16 jaundice patients were palliated by transhepatic
biliary drainage. When the results were compared to the 35 open double bypass
(roux-en-Y choledochojejunostomy and gastrojejunostomy) during the same study
period, the median operation time was significantly shorter (80 vs. 135 minutes; 
P=0.0001) and median intraoperative bleeding was significantly less in the
endo-laparoscopic group (0 vs. 100mL; P=0.0001). Two patients in the
endo-laparoscopic group were converted to open because of tumor infiltration of
the small bowel mesentery causing difficulty in construction of
gastrojejunostomy. Although the overall complication rate (13 vs. 17; P=0.387)
and incidence of delayed gastric emptying (7 vs. 7, P=0.952) were similar in both
groups, the incidence of wound infection was remarkably less common in the
endo-laparoscopic group (0 vs. 6, P=0.012). The 15 postoperative complications
(13 patients) in the endo-laparoscopic group (38.2%) included prolonged gastric
stasis (7), biliary sepsis (2), chest infection (2), myocardial ischemia (2),
gastrointestinal bleeding (1) and extensive ischemic stroke (1). Median time to
resume diet was statistically shorter in endo-laparoscopic group (5 vs. 7 days,
P=0.009) however the hospital stay was similar in both groups (11.5 vs. 14 days, 
P=0.238). The hospital mortality rate was again comparable between the two groups
(6 vs. 5, P=0.703). The short median survival in the endolaparoscopic group (3
vs. 7 months; P=0.0001) might just be a reflection of selection bias.
CONCLUSIONS: With the advent of laparoscopic and endoscopic surgery, palliation
of both gastric outflow obstruction and obstructive jaundice can also be
accomplished using the endo-laparoscopic approach. In comparing to the open
double bypass, operation time, intraoperative blood loss and incidence of wound
infection are significantly less and patients can have early resumption of diet. 
However, the results can be improved further with a better patient selection and 
perioperative optimization.

PMID: 15783012 [PubMed - indexed for MEDLINE]

293: Hepatogastroenterology. 2005 Jan-Feb;52(61):52-4.

Renal failure in obstructive jaundice.

Uslu A, Cayci M, Nart A, Karaca C, Zalluhoglu N, Gürkan A, Varilsuha C, Adagülü
H.

First Department of General Surgery and Organ Transplantation Center, SSK Tepecik
Teaching Hospital, Izmir, Turkey.

BACKGROUND/AIMS: The optimal preoperative management of patients with acute
obstructive jaundice is still a matter of debate. Reduction in effective plasma
volume and systemic endotoxemia are major consequences both in experimental acute
bile duct ligation and in patients with acute obstructive jaundice (AOJ). The
objective of this study is to show the necessity for adequate preoperative
hydration and lactulose administration for the prevention of postoperative renal 
dysfunction in patients with AOJ. METHODOLOGY: Fifty-five patients (35 male, 20
female) with a mean age of 62 years were entered into the study. There were 23
benign and 32 malignant strictures in this group. All patients received oral
lactulose (30-45mL per day) and IV cefazoline (3-4g/day) before surgery. Fluid
and electrolyte balance was precisely maintained throughout the hospitalization
via daily body weight calculations. High-risk elderly patients with left
ventricular systolic dysfunction were assessed by echocardiography and
therapeutic measures were undertaken. Renal function was assessed by creatinine
clearance (ClCr) measurements and impairment of renal function was defined as a
>20% fall in ClCr value post-surgery. RESULTS: Mean preoperative bilirubin level 
was 11.05mg/dL (range: 3.45-27.0mg/dL). None of the patients developed
postoperative renal failure. The difference between pre- and postoperative ClCr
value (104.02mL/min vs. 101.0mL/min respectively) was not significant (t=0.698,
P=0.489). One patient with mild renal function impairment before surgery
(ClCr=45.4mL/min) successfully recovered with 60% rise in creatinine clearance
(ClCr=78.1mL/min) after the operation. Three patients with normal functioning
kidneys died within 30 days of operation. The principle cause of death was
carcinomatosis and pulmonary embolus in two and intraoperative hemorrhagic shock 
in one patient. CONCLUSIONS: These results further substantiated the importance
of adequate preoperative hydration and endotoxin inactivation in terms of acute
renal failure prophylaxis in patients with AOJ. This regimen obviates the
afferent events in obstructive jaundice and provides prevention of acute renal
failure even in high-risk elderly patients.

Publication Types: 
    Clinical Trial

PMID: 15782993 [PubMed - indexed for MEDLINE]

294: Intensive Care Med. 2005 May;31(5):709-17. Epub 2005 Mar 22.

Bile modulates intestinal epithelial barrier function via an extracellular signal
related kinase 1/2 dependent mechanism.

Yang R, Harada T, Li J, Uchiyama T, Han Y, Englert JA, Fink MP.

Department of Critical Care Medicine, School of Medicine, University of
Pittsburgh, 3550 Terrace Street, Pittsburgh, PA 15261, USA.

OBJECTIVE: Obstructive jaundice is frequently complicated by infections and has
been associated with increased bacterial translocation and gut mucosal
hyperpermeability in animal models. Proper expression of the tight junction (TJ) 
proteins ZO-1 and occludin is important for normal gut barrier function. We
tested whether bile modulates intestinal epithelial ZO-1 and occludin expression.
ANIMALS: (a) Male C57BL/6 mice; (b) male Sprague-Dawley rats. INTERVENTIONS: (a) 
Mice were subjected to common bile duct ligation (CBDL) or a sham procedure, and 
96 h later all surviving animals were killed for measurement of ileal mucosal
permeability to FITC-labeled dextran (everted gut sac technique), bacterial
translocation to mesenteric lymph nodes, and ileal epithelial ZO-1 and occludin
expression (western blots). (b) Rat IEC-6 enterocytic monolayers were incubated
in the presence or absence of graded concentrations of rat bile and/or U0126, an 
inhibitor of extracellular signal related kinase (ERK) 1/2 activation. RESULTS:
(a) Compared to sham-treated controls, CBDL significantly increased gut mucosal
permeability and bacterial translocation and markedly decreased ileal epithelial 
expression of ZO-1 and occludin. In a follow-up in vivo experiment, gavaging mice
with fresh rat bile twice daily significantly ameliorated the deleterious effects
of CBDL on gut barrier function. (b) Addition of 1% (v/v) bile to media enhanced 
phosphorylation of ERK1/2, increased the expression of ZO-1 and occludin and
decreased permeability to FITC-dextran. All of these bile-mediated effects were
blocked by 10 microM U0126. CONCLUSIONS: These data support the view that the
presence of bile in the intestinal lumen is essential for normal gut barrier
function, possibly because compounds present in bile initiate ERK1/2-dependent
signaling that is essential for normal expression of key TJ proteins.

Publication Types: 
    Evaluation Studies
    Research Support, N.I.H., Extramural

PMID: 15782315 [PubMed - indexed for MEDLINE]

295: World J Surg. 2005 Apr;29(4):519-23.

Jaundice at presentation heralds advanced disease and poor prognosis in patients 
with ampullary carcinoma.

Yokoyama N, Shirai Y, Wakai T, Nagakura S, Akazawa K, Hatakeyama K.

Division of Digestive and General Surgery, Niigata University Graduate School of 
Medical and Dental Sciences, Asahimachi-dori 1-757, Niigata, 951-8510, Japan.

Jaundice is a common manifestation of ampullary carcinoma. The aim of this study 
was to evaluate the correlation between jaundice at initial presentation and the 
degree of tumor spread and to determine the prognostic significance of jaundice
in patients with ampullary carcinoma. Fifty-nine patients who had undergone
curative resection for ampullary carcinoma were analyzed retrospectively.
Jaundice was defined as a total bilirubin serum concentration of > or = 3 mg/dl. 
The median follow-up time was 106 months. Jaundice was noted at the time of
initial presentation in 43 (73%) patients. Jaundice at presentation correlated
with lymph node metastasis (p < 0.0001), lymphatic vessel invasion (p < 0.0001), 
invasion into the pancreas (p = 0.0007), and vascular invasion (p = 0.0487).
Pancreatic invasion was absent in patients without jaundice. Superior mesenteric 
nodal involvement was more frequent in patients with jaundice (15/43) than in
those without (0/16) (p = 0.0062). The survival of patients with jaundice (median
survival 48 months; cumulative 10-year survival rate 39%) was worse than for
patients without jaundice (median survival time not available; cumulative 10-year
survival rate 86%) (p = 0.0014). In conclusion, jaundice at presentation predicts
advanced-stage ampullary carcinoma and a poor prognosis. Pancreatic invasion and 
superior mesenteric nodal involvement were not observed in nonjaundiced patients.

PMID: 15770375 [PubMed - indexed for MEDLINE]

296: Gastrointest Endosc. 2005 Mar;61(3):467-72.

EUS-guided trucut biopsy in establishing autoimmune pancreatitis as the cause of 
obstructive jaundice.

Levy MJ, Reddy RP, Wiersema MJ, Smyrk TC, Clain JE, Harewood GC, Pearson RK,
Rajan E, Topazian MD, Yusuf TE, Chari ST, Petersen BT.

Division of Gastroenterology and Hepatology, Mayo CLinic, 200 First Street SW,
Rochester, MN 55905, USA.

BACKGROUND: The diagnosis of autoimmune pancreatitis can be difficult and often
requires a larger specimen than can be provided by FNA alone to determine if the 
tissue sample obtained with EUS trucut biopsy (TCB) is sufficient to allow
adequate histologic review to establish the diagnosis of autoimmune pancreatitis.
METHODS: EUS TCB was performed in patients presenting with obstructive jaundice
who were suspected of having autoimmune pancreatitis based on their clinical,
laboratory and imaging studies. The charts were retrospectively reviewed to
determine the feasibility of TCB. RESULTS: Between August 2002 and June 2004, 3
patients with obstructive jaundice and suspected autoimmune pancreatitis (AIP)
underwent EUS TCB. In each case, a diagnosis of pancreatic cancer also was
considered, and surgical resection was the planned therapy before the patient
underwent EUS TCB. Histologic review of the TCB specimens established the
diagnosis of AIP in two patients and identified nonspecific changes of chronic
pancreatitis in the third patient. EUS-guided FNA was performed in two of the 3
patients and failed to establish the diagnosis in either patient. Other than mild
transient abdominal pain (n = 1), no complications were identified. CONCLUSIONS: 
This preliminary study suggests that EUS TCB can safely establish the diagnosis
of AIP. Doing so helps guide management and may help to avoid unnecessary
surgery. Prospective studies are needed to verify these findings and to more
clearly define the role of EUS TCB in these patients.

Publication Types: 
    Case Reports

PMID: 15758927 [PubMed - indexed for MEDLINE]

297: Saudi Med J. 2005 Jan;26(1):111-3.

Castleman disease presenting as obstructive jaundice.

Al-Salamah SM, Khan IA, Khalid K, Al-Shakweer WA.

King Saud University Unit, Riyadh Medical Complex, PO Box 31168, Riyadh 11497,
Kingdom of Saudi Arabia. smsalamah@hotmail.com

A 48-year-old Saudi male was admitted with features of obstructive jaundice.
Endoscopic retrograde cholangiopancreatography showed stricture in distal common 
bile duct CBD. Computed tomography scan revealed lymphadenopathy along CBD and in
porta hepatis. Cholangiocarcinoma, lymphoma or metastatic deposits were suspected
but no definite preoperative diagnosis could be established. Laparotomy disclosed
lymph node enlargement in porta hepatis and along the CBD and lesser curvature of
the stomach. Triple bypass procedure was performed to relieve the obstruction.
Pathological examination of the lymph nodes showed Castleman disease of hyaline
vascular type.

Publication Types: 
    Case Reports

PMID: 15756365 [PubMed - indexed for MEDLINE]

298: Anesthesiology. 2005 Mar;102(3):562-5.

Awakening concentration of desflurane is decreased in patients with obstructive
jaundice.

Song JG, Cao YF, Yang LQ, Yu WF, Li Q, Song JC, Fu XY, Fu Q.

Department of Anesthesiology, Eastern Hepatobiliary Surgery Hospital, Second
Military Medical University. Shanghai, China.

BACKGROUND: Some studies suggest that behavioral complications of cholestasis,
such as fatigue and pruritus, may be associated with altered neurotransmission in
the brain. Because inhaled anesthetics primarily act on ion channels and
receptors on the neuronal cell membrane and alter synaptic transmission in the
central nervous system, it is possible that altered sensitivity to inhaled
anesthetics may occur in cholestatic patients. Therefore, the authors compared
the minimum alveolar concentration (MAC)-awake of desflurane in obstructive
jaundiced patients with the MACawake in nonjaundiced patients. METHODS: Patients 
underwent inhalational induction of anesthesia with desflurane. MACawake was
determined in each patient by observing the response to a verbal command (open
eyes on request). An end-tidal anesthetic concentration was maintained at an
initial target level of 1.4% for 15 min before a command. If a positive response 
was observed, the concentration of desflurane was increased by 0.1% and again
kept constant for 15 min. The verbal command was then continued. This process was
repeated until an end-tidal concentration was reached at which the patient did
not respond to command. The anesthetic concentration midway between the value
permitting the response and that just preventing the response was defined as
MACawake for each patient. RESULTS: The MACawake of desflurane for patients with 
obstructive jaundice (1.78 +/- 0.19%) was significantly less than those observed 
for the control group (2.17 +/- 0.25%; P < 0.001) and correlated significantly
with serum total bilirubin (r = -0.67, P = 0.0004). CONCLUSIONS: The MACawake of 
desflurane is reduced in obstructive jaundiced patients compared with
nonjaundiced controls.

Publication Types: 
    Research Support, Non-U.S. Gov't

PMID: 15731594 [PubMed - indexed for MEDLINE]

299: Hepatobiliary Pancreat Dis Int. 2005 Feb;4(1):98-103.

Endobiliary brush cytology during percutaneous transhepatic cholangiodrainage in 
patients with obstructive jaundice.

Xing GS, Geng JC, Han XW, Dai JH, Wu CY.

Department of Radiology, First Hospital of Tsinghua University, Beijing 100016,
China. xgs1259@yahoo.com.cn

BACKGROUND: Nonsurgical pathologic diagnosis of malignant bile duct stricture
with a high sensitivity and specificity is desirable for therapeutic scheme.
Percutaneous transhepatic endobiliary brush cytology in detecting obstructive
jaundice is evaluated. METHODS: Fifty-eight consecutive patients with obstructive
jaundice underwent percutaneous transhepatic cholangiodrainage (PTCD). During the
process, a brush was inserted into the bile duct through the preexisted
percutaneous transhepatic 8-F sheath, then exfoliated cells were collected from
the bile duct stenosis and sent for cytologic diagnosis. The suspicious results
were considered of negative diagnosis. All patients had relevant clinical data
and follow-up results (15 months to 3 years). Statistical analysis was performed 
with the chi-square test and Fisher's exact test of probabilities, and a P
value</=0.05 was considered significantly different. RESULTS: Of all patients, 42
were diagnosed as having malignant stenosis according to brush cytology. Atypical
hyperplasia was found in 9 patients and was suspicious of cholangiocarcinoma.
Seven patients were found to have benign strictures.The sensitivity, specificity,
positive predictive value, negative predictive value and accuracy of brush
cytology were 75%(42/56), 100%(2/2), 100%(42/42), 12.5%(2/16), and 75.9%(44/58), 
respectively. No complications were related to the procedures. In all patients
with malignant stenosis, the sensitivity of brushing in diagnosis of
cholangiocarcinoma was greater than that in those with non-cholangiocarcinoma
(P<0.05). The site of stenosis did not influence the sensitivity and technical
success (P>0.05). CONCLUSION: The results of this study indicate that cytological
brushing of biliary stricture during PTCD is a useful method to establish a
diagnosis of malignant biliary stenosis with a high sensitivity, but the negative
predictive value is not satisfied.

Publication Types: 
    Comparative Study

PMID: 15730930 [PubMed - indexed for MEDLINE]

300: J Pediatr Hematol Oncol. 2005 Feb;27(2):112-4.

Obstructive jaundice as a presentation of ganglioneuroblastoma.

Ito A, Uno T, Gunji Y, Yamauchi T, Egami S, Kawarasaki H, Momoi MY.

Department of Pediatrics, Jichi Medical School, Kawachi-gun, Tochigi-ken, Japan.

Obstructive jaundice is a rare symptom in the neuroblastic tumor. Seven cases of 
obstructive jaundice caused by neuroblastoma have been reported, and only three
of these patients had the symptom at the onset of the disease. The authors report
a case of ganglioneuroblastoma presenting with obstructive jaundice as a rare
initial feature. After the histologic diagnosis with open biopsy, chemotherapy
consisting of cisplatin, pirarubicin hydrochloride/doxorubicin, cyclophosphamide,
and vincristine was given. The treatment resulted in reduction in the tumor size 
and relief of the obstructive jaundice. Complete resection of the tumor was
possible after five courses of chemotherapy.

Publication Types: 
    Case Reports

PMID: 15701990 [PubMed - indexed for MEDLINE]

301: Hosp Med. 2005 Jan;66(1):17-22.

Imaging of the jaundiced patient.

O'Regan D, Tait P.

Imaging Department, Hammersmith Hospital, London W12 0HS.

Jaundice is a common condition which has a wide range of causes. Imaging plays a 
vital role in establishing the underlying aetiology and planning management.
Image-guided interventional techniques are used for therapeutic procedures and
for diagnostic purposes.

Publication Types: 
    Review

PMID: 15686161 [PubMed - indexed for MEDLINE]

302: J Gastroenterol Hepatol. 2005 Feb;20(2):304-8.

Three-dimensional helical computed tomography cholangiography with minimum
intensity projection in gallbladder carcinoma patients with obstructive jaundice:
comparison with magnetic resonance cholangiography and percutaneous transhepatic 
cholangiography.

Rao ND, Gulati MS, Paul SB, Pande GK, Sahni P, Chattopadhyay TK.

Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, 
B-3/185 Janak Puri, New Delhi 110-058, India.

OBJECTIVE: Computed tomography (CT) is traditionally used for evaluation and
staging of gallbladder carcinoma (GC). However, in the subgroup of patients with 
obstructive jaundice, magnetic resonance cholangiography (MRC) is generally
required to assess the level of biliary obstruction. The present study was
undertaken to evaluate the diagnostic potential of three-dimensional helical CT
cholangiography (3-D CTC) with minimum intensity projection (minIP), to determine
the presence and level of biliary obstruction. MATERIALS AND METHODS: Twenty-five
consecutive patients with proven GC, presenting with clinical and biochemical
features of obstructive jaundice, over a 1-year period were included in the
study. Dual phase helical CT data was obtained in the arterial and venous phases,
respectively, after intravenous contrast injection using a pressure injector.
Axial CT data (both arterial and venous phase) was studied for staging and
resectability of tumor. Three-dimensional helical CT cholangiography using minIP 
obtained from the venous phase data set, was used to assess the level of biliary 
obstruction and isolation of hepatic segmental ducts. Three-dimensional helical
CT cholangiography findings were compared with MRC and percutaneous transhepatic 
cholangiography (PTC) (gold standard). None of the patients were operated on as
they were all considered inoperable on axial CT images due to extensive local
disease or distant metastasis. RESULTS: In all patients, 3-D CTC demonstrated
dilated intrahepatic ducts up to tertiary branch level. The 3-D CTC correctly
diagnosed the level of biliary obstruction and demonstrated isolated segmental
ducts in all patients and correlated well in all cases with MRC and PTC findings 
in this regard. However, the 3-D CTC did not add any additional information over 
the axial source images. CONCLUSION: Three-dimensional helical CT cholangiography
with minIP can correctly determine the level of biliary obstruction in patients
with GC and may be a strong competitor with MRC, because it gives equivalent
information with regard to the level of ductal obstruction even while being a
part of an overall comprehensive CT staging study. Even though 3-D CTC did not
provide additional information on top of the source images, the referring
physicians found them very useful for conceptualization of the 3-D biliary
anatomy. (c) 2004 Blackwell Publishing Asia Pty Ltd.

Publication Types: 
    Comparative Study

PMID: 15683436 [PubMed - indexed for MEDLINE]

303: Gastroenterol Clin Biol. 2004 Dec;28(12):1209-13.

Endoscopic insertion of biliary stents in 18 patients with metallic duodenal
stents who developed secondary malignant obstructive jaundice.

Vanbiervliet G, Demarquay JF, Dumas R, Caroli-Bosc FX, Piche T, Tran A.

Service d'Hépato-Gastroentérologie, Hôpital de l'Archet 2, CHU, Nice.
geovbv@club-internet.fr

AIM: The aim of this work was to evaluate the feasibility of endoscopic insertion
of biliary stents in patients with duodenal stents who develop secondary
malignant obstructive jaundice. PATIENTS AND METHODS: The study population
included 133 patients with unresectable malignant duodenal obstruction. In 106
patients a biliary stent was inserted before or at the same time as the duodenal 
stent. Malignant biliary obstruction appeared secondarily in 18 patients; fifteen
of these patients already had a biliary stent. We present our experience of
biliary stent insertion in these 18 patients with metallic duodenal stents.
RESULTS: Biliary obstruction was successfully alleviated in 17 out of 18 patients
(94%) without complication. Insertion of a new biliary stent failed in one
patient because the mesh of the duodenal stent passed over the metallic biliary
stent already in place. Mean duration of endoscopic insertion was 95 minutes
(range: 60 - 180). All patients remained free of biliary complications to death
(57 days, range: 30 - 120). CONCLUSION: Our report shows that endoscopic
insertion of a biliary stent is feasible in patients who have metallic duodenal
stents. Technical difficulties exist especially if the mesh of the duodenal stent
passes over the papilla.

PMID: 15671930 [PubMed - indexed for MEDLINE]

304: JOP. 2005 Jan 13;6(1):29-35.

Pancreatic pseudoaneurysm of the superior mesenteric artery complicated with
obstructive jaundice. A case report.

Saftoiu A, Iordache S, Ciurea T, Dumitrescu D, Popescu M, Stoica Z.

Department of Gastroenterology, University of Medicine and Pharmacy Craiova,
Craiova, Dolj, România. adry@umfcv.ro <adry@umfcv.ro>

CONTEXT: Pancreatic pseudoaneurysm rupture is a rare complication of chronic
pancreatitis, with severe prognosis and high mortality. Angiography is usually
required for confirmation of the diagnosis, but transabdominal ultrasound and CT 
angiography are useful noninvasive diagnostic methods. CASE REPORT: We present
the case of a 66-year-old patient with a large pancreatic pseudoaneurysm of the
superior mesenteric artery complicated with obstructive jaundice. Transabdominal 
ultrasound with color and power Doppler showed a large pancreatic head
pseudoaneurysm that communicated directly to the superior mesenteric artery.
Presence of a spinning blood flow inside the pseudoaneurysm was visualized by
color Doppler, with evidence of bidirectional flow in the pseudoaneurysm neck
that was showed by Doppler spectral analysis. The contrast-enhanced helical
computer tomography with multiplanar sagittal and the 3D reconstruction of
coronal images confirmed the communication of the pseudoaneurysm with the
superior mesenteric artery. The patient was scheduled for selective angiography
and embolization. However, clinical evolution was rapidly deteriorating, with
collapse, hemorrhagic shock and massive hemorrhage. The patient was operated on
and subsequently died despite three days of intensive care, due to disseminated
intravascular coagulation and multiorgan failure. CONCLUSION: Non invasive
imaging methods consisting of transabdominal ultrasound with color Doppler and
contrast-enhanced computer tomography with sagittal reconstruction of coronal
images were very useful in the establishment of the diagnosis of pancreatic
pseudoaneurysm of the superior mesenteric artery complicated with cholestatic
jaundice. However, these imaging methods do not obviate the need for diagnostic
and therapeutic angiography, eventually followed by surgical intervention in
cases of recurrent bleeding or hemodynamic unstable patients.

Publication Types: 
    Case Reports
    Review

PMID: 15650282 [PubMed - indexed for MEDLINE]

305: QJM. 2005 Jan;98(1):35-40.

Erratum in:
    QJM. 2005 Mar;98(3):238.

Contrasting liver function test patterns in obstructive jaundice due to biliary
strictures [corrected] and stones.

Hayat JO, Loew CJ, Asrress KN, McIntyre AS, Gorard DA.

Department of Gstroenterology, Wycombe Hospital, Queen Alexandra Road, High
Wycombe, Bucks HP11 2TT, UK.

BACKGROUND: Obstructive jaundice is believed to be characterized by abnormalities
of alkaline phosphatase (ALP), rather than aspartate transaminase (AST). AIM: To 
compare liver function tests (LFTs) in obstructive jaundice due to malignant
strictures with those of jaundice due to gallstones. METHODS: LFTs were measured 
immediately before endoscopic retrograde cholangio-pancreatography (ERCP) in 207 
jaundiced patients. Group 1 (n = 69) had malignant strictures, group 2 (n = 97)
had common bile duct stone(s), and group 3 (n = 41) appeared to have recently
passed a stone. LFTs in groups 2 and 3 were also analysed at maximal liver enzyme
derangement, maximum hyperbilirubinaemia and during acute pain episodes. RESULTS:
Group 1 had higher median bilirubin, AST and ALP levels than groups 2 or 3 (p <
0.001). In group 1, median rise in ALP exceeded that in AST (4.3 x normal upper
limit (NUL) vs. 2.6 x NUL, p < 0.01), but in groups 2 and 3, AST and ALP were
similarly elevated (both approximately 2 x NUL). At the time of maximum enzyme
derangement in groups 2 and 3, median AST elevation (4.4 x NUL, 185 IU/l)
exceeded that for ALP (2.4 x NUL, 276 U/l), (p < 0.001), and this was also true
at peak hyperbilirubinaemia in these groups (AST 3.6 x NUL, ALP 2.4 x NUL, p <
0.01. Similarly, severe pain episodes in groups 2 and 3 were accompanied by
greater elevations in bilirubin and AST, but not ALP, compared with levels at
ERCP. DISCUSSION: The conventional wisdom that ALP rises more than AST in
obstructive jaundice holds true where the jaundice is due to strictures, but in
obstructive stone disease, the rise in AST may equal that in ALP, or even exceed 
it during maximum jaundice and during painful episodes. Clinicians should
consider the possibility of extrahepatic biliary obstruction, even when AST is
the predominantly elevated enzyme.

PMID: 15625352 [PubMed - indexed for MEDLINE]

306: Ann Surg. 2005 Jan;241(1):159-67.

Bombesin and neurotensin reduce endotoxemia, intestinal oxidative stress, and
apoptosis in experimental obstructive jaundice.

Assimakopoulos SF, Scopa CD, Zervoudakis G, Mylonas PG, Georgiou C, Nikolopoulou 
V, Vagianos CE.

Department of Internal Medicine, School of Medicine, University of Patras,
Patras, Greece. sassim@upatras.gr

OBJECTIVE: To evaluate the effect of bombesin (BBS) and neurotensin (NT) on
intestinal histopathology, intestinal oxidative stress, and endotoxemia in
experimental obstructive jaundice. SUMMARY BACKGROUND DATA: Obstructive jaundice 
compromises gut barrier function, resulting in endotoxemia. BBS and NT, exerting 
various biologic actions on gastrointestinal tissues, preserve gut mucosal
integrity in cases of injury or atrophy. METHODS: Seventy male Wistar rats were
randomly divided into 5 groups: I = controls, II = sham operated, III = bile duct
ligation (BDL), IV = BDL + BBS (30 microg/kg/d), V = BDL + NT (300 microg/kg/d). 
By the end of the experiment, on day 10, endotoxin was measured in portal and
aortic blood. Tissue sections of the terminal ileum were examined histologically,
and villus density, mucosal thickness, mitotic activity and apoptosis in crypts
were assessed. In addition, ileal mucosa was analyzed for DNA and protein
content. To estimate intestinal oxidant/antioxidant equilibrium, lipid
peroxidation, protein oxidation, and thiol redox state (reduced glutathione
[GSH], oxidized glutathione [GSSG], total nonprotein mixed disulfides [NPSSR],
protein thiols [PSH], and protein disulfides [PSSP]) were determined on tissue
homogenates from the terminal ileum. RESULTS: BBS or NT administration
significantly reduced portal and systemic endotoxemia observed in obstructive
jaundice. Both factors reversed obstructive jaundice-induced morphologic features
of intestinal atrophy, increasing villus density and mucosal thickness. This
effect was accompanied by induction of mitoses and reduction of apoptosis in
intestinal crypts. Mucosal DNA and protein content were reduced, although not to 
significant levels, in BDL animals and restored to control levels after BBS or NT
treatment. Moreover, BBS or NT administration protected the intestine in
jaundiced rats against oxidative stress, as demonstrated by reduction of
intestinal lipid peroxidation, increase of the antioxidant GSH, and decrease of
the oxidized forms GSSG and NPSSR, while BBS additionally reduced protein
oxidation as well. CONCLUSIONS: Administration of BBS or NT in bile duct-ligated 
rats exerts beneficial effects on intestinal oxidative stress, cell
proliferation, apoptosis, and endotoxemia. This observation might be of potential
value in patients with extrahepatic cholestasis.

Publication Types: 
    Evaluation Studies

PMID: 15622004 [PubMed - indexed for MEDLINE]

307: J Chin Med Assoc. 2004 Sep;67(9):476-8.

Biliary stenting with puncturing technique using Baron aspiration needle in
ulcerative papillary carcinoma.

Lin LF, Siauw CP, Ho KS, Tumg JN.

Division of Gastroenterology, Department of Internal Medicine, Tung's Taichung
Metroharbor Hospital, Taichung, Taiwan, ROC. lienfu42@ms10.hinet.net

A 60 year-old man with obstructive jaundice due to an ulcerative papillary
carcinoma underwent endoscopic retrograde cholangiopancreatography. Owing to the 
totally destroyed papilla of Vater, access to the biliary tract was impossible.
Instead of needle knife fistulotomy, puncturing with an 18-G aspiration needle on
the supra-papillary bulge followed by biliary stenting was performed
successfully. To our knowledge, this technique has not been reported before in
the English literature and probably can have fewer complications of bleeding and 
perforations produced by needle knife fistulotomy.

Publication Types: 
    Case Reports

PMID: 15617309 [PubMed - indexed for MEDLINE]

308: J Gastroenterol Hepatol. 2005 Jan;20(1):117-25.

Effects of obstructive jaundice on neutrophil production and acquisition of
chemotactic activity in the bone marrow.

Shimatani M, Tsuji K, Aze Y, Yamamoto S, Shibatani N, Imai Y, Takamido S, Kubota 
Y, Okazaki K.

The Third Department of Internal Medicine, Kansai Medical University, Osaka,
Japan. smtnmk@nifty.com

BACKGROUND AND AIMS: Increased numbers and enhanced functions of peripheral
neutrophils have been observed in obstructive jaundice. However, the effects of
obstructive jaundice on the bone marrow, that is neutrophil production and
acquisition of neutrophil chemotactic activity, have been poorly understood. In
the present study, differentials of bone marrow cells and chemotactic activity of
bone marrow neutrophils were evaluated in bile duct-obstructed rats. METHODS:
Male Wistar rats underwent either bile duct obstruction for 10 days or bile duct 
obstruction for 4 days followed by 6 days' internal biliary drainage.
Differentials of peripheral blood and bone marrow cells were sequentially
determined. Chemotactic activity of peripheral and bone marrow neutrophils was
evaluated with a modified Boyden method using interleukin-8 (recombinant rat
Gro-beta) as a chemoattractant. RESULTS: Numbers of peripheral neutrophils
significantly increased after bile duct obstruction. Significant increases in the
myeloid/erythroid (M/E) ratio of bone marrow cells were observed after bile duct 
obstruction. The neutrophil proliferative pool (promyelocytes and myelocytes)
increased initially, followed by an increased neutrophil storage pool
(metamyelocytes, bands, and segmented neutrophils). The M/E ratio as well as the 
neutrophil proliferative and storage pools normalized after internal biliary
drainage. Chemotactic activity was enhanced in both peripheral and bone marrow
neutrophils after bile duct obstruction, and enhanced chemotaxis was alleviated
with internal biliary drainage. CONCLUSION: The present results strongly suggest 
the principal role of the bone marrow in increasing the number of neutrophils and
their chemotactic activity during obstructive jaundice.

PMID: 15610456 [PubMed - indexed for MEDLINE]

309: J Gastroenterol Hepatol. 2005 Jan;20(1):56-61.

Extrahepatic portal venous obstruction and obstructive jaundice: approach to
management.

Khare R, Sikora SS, Srikanth G, Choudhuri G, Saraswat VA, Kumar A, Saxena R,
Kapoor VK.

Department of Surgical Gastroenterology, Sanjay Gandhi Postgraduate Institute of 
Medical Sciences, Lucknow, India.

BACKGROUND: Patients with long-standing extrahepatic portal venous obstruction
(EHPVO) develop extensive collaterals in the hepatoduodenal ligament as a result 
of enlargement of the periportal veins. These patients are also prone to develop 
obstructive jaundice as a result of strictures and/or choledocholithiasis.
Surgical management of obstructive jaundice in such patients becomes difficult in
the presence of these collaterals. AIM: To review the approach to management of
patients with EHPVO and obstructive jaundice. METHODS: Retrospective review of
patients with EHPVO and obstructive jaundice requiring surgical and/or endoscopic
management between 1992 and 2002. RESULTS: Thirteen patients (nine males, aged
12-50 years) with EHPVO and obstructive jaundice were evaluated. No patient had
underlying cirrhosis or hepatocellular carcinoma. Five patients (group A) had
biliary stricture; three (group B) had choledocholithiasis; and five (group C)
had biliary stricture with choledocholithiasis. Primary surgical management was
performed in group A (portosystemic shunt in four-strictures resolved in three;
hepaticojejunostomy in one). In group B (n = 3) endoscopic stone extraction was
successful in two patients. One patient underwent staged procedure (portosystemic
shunt followed by biliary surgery). In group C, initial endoscopic management
failed in four patients in whom it was attempted. All five patients thereafter
underwent surgery (staged procedure, one; choledochoduodenostomy, one;
devascularization, one; abandoned, two). Repeat postoperative endoscopic
management was successful in two of the group C patients. Overall (group B and
C), massive intraoperative hemorrhage occurred in three patients (one died).
Postoperative hemorrhage occurred in one patient. CONCLUSION: In patients with
EHPVO and obstructive jaundice, primary biliary tract surgery has significant
morbidity and mortality. Endoscopic management should be the preferred modality. 
In patients with endoscopic failure, a staged procedure (portosystemic shunt
followed by biliary surgery) should be preferred. Strictures alone may resolve
after a portosystemic shunt. Endoscopic stenting may be required as an adjunct.

PMID: 15610447 [PubMed - indexed for MEDLINE]

310: Am J Med Sci. 2004 Dec;328(6):348-50.

Severe cholestatic jaundice in hyperthyroidism after treatment with 131-iodine.

Hasan MK, Tierney WM, Baker MZ.

Department of Internal Medicine, University of Oklahoma Health Sciences Center,
Oklahoma City, Oklahoma 73104, USA.

A 39-year-old white man was referred to our hospital for evaluation of his
jaundice and pruritus. The patient was treated with I for diffuse toxic goiter
prior to his referral to our hospital. Clinical examination and laboratory
investigations excluded viral hepatitis, autoimmune hepatitis, granulomatous
disease, primary biliary disease, extrahepatic biliary obstruction, and heart
failure. Liver biopsy showed severe intrahepatic and canalicular cholestasis with
minimal inflammatory changes. The patient's jaundice promptly resolved with
therapy for hyperthyroidism and thyroid storm as bilirubin levels decreased from 
35 mg/dL (normal: 0.5-1.2 mg/dL) to 0.4 mg/dL. Thyrotoxicosis can be an uncommon 
cause of profound cholestasis. Our case differs from all other reports in the
literature because of the severity of the cholestasis and its prompt resolution
with treatment for thyrotoxicosis.

Publication Types: 
    Case Reports

PMID: 15599331 [PubMed - indexed for MEDLINE]

311: J Int Med Res. 2004 Nov-Dec;32(6):633-8.

Predictive value of risk factors in patients with obstructive jaundice.

Pitiakoudis M, Mimidis K, Tsaroucha AK, Papadopoulos V, Karayiannakis A,
Simopoulos C.

Second Department of Surgery, Medical School, Democritus University of Thrace,
Alexandroupolis, Greece.

Clinical and laboratory parameters that may affect post-operative mortality and
morbidity were studied in 215 patients operated on for obstructive jaundice. The 
cause of the bile duct obstruction was benign disease in 56.7% of patients and
malignant disease in 43.3%. Overall postoperative mortality and morbidity rates
were 21.9% and 33.5%, respectively. Eight risk factors were shown to be
associated with increased mortality: age > 70 years; malignancy; leucocytosis >
15 000 cells/microl and fever > 38.5 degrees C; haematocrit < or = 30%;
creatinine > 1.3 mg/dl; albumin < or = 3 g/dl; bilirubin > 20 mg/dl; and serum
alkaline phosphatase > 100 IU/l. The simultaneous presence of less than three
risk factors was always associated with post-operative survival, but concomitant 
existence of seven or more risk factors indicated 100% mortality. Understanding
the factors related to post-operative morbidity and mortality in patients with
obstructive jaundice will better guide appropriate surgical or non-surgical
management and lead to improved survival.

PMID: 15587757 [PubMed - indexed for MEDLINE]

312: J Gastroenterol. 2004 Nov;39(11):1110-3.

Obstructive jaundice caused by enteropathy-associated T-cell lymphoma in a
patient with celiac sprue.

Buess M, Steuerwald M, Wegmann W, Rothen M.

Medizinische Universitätsklinik Kantonsspital Bruderholz, Bruderholz,
Switzerland.

Patients with celiac sprue carry a considerable risk of gastrointestinal
malignancies; in particular, non-Hodgkin's lymphoma. These malignancies represent
the most serious complications of celiac disease. Commonly, patients present with
deteriorating symptoms of the underlying disease, which makes an early diagnosis 
difficult. We report a patient with a 13-year history of celiac sprue presenting 
with painless jaundice and a Courvoisier gallbladder. Abdominal computed
tomography (CT) scan showed thickening of the duodenal wall, suggesting a
neoplastic infiltration of the papilla of Vater, causing biliary obstruction.
Biopsies taken on endoscopy revealed enteropathy-associated T-cell lymphoma of
the duodenum. Biliary obstruction is a rare clinical finding in
enteropathy-associated T-cell lymphoma. To our knowledge, this is the first
reported case of this unusual manifestation in celiac disease.

Publication Types: 
    Case Reports

PMID: 15580407 [PubMed - indexed for MEDLINE]

313: World J Surg. 2004 Oct;28(10):967-70. Epub 2004 Sep 29.

Altered serum transforming growth factor-beta1 and monocyte chemoattractant
protein-1 levels in obstructive jaundice.

Sheen-Chen SM, Eng HL, Hung KS.

Department of Surgery, College of Medicine, Chang Gung University, Chang Gung
Memorial Hospital, Kaohsiung, 123 Ta-Pei Road, Niao-Sung Hsiang, Kaohsiung Hsien,
Taiwan. smsheen@yahoo.com

Impaired immune function has long been documented in patients with obstructive
jaundice, and those with jaundice due to extrahepatic biliary obstruction still
experience a high rate of postoperative complications and death. Transforming
growth factor-beta1 (TGFbeta1) appears to be an important regulator of both
normal and pathologic conditions in the liver. Monocyte chemoattractant protein-1
(MCP-1) is an important mediator of monocyte recruitment to inflammatory sites.
We hypothesize that obstructive jaundice may alter serum TGFbeta1 and MCP-1
expressions in the rat and that oral bile acid or glutamine (or both) can restore
the altered serum TGFbeta1 and MCP-1 expression in rats with obstructive
jaundice. Male Sprague-Dawley rats weighing 250 to 300 g were randomized to four 
groups (n = 10 in each group). Group 1 underwent a sham operation with oral
normal saline administration. Group 2 underwent common bile duct ligation (CBDL) 
with oral normal saline administration. Group 3 underwent CBDL with oral bile
acid replacement. Group 4 underwent CBDL with oral glutamine administration.
Animals were sacrificed after 3 days (n = 5) and 7 days (n = 5), and blood
samples were collected. Serum was obtained after centrifugation for measurement
of TGFbeta1 and MCP-1 levels by an enzyme-linked immunosorbent assay. The serum
TGFbeta1 level was significantly elevated (p = 0.006) 3 days after CBDL. Oral
glutamine administration prevented this elevation, but oral bile acid replacement
did not. The serum MCP-1 level showed similar changes. After 3 days of
obstructive jaundice, the TGFbeta1 and MCP-1 levels were altered in the rat. Oral
glutamine administration, not oral bile acid replacement, was able to prevent
these alterations.

Publication Types: 
    Research Support, Non-U.S. Gov't

PMID: 15573249 [PubMed - indexed for MEDLINE]

314: Liver Transpl. 2004 Dec;10(12):1497-503.

Comment in:
    Liver Transpl. 2004 Dec;10(12):1504-6.

Factors that identify survival after liver retransplantation for allograft
failure caused by recurrent hepatitis C infection.

Neff GW, O'Brien CB, Nery J, Shire NJ, Nishida S, delaGarza J, Montalbano M,
Safdar K, Ruiz P, Rideman E, Gascon JA, Tzakis AG, Madariaga J, Rudich SM.

University of Cincinnati, Ohio, USA. neffgw@ucmail.uc.edu <neffgw@ucmail.uc.edu>

Hepatitis C virus (HCV) is becoming the most common indication for liver
retransplantation (ReLTx). This study was a retrospective review of the medical
records of liver transplant patients at our institution to determine factors that
would identify the best candidates for ReLTx resulting from allograft failure
because of HCV recurrence. The patients were divided into 2 groups on the basis
of indication for initial liver transplant. Group 1 included ReLTx patients whose
initial indication for LTx was HCV. Group 2 included patients who received ReLTx 
who did not have a history of HCV. We defined chronic allograft dysfunction (AD) 
as patients with persistent jaundice (> 30 days) beginning 6 months after primary
liver transplant in the absence of other reasons. HCV was the primary indication 
for initial orthotopic liver transplantation (OLT) in 491/1114 patients (44%)
from July 1996 to February 2004. The number of patients with AD undergoing ReLTx 
in Groups 1 and 2 was 22 and 12, respectively. The overall patient and allograft 
survival at 1 year was 50% and 75% in Groups 1 and 2, respectively (P = .04). The
rates of primary nonfunction and technical problems after ReLTx were not
different between the groups. However, the incidence of recurrent AD was higher
in Group 1 at 32% versus 17% in Group 2 (P = .04). Important factors that
predicted a successful ReLTx included physical condition at the time of ReLTx (P 
= .002) and Child-Turcotte-Pugh score (P = .008). In conclusion, HCV is
associated with an increased incidence of chronic graft destruction with a
negative effect on long-term results after ReLTx. The optimum candidate for ReLTx
is a patient who can maintain normal physical activity. As the allograft shortage
continues, the optimal use of cadaveric livers continues to be of primary
importance. The use of deceased donor livers in patients with allograft failure
caused by HCV remains a highly controversial issue.

PMID: 15558835 [PubMed - indexed for MEDLINE]

315: Scand J Surg. 2004;93(3):176-83.

Diagnostic approach to the patient with jaundice following trauma.

Labori KJ, Raeder MG.

Department of Gastroenterological Surgery and Institute for Experimental Medical 
Research, Ullevaal University Hospital, Oslo, Norway. k.j.labori@medisin.uio.no

BACKGROUND AND AIMS: Jaundice in trauma patients may reflect serious underlying
pathology. The aim of this review was to determine the appropriate diagnostic
approach to the patient with jaundice following trauma. METHODS: A MEDLINE search
was performed to retrieve publications which outlined the causes of jaundice in
trauma patients. RESULTS: The main causes of jaundice in trauma patients were
found to be bilirubin overload caused by breakdown of transfused- and
extravasated blood and hepatic dysfunction caused by sepsis, infections, initial 
shock and systemic hypotension. Bile duct injury or drug induced liver injury are
rare. Liver function tests are often uninformative but commonly show a
cholestatic pattern. Ultrasound, CT or ERCP are the diagnostic imaging methods
most widely used. Abdominal ultrasound and CT may reveal specific organ injuries,
bile duct dilatation, intraabdominal fluid collections, hematomas or acalculus
cholecystitis. ERCP is often diagnostic and permits a therapeutic intervention
when a bile duct injury is present. CONCLUSIONS: The primary aim of the
diagnostic approach should be to identify all cases of bile duct injury or
obstruction. Sepsis and infections should be actively looked for. The number of
blood transfusions must be calculated. Ultrasound, CT or ERCP are the diagnostic 
imaging methods most widely used.

Publication Types: 
    Review

PMID: 15544071 [PubMed - indexed for MEDLINE]

316: Int Arch Occup Environ Health. 2004 Nov;77(8):592-4. Epub 2004 Nov 9.

The Epping Jaundice outbreak: mortality after 38 years of follow-up.

Nichols L.

Institute of Occupational and Environmental Medicine, University of Birmingham,
Edgbaston, Birmingham B15 2TT, UK. L.Nichols@bham.ac.uk

OBJECTIVE: To investigate mortality in individuals exposed to
4,4'-methylenedianiline (MDA). METHODS: The mortality of 84 individuals,
accidentally poisoned with MDA during the "Epping Jaundice" outbreak of 1965, was
compared with expected values based on national rates defined by age, period and 
sex, for the period 1965-2002. In addition, cancer registration data were
analysed for the period 1971-2002. RESULTS: The vital status of 83% of the group 
was established, with 37 deaths occurring before the end of follow-up. Mortality 
from all causes was close to expectation among females (Obs, 25; Exp, 30.3; SMR, 
82), and below expectation among males (Obs, 12; Exp, 26.7; SMR, 45). There were 
no observed deaths from cancer of the liver or from nonmalignant liver disease.
CONCLUSIONS: This study has found no evidence to suggest that the ingestion of
MDA had adversely affected mortality.

PMID: 15538614 [PubMed - indexed for MEDLINE]

317: J Trop Pediatr. 2004 Dec;50(6):372-4.

An uncommon presentation: chronic meningococcaemia associated with cholestatic
hepatitis in a Turkish child.

Totan M, Yildiz G, Kalayci AG.

Department of Pediatrics, Ondokuz Mayis University Faculty of Medicine,
Samsun,Turkey. mtotan@omu.edu.tr

Chronic meningococcaemia is a very rare clinical manifestation of invasive
infection by Neisseria meningitidis. A 9-year-old girl was admitted to our clinic
with complaints of fever, headache, arthralgia, and maculopapular rash. The
diagnosis was made by the growth of Neisseria meningitidis in the blood cultures.
Four days after admission, liver function tests were increased and were
compatible with cholestatic hepatitis. Thereafter, the patient was successfully
treated and symptoms were completely resolved. To our knowledge, there have been 
no previous reports of Neisseria meningitidis causing cholestatic hepatitis.
Herein, we present an unusual child patient with chronic meningococcaemia
associated with cholestatic hepatitis.

Publication Types: 
    Case Reports

PMID: 15537727 [PubMed - indexed for MEDLINE]

318: Ren Fail. 2004 Sep;26(5):507-16.

Are bile acids involved in the renal dysfunction of obstructive jaundice? An
experimental study in bile duct ligated rats.

Kaler B, Karram T, Morgan WA, Bach PH, Yousef IM, Bomzon A.

Department of Life Sciences, University of East London, London, UK .

BACKGROUND: Surgery on patients with obstructive jaundice is associated with a
significant risk of postoperative renal failure. Bile acids are implicated as
nephrotoxins because they accumulate in the plasma and the kidney becomes their
only excretory route in cholestasis. The experimental evidence favoring this
proposal is inadequate and unconvincing. Therefore, we designed an animal
experiment involving bile duct ligated (BDL) rats in which we could correlate
variations in serum and urine bile acids with indices of nephrotoxicity and renal
function. HYPOTHESIS: Bile acids are putative nephrotoxins. MATERIALS AND
METHODS: Total serum and urine bile acid concentrations and profiles were
determined using liquid chromatography/gas chromatography/mass spectrometry
selected ion monitoring. Nephrotoxicity was assessed by renal histopathology and 
by determination of the urinary activities of the following enzymes: muramidase, 
glutamate dehydrogenase, alkaline phosphatase, N-acetyl-beta-D-glucosaminidase,
and lactate dehydrogenase. Renal function was assessed by measuring urine
osmolality, daily osmolar excretion, sodium excretion (U(Na)V), potassium
excretion (U(K)V), and total protein and albumin excretion. RESULTS: Maximum
plasma concentrations and renal clearance of bile acids occurred between the
third or fourth postoperative day following BDL. This peak coincided with maximal
disruption of proximal convoluted tubule architecture and postoperative changes
in renal function-increased urine flow rate and decreases in urine osmolality and
sodium excretion. Thereafter, 1) plasma levels of bile acids returned toward
normal levels, 2) urinary bile acid clearance declined, 3) normal renal histology
was restored, and 4) normal renal function was reestablished. Throughout this
period, fluctuations in enzymuria were evident. However, these shifts did not
coincide with plasma and urine bile acid concentrations and histological and
functional changes. DISCUSSION AND CONCLUSIONS: Transient functional impairment
of renal cation and water transport and nonspecific morphological changes in the 
proximal convoluted tubule occur 3 to 4 days following bile duct ligation in
rats. These functional and morphological changes occurred when plasma total and
urinary bile acids were at their peaks. Although it is tempting to equate
association with causality, we cannot implicate bile acids as being responsible
for the aberrations in renal function and structure following BDL. Accordingly,
we have concluded that elevated plasma concentrations of bile acids are renal
exacerbates acting in concert with other factors, be they prerenal or renal in
origin to precipitate a cascade of events leading to postoperative renal failure 
in cholestasis.

Publication Types: 
    Evaluation Studies
    Research Support, Non-U.S. Gov't

PMID: 15526908 [PubMed - indexed for MEDLINE]

319: World J Gastroenterol. 2004 Dec 1;10(23):3506-10.

HDR-192Ir intraluminal brachytherapy in treatment of malignant obstructive
jaundice.

Chen Y, Wang XL, Yan ZP, Cheng JM, Wang JH, Gong GQ, Qian S, Luo JJ, Liu QX.

Department of Radiology, Affiliated Zhongshan Hospital, Medical Center of Fudan
University, Shanghai 200032, China.

AIM: To determine the feasibility and safety of intraluminal brachytherapy in
treatment of malignant obstructive jaundice (MOJ) and to evaluate the clinical
effect of intraluminal brachytherapy on stent patency and patient survival.
METHODS: Thirty-four patients with MOJ were included in this study. Having
biliary stent placed, all patients were classified into intraluminal
brachytherapy group (group A, n = 14) and control group (group B, n = 20)
according to their own choice. Intraluminal brachytherapy regimen included:
HDR-192Ir was used in the therapy, fractional doses of 4-7 Gy were given every
3-6 d for 3-4 times, and standard points were established at 0.5-1.0 cm. Some
patients of both groups received transcatheter arterial chemoembolization (TACE) 
after stent placement. RESULTS: In group A, the success rate of intraluminal
brachytherapy was 98.0%, RTOG grade 1 acute radiation morbidity occurred in 3
patients, RTOG/EORTC grade 1 late radiation morbidity occurred in 1 patient. Mean
stent patency of group A (12.6 mo) was significantly longer than that of group B 
(8.3 mo) (P<0.05). There was no significant difference in the mean survival (9.4 
mo vs 6.0 mo) between the two groups. CONCLUSION: HDR-192Ir intraluminal
brachytherapy is a safe palliative therapy in treating MOJ, and it may prolong
stent patency and has the potentiality of extending survival of patients with
MOJ.

Publication Types: 
    Clinical Trial

PMID: 15526374 [PubMed - indexed for MEDLINE]

320: Br J Surg. 2005 Jan;92(1):39-43.

Randomized clinical trial of the effect of intravenous fluid administration on
hormonal and renal dysfunction in patients with obstructive jaundice undergoing
endoscopic drainage.

Padillo FJ, Briceño J, Cruz A, Chicano M, Naranjo A, Vallejo J, Martín-Malo A,
Pera-Madrazo C, Sitges-Serra A.

Department of Surgery, Hospital Universitari del Mar, Barcelona, Spain.

BACKGROUND: Renal dysfunction in patients with biliary obstruction is associated 
with extracellular water depletion. This study examined the effect of
preoperative saline infusion before biliary drainage on hormonal and renal
functional derangements in patients with obstructive jaundice. METHODS: In a
randomized study, 49 patients with malignant obstructive jaundice were
investigated at baseline, on the day of drainage, and at 24 h, 72 h and 7 days
after internal endoscopic biliary drainage. Patients were randomized to receive
(n = 22) or not to receive (n = 27) 3000 ml normal saline intravenously for 24 h 
before drainage. Variables analysed included extracellular water volume,
creatinine clearance, and serum levels of aldosterone, renin, atrial natriuretic 
peptide (ANP), vasopressin and albumin. RESULTS: Preoperative saline infusion
produced a rise in creatinine clearance, diuresis, ANP concentration and
extracellular water volume but this did not translate into better recovery of
renal function after operation. Drainage produced a fall in creatinine clearance 
in all patients, but hormonal and renal function had recovered by 2 days after
restoration of bile flow, independently of preoperative hydration. CONCLUSION:
Fluid administration expands the extracellular water compartment before drainage 
but fails to improve renal function after drainage. Definitive improvement in
endocrine and renal function requires the restoration of bile flow into the
duodenum.

Publication Types: 
    Clinical Trial
    Randomized Controlled Trial
    Research Support, Non-U.S. Gov't

PMID: 15521079 [PubMed - indexed for MEDLINE]

321: Ann Hepatol. 2004 Jul-Sep;3(3):114-7.

Polysplenia syndrome in the adult patient. Case report with review of the
literature.

Plata-Muñoz JJ, Hernández-Ramírez D, Anthón FJ, Podgaetz E, Avila-Flores F, Chan 
C.

Surgery Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador
Zubirán, Tlalpan, CP. 14000, Mexico City, Mexico.

AIMS: To report a case of polysplenia syndrome (PSS) in an adult patient.
BACKGROUND: The PSS is a form of situs ambiguous with multiple spleen, cardiac
anomalies, abdominal heterotaxia, short pancreas, major venous system and
bronquial malformations. It is a rare syndrome, more often found in childhood,
and only the 10% of the patients that do not have cardiac anomalies can reach
adulthood. RESULTS: A 56 y/o male with obstructive jaundice and intestinal
obstruction who was submitted to an abdominal laparotomy suspecting
cholangiocarcinoma. He had choledocolithiasis, duodenal kinking by a preduodenal 
portal vein, intestinal levorotation, hypoplasic vena cava with a prominent
acigos vein, short pancreas and polysplenia. A cholecistectomy, biliodigestive
and gastroyeyunal bypasses were performed without any complications and with a
successful evolution. CONCLUSIONS: In conclusion, PSS is a rare hereditary
syndrome that often occurs in childhood and its discovery in an adult is
frequently fortuitus. Surgical treatment is an excellent therapeutic option,
however is reserved just for complications. The outcome is good and the final
evolution depends on the degree of the cardiac anomalies.

Publication Types: 
    Case Reports
    Review

PMID: 15505598 [PubMed - indexed for MEDLINE]

322: J Clin Gastroenterol. 2004 Nov-Dec;38(10):887-90.

Comment in:
    J Clin Gastroenterol. 2004 Nov-Dec;38(10):839-40.

Magnetic resonance cholangiopancreatography in obstructive jaundice.

Vaishali MD, Agarwal AK, Upadhyaya DN, Chauhan VS, Sharma OP, Shukla VK.

Department of Radiology, Institute of Medical Sciences, Banaras Hindu University,
Varanasi, India.

GOALS: To determine the ability of magnetic resonance cholangiopancreatography
(MRCP) to diagnose the level and cause of obstruction in patients with
obstructive jaundice. BACKGROUND: The limitations of available imaging modalities
have led to the increasing use of MRCP, which is a noninvasive and highly
accurate technique in evaluating patients with biliary obstruction. STUDY: Thirty
patients were included in this study. MRCP was done using a fat suppressed,
heavily T2 weighted fast spin echo sequence. The MRCP findings were confirmed on 
surgical exploration or clinical follow-up. RESULTS: MRCP could correctly
identify ductal dilatation and the level of obstruction in all cases, except one.
All causes of obstruction, except three, were detected. It failed to detect a
common bile duct calculus in a minimally dilated ductal system and misdiagnosed a
case of focal chronic pancreatitis as carcinoma head pancreas and a small
pancreatic head mass as cholangiocarcinoma. It had a sensitivity of 94.44%,
specificity of 81.81%, positive predictive value of 89.47%, and negative
predictive value of 90% for the detection of malignant causes. The overall
diagnostic accuracy for detection of level and cause of obstruction was 96.3% and
89.65%, respectively. CONCLUSION: The high diagnostic accuracy of MRCP in
evaluating patients with obstructive jaundice indicates that it has the potential
to become the diagnostic modality of choice in such patients.

Publication Types: 
    Comparative Study

PMID: 15492607 [PubMed - indexed for MEDLINE]

323: Acta Chir Belg. 2004 Aug;104(4):457-8.

Cavernous transformation of the portal vein causing jaundice, presenting in the
form of Wilson's disease.

Ruszinkó V, Kovács M, Szönyi L, Verebély T, Willner P.

Dept of Pediatrics, Petz Aladár County Teaching Hospital, Hungary.

The following is a case review of portal vein cavernous malformation presenting
with intermittent cholestasis and jaundice in a 4 year old child. Correct
assessment was supported by radiology, later laparoscopy, yet hindered by
histopathology representative Wilson's disease and elevated urinary copper
excretion. During surgical procedure the stenosis of the common bile duct
secondary to extremely dilated portal vein reticulation was solved by Roux-en-Y
choledochojejunostomy. After a one-year follow up the child remains asymptomatic.

Publication Types: 
    Case Reports

PMID: 15469163 [PubMed - indexed for MEDLINE]

324: Scott Med J. 2004 Aug;49(3):84-7.

The impact of specialist management of jaundiced alcoholic liver disease
patients.

Forrest EH.

Department of Gastroenterology, Victoria Infirmary, Glasgow.
Ewan.Forrest@gvic.scot.nhs.uk

BACKGROUND: Patients with alcoholic liver disease (ALD) presenting with jaundice 
have advanced chronic ALD and/or acute alcoholic hepatitis. Their prognosis is
poor. These patients may be managed by General Medical physicians (GM) or by
Gastroenterologists (GE). AIM: This study aimed to retrospectively assess the
differences in management and outcome of jaundiced ALD between GM and GE.
PATIENTS AND METHODS: Patients with a serum bilirubin greater than 80 mmol/l on
admission and a history of alcohol excess until within three weeks of admission
were identified retrospectively. In particular the use of corticosteroids (CS),
nutritional support (N) and the use of broad-spectrum antibiotics (A/b) were
noted. RESULTS: 97 patients were identified, 62 managed by GE. Differences were
apparent between GE and GM managed patients with respect to CS (p = 0.017), N (p 
< 0.001) and A/b (p < 0.001). The overall mortality was 27.8%, 34.0%, and 37.1%
at 28, 56, and 84 days respectively. Mortality for patients with a Discriminant
Function approximately 32 was greater in GM managed patients compared with GE at 
28 (p = 0.006), 56 (p = 0.013), and 84 days (p = 0.036). CONCLUSION: Differences 
exist between the management of jaundiced ALD between GM and GE. Such differences
may translate into improved outcomes.

PMID: 15462220 [PubMed - indexed for MEDLINE]

325: Hepatology. 2004 Aug;40(2):414-23.

Kupffer cell-derived interleukin 10 is responsible for impaired bacterial
clearance in bile duct-ligated mice.

Abe T, Arai T, Ogawa A, Hiromatsu T, Masuda A, Matsuguchi T, Nimura Y, Yoshikai
Y.

Laboratory of Host Defense and Germfree Life, Research Institute for Disease
Mechanism and Control, Nagoya University School of Medicine, Nagoya, Japan.
te-abe@med.nagoya-u.ac.jp

Extrahepatic cholestasis often evokes liver injury with hepatocyte apoptosis,
aberrant cytokine production, and-most importantly-postoperative septic
complications. To clarify the involvement of aberrant cytokine production and
hepatocyte apoptosis in impaired resistance to bacterial infection in obstructive
cholestasis, C57BL/6 mice or Fas-mutated lpr mice were inoculated
intraperitoneally with 10(7) colony-forming units of Escherichia coli 5 days
after bile duct ligation (BDL) or sham celiotomy. Cytokine levels in sera, liver,
and immune cells were assessed via enzyme-linked immunosorbent assay or real-time
reverse-transcriptase polymerase chain reaction. BDL mice showed delayed
clearance of E. coli in peritoneal cavity, liver, and spleen. Significantly
higher levels of serum interleukin (IL) 10 with lower levels of IL-12p40 were
observed in BDL mice following E. coli infection. Interferon gamma production
from liver lymphocytes in BDL mice was not increased after E. coli infection
either at the transcriptional or protein level. Kupffer cells from BDL mice
produced low levels of IL-12p40 and high levels of IL-10 in vitro in response to 
lipopolysaccharide derived from E. coli. In vivo administration of anti-IL-10
monoclonal antibody ameliorated the course of E. coli infection in BDL mice.
Furthermore, BDL-lpr mice did not exhibit impairment in E. coli killing in
association with little hepatic injury and a small amount of IL-10 production. In
conclusion, increased IL-10 and reciprocally suppressed IL-12 production by
Kupffer cells are responsible for deteriorated resistance to bacterial infection 
in BDL mice. Fas-mediated hepatocyte apoptosis in cholestasis may be involved in 
the predominant IL-10 production by Kupffer cells. Copyright 2004 American
Association for the Study of Liver Diseases

Publication Types: 
    Research Support, Non-U.S. Gov't

PMID: 15368446 [PubMed - indexed for MEDLINE]

326: J Nephrol. 2004 May-Jun;17(3):449-51.

Ascariasis as a cause of obstructive jaundice in a renal transplant patient.

Sunil P, Tribhuvan G, Anil M.

Nephrology Division, Northern Railway Central Hospital, New Delhi, India.
prakashsunil70@hotmail.com

Jaundice and pancreatitis are serious complications in post renal
transplantations; hepatotropic viruses and drugs are commonly implicated. We
describe ascaris infestation causing pancreatitis and obstructive jaundice in a
renal transplant patient.

Publication Types: 
    Case Reports

PMID: 15365970 [PubMed - indexed for MEDLINE]

327: Hepatogastroenterology. 2004 Sep-Oct;51(59):1292-4.

Curative resection of a huge bile duct cancer without pancreatoduodenectomy.

Tanaka S, Hirohashi K, Kubo S, Yamamoto T, Uenishi T, Tanaka H, Shuto T, Takemura
S, Ogawa M, Yamasaki K, Kinoshita H.

Hepato-Biliary-Pancreatic Surgery, Osaka City University Graduate School of
Medicine, Osaka, Japan. m8827074@msic.med.osaka-cu.ac.jp

A 71-year-old woman was admitted to our hospital with obstructive jaundice.
Magnetic resonance cholangiography revealed a 9-cm spindle-shaped tumor in the
common bile duct. Laboratory examination noted a high concentration of total
serum bilirubin. Although the serum concentration of carcinoembryonic antigen was
within normal limits, the serum concentration of carbohydrate antigen 19-9 was
elevated. We diagnosed the lesion as an extrahepatic bile duct cancer and
performed a laparotomy. The anterior wall of the common bile duct was incised,
and the tumor was found to have a small base in only the posterior wall of the
duct, and spread within the duct was from the common hepatic duct to the
intrapancreatic bile duct. Bile duct resection, cholecystectomy with
lymphadenectomy and hepaticojejunostomy were performed. Frozen sections of the
proximal and distal surgical margins of the bile duct were free of cancer.
Macroscopically, the lesion was an expansive polypoid tumor measuring 9x3cm in
diameter arising from a 5-mm base. Histologic examination revealed that the tumor
was a well-differentiated tubular adenocarcinoma that had infiltrated the
fibromuscular layer at its base. Longitudinal spread was more extensive
hepatopetally than hepatofugally. The patient is alive and well without any
complaints 8 months after surgery.

Publication Types: 
    Case Reports

PMID: 15362736 [PubMed - indexed for MEDLINE]

328: J Formos Med Assoc. 2004 Aug;103(8):633-6.

Alveolar hydatid disease causing total occlusion of the inferior vena cava.

Huang J, Wu YM, Liang PC, Lee PH.

Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan.

Alveolar hydatid disease is a malignancy-like parasitic disease. It is invasive, 
metastatic, and almost always lethal if left untreated. A case of alveolar hyatid
disease presenting with total of the inferior vena cava is reported. This
28-year-old man was referred for elevation of obstructive jaundice. He was a lama
and had recently arrived in Taiwan after touring temples in Nepal, India, and
Singapore. Computed tomography showed calcified mass which occupied the right
hepatic lobe with extension to the left hepatic lobe. The inferior vena cava was 
occluded and stricture of biliary tree and portal vein at the hilum was also
noted. The patient was treated successfully with palliative resection combined
with postoperative albendazole. With increasing travel and immigration,
clinicians will be more likely to encounter this rare disease, and thus should be
able to recognize its symptoms.

Publication Types: 
    Case Reports

PMID: 15340664 [PubMed - indexed for MEDLINE]

329: J Korean Med Sci. 2004 Aug;19(4):604-7.

Duodenal duplicated cyst manifested by acute pancreatitis and obstructive
jaundice in an elderly man.

Jo YC, Joo KR, Kim DH, Park JH, Suh JH, Kim YM, Nam CW.

Department of Internal Medicine, Ulsan University Hospital, University of Ulsan
College of Medicine, Ulsan, Korea.

A duodenal duplication cyst is an uncommon congenital anomaly that is usually
encountered during infancy or in early childhood. Duodenal duplication cysts
generally appear on the first or second portion of the duodenum and may cause
duodenal obstruction, hemorrhage or pancreatitis. Here, we report a case of a
duodenal duplication cyst on the second and third portion of the duodenum in an
old aged man with obstructive jaundice and acute pancreatitis, which was treated 
successfully by a surgical excision. Copyright The Korean Academy of Medical
Sciences

Publication Types: 
    Case Reports

PMID: 15308856 [PubMed - indexed for MEDLINE]

330: J Gastroenterol Hepatol. 2004 Sep;19(9):1052-7.

Experimental bile-duct ligation resulted in accumulation of oxidized low-density 
lipoproteins in BALB/c mice liver.

Cömert M, Tekin IO, Acikgöz S, Ustündağ Y, Uçan BH, Acun Z, Barut F, Sümbüloğlu
V.

Department of Surgery, School of Medicine, Zonguldak Karaelmas University,
Zonguldak, Turkey. mustafacomert@hotmail.com

BACKGROUND AND AIM: Oxidized low-density lipoproteins (LDL), which are produced
during oxidative stress by the process of lipid peroxidation, have also been
proposed to have complex roles in many other immuno-inflammatory mechanisms. It
has been shown that bile-duct ligation results in oxidative stress in the liver
of animals. The aim of this study was to investigate if oxidized LDL are produced
in the liver tissues of bile-duct-ligated mice. METHODS: Obstructive jaundice was
induced in BALB/c mice by the ligation and division of the common bile duct.
Liver concentrations of glutathione and malondialdehyde were measured in the
sham-operated (n = 10) and bile-duct-ligated (n = 10) mice on the 10th day of
obstructive jaundice. The presence of oxidized LDL in the liver tissue sections
was evaluated using a special, novel immunofluorescent staining method. The final
step was to explore the existence of oxidized LDL under fluorescent microscopy.
RESULTS: Compared with sham-operated mice, jaundiced mice showed significantly
higher levels of malondialdehyde and lower concentrations of reduced glutathione 
in the liver. While there was no staining in the sham-operated group, bile-duct
ligation resulted in positive oxidized LDL staining in the liver tissues of mice.
The present study testifies that bile-duct ligation results in oxidative stress
and enhanced lipid peroxidation in the hepatic tissues of BALB/c mice and
moreover, that oxidized LDL accumulate in the liver of mice with experimental
obstructive jaundice. CONCLUSION: Oxidized LDL may be an important and direct
indicator of ongoing oxidative stress and enhanced lipid peroxidation in
obstructive jaundice. The potential roles of this finding were also discussed,
briefly. Copyright 2004 Blackwell Publishing Asia Pty Ltd

PMID: 15304124 [PubMed - indexed for MEDLINE]

331: J Int Med Res. 2004 Jul-Aug;32(4):400-5.

Dehydroepiandrosterone prevents oxidative injury in obstructive jaundice in rats.

Celebi F, Yilmaz I, Aksoy H, Gümüş M, Taysi S, Oren D.

Department of General Surgery, Atatürk University, School of Medicine, Erzurum,
Turkey. fcelebi@atauni.edu.tr

We investigated the effect of dehydroepiandrosterone (DHEA) on oxidative injury
in obstructive jaundice using three groups of rats: sham-operated group; common
bile duct (CBD) group--the CBD was ligated; and DHEA group--DHEA administration
followed CBD ligation. Liver function tests were performed using blood samples,
and malondialdehyde concentration (MDA), superoxide dismutase activities (SOD),
glutathione peroxidase (GPx), and total glutathione (tGSH) concentrations were
measured in liver tissue. Serum alkaline phosphatase, gamma-glutamyltransferase
and alanine aminotransferase activity were significantly elevated in the CBD
group compared with the other groups. Serum aspartate aminotransferase and total 
bilirubin were highest in the CBD group; the MDA concentration was higher in the 
CBD group than the sham group. There were no significant differences in GPx
activity among the groups. SOD activity and tGSH concentration were significantly
lower in the CBD group than the other groups. DHEA may protect hepatic tissue
against oxidative injury in obstructive jaundice by decreasing MDA concentration 
and increasing SOD activity and tGSH concentration.

PMID: 15303771 [PubMed - indexed for MEDLINE]

332: Postgrad Med J. 2004 Aug;80(946):489-90.

IgA multiple myeloma presenting as non-obstructive jaundice.

Arebi N, Patel B, Aqel NM, Pitcher MC.

Department of Gastroenterology, Northwick Park and St Mark's Hospitals, Watford
Road, Harrow HA1 3UJ, UK. naila.arebi@ic.ac.uk

Multiple myeloma can occasionally present with jaundice. The underlying process
may be pancreatic head myeloma infiltration causing obstructive jaundice or
hepatic amyloid deposition resulting in cholestatic jaundice. A rare case of
myeloma presenting as jaundice due to hepatic myeloma infiltration is reported.

Publication Types: 
    Case Reports

PMID: 15299163 [PubMed - indexed for MEDLINE]

333: J Gastroenterol. 2004 Jul;39(7):692-6.

Primary non-Hodgkin's lymphoma of the common bile duct presenting as obstructive 
jaundice.

Joo YE, Park CH, Lee WS, Kim HS, Choi SK, Cho CK, Rew JS, Kim SJ, Maetani I.

Department of Internal Medicine, Chonnam National University Medical School, 8
Hak-Dong, Dong-ku, Gwangju 501-757, Korea.

Primary non-Hodgkin's lymphoma of the extrahepatic bile duct presenting as
obstructive jaundice is an extremely rare disease. At this writing, a review of
the medical literature disclosed 17 reported cases of primary non-Hodgkin's
lymphoma arising from the extrahepatic bile duct. We, herein, report an
additional case of obstructive jaundice caused by primary non-Hodgkin's lymphoma 
of the common bile duct, in a 21-year-old woman. Our patient showed clinical
evidence of obstructive jaundice, and endoscopic retrograde
cholangiopancreatography and abdominal magnetic resonance imaging demonstrated a 
long strictured segment of the common bile duct with proximal bile duct
dilatation. These clinical and radiological findings resembled those of
cholangiocarcinoma. Resection of the common bile duct tumor, cholecystectomy,
lymph node dissection, and Roux-en-Y hepaticojejunostomy were carried out.
Histology and immunohistochemistry of the resected specimen confirmed a diffuse
large B-cell-type malignant lymphoma involving the common bile duct. She received
four courses of combination chemotherapy, including cyclophosphamide,
doxorubicin, vincristine, and prednisone (CHOP), and 3060 cGy external
irradiation. She has been well, without evidence of tumor recurrence, 17 months
after the surgery. In summary, first, primary non-Hodgkin's lymphoma of the
extrahepatic bile duct, despite its rarity, should be considered in the
differential diagnosis of causes of obstructive jaundice. Second, an accurate
histopathologic diagnosis and surgical resection, if feasible, combined with
chemotherapy with or without radiotherapy may be the approach to offer a chance
for cure.

Publication Types: 
    Case Reports
    Review

PMID: 15293142 [PubMed - indexed for MEDLINE]

334: Acta Chir Belg. 2004 Jun;104(3):347-9.

Gall-bladder agenesis presenting with obstructive jaundice and elevated CA 19-9.

Trompetas V, Panagopoulos E, Ramantanis G.

2nd Surgical Department, 'Saint Savvas' Anticancer Hospital, Athens, Greece.
vtrompetas@yahoo.gr

We report the case of an 81-year-old man with agenesis of the gall-bladder that
presented with choledocholithiasis, obstructive jaundice, and very high CA 19-9
serum level (2765 U/ml). On ultrasound and CT scan, the gallbladder was not
visualised and it was assumed shrunken and filled with gall-stones. After
repeated unsuccessful endoscopic retrograde cholangiopancreatography, the patient
was operated on for common bile duct (CBD) stones. At laparotomy the gall-bladder
was not identified but a 3 cm long gall-stone was removed from the CBD. After
decompression of the CBD all symptoms disappeared and the CA 19-9 returned to
normal. We believe that this is the first report in the literature of
gall-bladder agenesis presenting with high serum level of CA 19-9.

Publication Types: 
    Case Reports

PMID: 15285554 [PubMed - indexed for MEDLINE]

335: Can Vet J. 2004 Jun;45(6):507-10.

Comment in:
    Can Vet J. 2004 Dec;45(12):971; discussion 971.

Challenging diagnosis--icterus associated with a single perforating duodenal
ulcer after long-term nonsteroidal antiinflammatory drug administration in a dog.

Duerr FM, Carr AP, Bebchuk TN, Pople NC.

University of Saskatchewan, Veterinary Teaching Hospital, Western College of
Veterinary Medicine, Department of Small Animal Clinical Sciences, 52 Campus
Drive, Saskatoon, Saskatchewan. felix.duerr@usask.ca

A dog developed icterus, vomiting, and anorexia 2 wk after orthopedic surgery and
treatment with meloxicam for approximately 1 y. Exploratory laparotomy revealed a
single perforated duodenal ulcer. The most likely cause of the hyperbilirubinemia
was intrahepatic cholestasis resulting from peritonitis associated with the
perforation.

Publication Types: 
    Case Reports

PMID: 15283521 [PubMed - indexed for MEDLINE]

336: Am Surg. 2004 Jul;70(7):620-4.

Unusual cases of jaundice secondary to non-neoplastic bile duct obstruction.

Peyré CG, Wakim M, Mateo R, Genyk Y, Singh G, Selby RR, Jabbour N.

Department of Surgery, Keck School of Medicine, University of Southern
California, Los Angeles, California, USA.

Obstructive jaundice secondary to common bile duct stricture is most commonly
attributed to malignancy. Here we present three unusual cases that mimicked
carcinoma in presentation but were histologically diagnosed as benign
inflammatory processes during operative care. The first case was attributed to
obstruction-induced chronic pancreatitis secondary to Crohn's disease of the head
of the pancreas, the second was due to sarcoidosis within periportal and
extrahepatic biliary lymph nodes and distal common bile duct, and the third case 
was due to tuberculosis of biliary lymph nodes. All were successfully managed
surgically, but potentially these patients may have been effectively treated
pharmacologically, without the need for invasive surgical intervention, if an
earlier diagnosis were available to the clinicians. A retrospective and
comparative review of the data of each case demonstrated subtle clues such as
multiple enlarged biliary lymph node involvement and only moderately elevated
bilirubin levels that pointed toward possible nonmalignant processes.

Publication Types: 
    Case Reports

PMID: 15279187 [PubMed - indexed for MEDLINE]

337: J Pediatr Gastroenterol Nutr. 2004 Aug;39(2):115-28.

Erratum in:
    J Pediatr Gastroenterol Nutr. 2004 Sep;39(3):306.

Guideline for the evaluation of cholestatic jaundice in infants: recommendations 
of the North American Society for Pediatric Gastroenterology, Hepatology and
Nutrition.

Moyer V, Freese DK, Whitington PF, Olson AD, Brewer F, Colletti RB, Heyman MB;
North American Society for Pediatric Gastroenterology, Hepatology and Nutrition.

For the primary care provider, cholestatic jaundice in infancy, defined as
jaundice caused by an elevated conjugated bilirubin, is an uncommon but
potentially serious problem that indicates hepatobiliary dysfunction. Early
detection of cholestatic jaundice by the primary care physician and timely,
accurate diagnosis by the pediatric gastroenterologist are important for
successful treatment and a favorable prognosis. The Cholestasis Guideline
Committee of the North American Society for Pediatric Gastroenterology,
Hepatology and Nutrition has formulated a clinical practice guideline for the
diagnostic evaluation of cholestatic jaundice in the infant. The Cholestasis
Guideline Committee, consisting of a primary care pediatrician, a clinical
epidemiologist (who also practices primary care pediatrics), and five pediatric
gastroenterologists, based its recommendations on a comprehensive and systematic 
review of the medical literature integrated with expert opinion. Consensus was
achieved through the Nominal Group Technique, a structured quantitative
method.The Committee examined the value of diagnostic tests commonly used for the
evaluation of cholestatic jaundice and how those interventions can be applied to 
clinical situations in the infant. The guideline provides recommendations for
management by the primary care provider, indications for consultation by a
pediatric gastroenterologist, and recommendations for management by the pediatric
gastroenterologist.The Cholestasis Guideline Committee recommends that any infant
noted to be jaundiced at 2 weeks of age be evaluated for cholestasis with
measurement of total and direct serum bilirubin. However, breast-fed infants who 
can be reliably monitored and who have an otherwise normal history (no dark urine
or light stools) and physical examination may be asked to return at 3 weeks of
age and, if jaundice persists, have measurement of total and direct serum
bilirubin at that time.This document represents the official recommendations of
the North American Society for Pediatric Gastroenterology, Hepatology and
Nutrition on the evaluation of cholestatic jaundice in infants. The American
Academy of Pediatrics has also endorsed these recommendations. These
recommendations are a general guideline and are not intended as a substitute for 
clinical judgment or as a protocol for the care of all patients with this
problem.

Publication Types: 
    Guideline
    Practice Guideline

PMID: 15269615 [PubMed - indexed for MEDLINE]

338: Turk J Gastroenterol. 2004 Mar;15(1):53-5.

Paraneoplastic cholestasis associated with prostate carcinoma.

Koruk M, Büyükberber M, Savaş C, Kadayifçi A.

Department of Gastroenterology, Medical Faculty, Gaziantep University, Gaziantep,
Turkey. mkoruk@gantep.edu.tr

Paraneoplastic syndromes associated with prostate carcinoma are very rare. We
report a patient with prostate carcinoma and cholestatic jaundice without biliary
obstruction, hepatic involvement or infectious etiology. In the literature, only 
one case of idiopathic cholestatic jaundice with prostate carcinoma has been
reported and a paraneoplastic etiology was suggested. In our case, cholestasis
rapidly regressed with chemotherapy and the patient is well at six months of
follow-up. Paraneoplastic cholestasis should be kept in mind in the absence of
biliary tract obstruction, hepatic involvement or infectious etiology.

Publication Types: 
    Case Reports

PMID: 15264123 [PubMed - indexed for MEDLINE]

339: Eur Surg Res. 2004 Jul-Aug;36(4):226-33.

Effects of obstructive jaundice on the peripheral nerve: an ultrastructural study
in rats.

Can B, Saray A, Caglikulekçi M, Saran Y.

Department of Histology and Embryology, Ankara University School of Medicine,
Ankara, Turkey.

Obstructive jaundice (OJ) and hepatic disorders have been shown to be associated 
with peripheral neuropathy in several clinical studies. The study evaluated the
effect of OJ on the ultrastructure of the rat sciatic nerve. In the OJ group,
jaundice was created by ligation of common bile duct in Wistar-Albino rats. In
the sham-operated control group the same procedure was performed without ligation
of the bile duct. On day 7, all rats were re-operated and sciatic nerves were
explored to harvest 2-cm-long nerve segments for quantitative and qualitative
histopathological analysis by light and electron microscopy. Bilirubin was
measured on serum samples. Bilirubin levels were significantly higher in
jaundiced rats compared with that of controls (8.46 +/- 0.45 vs. 0.80 +/- 0.14
mmol/l, means +/- SD, p < 0.01). Control nerves did not show anything other than 
the normal histology. In the OJ group, degenerative changes such as
irregularities, thinning, ruffling and invaginations, irregularshaped bodies,
vacuolizations and focal segmental demyelination were observed in the myelin
sheath. Myelin clusters were noted in the axoplasm. A varying degree of swelling 
was noted in the nucleus and cytoplasm of the Schwann cells. Morphometric
analysis of specimens obtained from sciatic nerves showed that myelin injury
(370.9 +/- 51.3 vs. 11.6 +/- 0.5 axons), axonal edema (142.1 +/- 24.2 vs. 10.6
+/- 0.5 edematous axons) and Schwann cell degeneration (50.3 +/- 11.6 vs. 3.2 +/-
0.2 Schwann cells) was significantly higher in the jaundiced rats than in the
control group (p < 0.01). The ultrastructural alterations spotted in the rat
peripheral nerve were attributed to hyperbilirubinemia and increased
concentrations of several neurotoxic substances released from the Kupffer cells
in OJ. Neuropathy in jaundiced patients seems to result from accompanying
degenerative changes in the peripheral nervous system. However, the exact nature 
and initiating factors of this nerve injury remains to be unveiled. Copyright
2004 S. Karger AG, Basel

PMID: 15263828 [PubMed - indexed for MEDLINE]

340: J Assoc Physicians India. 2003 Nov;51:1069-72.

Comment in:
    J Assoc Physicians India. 2005 Jul;53:653; author reply 653-5.

Malarial hepatitis.

Kochar DK, Singh P, Agarwal P, Kochar SK, Pokharna R, Sareen PK.

Department of Gastroenterology, SP Medical College, Bikaner 334001.

AIMS AND OBJECTIVE: To study the clinical, biochemical and histopathological
changes in the liver of patients of Plasmodium falciparum malaria with jaundice. 
MATERIAL AND METHOD: This study was conducted on 50 PBF confirmed cases of
Plasmodium falciparum malaria with jaundice. Detailed history, clinical
examination, biochemical parameters for liver function test and blood for
hepatitis B and C was done in all patients. Liver biopsy was done for detailed
histopathological examination in all the 20 patients having serum bilirubin
between 3 to 10 mg%. All patients were treated by IV/oral quinine using standard 
regimen. RESULTS: Age of the patient was ranging from 15-45 years. All patients
had jaundice, 70% had pallor, 56% had splenomegaly, 48% had hepatomegaly and 24% 
of cases had coma. Based on serum bilirubin level, the patients were categorized 
in group A (18 patients, serum bilirubin < 3 mg%), in group B (20 patients, serum
bilirubin 3-10 mg%) and in group C (12 patients, serum bilirubin >10 mg%).
Histopathological examination done in all the 20 patients of group B, showed
evidence of swollen hepatocytes (100%), malarial pigment deposition (75%),
inflammatory infiltrates (60%), congestion of hepatocyte (50%) alongwith
centrizonal necrosis in 25% of cases. CONCLUSION: The evidence of predominant
conjugated hyperbilirubinemia, increased levels of AST and ALT along with
evidence of hepatocellular necrosis in histopathological examination are strong
evidence of gross hepatocytic dysfunction in patients of Plasmodium falciparum
malaria with jaundice. Therefore the term malarial hepatitis should not be taken 
as a misnomer.

PMID: 15260391 [PubMed - indexed for MEDLINE]

341: Hepatogastroenterology. 2004 Jul-Aug;51(58):954-7.

Relief of jaundice by external beam radiotherapy and intraluminal brachytherapy
in patients with extrahepatic cholangiocarcinoma: results without stenting.

Ishii H, Furuse J, Nagase M, Kawashima M, Ikeda H, Yoshino M.

Division of Hepatobiliary & Pancreatic Medical Oncology, National Cancer Center
Hospital East, Kashiwa, Chiba, Japan. hirishii@east.ncc.go.jp

BACKGROUND/AIMS: To clarify whether external beam radiotherapy combined with
intraluminal brachytherapy without stenting provides long-term relief of jaundice
in extrahepatic cholangiocarcinoma patients. METHODOLOGY: Twenty-five patients
with unresectable hilar or distal cholangiocarcinoma were treated by external
beam radiotherapy (30 or 50 Gy) combined with intraluminal brachytherapy (24 to
40 Gy). After radiotherapy, we removed the biliary drainage tubes from the
patients who responded, and we did not perform stenting in these patients.
RESULTS: In 19 (76%) patients, full patency was achieved at the treated lesion,
and they were tube-free thereafter. The tube-free survival time in the 19
patients ranged from 7 to 468 days (median: 76 days). Cholangitis and
gastroduodenal ulcer developed in 10 (40%) and 2 (8%) patients, respectively, as 
adverse events after the combined radiotherapy. The median survival time of all
patients was 9.3 months, and their 6- and 12-month survival rates were 75.3% and 
29.3%, respectively. The ratios of tube-free to overall survival in the 19
patients ranged from 2.4% to 79.4% (median: 26.8%). Eight patients died
tube-free. CONCLUSIONS: Although there were limitations to the long-term relief
of jaundice by this combined radiotherapy alone, tube-free status was achieved in
some patients without stenting.

Publication Types: 
    Clinical Trial

PMID: 15239222 [PubMed - indexed for MEDLINE]

342: Minerva Chir. 2004 Apr;59(2):137-49.

Surgical palliation in pancreatic cancer.

Kuhlmann KF, De Castro SM, Gouma DJ.

Department of Surgery, Academic Medical Center, University of Amsterdam,
Amsterdam, The Netherlands.

The prognosis of patients with pancreatic carcinoma is poor. At the time of
diagnosis, approximately 80% of patients are found to have an unresectable
tumour, because of local spread or metastatic disease. Therefore, most patients
will undergo palliative treatment, which is aimed at the improvement of the
quality of life and the prevention of symptoms. The most important symptoms which
are associated with advanced pancreatic cancer are pain, obstructive jaundice and
gastric outlet obstruction. Controversy remains on the question whether these
symptoms should be treated surgically or non-surgically. This review describes
the best evidence (if possible randomised controlled trials) in recent literature
on the palliation of most important symptoms and focuses on surgical palliative
treatment options.

Publication Types: 
    Review

PMID: 15238888 [PubMed - indexed for MEDLINE]

343: Minerva Chir. 2004 Apr;59(2):113-22.

Palliation of pancreatic neoplasms.

Thomson BN, Parks RW.

Department of Clinical and Surgical Sciences (Surgery), Royal Infirmary of
Edinburgh, Edinburgh, UK.

Pancreatic adenocarcinoma accounts for 80% of pancreatic tumours. The majority
are unresectable at diagnosis and only 10% of patients survive to 1 year.
Therefore, selection of appropriate palliative procedures for jaundice, gastric
outlet obstruction or pain is a vitally important aspect of the management of
these patients. Overall survival is equivalent following surgical or non-surgical
palliation of biliary obstruction. Operative biliary bypass is a more major
intervention but is associated with longer relief of symptoms and fewer
readmissions compared to non-operative procedures. Prognostic factors such as
histopathology, presence of metastatic disease and C reactive protein levels may 
allow better prediction of survival, therefore aiding selection of the most
appropriate palliative techniques.

Publication Types: 
    Review

PMID: 15238886 [PubMed - indexed for MEDLINE]

344: J Hepatobiliary Pancreat Surg. 2004;11(3):176-80.

Short-term effects of external and internal biliary drainage on liver and
cellular immunity in experimental obstructive jaundice.

Mizuguchi K, Ajiki T, Onoyama H, Tomita M, Kuroda Y.

Department of Gastroenterological Surgery, Graduate School of Medical Sciences,
Kobe University, 7-5-2 Kusunoki-cho, Chuo-ku, 650-0017, Kobe, Japan.

BACKGROUND/PURPOSE: The effects of preoperative biliary drainage for obstructive 
jaundiced patients are controversial. Although experimental studies have proven
the benefit of internal biliary drainage (ID) over external biliary drainage
(ED), ID has several clinical problems, such as clogging or tube replacement. The
aim of this study was to determine whether there were any differences in T-cell
function, liver function, and histology, between rats in ID and ED groups in
short-term experiments. METHODS: Following bile duct ligation (BDL) for 14 days, 
rats in the ED and ID groups had 7 days of ED and 7 days of ID, respectively.
Normal rats were used as negative controls (control group). For positive
controls, we used a group with BDL and no drainage (BDL group). Serum bilirubin, 
aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline
phosphatase (ALP) were measured, splenic T-cell proliferation was assayed to
check cellular immunity, and liver histology was examined. RESULTS: Recovery of
bilirubin and ALT was similar in the ED and ID groups. Recovery of AST was worse 
in the ID group than in the ED group, but the difference was not statistically
significant. Levels of ALP in the BDL and ID groups were significantly higher
than those in the control and ED groups. Rats in the BDL group showed a
significant decrease in T-cell function compared to the control group. The ED
group showed better recovery of T-cell function than the ID group in the 7 days
after relief of obstructive jaundice. The livers in the ID group demonstrated
histologically moderate interface hepatitis with periportal inflammation and
lymphocyte infiltration, which strongly suggested incomplete tube obstruction,
but those in the ED group showed minimal change. CONCLUSIONS: ED is superior to
ID concerning the recovery of cellular immunity and liver inflammation in the
short-term after relief from biliary obstruction in this model. As the patency of
the tube is well maintained in ED compared to ID, patency of the tube is
essential to obtain good recovery of cellular immunity, irrespective of the
drainage method. Copyright 2004 Springer-Verlag

Publication Types: 
    Comparative Study

PMID: 15235890 [PubMed - indexed for MEDLINE]

345: Rom J Gastroenterol. 2004 Jun;13(2):139-46.

Echoguided percutaneous biliary drainage. Indications, performances,
complications.

Spârchez Z.

3rd Medical Clinic, Str. Croitorilor 19-21, 400162 Cluj-Napoca, Romania.
mircea.dragoteanu@xnet.ro

Biliary drainage is a well-accepted procedure for decompression of bile ducts or 
drainage of infected bile. Percutaneous biliary drainage (PBD) can be performed
under fluoroscopic, combined fluoroscopic-US or pure US guidance. The indications
of PBD are not well established being closely related to the possibility of an
endoscopic stenting. Generally, PBD is indicated in malignant obstructive
jaundice especially if accompanied by cholangitis. The main contraindications of 
percutaneous biliary drainage are bleeding disorders, ascites and rupture of an
echinococcus cyst. The rate of successful percutaneous US-guided biliary drainage
varies between 85-100% being lower in cases with nondilated bile ducts. Acute
complications after US-guided PBD (bleeding, septicemia and bile leakage) are
rare (1-5%). Delayed complications include catheter occlusion with cholangitis,
intrahepatic abscesses, catheter dislodgment with subsequent bile peritonitis,
pericatheter leakage and maldigestion. In percutaneous US-guided biliary drainage
there are some pitfalls and critical points. Being aware of them and knowing the 
implied therapeutic approach is very important in the success of procedure and
limitation of incidents and complications.

Publication Types: 
    Review

PMID: 15229780 [PubMed - indexed for MEDLINE]

346: Eur Rev Med Pharmacol Sci. 2003 Nov-Dec;7(6):175-80.

Palliative treatment for malignant jaundice: endoscopic vs surgical approach.

Santagati A, Ceci V, Donatelli G, Pasqualini MJ, Silvestri F, Pitasi F, Sportelli
G, Fiocca F.

Surgery Department "P. Stefanini", University of Rome "La Sapienza", Rome, Italy.

In this retrospective, comparative study a total of 107 patients, presenting with
malignant inoperable strictures of common bile duct, due to a pancreatico-biliary
malignancy, underwent palliative treatments. In a group, consisting of 82
patients (76.64%), endoscopic stenting procedures were performed; polyethylene
stents or self-expanding metal stents were applied in 37 and 45 patients,
respectively. The prerequisites for a successful endoscopic stenting were a)
accuracy of diagnosis and b) exclusion of patients presenting with tumors
potentially treatable by a curative resection. In the other group, consisting of 
25 patients (23.36%), biliary-enteric bypass procedures were performed.
Endoscopic treatment was successful in 97.5% of the cases (80/82); complication
rate was 7.3% (6 patients on 82), and mortality rate was 3.6% (3 patients on 82).
Median hospital stay was 13.4 and 7.3 days in patients treated with plastic
stents and metallic stents, respectively. Bypass surgery was successful in 99% of
the cases (24/25); complication rate was 24% (6 patients on 25), and mortality
rate was 16% (4 patients on 25). Median hospital stay was 26 days. For the
patients in whom a curative resection could not be performed, both the above
mentioned methods resulted in a high rate of immediate technical and therapeutic 
success. However, the surgical approach showed a significantly higher rate in
procedure-related mortality and morbidity; in addition, the hospital stay lasted 
longer in surgically treated patients. The patients who are definitely unsuitable
for curative resection are better managed by positioning a stent. The use of
metal stents should be preferred in those less serious patients who may
supposedly survive longer.

PMID: 15206487 [PubMed - indexed for MEDLINE]

347: J Invest Surg. 2004 May-Jun;17(3):119-26.

Endotoxin challenge causes a proinflammatory state in obstructive jaundice.

Yorganci K, Baykal A, Kologlu M, Saribaş Z, Hascelik G, Sayek I.

Departments of Surgery and Clinical Pathology, Faculty of Medicine, Hacettepe
University, Ankara, Turkey. yorganci@hacettepe.edu.tr

The aim of this study was to investigate the relationship between the obstructive
jaundice-induced cellular immune suppression and endotoxin challenge with respect
to the levels of tumor necrosis factor (TNF), interleukin-10 (IL-10), and
interleukin-2 (IL-2). Rats underwent either bile duct ligation or sham operation.
At 21 days, all rats were challenged either with lipopolysaccharide (LPS) or
saline. In the sham-operated group LPS injection significantly increased TNF
levels at 90 min. The common bile duct ligated group showed a significant
increase in TNF levels compared with all other groups, including the
sham-operated, LPS-injected group, at 90 min. At 180 min following LPS challenge,
TNF levels decreased, and there was no difference between any of the
LPS-challenged groups at 180 min and any of the saline groups at either 90 or 180
min. In the sham-operated group, LPS injection significantly increased IL-10
levels at both 90 and 180 min. In the bile duct ligated group, LPS injection
significantly increased IL-10 levels compared with saline injection at both 90
and 180 min. On the other hand, bile duct ligated animals had significantly less 
increase in IL-10 levels following LPS challenge at 90 min but not at 180 min. In
common bile duct ligated rats, LPS challenge induced a significantly greater
increase in IL-2 levels compared with all other groups. In conclusion, in the
presence of obstructive jaundice, endotoxemia primes a more vigorous inflammatory
response despite cellular immune depression.

Publication Types: 
    Research Support, Non-U.S. Gov't

PMID: 15204955 [PubMed - indexed for MEDLINE]

348: J Microbiol Immunol Infect. 2004 Apr;37(2):103-8.

Acute hepatitis with or without jaundice: a predominant presentation of acute Q
fever in southern Taiwan.

Chang K, Yan JJ, Lee HC, Liu KH, Lee NY, Ko WC.

Division of Infectious Diseases, Department of Internal Medicine, National Cheng 
Kung University, University Hospital, 138 Sheng Li Road, Tainan, Taiwan 704, ROC.

Acute Q fever was previously regarded as an uncommon infectious disease in Taiwan
but has been increasingly recognized recently. Acute febrile illness, hepatitis, 
and pneumonia are the 3 most common manifestations of this condition, whereas
jaundice is rarely reported among patients with acute Q fever. We report 2 cases 
of acute Q fever with jaundice and multi-organ involvement. The first patient
presented with fever, severe headache, and acute abdomen necessitating laparotomy
and was complicated with acute cholestatic hepatitis, acute non-oliguric renal
failure and disseminated intravascular coagulation. The second patient had acute 
cholestatic hepatitis and thrombocytopenia, and the latter was likely related to 
the infection of bone marrow by Coxiella burnetii, as evidenced by the presence
of C. burnetii DNA detected by nested polymerase chain reaction. The incidence
and clinical significance of hyperbilirubinemia was also determined by review of 
medical records of 35 cases of acute Q fever cases diagnosed serologically at
National Cheng Kung University Hospital from 1994 to 2001. All had biochemical
hepatitis and 23% had hyperbilirubinemia (serum bilirubin > or =2 mg/dL). The
febrile course before admission and the period between the initiation of
effective medication to defervescence were longer in patients with
hyperbilirubinemia than in patients without hyperbilirubinemia, although this
difference was not significant. Our results suggest that the predominant
presentation of acute Q fever in southern Taiwan is acute febrile illness with
hepatitis and that jaundice is not uncommon. Due to the clinical polymorphism of 
acute Q fever, the threshold of surveys for C. burnetii infections should be low 
for febrile patients with elevated transaminases or hyperbilirubinemia of unknown
cause.

Publication Types: 
    Case Reports

PMID: 15181492 [PubMed - indexed for MEDLINE]

349: Rev Esp Enferm Dig. 2004 May;96(5):305-14.

Biliopancreatic tumors: patient survival and quality of life after palliative
treatment.

[Article in English, Spanish]

García Sánchez MV, López Vallejos P, Pérez de Luque D, Naranjo Rodríguez A,
Hervás Molina A, González Galilea A, Calero Ayala B, Padillo Ruiz J, Solórzano
Peck G, de Dios Vega JF.

Service of Digestive Diseases, Hospital Universitario Reina Sofía, Córdoba,
Spain. vallegarcia@supercable.es

OBJECTIVES: to analyse survival and quality of life of patients with malignant
obstructive jaundice after palliative treatment, comparing endoscopic stent
insertion and palliative surgical (palliative resection and bypass surgical).
PATIENTS AND METHOD: eighty and seven patients were included in a trial. They
were distributed to endoscopic stent (50) and palliative surgical (37). It
analysed survival, quality of life and comfort index of jaundiced patients. The
good quality of life was defined by absence of jaundice, pruritus and cholangitis
after the initial treatment. RESULTS: the median survival of the patients treated
to endoscopic stent was 9,6 months whereas the patients to surgical treatment
survived a median of 17 months. The time free of disease was 4 months in stented 
patients and 10,5 months in surgical patients. There was no significant
difference in comfort index between the two groups (stented 34%, surgical 42,5%) 
Neither was there significant difference in survival and quality of life between 
palliative resection and bypass surgery. CONCLUSIONS: despite the survival and
time free of disease being better in surgical patients, there was no significant 
difference in overall quality of life between the two groups. The survival and
quality of life are the same after palliative resection as after bypass surgery, 
for this should not be performed routinely or to justify resection as a debulking
procedure.

PMID: 15180442 [PubMed - indexed for MEDLINE]

350: Osaka City Med J. 2003 Dec;49(2):67-70.

Limy bile: a case of obstructive jaundice and review of 26 cases.

Tsukamoto T, Ohta Y, Shuto T, Hirohashi K, Kubo S, Tanaka H, Takemura S,
Kinoshita H.

Department of Gastroenterological Surgery, Osaka City University, Graduate School
of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka 545-8585, Japan.
tsukamotot@msic.med.osaka-cu.ac.jp

BACKGROUND: A number of reports on limy bile have been published but obstructive 
jaundice due to limy bile is quite rare. We report a case of obstructive jaundice
due to limy bile and review 26 cases of limy bile diagnosed in our institution.
CASE OUTLINE: A 39-year-old woman was admitted to our hospital with epigastric
pain and jaundice. Abdominal ultrasonography and computed tomography revealed
limy bile in the common bile duct and a gallbladder stone with biliary
obstruction. Percutaneous transhepatic biliary drainage was performed. The limy
bile drained out through the catheter over a few weeks. Cholecystectomy and
choledochotomy with choledocholithotomy were subsequently performed. DISCUSSION: 
The strategy for managing patients with limy bile is individualized based on
symptoms, the clinical conditions, and the location of the limy bile, and any
associated biliary stones or lesions causing cystic duct obstruction.

Publication Types: 
    Case Reports

PMID: 15179834 [PubMed - indexed for MEDLINE]

351: Am Surg. 2004 May;70(5):448-52.

Common bile duct papillary adenoma causing obstructive jaundice: case report and 
review of the literature.

Fletcher ND, Wise PE, Sharp KW.

Department of Surgery, Division of General Surgery, Vanderbilt University Medical
Center, Nashville, Tennessee 37232, USA.

Common bile duct (CBD) adenomas are rare tumors that often present in a fashion
similar to their malignant counterparts. We report a case of a papillary CBD
adenoma causing obstructive jaundice. We also present a review of the CBD
adenomas found in the English literature through a Medline search (1970-2003). A 
74-year-old female presented with a 10-day history of pruritus, progressive
painless jaundice, acholic stools, bilirubinuria, and 10-lb weight loss.
Abdominal exam showed no masses. Abdominal ultrasound (U/S) showed cholelithiasis
without choledocholithiasis. Endoscopic retrograde cholangiopancreatography
(ERCP) and endoscopic U/S revealed a shelf-like stricture, 1.5 cm long and 0.9 cm
in diameter, located in the distal CBD. At the time of biliary stent placement,
fine-needle aspiration showed benign ductal epithelial cells in sheets and
clusters. Abdominal CT scan showed a low attenuation 15 x 17 mm lesion in the
head of the pancreas that abutted the superior mesenteric vein (SMV) but no
metastatic lesions. We performed a standard pancreaticoduodenectomy (Whipple
procedure). Final pathology showed a papillary adenoma without evidence of
dysplasia in the distal common bile duct proximal to the ampulla of Vater. The
incidence of these tumors and their potential for malignant degeneration is
unknown. Pancreaticoduodenectomy is an effective means of treatment and cure for 
CBD adenoma.

Publication Types: 
    Case Reports
    Review

PMID: 15156955 [PubMed - indexed for MEDLINE]

352: J Gastroenterol Hepatol. 2004 Jun;19(6):713-5.

Painful jaundice revealing Kawasaki disease in a young man.

Granel B, Serratrice J, Ene N, Igual JP, Habib G, Disdier P, Weiller PJ.

Service de Médecine Interne, Marseille, France.

Liver involvement is usually a minor manifestation of Kawasaki disease and
includes hepatobiliary dysfunction or gallbladder hydrops. We describe here an
unusual case of jaundice revealing an adult onset Kawasaki disease. An
18-year-old man presented with abdominal pain and jaundice associated with
cholestasis as the initial manifestation of Kawasaki disease. Abdominal
evaluation (ultrasonography and CT-scan) did not find abnormality. Other signs
typical of the Kawasaki disease occurred a few days later and permitted
diagnosis. With aspirin and intravenous immunoglobulins, outcome was favorable
without any cardiovascular complication. Our case suggests that Kawasaki disease 
should be added to the etiological list of painful febrile icterus in young
patients.

Publication Types: 
    Case Reports

PMID: 15151633 [PubMed - indexed for MEDLINE]

353: J Pak Med Assoc. 2004 Mar;54(3):128-32.

The role of magnetic resonance cholangiopancreatography (MRCP) in obstructive
jaundice.

Munir K, Bari V, Yaqoob J, Khan DB, Usman MU.

Department of Radiology, Aga Khan University Hospital, Karachi.

OBJECTIVE: To evaluate the diagnostic value of MRCP in studying the sites and
cause of obstructive jaundice in comparison with other imaging modalities at the 
Department of Radiology, Aga Khan University Hospital, from January 1999 to May
2001. METHODS: Forty nine consecutive patients included 19 men and 30 women,
suspected of obstructive jaundice. Patients underwent ultrasound (n = 49), CT (n 
= 11), ERCP (n = 25) and biliary surgery (n = 17). Final diagnosis was
established by surgical exploration, endoscopic sphincterectomy, cytology and
clinical follow up. RESULTS: Of the 49 patients 17 had choledocholithiasis.
Twenty five patients had malignant strictures, out of which 11 had non-specific
malignant strictures, 7 had pancreatic carcinoma, 3 had Klatskin tumors, 3 had
periampullary carcinoma and 1 had gallbladder carcinoma. Six patients had benign 
strictures and 1 patient had choledochal cyst. Overall, MRCP was sensitive (88%) 
and specific (96.8%) in detecting choledocholithiasis. MRCP sensitivity and
specificity in detecting benign main bile duct stricture was equal to 83.3% and
97.6% respectively, and 92% and 100% for malignant stricture. CONCLUSION: Our
prospective study confirms that MRCP, a noninvasive and well tolerated imaging
technique is of value in the diagnosis of obstructive jaundice.

PMID: 15129871 [PubMed - indexed for MEDLINE]

354: J Clin Pathol. 2004 May;57(5):544-5.

Acute myeloid leukaemia presenting as cholestatic hepatitis.

Wandroo FA, Murray J, Mutimer D, Hubscher S.

University of Birmingham Queen Elizabeth Hospital Birmingham, Birmingham B15 2SQ,
UK. fwandroo@hotmail.com

A 40 year old man presented with abdominal pain, jaundice, weight loss, and
hepatosplenomegaly. Liver function tests revealed cholestatic jaundice and a
computed tomography scan showed an enlarged liver, with a normal biliary tree.
Liver biopsy showed diffuse infiltration by neutrophils, monocytoid cells, and
blasts. Peripheral blood film and bone marrow were consistent with acute myeloid 
leukaemia. After treatment with chemotherapy using an acute myeloid leukaemia
protocol (UK Medical Research Council AML-12), there was complete resolution of
jaundice and the patient went into complete molecular remission.

Publication Types: 
    Case Reports

PMID: 15113866 [PubMed - indexed for MEDLINE]

355: J Am Coll Surg. 2004 May;198(5):748-57.

Experimental obstructive jaundice disrupts intestinal mucosal barrier by altering
occludin expression: beneficial effect of bombesin and neurotensin.

Assimakopoulos SF, Scopa CD, Charonis A, Spiliopoulou I, Georgiou C, Nikolopoulou
V, Vagianos CE.

Department of Internal Medicine, Division of Gastroenterology, University of
Patras, Greece.

BACKGROUND: Little is known of the molecular events leading to increased
intestinal permeability in obstructive jaundice. This study was undertaken to
investigate the influence of experimental obstructive jaundice on the expression 
of the tight junction-associated protein occludin in the intestinal epithelium.
STUDY DESIGN: Seventy male Wistar rats were randomly divided into five groups: I,
controls; II, sham-operated; III, bile duct ligation (BDL); IV, BDL+Bombesin
(BBS) (30 microg/kg/d); and V, BDL+Neurotensin (NT) (300 microg/kg/d). At the end
of the experiment, on day 10, endotoxin was measured in portal and aortic blood. 
Tissue sections of the terminal ileum were examined histologically and
immunohistochemically for evaluation of occludin expression in the intestinal
epithelium. Lipid peroxidation and protein oxidation were determined on tissue
homogenates from terminal ileum and microbiologic analysis was performed in cecal
contents. RESULTS: Obstructive jaundice resulted in portal and aortic
endotoxemia, which was significantly reduced after BBS or NT administration. In
the BDL group, there was total loss of occludin expression in numerous
enterocytes mainly at the upper third of the villi, while a gradient of
positivity existed from crypt to tip. Occludin expression was restored to control
state after treatment with BBS or NT. In addition, both peptides reduced
intestinal lipid peroxidation, while BBS reduced protein oxidation as well.
CONCLUSIONS: Experimental obstructive jaundice induces regional loss of occludin 
expression in the intestinal epithelium, which may be a key factor contributing
to the disruption of the mucosal barrier. Gut regulatory peptides BBS and NT
prevent this alteration, leading to lower portal and systemic endotoxemia.

PMID: 15110809 [PubMed - indexed for MEDLINE]

356: World J Surg. 2004 May;28(5):475-81. Epub 2004 Apr 19.

Safe and permissible limits of hepatectomy in obstructive jaundice patients.

Takahashi T, Togo S, Tanaka K, Endo I, Fujii Y, Shimada H.

Second Department of Surgery, Yokohama City University School of Medicine, 3-9
Fukuura, Kanazawa-ku, 236-0004 Yokohama, Japan. ex7t-tkhs@asahi-net.or.jp

The safe and permissible limits of hepatectomy in obstructive jaundice patients
and the usefulness of preoperative portal embolization (PE) for increasing the
limit for safe hepatectomy were examined. We classified 416 patients with
hepatectomy performed over 9 years under the following headings: normal liver
function (n = 242); chronic hepatitis (n = 71); liver cirrhosis (n = 64); and
liver after relief of obstructive jaundice (n = 39). Hepatectomy was done after
the total bilirubin level was reduced below 3 mg/dl by preoperative biliary
drainage. Factors influencing the maximum total bilirubin level measured within 2
weeks after hepatectomy were investigated, and this level was taken to reflect
the degree of surgical stress. PE was carried out in 18 patients with obstructive
jaundice. The maximum total bilirubin, expressed as a logarithm, was
significantly correlated with the percent of liver resected in all groups.
Hepatectomy followed by a maximum total bilirubin of less than 8.5 mg/dl was
accepted as safe, and hepatectomy followed by a bilirubin level of 14.4 mg/dl was
deemed the maximum permissible resection. On the basis of these results, the safe
and permissible limits of hepatectomy in patients with obstructive jaundice were 
48.7% and 71.6%, respectively. PE decreased the maximum total bilirubin from 8.5 
mg/dl to 3.9 mg/dl when 48.7% of the liver (a safe proportion in all cases) was
resected; PE increased the safe limit of hepatectomy from 48.7% to 67.4% when a
maximum posthepatectomy total bilirubin level of 8.5 mg/dl was accepted as safe.

PMID: 15085400 [PubMed - indexed for MEDLINE]

357: World J Surg. 2004 May;28(5):471-5. Epub 2004 Apr 19.

Hepatic resection for hepatocellular carcinoma with obstructive jaundice due to
biliary tumor thrombi.

Yeh CN, Jan YY, Lee WC, Chen MF.

Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5
Fu-Hsing Street, Kwei-Shan, Taoyuan, Taiwan. ycn@adm.cgmh.org.tw

Hepatocellular carcinoma (HCC) with obstructive jaundice due to biliary tumor
thrombi is uncommon, and few studies have examined the outcome of hepatectomy for
HCC with this unusual entity. This study examined the clinicopathologic factors
influencing the outcomes of 17 HCC patients with obstructive jaundice due to
biliary tumor thrombi undergoing hepatectomy. The clinical features of 17 HCC
patients with obstructive jaundice due to biliary tumor thrombi (group A)
undergoing hepatectomy from 1986 to 1998 were reviewed. The clinical features and
factors influencing the outcome of 555 HCC patients without biliary tumor thrombi
(group B) undergoing hepatectomy were used for comparison. Of 572 patients with
surgically resected HCCs, 17 (3.0%) were classified into group A. Right upper
quadrant pain, physical signs of jaundice, low albumin level, elevated bilirubin 
level, small tumor size, more vascular invasion, and tumor rupture were
characteristic of group A patients. Multivariate stepwise logistic regression
analysis revealed no independently significant factor differentiating group A
patients from group B patients. The disease-free survival was similar between the
group A and B patients, although group B patients exhibited significantly better 
overall survival (p = 0.014). Vascular invasion may adversely influence overall
survival in group A patients undergoing hepatic resection (p = 0.0709). When
feasible, hepatic resection is the preferred treatment for HCC patients with
obstructive jaundice due to biliary tumor thrombi. It can achieve a disease-free 
survival comparable to that of HCC patients without biliary tumor thrombi.
However, HCC patients with biliary tumor thrombi had significantly worse overall 
survival than did those without biliary tumor thrombi, especially those with
concomitant vascular invasion.

PMID: 15085398 [PubMed - indexed for MEDLINE]

358: Clin Liver Dis. 2004 Feb;8(1):151-66.

Postoperative jaundice.

Faust TW, Reddy KR.

Division of Gastroenterology, Department of Internal Medicine, The University of 
Pennsylvania School of Medicine, 3 Ravdin, 3400 Spruce Street, Philadelphia, PA
19104, USA. thomas.faust@uphs.upenn.edu

Abnormal LCTs after surgery are common, and consultants are frequently called on 
to evaluate critically ill patients with abnormal tests. All patients undergoing 
consideration for elective surgery and a history of either acute or chronic liver
disease require careful presurgical evaluation. A thorough history and physical
examination, complete blood count, routine electrolytes, LCTs, and a coagulation 
profile should be ordered. For patients with marginal hepatic reserve, it is
important that patient well-being be maximized before any elective operation. The
type of surgery to be performed should also be reviewed. All patients with
postoperative jaundice should be evaluated for a history of liver disease. The
consultant should also review the surgical procedure performed, anesthetic agents
administered, other medications used, and whether blood products were given
during the perioperative and postoperative periods. The pattern and timing of LCT
abnormalities may also give a clue to the underlying disorder. As in the
preoperative assessment, a routine complete blood count,electrolyte panel, LCTs, 
and coagulation profile should be ordered. Unconjugated hyperbilirubinemia can
develop as a consequence of blood transfusions, underlying hemolytic disorders,
resorbing hematomas, drug effects, or Gilbert's syndrome. A haptoglobin,
reticulocyte count, LDH, and Coomb's test should be considered in patients with
unconjugated hyperbilirubinemia. Treatment is directed toward the underlying
condition. Conjugated hyperbilirubinemia can occur as a result of either
intrahepatic or extrahepatic disorders. Markedly abnormal aminotransferases and
LDH in conjunction with a normal abdominal ultrasound scan suggest ischemic liver
injury, drug-induced hepatitis, or viral infections of the liver. Treatment
entails restoration of hepatic perfusion, removal of offending medications, and
supportive care or antiviral agents, respectively. Extrahepatic biliary
obstruction must be considered in all patients with conjugated
hyperbilirubinemia. Abdominal sonography is the best screening test to assess for
obstruction. Patients with common bile duct stones usually require ERCP with
sphincterotomy and stone removal. Biliary strictures or leaks may require ERCP
with balloon dilation of strictures or stent placement for strictures and leaks; 
percutaneous drainage of bilomas in combination with broad-spectrum antibiotic
agents is recommended for patients with bile leaks and large intra-abdominal
fluid collections. Surgery may be required for patients with strictures or leaks 
not amenable to either endoscopic or percutaneous intervention or for patients
who have transected bile ducts after laparoscopic cholecystectomy. Medication
effects, benign postoperative jaundice, sepsis, TPN, and acalculous cholecystitis
are responsible for intrahepatic cholestasis and conjugated hyperbilirubinemia.
Treatment includes removal of offending drugs, supportive care, broad-spectrum
antibiotic agents with drainage of infected fluid collections, adjustment of TPN,
and either cholecystectomy or cholecystostomy, respectively.

Publication Types: 
    Review

PMID: 15062198 [PubMed - indexed for MEDLINE]

359: Eur J Gastroenterol Hepatol. 2004 Apr;16(4):407-9.

Comment in:
    Eur J Gastroenterol Hepatol. 2006 Jul;18(7):809-10.

Eosinophilic gastroenteritis presenting as obstructive jaundice.

Whitaker IS, Gulati A, McDaid JO, Bugajska-Carr U, Arends MJ.

University of Cambridge, Cambridge, UK. iain_Whitaker@yahoo.com

Eosinophilic gastroenteritis is a rare condition of unknown aetiology, first
described by Kaijser in 1937. It is manifest by eosinophilic infiltration of the 
gastrointestinal tract and peripheral eosinophilia. Patients have various
clinical presentations depending on the region of the gastrointestinal tract
involved and the depth and extent of the bowel wall involvement. Whereas
gastrointestinal obstruction associated with this condition is not uncommon,
isolated biliary obstruction has only been reported twice. We present a case of
eosinophilic gastroenteritis with involvement of the biliary tract causing
ulceration, fibrosis and obstruction. Although a rare condition, we believe the
diagnosis of eosinophilic gastroenteritis should be entertained in patients with 
gastrointestinal symptoms and a peripheral eosinophilia who have no evidence of
parasitic infection, vasculitis or neoplasms.

Publication Types: 
    Case Reports

PMID: 15028974 [PubMed - indexed for MEDLINE]

360: Ann Surg. 2004 Apr;239(4):510-7.

The value of bile replacement during external biliary drainage: an analysis of
intestinal permeability, integrity, and microflora.

Kamiya S, Nagino M, Kanazawa H, Komatsu S, Mayumi T, Takagi K, Asahara T, Nomoto 
K, Tanaka R, Nimura Y.

Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate 
School of Medicine, Nagoya, Japan.

OBJECTIVE: To investigate the effect of bile replacement following percutaneous
transhepatic biliary drainage, ie, external drainage, on intestinal permeability,
integrity, and microflora in a clinical setting. SUMMARY BACKGROUND DATA: Several
authors have reported that internal biliary drainage is superior to external
drainage. However, it is unclear whether bile replacement following external
drainage is beneficial. METHODS: Twenty-five patients with biliary cancer
underwent percutaneous transhepatic biliary drainage (PTBD) as a part of
presurgical management. All externally drained bile was replaced either per os or
by administration through a nasoduodenal tube. The interval between PTBD and the 
beginning of bile replacement was 21.3 +/- 19.7 days, and the length of bile
replacement was 20.7 +/- 9.6 days. The lactulose-mannitol test, measurement of
serum diamine oxidase (DAO) activity, and analyses of fecal microflora and
organic acids were performed before and after bile replacement. RESULTS: The
volume of externally drained bile varied widely from patient to patient, ranging 
from 220 +/- 106 mL/d to 1616 +/- 394 mL/d (mean, 714 +/- 346 mL/d). Biliary
concentrations of bile acids, cholesterol, and phospholipids increased
significantly after bile replacement. The lactulose-mannitol (L/M) ratio
decreased from 0.063 +/- 0.060 before bile replacement to 0.038 +/- 0.032 after
bile replacement (P < 0.05). Serum DAO activity increased from 3.9 +/- 1.4 U/L
before bile replacement to 5.1 +/- 1.6 U/L after bile replacement (P < 0.005),
and the magnitude of change in serum DAO activity correlated with the length of
bile replacement (r = 0.483, P < 0.05). Neither the L/M ratios nor serum DAO
activities before bile replacement correlated with the interval between PTBD and 
the beginning of bile replacement. Fecal microflora and organic acids were
unchanged. CONCLUSION: Impaired intestinal barrier function does not recover by
PTBD without bile replacement. Bile replacement during external biliary drainage 
can restore the intestinal barrier function in patients with biliary obstruction,
primarily due to repair of physical damage to the intestinal mucosa. Our results 
support the hypothesis that bile replacement during external drainage is
beneficial.

Publication Types: 
    Comparative Study

PMID: 15024312 [PubMed - indexed for MEDLINE]

361: Clin Gastroenterol Hepatol. 2003 Nov;1(6):480-3.

Cholestatic jaundice as a paraneoplastic manifestation of prostate
adenocarcinoma.

Karakolios A, Kasapis C, Kallinikidis T, Kalpidis P, Grigoriadis N.

Department of Internal Medicine, Serres General Hospital, Serres, Greece.
akarako@otenet.gr

Malignancies may cause cholestatic jaundice through well-recognized mechanisms
(e.g., bile duct obstruction or widespread hepatic infiltration). Paraneoplastic 
syndromes associated with malignancy, particularly with renal cell carcinoma
(Stauffer's syndrome) and malignant lymphoproliferative diseases, can induce a
reversible form of cholestasis through an unclear pathogenetic mechanism.
Prostate cancer presenting initially with cholestatic jaundice without any
obvious cause (i.e., obstruction or infiltration) has been reported in 2 cases in
the medical literature. We report a patient who presented with pruritus and
cholestatic jaundice. During the diagnostic work-up, prostate cancer was
diagnosed. Conjugated bilirubin and alkaline phosphatase levels were increased
markedly with modest increases of gamma-glutamyltranspeptidase and transaminase
levels. The results of appropriate investigations performed during the patient's 
hospitalizations indicated no evidence of hepatic metastases or extrahepatic
biliary obstruction. After treatment with flutamide and leuprolide, the patient's
symptoms and the laboratory abnormalities reversed rapidly. We regard the
cholestatic jaundice of this patient as part of a paraneoplastic syndrome; the
cause of cholestasis remains an enigma. Patients with unexplained cholestasis
should be investigated for malignancies, including prostate cancer.

Publication Types: 
    Case Reports

PMID: 15017648 [PubMed - indexed for MEDLINE]

362: J Surg Res. 2004 Feb;116(2):314-21.

Reversibility of leukocyte dysfunction in rats with obstructive jaundice.

Li W, Sung JJ, Chung SC.

Department of Medicine and Therapeutics, The Chinese University of Hong Kong,
Prince of Wales Hospital, Hong Kong SAR, People's Republic of China.

BACKGROUND: The role of leukocytes in obstructive jaundice is obscure and the
effect of relieving cholestasis on leukocyte function is unclear. We postulated
that cholestasis affects systemic polymorphonuclear leukocyte function by
deranging phagocytosis and hydrogen peroxide release and the leukocyte
dysfunction is reversible by internal and external biliary drainage. MATERIALS
AND METHODS: Sixty male Sprague Dawley rats were randomly assigned to four
groups: obstructive jaundice (OJ), sham operation (SH), OJ with internal drainage
(ID), and OJ with external drainage (ED). The phagocytic functions of neutrophils
and monocytes in whole blood were measured with flow cytometry using fluorescent 
microspheres. Intracellular hydrogen peroxide production by leukocytes was
assessed with flow cytometry using dihydrorhodamine-123 as probes. RESULTS:
Leukocyte count and percentage of monocytes in rats with OJ was significantly
increased compared with SH rats (P < 0.001). These elevations could be reversed
by both ID and ED method (P < 0.001). The phagocytic function of neutrophils and 
monocytes was significantly depressed in OJ rats compared with that in SH rats (P
< 0.001). After relief of the OJ, the suppressed phagocytic function of
neutrophils and monocytes was completely improved in ID rats (ID versus OJ, P <
0.001), but only partially reversed in ED rats. The hydrogen peroxide production 
by monocytes and lymphocytes was significantly increased in OJ rats (P < 0.05).
ID reversed the increased hydrogen peroxide generation (P < 0.05), but ED only
partially did. CONCLUSIONS: In our rodent model of biliary obstruction, deranged 
phagocytosis, and hydrogen peroxide generation by leukocytes was found. Internal 
drainage is superior to external drainage for reversal of the distorted leukocyte
function.

Publication Types: 
    Comparative Study
    Research Support, Non-U.S. Gov't

PMID: 15013371 [PubMed - indexed for MEDLINE]

363: Hepatogastroenterology. 2004 Jan-Feb;51(55):171-5.

Intestinal ischemia-reperfusion injury augments intestinal mucosal injury and
bacterial translocation in jaundiced rats.

Yüksek YN, Kologlu M, Daglar G, Doganay M, Dolapci I, Bilgihan A, Dolapçi M, Kama
NA.

Department of General Surgery, Ankara Numune Hospital, Ankara, Turkey.

BACKGROUND/AIMS: The aim of this study was to evaluate local effects and degree
of bacterial translocation related with intestinal ischemia-reperfusion injury in
a rat obstructive jaundice model. METHODOLOGY: Thirty adult Sprague-Dawley rats
(200-250 g) were divided into three groups; including Group 1 (jaundice group),
Group 2 (jaundice-ischemia group) and Group 3 (ischemia group). All rats had 2
laparotomies. After experimental interventions, tissue samples for translocation;
liver and ileum samples for histopathological examination, 25 cm of small
intestine for mucosal myeloperoxidase and malondialdehyde levels and blood
samples for biochemical analysis were obtained. RESULTS: Jaundiced rats had
increased liver enzyme levels and total and direct bilirubin levels (p<0.05).
Intestinal mucosal myeloperoxidase and malondialdehyde levels were found to be
high in intestinal ischemia-reperfusion groups (p<0.05). Intestinal mucosal
damage was more severe in rats with intestinal ischemia-reperfusion after bile
duct ligation (p<0.05). Degree of bacterial translocation was also found to be
significantly high in these rats (p<0.05). CONCLUSIONS: Intestinal mucosa is
disturbed more severely in obstructive jaundice with the development of ischemia 
and reperfusion. Development of intestinal ischemia-reperfusion in obstructive
jaundice increases bacterial translocation.

PMID: 15011857 [PubMed - indexed for MEDLINE]

364: Int J Dermatol. 2004 Mar;43(3):173-5.

Familial hypercholesterolemia (Type IIb) in a child: a case report with
interesting features.

Prasad PV, Chidambaram N.

Department of Dermatology, Rajah Muthiah Medical College and Hospital, Annamalai 
University, No. 88 Auta Nagar, Sivapuri-post, Annamalainagar-608 002, India.

Familial hypercholesterolemia (FH) is the most commonly recognized disorder of
lipoprotein metabolism in childhood. We report a case of FH in a 5-year-old boy
with onset of jaundice since birth, and multiple planar, tuberous, palmar and
intertrigenous xanthomas covering the trunk and limbs. His total cholesterol was 
590 mg/dl and triglycerides were 171 mg/dl. Echocardiography revealed mild aortic
stenosis as a result of premature atherosclerosis. He was diagnosed with
homozygous FH, and is reported here because of the interesting clinical features.

Publication Types: 
    Case Reports

PMID: 15009385 [PubMed - indexed for MEDLINE]

365: Ann Trop Paediatr. 2004 Mar;24(1):103-6.

Burkitt's lymphoma presenting as obstructive jaundice.

Wammanda RD, Ali FU, Adama SJ, Idris HW, Abubakar U.

Department of Paediatrics, Ahmadu Bello University Teaching Hospital, Zaria,
Nigeria. wammanda@inet-global.com

A 12-year-old boy presented with a 5-month history of yellowness of the eyes,
progressive painless abdominal swelling and weight loss. Physical examination
revealed a grossly wasted child with marked jaundice and non-tender hepatomegaly.
Liver function tests and abdominal ultrasound suggested obstructive liver
disease. Tissue biopsy at laparotomy showed histological findings consistent with
Burkitt's lymphoma. He was commenced on cytotoxic chemotherapy and, after two
courses, the jaundice disappeared and he remained well. Although ante-mortem
presentation of Burkitt's lymphoma as hepatic disease is rare, this condition
should be included in the differential diagnosis of a child with obstructive
jaundice.

Publication Types: 
    Case Reports

PMID: 15005975 [PubMed - indexed for MEDLINE]

366: Ann Surg Oncol. 2004 Mar;11(3):310-5.

Jaundice predicts advanced disease and early mortality in patients with
gallbladder cancer.

Hawkins WG, DeMatteo RP, Jarnagin WR, Ben-Porat L, Blumgart LH, Fong Y.

Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA.

BACKGROUND: In patients with gallbladder cancer, jaundice suggests tumor
involvement of the porta hepatis. This study reports on the prevalence, etiology,
and clinical significance of jaundice in patients with gallbladder cancer.
METHODS: Patients who presented with gallbladder cancer from 1995 to 2002 were
entered into a prospective database. Disease-specific survival and
clinicopathologic correlates were analyzed. RESULTS: Eighty-two (34%) of 240
patients with gallbladder cancer presented with jaundice. Jaundiced patients
(96%) were more likely (P <.001) to have advanced-stage disease than nonjaundiced
patients (60%). Only six (7%) jaundiced patients were resected with curative
intent, and only four (5%) had negative surgical margins. This was significantly 
different from the nonjaundiced group, in which 62 patients (39%) had negative
margins (P <.001). The median disease-specific survival in patients presenting
with jaundice was 6 months and was significantly lower compared with 16 months in
patients without jaundice (P <.0001). In the group presenting with jaundice,
there were no disease-free survivors at 2 years, compared with 21% in the group
without jaundice. CONCLUSIONS: Jaundice is common (34%) in patients who present
with gallbladder cancer and is an indicator of advanced malignancy. These data do
not support routine operative exploration of patients with jaundice secondary to 
gallbladder cancer.

PMID: 14993027 [PubMed - indexed for MEDLINE]

367: J Int Assoc Physicians AIDS Care (Chic Ill). 2003 Oct-Dec;2(4):133-9.

Clinical vignette in antiretroviral therapy: jaundice.

Zell SC.

Department of Internal Medicine and Health Care Research, University of Nevada
School of Medicine, Reno, Nevada, USA. sczell@unr.edu

HIV caregivers face many challenges following initiation of ART. The development 
of jaundice is uncommon but worrisome. In this case, two distinct and contrasting
episodes of jaundice were observed. In the first instance, isolated elevation of 
the indirect bilirubin without elevation of the alkaline phosphatase was noted.
The normal PT and serum aminotransferase levels indicate the absence of intrinsic
liver dysfunction. Elevations in the indirect bilirubin may result from either
impaired uptake/conjugation or excess production. The latter, usually from
acquired hemolysis, may be a complication of an occult NHL. A work-up for this
AIDS-related malignancy was not initiated since the caregivers recognized
jaundice as a complication of IDV, which inhibits UDP-glucuronyl transferase and 
produces a Gilbert's-like syndrome. Physicians can expect to encounter this
syndrome even more frequently with ATV. Experienced patients given RTV-boosted
ATV have experienced elevations of unconjugated hyper-bilirubinemia in up to 45
percent of cases in clinical trials. However, such elevations do not reflect
liver dysfunction and symptomatic jaundice requiring dosage reduction that
occurred infrequently (7 to 8 percent of study patients). Counseling patients
about this syndrome may promote adherence and prevent self-directed interruptions
of ATV that compromise efficacy. The second case of jaundice provides a more
formidable diagnostic challenge. The triad of LFT abnormalities (mild elevation
of aminotransferases, normal PT, and marked cholestatic jaundice) implies an
acute process that is mildly toxic to hepatocytes without affecting their
synthetic function. The subacute nature of the patient's cholestatic jaundice
suggests either intrahepatic infiltrative disease of the liver or extrahepatic
obstruction of the biliary tree, most likely due to the patient's relatively
modest level of pain and lack of fever. Despite LFT abnormalities occurring 17
months after a switch in his ART, cumulative drug-related toxicities must still
be considered. Ritonavir can produce significant elevations in the AST/ALT,
especially with pre-existing chronic liver disease as with hepatitis C virus
coinfection. The NRTIs can produce hepatic steatosis, a result of mitochondrial
toxicity and impaired fatty acid oxidation. However, jaundice and cholestasis are
not typical of the latter syndrome. With a negative contrast CT that excludes
parenchymal liver disease, investigation of the biliary tree to assess the
presence of AIDS-related cholangitis was the next step. Performing a
sphincterotomy or stent placement, and obtaining brushings or biopsy specimens to
determine the extent of extrahepatic obstruction may help define a pathogen and
be life-saving. The negative results of the ERCP justify the final diagnostic
step, a liver biopsy to evaluate microscopic infiltrative disease that might not 
have been detected on contrast abdominal CT. Examples might include granulomatous
disease (MAC), fungal etiologies (histoplasmosis), carcinomatosis (lymphoma,
hepatoma, cholangiocarcinoma), and microvascular disease (bacillary
angiomatosis). The failure to observe granulomatous inflammation in the liver
does not exclude MAC infection, as MAC may involve other peri-aortic or
mesenteric lymph nodes. This form of IRIS is unlikely given the abdominal CT
findings, lack of systemic complaints, and extended persistence of liver
aminotransferases. The nonspecific results of the liver biopsy are a common
outcome in advanced AIDS patients with elevated alkaline phosphatase levels.
Despite not having identified a pathogen, the biopsy establishes chronic liver
disease and prompts re-evaluation and change of treatment to NFV. The subsequent 
normalization of the patient's aminotransferase levels suggests a prior adverse
effect of LPV/r in the setting of unexplained, chronic liver disease. Most
importantly, this case highlights the importance of HIV caregivers to review ART 
for safety when noting chronic liver dysfunction. Patients need to be counseled
to minimize acetaminophen use, to consume alcohol in moderation, and to avoid
behavior with risk for hepatitis C. Finally, all HIV patients should receive
appropriate vaccination against hepatitis A and B if serology shows lack of
protective immunity.

Publication Types: 
    Case Reports

PMID: 14986514 [PubMed - indexed for MEDLINE]

368: South Med J. 2004 Feb;97(2):178-82.

Methimazole-induced cholestatic jaundice.

Mikhail NE.

Division of Endocrinology, Department of Medicine, Olive View UCLA Medical
Center, Sylmar, CA 91342-1495, USA. nasser.mikhail@gte.net

Methimazole is a widely used and generally well-tolerated antithyroid agent. A
43-year-old woman had severe jaundice and itching 1 month after receiving
methimazole (10 mg tid) and propranolol (20 mg tid) for treatment of
hyperthyroidism. The patient continued treatment for another 4 days after the
appearance of jaundice until she finished both medications. When seen at the
emergency department 2 weeks later, she still had severe icterus, pruritus, and
hyperbilirubinemia, formed mainly of the conjugated fraction. Methimazole-induced
cholestasis was diagnosed, and propranolol therapy was resumed. Over the
following 9 days, the symptoms improved and plasma bilirubin levels were normal
after 12 weeks without methimazole. In rare cases within the first few weeks of
therapy, this drug can cause severe and reversible cholestatic jaundice.
Physicians and patients should be aware of this adverse effect so that, upon
occurrence, they can discontinue methimazole therapy and avoid unnecessary
invasive procedures.

Publication Types: 
    Case Reports

PMID: 14982270 [PubMed - indexed for MEDLINE]

369: Anticancer Res. 2003 Nov-Dec;23(6C):4859-63.

Hepatocyte ultrastructural aspects after preoperative biliary drainage in
pancreatic cancer patients with cholestatic jaundice.

Fiori E, Macchiarelli G, Schillaci A, Lamazza A, Burza A, Paparelli C, Cavallaro 
A, Cangemi V.

Department of Surgery, Pietro Valdon, University of Rome La Sapienza, Italy.
Enrico.Fiori@uniroma1.it

BACKGROUND: The usefulness of preoperative biliary drainage in long-standing
obstructive jaundice remains controversial. This study was designed to assess
microscopic and ultrastructural changes in the morphology of hepatocytes from
patients with obstructive jaundice treated with biliary drainage for 14 days.
PATIENTS AND METHODS: In 8 patients with jaundice due to pancreatic neoplasms we 
obtained two fine-needle liver biopsies: the first during a transhepatic
cholangiographic examination before placing preoperative drainage and the second 
at surgery, on day 14 of drainage. Biopsy samples were examined by light and
electron microscopy and correlated to serum liver functional tests recorded
before and after biliary drainage. RESULTS: Pre-drainage biopsy presented diffuse
morphological signs of congestion and cholestasis, lipid and bilirubin cytoplasm 
inclusions, loss of bile canaliculi microvilli and diffuse bile canaliculi
dilatation. After-drainage biopsies presented reduction of bile canaliculi
dilatation, partial restoring of bile canaliculi microvilli and persistence of
diffuse hepatocyte structural and ultrastructural changes. Patients' laboratory
values (bilirubin, alkaline phosphatase, SGGT, SGOT and SGPT), that were
significantly impaired before drainage, returned almost to normal within two
weeks after drainage. CONCLUSION: Preoperative biliary drainage in patients with 
long-standing obstructive jaundice has received wide yet controversial support
due to a well established pathophysiological background. The present findings of 
scarce recovery of hepatocyte changes after 14 days' drainage seemingly question 
its appropriateness.

Publication Types: 
    Clinical Trial
    Research Support, Non-U.S. Gov't

PMID: 14981936 [PubMed - indexed for MEDLINE]

370: Obes Surg. 2004 Jan;14(1):77-83.

Clinical hepatic impairment after the duodenal switch.

Baltasar A, Serra C, Pérez N, Bou R, Bengochea M.

General Surgical Service, "Virgen de los Lirios" Hospital, Alcoy, Alicante,
Spain. abaltasar@seco.org

BACKGROUND: Nonalcoholic steatohepatitis (NASH) is the most common histological
finding in morbidly obese patients undergoing liver biopsy. Biliopancreatic
diversion has been widely used for the treatment of morbid obesity and hepatic
steatosis, and very few cases of liver impairment as a complication of this
operation have been reported. METHODS: During the last 9 years, 470 morbidly
obese patients were operated by means of a biliopancreatic diversion with
duodenal switch ( BPD-DS), and 93 of them were performed laparoscopically.
RESULTS: 10 cases of clinical hepatic impairment occurred after the BPD-DS. The
clinical course of these patients ranged from transient subclinical alterations
of liver function tests to severe cases of jaundice and one death from liver
failure. CONCLUSION: Randomized prospective studies with standardization of
BPD-DS are needed, to know the real incidence of hepatic impairment and the
proper treatment for this condition. Careful follow-up and correction of possible
malnutrition should be addressed to avoid hepatic impairment and/or progression
of liver disease.

PMID: 14980038 [PubMed - indexed for MEDLINE]

371: World J Surg. 2004 Mar;28(3):277-82. Epub 2004 Feb 17.

Changes in extrathymic T cells in the liver and intestinal intraepithelium in
mice with obstructive jaundice.

Ueno K, Ajiki T, Watanabe H, Abo T, Takeyama Y, Onoyama H, Kuroda Y.

Department of Gastroenterological Surgery, Kobe University Graduate School of
Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, 650-0017 Kobe, Japan.

Recently, T cells were classified into two categories: intrathymic T cells (ITCs;
thymus-derived T cells) and extrathymic T cells (ETCs). ETC, localized in the
liver and intestinal intraepithelium (IE), play an important immunologic role in 
the suppressed condition of T-cell development in the thymus. Given the fact that
complications of surgery in patients with obstructive jaundice are often related 
to immunosuppression in the gut-liver circulation, we attempted to investigate
the changes in the proportion of ETCs in mice with obstructive jaundice. Three
mice models were prepared ( n = 10 per group): sham group with simple laparotomy;
ligation group with common bile duct ligation; deoxycholic acid (DCA) group with 
an oral intake of DCA as a model of the presence of bile salts in the gut lumen. 
In each model, total mononuclear cells (MNCs), ITCs in the thymus, and ETCs in
the liver and IE were counted using monoclonal antibodies in conjunction with a
two-color immunofluorescence test by flow cytometry. In the ligation group the
number of MNCs was reduced in the thymus and IE, and only those in the IE
recovered after oral intake of DCA. A decrease of ITCs in the thymus and the
increase in ETCs in the liver and IE occurred simultaneously during the early
phase of biliary obstruction. At day 7 after biliary obstruction, ETCs in the
livers of the DCA and ligation groups decreased to nearly the level in the sham
group. However, on day 7 the ETCs in the IE remained significantly higher in the 
DCA group than in the ligation group. These results suggested that ETCs can act
in place of ITCs at an early phase of obstructive jaundice, and the presence of
bile in the gut lumen may be associated with the consumption of ETCs in the IE, a
reaction that may bring about improved immunoreactivity.

Publication Types: 
    Comparative Study

PMID: 14961202 [PubMed - indexed for MEDLINE]

372: World J Surg. 2004 Mar;28(3):283-7. Epub 2004 Feb 17.

Obstructive jaundice in rats: cause of spatial memory deficits with recovery
after biliary decompression.

Huang LT, Hsieh CS, Chou MH, Chuang JH, Liou CW, Tiao MM, Lai MC.

Department of Pediatrics, Chang Gung Memorial Hospital, 123 Ta-Pei Road,
Niao-Sung Hsiang, Kaohsiung, Taiwan.

Children with end-stage liver disease have been found to have cognitive deficits.
The aim of this study was to examine whether cholestatic jaundice causes spatial 
deficits in rats and if these cognitive deficits are reversed by biliary
drainage. Rats were randomly divided into three groups. In the first group, the
bile duct was ligated for 3 weeks (BDL group); in the second group, the proximal 
bile duct was ligated with a Broviac CV catheter for 2 weeks followed by a tube
bilioduodenostomy (TBD group); in the third group, a sham operation was performed
(SHAM group). All the surviving rats were assessed for spatial learning and
memory (a major cognitive function in rats) by the Morris water maze task about 3
weeks after the first operation. Blood was aspirated by cardiocentesis and
assayed for total bilirubin, albumin, ammonia, and hemoglobin levels on the day
following the water maze task. During the four consecutive acquisition trial days
of the Morris water maze, jaundiced rats (BDL group) had a significant longer
latency to escape than the SHAM group ( p < 0.05). Rats that underwent biliary
decompression for 1 week (TBD group) showed improved status of the spatial
deficit, as they required less time to reach the escape platform, approaching the
performance of the SHAM group. The BDL group had a significantly higher serum
ammonia level, higher bilirubin level, and lower hemoglobin level than the other 
two groups. After biliary decompression for 1 week, the serum albumin
concentration in the TBD group still did not return to the level of the SHAM
group. The results of this study suggest that long-term cholestasis results in
spatial memory deficits in rats that correlate with anemia and hyperbilirubinemia
encephalopathy. Early biliary decompression of obstructive jaundice improves
spatial memory deficits, possibly related to the recovery of the serum ammonia
and hemoglobin levels.

Publication Types: 
    Comparative Study
    Research Support, Non-U.S. Gov't

PMID: 14961195 [PubMed - indexed for MEDLINE]

373: Kurume Med J. 2003;50(3-4):155-9.

Markedly prolonged jaundice from simultaneous infection with hepatitis E virus
and leptospira.

Suzuki A, Kumashiro R, Shirachi M, Kuroki M, Suzuki H, Tanikawa K, Sata M.

Department of Medicine, Kurume University School of Medicine, 67 Asahi-machi,
Kurume 830-0011, Japan.

We treated a patient simultaneously infected with hepatitis E virus and
Leptospira interrogans, both acquired in China. Severe hyperbilirubinemia
required nearly 200 days to resolve, transminase elevation showed a fluctuating
course, and liver biopsy specimens showed fibrosis unusual for hepatitis E.
Leptospirosis appeared to have altered the course of hepatitis E virus infection 
in this patient, even though infection with Leptospira was cleared with
antibiotics by 50 days after the onset of the hepatitis symptoms.

Publication Types: 
    Case Reports

PMID: 14768480 [PubMed - indexed for MEDLINE]

374: Am Fam Physician. 2004 Jan 15;69(2):299-304.

Comment in:
    Am Fam Physician. 2005 Feb 1;71(3):425-6.    Am Fam Physician. 2005 Jan 1;71(1):49.

Jaundice in the adult patient.

Roche SP, Kobos R.

Department of Family and Community Medicine, Albany Medical College, Albany, New 
York 12208, USA.

Jaundice in an adult patient can be caused by a wide variety of benign or
life-threatening disorders. Organizing the differential diagnosis by prehepatic, 
intrahepatic, and posthepatic causes may help make the work-up more manageable.
Prehepatic causes of jaundice include hemolysis and hematoma resorption, which
lead to elevated levels of unconjugated (indirect) bilirubin. Intrahepatic
disorders can lead to unconjugated or conjugated hyperbilirubinemia. The
conjugated (direct) bilirubin level is often elevated by alcohol, infectious
hepatitis, drug reactions, and autoimmune disorders. Posthepatic disorders also
can cause conjugated hyperbilirubinemia. Gallstone formation is the most common
and benign posthepatic process that causes jaundice; however, the differential
diagnosis also includes serious conditions such as biliary tract infection,
pancreatitis, and malignancies. The laboratory work-up should begin with a urine 
test for bilirubin, which indicates that conjugated hyperbilirubinemia is
present. If the complete blood count and initial tests for liver function and
infectious hepatitis are unrevealing, the work-up typically proceeds to abdominal
imaging by ultrasonography or computed tomographic scanning. In a few instances, 
more invasive procedures such as cholangiography or liver biopsy may be needed to
arrive at a diagnosis.

Publication Types: 
    Review

PMID: 14765767 [PubMed - indexed for MEDLINE]

375: Abdom Imaging. 2003 Nov-Dec;28(6):835-7.

Hepatic artery aneurysm, an unusual cause of obstructive jaundice: MR
cholangiography findings.

Mazziotti S, Blandino A, Gaeta M, Lamberto S, Vinci V, Ascenti G.

Institute of Radiological Sciences, Policlinico G. Martino, University of
Messina, Messina, 98100 Italy.

Hepatic artery aneurysms are rare vascular lesions, often with a nonspecific
clinical presentation, and difficult to diagnose before rupture. We report the
case of a patient with obstructive jaundice caused by a compression on the right 
biliary duct by a right hepatic artery aneurysm in which the diagnosis was
suggested by magnetic resonance cholangiography and confirmed by Doppler
sonography and preoperative digital subtraction angiography.

Publication Types: 
    Case Reports

PMID: 14753601 [PubMed - indexed for MEDLINE]

376: Eur J Obstet Gynecol Reprod Biol. 2004 Feb 10;112(2):228-9.

Severe jaundice in early IVF pregnancy.

Wånggren K, Sparre LS, Wramsby H.

Division of Obstetrics and Gynecology, Karolinska Institutet, Danderyd Hospital, 
S-17176 Danderyd, Sweden. kjell.wanggren@ks.se

Jaundice in early pregnancy after in vitro fertilization (IVF) is extremely rare.
We report a case of severe jaundice in an IVF treated patient, with a clinical
picture similar to intrahepatic cholestasis of pregnancy (ICP). We suggest
strategies to prevent similar cases in the future.

Publication Types: 
    Case Reports

PMID: 14746965 [PubMed - indexed for MEDLINE]

377: Eur J Pediatr Surg. 2003 Dec;13(6):421-4.

Inflammatory myofibroblastic tumour of the extrahepatic bile ducts: an unusual
cause of obstructive jaundice in children.

Büyükyavuz I, Karnak I, Haliloglu M, Senocak ME.

Department of Paediatric Surgery, Hacettepe University Faculty of Medicine,
Ankara, Turkey.

Inflammatory myofibroblastic tumour is a rare entity in children with few
reported series. The extrahepatic bile duct is an unusual location for this
tumour. The authors report here the case of an 8-year-old girl presenting with
obstructive jaundice due to inflammatory myofibroblastic tumour of the
extrahepatic bile ducts with differential diagnosis of obstructive jaundice in
children.

Publication Types: 
    Case Reports

PMID: 14743334 [PubMed - indexed for MEDLINE]

378: Acta Physiol Scand. 2004 Feb;180(2):177-85.

Evidence for intestinal oxidative stress in obstructive jaundice-induced gut
barrier dysfunction in rats.

Assimakopoulos SF, Vagianos CE, Patsoukis N, Georgiou C, Nikolopoulou V, Scopa
CD.

Department of Internal Medicine, Division of Gastroenterology, School of
Medicine, University of Patras, Patras, Greece.

AIM: An important factor that promotes bacterial and endotoxin translocation in
obstructive jaundice is intestinal injury that causes increased permeability.
However, little is known of the submicroscopic biochemical events leading to
defects of the intestinal barrier. This study was undertaken to investigate the
effect of experimental obstructive jaundice on intestinal lipid peroxidation,
protein oxidation and thiol redox state. METHODS: Rats were randomly divided into
controls, sham operated and bile duct ligated (BDL). After 10 days, intestinal
barrier function was assessed by measuring endotoxin in portal and aortic blood. 
Tissue samples from the terminal ileum were examined histologically and
morphometrically, while other samples were homogenized for the determination of
lipid peroxidation, protein oxidation and thiol redox state [reduced glutathione 
(GSH), oxidized glutathione (GSSG), total non-protein mixed disulphides (NPSSR), 
protein thiols (PSH) and protein disulphides (PSSP)]. RESULTS: Obstructive
jaundice compromised intestinal barrier function leading to significant portal
and systemic endotoxaemia. The intestinal mucosa in jaundiced rats was atrophic
with significantly decreased villous density and total mucosal thickness.
Determination of biochemical parameters of oxidative stress in the intestine
showed increased lipid peroxidation and protein oxidation in BDL-rats. Thiol
redox state revealed the presence of intestinal oxidative stress in jaundiced
rats, indicated by a decrease in GSH and increased GSSG, NPSSR and PSSP.
CONCLUSIONS: This study shows that experimental obstructive jaundice induces
intestinal oxidative stress, which may be a key factor contributing to intestinal
injury and leading to endotoxin translocation.

PMID: 14738476 [PubMed - indexed for MEDLINE]

379: J Gastroenterol Hepatol. 2004 Feb;19(2):160-5.

Superoxide and nitric oxide production by Kupffer cells in rats with obstructive 
jaundice: effect of internal and external drainage.

Li W, Chan AC, Lau JY, Lee DW, Ng EK, Sung JJ, Chung SC.

Department of Gastroenterology, The General Hospital of the Chinese People's
Liberation Army, Beijing, China.

BACKGROUND AND AIMS: The role of Kupffer cells in obstructive jaundice (OJ) has
not been fully understood. The aims of the present study were to measure
superoxide and nitric oxide (NO) production by Kupffer cells in experimental OJ
in rats and to investigate the response to internal and external biliary
drainage. METHODS: Eighty male Sprague-Dawley rats were assigned to four groups: 
sham operation, OJ, and internal and external biliary drainage. Kupffer cells
were isolated on day 7 in the sham operation and OJ group, and on day 7 after
drainage procedures. Cells were cultured with or without lipopolysaccharide
(LPS). Superoxide production was quantified in cultured Kupffer cells at 2 h and 
48 h, respectively, after cell isolation using the superoxide dismutase
inhibitable ferricytochrome c reduction method. Nitrite production in cell
culture supernatants was measured 48 h later using Greiss reagents. RESULTS:
Without LPS stimulation, Kupffer cells produced comparable superoxide and nitrite
in each group (P > 0.05). With LPS stimulation, Kupffer cells in the OJ group
produced significantly higher superoxide anions than the other groups (P =
0.006). Nitrite production was significantly increased in the OJ group and
external biliary drainage group compared to rats in the sham operation and
internal drainage groups (P < 0.01). CONCLUSIONS: Kupffer cells from rats with OJ
produce great amounts of endotoxin-mediated oxidants. Both internal and external 
biliary drainage can decrease the elevated superoxide production. Internal
drainage is superior to external drainage for reversing the distortional capacity
of NO production by Kupffer cells.

Publication Types: 
    Comparative Study
    Research Support, Non-U.S. Gov't

PMID: 14731125 [PubMed - indexed for MEDLINE]

380: Eur Surg Res. 2004 Jan-Feb;36(1):45-52.

Effect of different enteral nutrients on bacterial translocation in experimental 
obstructive jaundice.

Kuru B, Dinc S, Altinok G, Aksoz T, Camlibel M, Gulcelik MA, Alagol H.

Department of Surgery, Ankara Oncology Training and Research Hospital, Ankara,
Turkey. bekirkuru@hotmail.com

Obstructive jaundice leads to bacterial translocation (BT) by disruption of the
gut barrier, intestinal microecology, and impaired host immune defence. The
objective of the present study is to investigate the effects of different enteral
nutrients on BT that is induced by obstructive jaundice in rats. Eighty male
Wistar-Albino rats were randomly assigned into 4 groups. Group 1: 20 rats
underwent laparotomy, common bile duct (CBD) was not actually ligated and
transected, but sham ligation of CBD was performed. Groups 2-4: 60 rats underwent
laparotomy, CBD ligation and transection. Group 1 and 2 rats were given rat chow,
group 3 rats were fed a glutamine and arginine supplemented enteral diet, and
group 4 rats were fed an arginine, m-RNA and omega-3 supplemented enteral diet,
an immunonutrient. Rats in groups 3 and 4 had significantly less BT to mesenteric
lymph nodes compared to rats in group 2 (p = 0.001). These findings suggest that 
oral administration of an arginine and glutamine supplemented diet and
immunonutrition reduce BT in rats with obstructive jaundice. Copyright 2004 S.
Karger AG, Basel

PMID: 14730223 [PubMed - indexed for MEDLINE]

381: Pharmacol Res. 2004 Mar;49(3):227-38.

The effect of N-acetylcysteine (NAC) on liver and renal tissue inducible nitric
oxide synthase (iNOS) and tissue lipid peroxidation in obstructive jaundice
stimulated by lipopolysaccharide (LPS).

Cağlikülekci M, Pata C, Apa DD, Dirlik M, Tamer L, Yaylak F, Kanik A, Aydin S.

Department of General Surgery, Mersin University Medical School, Mersin, Turkey. 
mcaglikulekci@yahoo.com

Morbidity and mortality rates are very high in obstructive jaundice when it is
associated with sepsis and multiple organ failure. Nitric oxide (NO) formation
and increased expression of inducible nitric oxide synthase (iNOS) also take
place in obstructive jaundice (OJ). N-Acetylcysteine (NAC) has a beneficial
effect by demonstrating anti-inflammatory activity such as inhibits cytokine
expression/release, inhibiting the adhesion molecule expression and inhibiting
nuclear factor kappa B (NFkappaB). The aim of this study was to investigate the
effects of NAC on liver and renal tissue iNOS, and liver tissue lipid
peroxidation in lipopolysaccharide (LPS) induced obstructive jaundice. We
randomized 48 rats into six groups. Group A: Sham group; group B: OJ group; group
C: OJ+NAC; group D: OJ+LPS (Escherichia coli LPS serotype L-2630, 100mg, Sigma)
group E: OJ+NAC+LPS; group F: OJ+LPS+NAC. NAC was started subcutaneously
100mg/kg. LPS was injected intraperitoneally and then at the tenth day we
sacrificed the rats.Liver malondialdehyde (MDA) increased and liver ATPase
decreased in groups B-D when compared to group A. After the administration of NAC
(groups C-E), liver MDA levels decreased, tissue ATPase levels increased as
compared to other groups. The liver and renal tissue iNOS expression was
increased in groups B, D, and F. After the administration of NAC (groups C-E) the
liver and renal tissue iNOS expression were decreased. Our results indicated that
NAC prevented the deleterious effects of LPS in OJ by reducing iNOS expression
via lipid peroxidation in liver and renal tissue; if it was administrated before 
LPS. But NAC failed to prevent the iNOS expression and lipid peroxidation if
there was established endotoxemia in OJ.

Publication Types: 
    Comparative Study

PMID: 14726217 [PubMed - indexed for MEDLINE]

382: Semin Gastrointest Dis. 2003 Oct;14(4):156-64.

Clinical problems with developmental anomalies of the biliary tract.

Suchy FJ.

Department of Pediatrics, Mount Sinai School of Medicine, New York, NY
10029-6574, USA.

Cholestatic jaundice defined as conjugated hyperbilirubinemia is a typical
feature of neonatal liver disease. Biliary atresia is the most common disorder
producing cholestasis during the first 2 months of life. Syndromic and
non-syndromic paucity of the intralobular bile ducts and choledochal cysts can
also present with cholestasis during early life. Liver dysfunction from
obstruction of the biliary tree must be differentiated from numerous disorders
affecting hepatocytes such as congenital infection and inborn errors of
metabolism. Early recognition and a stepwise diagnostic evaluation of the
cholestatic infant are essential in successfully treating many metabolic and
infectious liver diseases of the infant as well as surgically relieving
obstruction in patients with biliary atresia.

Publication Types: 
    Case Reports
    Review

PMID: 14719766 [PubMed - indexed for MEDLINE]

383: J Lab Clin Med. 2003 Dec;142(6):391-8.

Impairment of blood rheology by cholestatic jaundice in human beings.

Mark M, Walter R, Contesse J, Reinhart WH.

Department of Internal Medicine, Kantonsspital, Chur, Switzerland.

Bilirubin and bile acids may affect erythrocytes. We investigated blood viscosity
and erythrocyte structure in patients with cholestatic jaundice ex vivo and
studied the short-term effects of bilirubin and bile acids in vitro. Seventeen
patients with cholestatic jaundice and controls were studied. Whole-blood
viscosity (adjusted hematocrit 45%) at high (94.5 sec(-1)) and low (0.1 sec(-1)) 
shear rate and plasma viscosity were measured. Erythrocyte structure was assessed
in wet preparations of fixed cells. In vitro whole blood was incubated with
increasing concentrations of bilirubin (83% conjugated) and bile acids (cholic,
lithocholic, deoxycholic, and chenodeoxycholic acid) and the abovementioned
investigations were performed. In patients we observed increased whole-blood
viscosity at high shear rate (5.82 +/- 0.69 vs 5.04+/- 0.27 mPa. sec, P =.0001), 
plasma viscosity (1.48 +/- 0.22 vs. 1.23 +/- 0.07 mPa. sec, P =.0004), and
fibrinogen level (4.70 +/- 0.98 g/L vs 2.63 +/- 0.21 g/L, P < 0.001) were
observed. The incubation of normal erythrocytes in patients' plasma confirmed an 
increase in blood viscosity at high shear rate. Erythrocytes from patients with
jaundice demonstrated a slight degree of stomatocytic shape transformation (P
<.0001). In vitro, bilirubin did not affect erythrocyte shape. Cholic and
lithocholic acids caused a slight stomatocytic shape transformation, whereas
deoxycholic acid and chenodeoxycholic acid influenced neither blood viscosity nor
erythrocyte structure. Patients with cholestatic jaundice have increased
whole-blood and plasma viscosity and slightly altered red blood cell shape,
possibly the result of a combination of increased levels of bilirubin and bile
acids plus an acute-phase reaction.

Publication Types: 
    Research Support, Non-U.S. Gov't

PMID: 14713891 [PubMed - indexed for MEDLINE]

384: Dig Dis Sci. 2003 Nov;48(11):2221-6.

Extrahepatic biliary schwannoma.

Honjo Y, Kobayashi Y, Nakamura T, Takehira Y, Kitagawa M, Ikematsu Y, Ozawa T,
Nakamura H.

Department of Gastroenterology, Hamamatsu Medical Center, Hamamatsu, Shizuoka,
Japan.

Schwannoma (neurilemoma or neurinoma) rarely develops in the biliary tract. We
report here a case of extrahepatic biliary schwannoma found in a 47-yr-old
Japanese woman presenting with obstructive jaundice. The radiological imaging
studies were suggestive of nonepithelial tumor involving the common bile duct.
The patient underwent tumor resection. The tumor extended inward and outward from
the wall of the common bile duct in the shape of a dumbbell. The extraductal
tumor was solid with microcystic changes, while the intraductal lesion presented 
cystic changes. Microscopically, the tumor was predominantly composed of
spindle-shaped cells with nuclear palisading, and it contained lymphoid
aggregates. Immunohistochemically, the tumor cells were positive for S-100
protein. The final diagnosis was benign schwannoma of the common bile duct. The
tumor differed from usual soft tissue schwannoma and closely resembled
gastrointestinal schwannoma.

Publication Types: 
    Case Reports

PMID: 14705833 [PubMed - indexed for MEDLINE]

385: Hepatogastroenterology. 2003 Nov-Dec;50(54):2185-7.

Monolobar Caroli's disease in an adult. Case report.

Giovanardi RO.

Department of Surgery, Fundação Universidade de Caxias do Sul, Department of
Surgery, Hospital Geral, Caxias do Sul, Centro Hepatobiliar, Caxias do Sul,
Brazil. rgiova@terra.com.br

Caroli's disease is the dilatation of the segmental intrahepatic bile ducts which
generally presents in a diffuse form, but may occasionally involve only a single 
lobe, commonly the left one. We report the case of a 64-year-old male who
presented with a clinical picture of obstructive jaundice, with Caroli's disease 
in segments II and III of the liver. Preoperative diagnosis was made using
abdominal ultrasound and computed tomography scan, confirmed by endoscopic
retrograde cholangiopancreatography. The treatment used was segmentectomy II and 
III (left lobectomy--Couinaud's classification) of the liver. Macroscopic
examination of the resected specimen revealed cystic dilatation of the
intrahepatic bile ducts and intrahepatic lithiasis. Histologically there was no
evidence of malignancy. Liver resection is the treatment of choice for Caroli's
disease confined to a single lobe or segment, eliminating the potential for
cholangitis, lithiasis and carcinoma.

Publication Types: 
    Case Reports

PMID: 14696493 [PubMed - indexed for MEDLINE]

386: Hepatogastroenterology. 2003 Nov-Dec;50(54):2057-60.

Hepatocellular carcinoma presenting with obstructive jaundice: a
clinicopathological study of eight cases.

Murata K, Shiraki K, Kawakita T, Yamamoto N, Okano H, Sakai T, Ohmori S, Deguchi 
M, Shimizu A, Nakano T.

First Department of Internal Medicine, Mie University School of Medicine, 2-174
Edobashi, Tsu, Mie, 514-8507, Japan.

BACKGROUND/AIMS: The prognosis of icteric type hepatocellular carcinoma is
extremely poor, not only because of obstructive jaundice, but also because of
difficulties for early diagnosis. The aim of this study is to evaluate
characteristics of icteric hepatocellular carcinoma for early diagnosis.
METHODOLOGY: Eight patients with icteric hepatocellular carcinoma among 326
patients with hepatocellular carcinoma in our hospitals were retrospectively
examined by laboratory data, image studies and pathology studies. RESULTS: Most
cases were already advanced, with a portal tumor thrombus at the time of
diagnosis. Imaging studies fail to reveal tumors because this type of
hepatocellular carcinoma has an irregular faint margin and has lost the
characteristic pattern of hepatocellular carcinoma, such as capsular formation or
early enhancement. Pathology observations demonstrated poorly or moderately
differentiated hepatocellular carcinoma in all our cases. CONCLUSIONS: This type 
of hepatocellular carcinoma should be considered in cirrhotic patients with
obstructive jaundice or in patients with high tumor marker levels even if image
studies fail to reveal tumors. For better prognosis, combination therapies such
as biliary drainage, support for portal flow as well as treatment for the
hepatocellular carcinoma, are necessary.

PMID: 14696464 [PubMed - indexed for MEDLINE]

387: J Pediatr Surg. 2004 Jan;39(1):16-8.

Percutaneous cholecysto-cholangiography in the diagnosis of obstructive jaundice 
in infants.

Meyers RL, Book LS, O'Gorman MA, White KW, Jaffe RB, Feola PG, Hedlund GL.

Division of Pediatric Surgery, Primary Children's Medical Center, University of
Utah School of Medicine, Salt Lake City, UT 84113, USA.

BACKGROUND: Once it is established that a jaundiced infant has an elevated direct
bilirubin level, the principal diagnostic concern is the differentiation of
hepatocellular from obstructive cholestasis, of disorders of physiology from
disorders of anatomy, and of disease that is managed medically from disease that 
is managed surgically. Traditional tests such as ultrasonography, liver biopsy,
and technotium 99m HIDA scan are often not sufficiently discriminating. General
anesthesia is required for invasive imaging with endoscopic retrograde cholangio 
pancreatography (ERCP) or operative cholangiogram. The authors describe a facile 
alternative using percutaneous cholecystocholangiography (PCC) with intravenous
sedation. METHODS: Nine cholestatic infants underwent PCC (age, 27 to 73 days;
mean, 44 days) after ultrasoundscan, liver biopsy, and (99mTc)HIDA scan failed to
provide a definitive diagnosis. RESULTS: In the 4 infants without complete
biliary filling, we found biliary atresia (3) and biliary hypoplasia (1). The
biliary tree was completely opacified in 5 infants with the following diagnosis: 
neonatal hepatitis (2), duplication of the gallbladder (1), choledochocele (1),
total parenteral nutrition (TPN) cholestasis (1). There were no complications.
CONCLUSIONS: When the etiology of cholestasis remains elusive after traditional
firstline tests, PCC has proven to be an accurate simple alternative in
differentiating obstructive from hepatocellular causes of infantile cholestatic
jaundice.

PMID: 14694364 [PubMed - indexed for MEDLINE]

388: World J Gastroenterol. 2003 Dec;9(12):2876-7.

Icteric flare of chronic hepatitis B in a 95-year old patient.

Song W, Leung WK, Chan HL.

Department of Medicine and Therapeutics, the Prince of Wales Hospital, Hong Kong 
SAR.

A 95-year old gentleman developed fatal icteric flare of chronic hepatitis B
despite lamivudine treatment. This article highlights the atypical presentations 
of chronic hepatitis B in elderly patient and the need to consider this
possibility for acute fulminant hepatitis in endemic areas.

Publication Types: 
    Case Reports

PMID: 14669358 [PubMed - indexed for MEDLINE]

389: World J Gastroenterol. 2003 Dec;9(12):2737-41.

Hepatocellular apoptosis after hepatectomy in obstructive jaundice in rats.

Wang DS, Dou KF, Li KZ, Gao ZQ, Song ZS, Liu ZC.

Department of Hepatobiliary Surgery, Xijing Hospital, the Fourth Military Medical
University, Xi'an 710032, Shannxi Province, China. wangdesh@163.com

AIM: To investigate the hepatocellular apoptosis after hepatectomy in obstructive
jaundice and biliary decompression rats. METHODS: After bile duct ligation for 7 
days, rats were randomly divided into OB group in which the rats underwent 70%
hepatectomy, OB-CD group in which the rats underwent hepatectomy accompanied by
choledochoduodenostomy, CD-Hx group in which the rats underwent
choledochoduodenostomy and then received 70% hepatectomy on the fifth day after
biliary decompression. The control group (Hx group) only underwent hepatectomy.
RESULTS: The level of total serum bilirubin and serum enzymes was significantly
lower in CD-Hx group than in OB-CD and OB groups on day 1, 3 and 5 after
hepatectomy. The apoptotic index was significantly lower in CD-Hx group than in
OB-CD and OB groups on day 3 and 5. The oligonucleosomal DNA fragments and
Caspase-3 activity were also lower in CD-Hx group than in OB-CD and OB groups 3
days after hepatectomy, without differences between CD-Hx and Hx groups.
CONCLUSION: Hepatocellular apoptosis plays vital roles in jaundice rats, and
biliary decompression is more effective in treatment of patients with severe
jaundice before operation.

Publication Types: 
    Research Support, Non-U.S. Gov't

PMID: 14669324 [PubMed - indexed for MEDLINE]

390: Endoscopy. 2003 Dec;35(12):992-7.

A prospective, randomized multicenter trial comparing DoubleLayer and
polyethylene stents for malignant distal common bile duct strictures.

Tringali A, Mutignani M, Perri V, Zuccalà G, Cipolletta L, Bianco MA, Rotondano
G, Philipper M, Schumacher B, Neuhaus H, Schmit A, Devière J, Costamagna G.

Digestive Endoscopy Unit, Catholic University, Rome, Italy.

BACKGROUND AND STUDY AIMS: Endoscopic biliary stenting is an established
treatment for malignant obstructive jaundice. Stent clogging continues to be a
major problem with plastic stents. The aim of this study was to carry out a
prospective comparison of two stents with different materials and shapes: the
Olympus DoubleLayer stent (DLS; perfluoro alkoxy, without sideholes) and the
standard polyethylene (PE) stent (with sideholes). PATIENTS AND METHODS: A total 
of 120 patients (70 women; mean age 71, range 36 - 91) with jaundice due to
malignant strictures of the middle to distal third of the common bile duct were
randomly assigned to receive either DLS (n = 60) or PE (n = 60) biliary stents.
Patients with cholangitis, hemobilia, previous biliary drainage, hilar stricture,
or ampullary cancer were excluded. RESULTS: In all, 28 DLS patients (47 %) and 17
PE stent patients (29 %) died without clinical evidence of stent occlusion after 
a mean of 114 and 105 days, respectively ( P < 0.05). Twenty-six DLS patients (43
%) and 38 PE stent patients (63 %) had symptoms of stent clogging after a mean of
144 and 99 days, respectively ( P < 0.05). Stent dysfunction (stent orifice
impacted on the bile duct or duodenal wall, stent migration) was recorded in six 
DLS patients (10 %) and five PE patients (8 %) (n. s.). Kaplan-Meier analysis of 
DLS and PE stent clogging-free survival showed a significantly longer patency
period with the DLS stents (P = 0.0005). CONCLUSIONS: These results show that
DoubleLayer stents have a longer patency period than PE stents. Patients who
received PE stents had a higher risk of stent occlusion (relative risk 3.05; 95 %
CI, 1.57 - 5.89) before death than DLS patients.

Publication Types: 
    Clinical Trial
    Comparative Study
    Multicenter Study
    Randomized Controlled Trial

PMID: 14648409 [PubMed - indexed for MEDLINE]

391: J Chin Med Assoc. 2003 Sep;66(9):555-9.

Endoscopic treatment in a patient with obstructive jaundice caused by pancreatic 
pseudocyst.

Yeh CL, Lai KH, Lo GH, Lin CK, Hsu PI, Chan HH, Tsai WL, Lin CP.

Division of Gastroenterology, Department of Internal Medicine, Kaoshiung Veterans
General Hospital, Kaohsiung, Taiwan, ROC.

We report a case of chronic alcoholic pancreatitis with obstructive jaundice due 
to compression of the common bile duct by pancreatic pseudocyst. Ultrasonography 
and computed tomographic scan on admission demonstrated an 8 cm cystic lesion
located at the head of the pancreas. Endoscopic retrograde
cholangiopancreatography (ERCP) revealed a segment of narrowing at the distal
common bile duct which was compressed by the pancreatic pseudocyst. Communication
between the cyst and pancreatic duct was also noted. Bacteriological examination 
of cystic contents yielded the growth of Proteus vulgaris, Morganella morganii,
Stenotrophomonas maltophilia and Pseudomonas aeruginosa. The patient was treated 
with broad-spectrum antibiotic, endoscopic sphincterotomy, endoscopic
nasopancreatic duct drainage, and transpapillary pancreatic endoprosthesis.
Jaundice subsided gradually during admission and a marked reduction of pancreatic
pseudocyst was found 18 months after discharge.

Publication Types: 
    Case Reports

PMID: 14649681 [PubMed - indexed for MEDLINE]

392: Australas Radiol. 2003 Dec;47(4):393-403.

Role of radiology in the treatment of malignant hilar biliary strictures 2: 10
years of single-institution experience with percutaneous treatment.

Hii MW, Gibson RN, Speer AG, Collier NA, Sherson N, Jardine C.

St Vincent's Hospital, Melbourne, Australia. mickhii@hotmail.com

We reviewed the results of percutaneous intervention of hilar biliary malignancy 
over a 10-year period at a single institution: the Royal Melbourne Hospital.
Ninety-nine patients (100 treated in total) were included. Information was
retrieved by retrospective examination of patient notes and radiology, combined
with interviews with family and relevant physicians. Sixty-nine patients were
treated with insertion of semipermanent stents, 19 had external drain tubes, and 
25 received percutaneous access for Iridium brachytherapy. Adequate drainage was 
achieved in 87% of the patients stented, and percutaneous access was successful
in 96% of patients planned for brachytherapy. Of those patients undergoing
endoprosthesis insertion, early complications occurred in 39% and late
complications in 23%. Average survival for the entire patient population was
227.3 days, with a median of 167 days. Longer survival times (213 vs 142 days)
and lower complication rates (44 vs 64%) are observed with metal stents in
comparison with plastic stents. Percutaneous intervention is an important
treatment option in hilar biliary malignancy, particularly in patients unfit for 
surgery. Reasonable survival with good palliation is the most common outcome, and
most patients do not require further intervention.

PMID: 14641192 [PubMed - indexed for MEDLINE]

393: World J Surg. 2004 Jan;28(1):43-6. Epub 2003 Nov 26.

Surgical intervention for obstructive jaundice due to biliary tumor thrombus in
hepatocellular carcinoma.

Peng SY, Wang JW, Liu YB, Cai XJ, Deng GL, Xu B, Li HJ.

Department of Surgery, Second Affiliated Hospital, School of Medicine, Zhejiang
University, Hangzhou, People's Republic of China. sypeng@mail.hz.zj.cn

This retrospective study in eight surgically treated patients with obstructive
jaundice due to biliary tumor thrombus in a patient with hepatocellular carcinoma
(HCC) was performed to evaluate the role of surgical intervention. All biliary
tumor thrombi were confirmed preoperatively or intraoperatively. Only two
manifested intraluminal biliary obstructions due to a primary tumor that had not 
been found preoperatively. The operative procedures included hepatectomy with
removal of the biliary tumor thrombus (n=3), hepatectomy combined with
extrahepatic bile duct resection (n=1), thrombectomy through a choledochotomy
(n=3), and piggyback orthotopic liver transplantation (n=1). The 1- and 3-year
survival rates were 62.5% and 37.5%, respectively. Two patients survived more
than 5 years. Surgical intervention was effective in patients with obstructive
jaundice due to a biliary tumor thrombus in an HCC. Thus surgery for a recurrence
can prolong survival, and liver transplantation is a treatment worthy of further 
investigation.

PMID: 14639491 [PubMed - indexed for MEDLINE]

394: Hepatobiliary Pancreat Dis Int. 2002 Feb;1(1):111-3.

Endoscopic retrograde cholangiopancreatography in evaluation of choledochal
dilatation in patients with obstructive jaundice.

Chen WX, Zhang Y, Li YM, Xu GQ, Fang Y, Cai SP.

Department of Gastroenterology, First Affilliated Hospital, Zhejiang University
School of Medicine, Hangzhou 310003, China. weixing121@sina.com

OBJECTIVE: To determine the causes of choledochal dilatation in patients with
obstructive jaundice. METHODS: One hundred and sixty-four patients with
obstructive jaundice were investigated by endoscopic retrograde
cholangiopancreatography(ERCP), and patients with choledochal dilatation (group
I, n=110) were compared with those without choledochal dilatation (group II,
n=54). RESULTS: The causes of common bile duct dilatation were choledocholith,
juxtapapillary duodenal diverticula and congenital dilatation of the common bile 
duct. The distal common bile duct and its surroundings were abnormal in 104
(94.55%) of the 110 patients and in 13 (24.08%) of the 54 patients (P<0.01).
Juxtapapillary duodenal diverticulum accounted for 24.55% in group I, and only in
9.26% in group II (P<0.05). Post-cholecystectomy patients were 13.64% in group I,
and only 5.56% in group II. CONCLUSIONS: The abnormalities of the distal common
bile duct and its surroundings can usually be detected as underlying causes of
common bile duct dilatation. ERCP is necessary before cholecystectomy, since it
is considered the "gold standard" for the diagnosis of distal common bile duct
abnormalities.

PMID: 14607637 [PubMed - indexed for MEDLINE]

395: Hepatobiliary Pancreat Dis Int. 2003 May;2(2):300-2.

Interventional therapy of malignant obstructive jaundice.

Feng GH, Cai Y, Jia Z, Yang DQ, Chen H, Jin HC, Yu QH, Zhu W, Wang CX.

Department of General Surgery, First People's Hospital, 261 Huansha Road,
Hangzhou 310006, China. caiyang68@hotmail.com

OBJECTIVE: To assess the short-term results of interventional therapy for
malignant obstructive jaundice. METHODS: In 82 patients with malignant
obstructive jaundice, hepatocellular carcinoma was detected in 10 patients,
carcinoma of gallbladder in 14, hilar biliary carcinoma in 22, pancreatic
carcinoma in 20, and hilar metastatic carcinoma in 16. Percutaneous transhepatic 
biliary internal and/or external drainage (PTBIED) was performed in 61 patients
and percutaneous transhepatic insertion of biliary stent (PTIBS) in 21. RESULTS: 
The level of total serum bilirubin (TSB) was reduced in 71 patients and less
markedly in others. The level of TSB of the 61 patients was reduced from
450.12+/-113.51 micromol/L before operation to 240.25+/-107.81 micromol/L and
90.91+/-101.72 micromol/L 1 and 2 weeks after operation respectively. The TSB
level of the 21 patients was reduced from 410.53+/-98.13 micromol/L to
270.23+/-115.64 micromol/L and 105.43+/-97.85 micromol/L 1 and 2 weeks after
operation, respectively. No significant difference was found in the effect
between PTBIED and PTIBS. Short-term complications developed in 33 patients.
Seven patients died 30 days after operation. CONCLUSION: Interventional therapy
may be simple, safe and effective in the treatment of malignant obstructive
jaundice.

Publication Types: 
    Clinical Trial

PMID: 14599989 [PubMed - indexed for MEDLINE]

396: Hepatobiliary Pancreat Dis Int. 2003 Aug;2(3):435-40.

Surgical mortality in patients with malignant obstructive jaundice: a
multivariate discriminant analysis.

Han XC, Li JL, Han G.

Department of Surgery, Second Hospital, Jilin University, Changchun 130041,
China. hanchun601@sohu.com

OBJECTIVE: To estimate the operative mortality in patients with malignant
obstructive jaundice. METHODS: Twelve risk factors were analyzed using
multivariate discriminant analysis in 90 patients who had been operated on.
RESULTS: Operative mortality was significantly related to the following factors: 
age, duration of jaundice, packed RBC volume, white blood cell count and
concentration of blood urine nitrogen; it was not significantly related to
diseases and types of operation. The following formula was obtained: packed RBC
volume x 0.09954-age x 0.04018- blood urine nitrogen x 0.23693-duration of
jaundice x 2.07388-WBC count x 0.21118+ 5.26593. With this formula, an operative 
mortality of 77.8% was predicted. CONCLUSION: With a positive value from the
formula, the patient should be operated on; otherwise non-operative treatment is 
advocated.

PMID: 14599955 [PubMed - indexed for MEDLINE]

397: Hepatobiliary Pancreat Dis Int. 2003 Aug;2(3):426-30.

Effects of different drainage procedures on levels of serum endotoxin and tumor
necrosis factor in patients with malignant obstructive jaundice.

Yang YJ, Shi JS, Xie SM, Zhang DT, Cui BS.

Lab of Hepatobiliary Surgery, First Hospital, Xi'an Jiaotong University, Xi'an
710061, China. dryyj@sina.com

OBJECTIVE: To assess the influence of different drainage procedures on the levels
of serum endotoxin and tumor necrosis factor (TNF) in patients with malignant
obstructive jaundice (MOJ). METHODS: The levels of endotoxin and TNF in 46
patients with MOJ were measured before and after cholangiojejunostomy (CJ) or
external bile drainage (EBD). RESULTS: In the CJ group, the levels of
postoperative serum endotoxin and TNF 10 days after operation were significantly 
lower than those before operation (P<0.01). In the EBD group, no significant
changes were observed in endotoxin and TNF levels before and after operation
(P>0.05). No significant differences were seen between the two groups before
operation (P>0.05), but the levels of endotoxin and TNF in the CJ group were
significantly lower than those in the EBD group after operation (P<0.01).
CONCLUSIONS: Cholangiojejunostomy other than external bile drainage can decrease 
the levels of serum endotoxin and TNF effectively, although both of them are able
to release jaundice. Cholangiojejunostomy should be performed as soon as possible
for patients with unresectable malignant tumor.

Publication Types: 
    Clinical Trial
    Comparative Study

PMID: 14599953 [PubMed - indexed for MEDLINE]

398: Am J Surg. 2003 Nov;186(5):420-5.

The effect of preoperative biliary stenting on postoperative complications after 
pancreaticoduodenectomy.

Hodul P, Creech S, Pickleman J, Aranha GV.

Divisions of Surgical Oncology, Surgical Service Hines VA Hospital, Hines, IL,
USA.

BACKGROUND: Preoperative biliary drainage (PBD) in jaundiced patients undergoing 
pancreaticoduodenectomy remains controversial. METHODS: Patients presenting with 
obstructive jaundice who subsequently underwent pancreaticoduodenectomy from
January 1996 to June 2002 were included in the study (n = 212). Patients with
preoperative biliary stents (n = 154) were compared with patients without
preoperative drainage (n = 58). RESULTS: Patients in the stented group required a
longer operative time (mean 6.8 hours versus 6.5 hours) and had greater
intraoperative blood loss (mean 1207 mL versus 1122 mL) compared with the
unstented group, (P = 0.046 and 0.018). No differences were found with respect to
operative mortality (2%), incidence of pancreatic fistula (10% versus 14%), or
intraabdominal abscess (7% versus 5%). Wound infection occurred more often in the
stented group (8% versus 0%, P = 0.039). CONCLUSIONS: PBD was associated with
increased operative time, intraoperative blood loss, and incidence of wound
infection. Although PBD did not increase major postoperative morbidity and
mortality, it should be used selectively in patients undergoing
pancreaticoduodenectomy.

PMID: 14599600 [PubMed - indexed for MEDLINE]

399: Clin Exp Med. 2003 Sep;3(2):124-8.

Endotoxinemia in the portal and the systemic circulation in obstructive jaundice.

Papakostas C, Bezirtzoglou E, Pitiakoudis M, Polychronidis A, Simopoulos C.

Department of Experimental Surgery, University of Thrace, Medical School,
Alexandroupolis, Greece.

Endotoxinemia in patients with obstructive jaundice is linked to acute renal
failure and sepsis and remains a major cause of complications during
postoperative treatment. The current study examines the mechanisms of
endotoxinemia in the portal and the systemic circulation in obstructive jaundice.
As an experimental model of the disease we used rabbits subjected to sham
operation. Serum total bilirubin aminotransferases and endotoxin concentrations
were determined at 2, 5, 8, and 13 days after operation. Endotoxin concentrations
were estimated by the limulus lysate endotoxin test. A high frequency of portal
or systemic endotoxinemia is observed in obstructive jaundice, but no difference 
between endotoxinemia levels in the portal and systemic circulation was observed.

PMID: 14598188 [PubMed - indexed for MEDLINE]

400: J Pediatr Surg. 2003 Oct;38(10):1471-9.

The spectrum of surgical jaundice in infancy.

Davenport M, Betalli P, D'Antiga L, Cheeseman P, Mieli-Vergani G, Howard ER.

Department of Paediatric Surgery, Kings College Hospital, Denmark Hill, London,
England, UK.

BACKGROUND: Conjugated jaundice arising during infancy may be caused by a number 
of different surgical conditions. The aim of this study was to compare clinical
features, management, and outcome of all types of surgical jaundice presenting in
the first year of life. METHODS: A retrospective review was conducted of all
infants born in the United Kingdom with jaundice caused by a surgical cause
referred to the authors' institution from January 1992 to December 1999. RESULTS:
There were 171 infants who could be separated into 3 specific groups: biliary
atresia (BA, n = 137), inspissated bile syndrome (IBS; n = 14), and choledochal
malformation (CM; n = 12) together with a group containing various miscellaneous 
conditions (n = 8). Infants with BA had higher bilirubin (P <.01) and aspartate
aminotransferase levels (P <.001) and came to surgery earlier (P <.01) than
infants with either IBS or CM. Infants with IBS and CM were more likely to be
premature and have other malformations, respectively. Ultrasound scan was the
principal investigation in the differentiation of BA from other causes of
jaundice. Accurate prelaparotomy diagnosis was made by percutaneous liver biopsy 
in 87% of cases later shown to be BA. Currently, 88 (64%) of children with BA are
alive with their native liver postportoenterostomy, 4 have died, and 45 have
undergone liver transplantation (with 1 death postoperatively). A policy of
primary portoenterostomy for BA followed by transplantation, if necessary,
resulted in a survival rate of over 95%. All children in the other diagnostic
groups are alive and anicteric after appropriate surgical intervention.
CONCLUSIONS: Approximately 80% of infants presenting with surgical jaundice have 
biliary atresia, whereas those with inspissated bile syndrome and choledochal
malformations make up most of the remainder. Mortality in this age-group is
confined to infants with BA, but even on these infants an overall survival rate
of greater than 95% is currently expected.

PMID: 14577070 [PubMed - indexed for MEDLINE]

401: J Surg Res. 2003 Nov;115(1):18-23.

Role of bile in intestinal barrier function and its inhibitory effect on
bacterial translocation in obstructive jaundice in rats.

Ogata Y, Nishi M, Nakayama H, Kuwahara T, Ohnishi Y, Tashiro S.

Department of Digestive Surgery, Graduate School of Medicine, University of
Tokushima, Tokushima, Japan.

BACKGROUND: Our previous study using genetically labeled Escherichia coli strain 
JNW14 revealed that obstructive jaundice promotes bacterial translocation in rats
and that the absence of bile in the intestinal tract is considered to be a factor
inducing bacterial translocation. The aim of this study was to investigate the
role of bile and bile acids in intestinal barrier function against bacterial
translocation. MATERIALS AND METHODS: Eight-week-old male specific-pathogen-free 
Wistar rats were subjected to ligation of their common bile ducts (CBDL). The
CBDL rats were treated with bacitracin, neomycin sulfate, and streptomycin
sulfate, and the intestinal tract was colonized with E. coli strain JNW14, which 
was genetically labeled with resistant markers against the above three
antibiotics, to monitor the bacterial translocation. The rats were then
administered saline, cholic acid (20 mg/100 g BW), taurocholic acid (TCA: 5-50
mg/100 BW), or bile (1.5-6 mL/day) via a duodenal catheter. The degree of
bacterial translocation of E. coli strain JNW14 to the mesenteric lymph nodes was
compared. Histopathological examination of the terminal ileum and intestinal
permeability test using phenolsulfonphthalein was also performed. RESULTS: Both
cholic acid and TCA showed no inhibitory effect on bacterial translocation at any
of the doses tested in CBDL rats, although TCA significantly decreased the
numbers of E. coli strain JNW14 in the cecum. However, bile administration
reduced the numbers of E. coli strain JNW14 in the cecum and mesenteric lymph
nodes in CBDL rats although the inhibitory effect was weak. The integrity and
permeability of the intestinal mucosa were kept at normal levels by bile
administration in CBDL rats whereas the morphological changes, such as villous
atrophy, villous edema, and lacteal canal dilatation, were observed in other CBDL
rats. CONCLUSION: Bile plays an important role in maintaining the intestinal
barrier function to prevent the invasion of enteric bacteria to the underlying
tissues, suggesting that the intestinal administration of bile to patients with
obstructive jaundice is a useful way to reduce infectious complications by
inhibiting bacterial translocation from the intestine to other organs.

Publication Types: 
    Research Support, Non-U.S. Gov't

PMID: 14572768 [PubMed - indexed for MEDLINE]

402: Hepatogastroenterology. 2003 Sep-Oct;50(53):1542-6.

Short and long-term effects of bacterial translocation due to obstructive
jaundice on liver damage.

Sakrak O, Akpinar M, Bedirli A, Akyurek N, Aritas Y.

Department of General Surgery, University of Erciyes, School of Medicine, 38039, 
Kayseri, Turkey.

BACKGROUND/AIMS: The present study was conducted to determine if obstructive
jaundice promotes bacterial translocation and to evaluate the changes in hepatic 
histopathology in patients with benign biliary obstruction. METHODOLOGY: Between 
January 1996 and January 1998, 19 patients treated for benign biliary obstruction
were studied. Fourteen patients with symptomatic cholelithiasis were taken as the
control group. Patient characteristics, preoperative and post-operative
laboratory tests with an interval of 7 days were recorded. In all patients, bile 
and mesenteric lymph nodes samples were taken for bacterial growth and
histopathologic changes were studied on the liver excised during surgery.
RESULTS: In the control group, bacterial growth was observed in the bile and
mesenteric lymph nodes cultures in one (7.1%) and two patients (14.3%),
respectively. In the study group, 8 patients (42%) had positive bile cultures and
12 patients (63.2%) had positive mesenteric lymph nodes cultures, respectively.
Histopathologic examination of the liver revealed significant increase in the
rate of periductal and portal fibrosis in the jaundiced patients, compared with
control group (p < 0.001). Postoperative complications in the study group were
wound infection (3 cases), renal failure (2 cases), ARDS (1 cases) and
intraabdominal abscess (1 cases). In the control group, one patient had wound
infection and one had atelectasis. Two patients with jaundice died of multiple
organ failure and respiratory failure. In long-term follow-up (mean 17 months),
when sclerosing cholangitis and secondary biliary cirrhosis developed in one
patient each in the study group, no long-term complication occurred in the
control group. CONCLUSIONS: Our clinical results demonstrate that extrahepatic
biliary obstruction promotes bacterial translocation and this process is an
important cause of morbidity and mortality in patients with jaundice. Also,
obstructive jaundice subsequently leads to significant functional and
morphological damage in the liver.

PMID: 14571782 [PubMed - indexed for MEDLINE]

403: Hepatogastroenterology. 2003 Sep-Oct;50(53):1250-4.

Mucin-producing carcinoma of the cystic duct that caused obstructive jaundice.

Nemoto A, Goshima H, Yoshimine S, Higashiguchi T, Takagi K, Fujii K, Kato H.

Department of Surgery, Owase General Hospital, 5-25 Ueno-cho, Owase, Mie,
519-3693, Japan. ows23111@quartz.ocn.ne.jp

We report a very rare case of what appeared to be mucin-producing carcinoma of
the cystic duct, and this is the forth case recorded in the English-language and 
Japanese literature. The patient was a 67-year-old man with a chief complaint of 
dark urine and jaundice. Cholangiography via an endoscopic nasobiliary drain
showed dilatation of the common hepatic duct to 14 mm, with no visualization of
the cystic duct or gallbladder, and an approximately 15-mm filling defect was
observed at the junction of the common bile duct and the cystic duct. Based on
these findings a diagnosis of cancer of the middle portion of the bile duct was
made. Cholecystectomy and resection of the bile duct with dissection of regional 
lymph Nodes and choledochoduodenostomy were performed. About a 1-cm mass was
palpable in the region of the cystic duct, and the gallbladder contained mucin
some of which reached the common bile duct. Histological examination revealed
well-differentiated ductal adenocarcinoma infiltrating the serosa, in which mucus
production was observed. The patient was discharged on postoperative day 50. At
the present time, 38 months postoperatively, there are no signs of recurrence,
and he is attending the outpatient clinical in good health.

Publication Types: 
    Case Reports

PMID: 14571711 [PubMed - indexed for MEDLINE]

404: Med J Malaysia. 2002 Mar;57(1):92-6.

Jaundice clearance and cholangitis in the first year following portoenterostomy
for biliary atresia.

Selvalingam S, Mahmud MN, Thambidorai CR, Zakaria Z, Mohan N, Isa, Sheila M.

Department of Surgery, Hospital University Kebangsaan Malaysia, Jalan Tenteram
Cheras, 56000, Kuala Lumpur.

Sixty-one patients with biliary atresia, who underwent portoenterostomy (PE)
between 1992 to 1998 in the Institute of Pediatrics, Kuala Lumpur and were
followed for a period of one year, were studied to analyze the factors associated
with jaundice clearance and cholangitis following PE. Sex distribution was equal.
Majority of patients were Malays. Mean age in days at admission to the surgical
ward was 66.90 +/- 23.36 and mean age at PE was 75.85 +/- 24.05. At the end of
one-year follow-up, six patients (10%) had died, 35 (57%) developed one or more
attacks of cholangitis, 35 (57%) had portal hypertension, eight (13%) liver
failure and six patients had esophageal variceal bleeding. Thirty-three patients 
(54%) had jaundice clearance with a mean clearance time of 85 days after PE. The 
study shows that when the ductules in the porta hepatis were < 150 mu in size,
persistence of jaundice after PE and the incidence of cholangitis in the first
post-operative year were higher; patients with cholangitis in the first year had 
lower rate of jaundice clearance. Jaundice clearance was achieved in more
patients when their postnatal age at the time of PE was lower but the
relationship was not linear. Age at PE also did not have a linear temporal
relationship to the incidence of cholangitis and the size of portal ductules.
Prospective, multi-center based local studies on a bigger patient population are 
needed to identify other indicators of successful outcome following PE. This
would help to define the indications for primary liver transplantation in the
local population.

PMID: 14569724 [PubMed - indexed for MEDLINE]

405: World J Gastroenterol. 2003 Oct;9(10):2374-6.

Effects of glycine on plasma and liver tissue changes of TNF-alpha, ET-1 and
nitric oxide contents in rats with obstructive jaundice.

Fang HQ, Liu YB, Li HJ, Peng SY, Wu YL, Xu B, Wang JW, Li JT, Wang XB.

Department of General Surgery, Second Affiliated Hospital, Medical College of
Zhejiang University, Hangzhou 310009, Zhejiang Province, China.

AIM: To evaluate the effect of glycine on plasma and liver tissue changes of
tumor necrosis factor-alpha (TNF-alpha), endothelin-1 (ET-1) and nitric oxide
(NO) contents in rats with obstructive jaundice. METHODS: Ninety healthy Wistar
rats of both sexes weighing 275+/-25 g were randomly divided into sham-operated, 
bile duct-ligated, and bile duct-ligated plus glycine-treated groups, the latter 
was performed with 5% glycine solution substituting for tap water drunk ad libium
for 5 days before and 6 days after operation. Blood and liver tissue were sampled
at the time of sacrifice on the 8th day post operation. Plasma total bilirubin,
endotoxin, levels, as well as TNF-alpha, ET-1 and NO contents in liver tissue
were determined. RESULTS: Plasma endotoxin and total bilirubin levels were
significantly higher in both bile duct-ligated and bile duct-ligated plus
glycine-treated rats than in sham-operated animals (P=0.000613, 0.00921 and
0.00737, 0.00841 respectively), whereas they did not display any statistically
significant difference between the former groups (P=0.417 and 0.374
respectively). Likewise, TNF-alpha, ET-1 and NO contents in both plasma and liver
tissue were significantly increased in both bile duct-ligated and bile
duct-ligated plus glycine-treated rats compared with sham-operated
animals(P=0.00813, 0.00793, 0.00671, 0.00804, 0.00872, and 0.00947 in plasma and 
0.00531, 0.00785, 0.00912, 0.00981 and 0.00635 in liver tissue respectively).
However, these inflammatory mediators in both plasma and liver tissue were
significantly reduced in bile duct-ligated rats fed on 5% glycine solution
compared with that without (P=0.00953, 0.00891, 0.0795, 0.00867, 0.0697 and
0.00907 in plasma and liver tissue respectively). CONCLUSION: Reduction of
TNF-alpha, ET-1 and NO contents in plasma and liver tissue of rats fed on glycine
may be helpful to alleviate pathological lesions in obstructive jaundice.

PMID: 14562417 [PubMed - indexed for MEDLINE]

406: Br J Cancer. 2003 Oct 20;89(8):1403-4.

Imatinib administration in two patients with liver metastases from GIST and
severe jaundice.

De Pas T, Danesi R, Catania C, Curigliano G, De Braud F; Italia Sarcoma Group.

Department of Medical Oncology, European Institute of Oncology, Via Ripamonti,
435, Milano 20141, Italy. tommaso.de-pas@ieo.it

Imatinib is the only effective and approved systemic therapy for the treatment of
patients with advanced gastrointestinal stromal tumours (GISTs). Although
metastases from GISTs most commonly involve the liver, yielding
hyperbilirubinaemia, very few data on imatinib administration in subjects with
jaundice are available. We provide evidence that imatinib tolerability was not
adversely affected by jaundice in two patients with advanced GIST.

Publication Types: 
    Case Reports

PMID: 14562006 [PubMed - indexed for MEDLINE]

407: Endocr Pract. 2003 Jul-Aug;9(4):307-9.

Metformin-induced cholestatic hepatitis.

Nammour FE, Fayad NF, Peikin SR.

Department of Medicine, Division of Gastroenterology, Cooper Hospital, University
Medical Center, and Robert Wood Johnson Medical School, Camden, New Jersey 08103,
USA.

OBJECTIVE: To report a case of metformin-induced cholestatic hepatitis. METHODS: 
We present a detailed case report, including laboratory and biopsy findings. In
addition, similar cases from the literature are reviewed. RESULTS: In a
68-year-old man with newly diagnosed diabetes mellitus, metformin therapy was
begun. The dosage initially was 500 mg twice daily and later was increased to 850
mg twice a day. Four weeks after met-formin treatment was initiated, jaundice,
pruritus, and liver enzyme abnormalities were noted. The patient underwent an
extensive work-up, including a hepatitis screen, ultrasonography, magnetic
resonance imaging, and endoscopic retrograde cholangiopancreatography, all of
which showed normal findings. A liver biopsy revealed severe cholestasis and mild
portal inflammation. Treatment with metformin was discontinued, and the liver
enzymes normalized except for a persistently increased level of alkaline
phosphatase, most likely related to a prolonged cholestatic effect of metformin. 
CONCLUSION: Although rare, metformin can be responsible for inducing liver
damage, and patients and physicians should be aware of this side effect.

Publication Types: 
    Case Reports

PMID: 14561576 [PubMed - indexed for MEDLINE]

408: JSLS. 2003 Jul-Sep;7(3):277-9.

Jaundice due to extrabiliary gallstones.

Stevens S, Rivas H, Cacchione RN, O'Rourke NA, Allen JW.

Department of Surgery, University of Louisville School of Medicine, Louisville,
Kentucky 40292, USA.

OBJECTIVE: Cholecystectomy is one of the most common general surgical procedures 
performed today. The laparoscopic approach is beneficial to patients in terms of 
length of stay, postoperative pain, return to work, and cosmesis. Some drawbacks 
are associated with the minimal access form of cholecystectomy, including an
increased incidence of common bile duct injuries. In addition, when the
gallbladder is inadvertently perforated during laparoscopic cholecystectomy,
retrieval of dropped gallstones may be difficult. We present a case in which
gallstones spilled during cholecystectomy, causing near circumferential,
extraluminal common hepatic duct compression, and clinical jaundice 1 year later.
METHODS: The patient experienced jaundice and pruritus 12 months after
laparoscopic cholecystectomy. A computed tomographic scan was interpreted as
cholelithiasis, but otherwise was normal (despite a previous cholecystectomy).
Endoscopic retrograde cholangiopancreatography was performed and a stent placed
across a stenotic common hepatic duct. RESULTS: The results of brush biopsies
were negative. The stent rapidly occluded and surgical intervention was
undertaken. At exploratory laparotomy, an abscess cavity containing multiple
gallstones was encountered. This abscess had encircled the common hepatic duct,
causing compression and fibrosis. The stones were extracted and a
hepaticojejunostomy was tailored. The patient's bilirubin level slowly decreased 
and she recovered without complication. CONCLUSIONS: Gallstones lost within the
peritoneal cavity usually have no adverse sequela. Recently, however, numerous
reports have surfaced describing untoward events. This case is certainly one to
be included on the list. A surgeon should make every attempt to retrieve spilled 
gallstones due to the potential later complications described herein.

Publication Types: 
    Case Reports

PMID: 14558721 [PubMed - indexed for MEDLINE]

409: Hong Kong Med J. 2003 Oct;9(5):377-80.

Comment in:
    Hong Kong Med J. 2004 Feb;10(1):72.

Cholestatic jaundice caused by sequential carbimazole and propylthiouracil
treatment for thyrotoxicosis.

Chan AO, Ng IO, Lam CM, Shek TW, Lai CL.

Department of Medicine, The University of Hong Kong, Queen Mary Hospital,
Pokfulam Road, Hong Kong, ROC. aoochan@hkusua.hku.hk

A 36-year-old Chinese man presented to the Queen Mary Hospital in August 1999
with a 2-week history of jaundice due to propylthiouracil treatment for
thyrotoxicosis. He had previously received carbimazole but had developed an
urticarial skin rash after 2 weeks of treatment. The patient developed liver
failure and fulminant pneumonitis shortly after hospital admission. Despite
receiving treatment with broad-spectrum antibiotics and intravenous
immunoglobulin, he died 11 days after the onset of the respiratory symptoms.
Postmortem examination using electron microscopy showed typical glycogen bodies
within the cytoplasm of the hepatocytes, which corresponded to eosinophilic
cytoplasmic inclusion bodies visible under light microscopy. Immunohistochemical 
studies of the inclusion bodies were positive for carcinoembryonic antigen and
albumin, and negative for fibrinogen, complement protein C3, immunoglobulins G,
M, and A, alpha-fetoprotein, and alpha-1-antitrypsin. This is the first report of
a patient who received two sequential antithyroid drugs and developed predominate
cholestasis with unique histological features. Extreme caution should be taken
when a patient develops allergy to one type of antithyroid drug, because
cross-reactivity may develop to the other type.

Publication Types: 
    Case Reports

PMID: 14530534 [PubMed - indexed for MEDLINE]

410: Acta Chir Belg. 2003 Aug;103(4):392-5.

The effects of dimethylsulfoxide in experimental obstructive jaundice.

Kucuk C, Ok E, Yilmaz Z, Sozuer E, Muhtaroglu S, Arar M.

Department of Surgery, Erciyes University School of Medicine, Kayseri, Turkey.
cankucuk@erciyes.edu.tr

MATERIAL AND METHODS: Thirty rats were divided into three groups, as sham,
control and DMSO groups. Laparatomy was performed on each animal in the control
and DMSO groups and common bile ducts were ligated. Common bile duct was observed
but was not ligated for the rats in the sham group. Saline solution injection
(1.5 mg/kg/intraperitoneally (i.p.)) was begun on the first day of surgical
procedure and repeated once a day for the next 5 days. The same procedure was
performed with DMSO (1.5 mg/kg/i.p.) instead of saline in the DMSO group. The
rats were sacrificed on the postoperative seventh day, at which time venous blood
and liver tissue specimens were taken. MAIN OUTCOME MEASUREMENTS: On the 7th
postoperative day, the bilirubin, AST, ALT, ALP and GGT levels of the control and
DMSO groups were significantly higher in comparison with the sham group (p <
0.01). On the 7th postoperative day, the erythrocyte superoxide dismutase (SOD)
and glutathione peroxidase (GSH-Px) levels of the control and DMSO groups were
significantly lower than those of the sham group (p < 0.01), but there was no
statistical difference between the two groups (p > 0.05). Erythrocyte and liver
malondialdehyde (MDA) levels in the control and DMSO groups were significantly
higher compared with the sham group (p < 0.01). However, the MDA levels were
significantly lower in the DMSO group compared to the control group (p < 0.01).
CONCLUSION: It is stated that free oxygen radicals seem to play a role in the
liver tissue injury, secondary to obstructive jaundice. In our experimental
study, exogenic DMSO seems to have decreased lipid peroxidation and to have
improved some of the parameters of liver tissue injury due to the obstructive
jaundice in rats.

PMID: 14524158 [PubMed - indexed for MEDLINE]

411: Surg Today. 2003;33(10):781-4.

Papillomatosis confined to the distal biliary tract--a rare cause of obstructive 
jaundice: report of a case.

Sotiropoulos GC, Lang H, Nadalin S, Holtmann G, Dirsch O, Broelsch CE.

Department of General Surgery and Transplantation, University Hospital Essen,
Hufelandstrasse 55, D-45122 Essen, Germany.

Based on the findings of a patient with recurrent obstructive jaundice due to
papillomatosis of the distal bile duct, we herein describe the diagnostic
difficulties and therapeutic options in this very rare disease. Endoscopic
retrograde cholangiopancreatography and, in particular, cholangioscopy are the
imaging procedures of choice if biliary papillomatosis is suspected. Due to the
tendency of such patients to demonstrate malignant transformation and develop
biliary cirrhosis with septic complications, an early and radical surgical
resection is recommended in rare cases of localized papillomatosis. This approach
may offer the only chance of a cure although the potential risk of multifocal
recurrence cannot be ruled out. When considering a radical resection,
intraoperative cholangioscopy is strongly recommended to confirm any localized
papillomatosis and rule out any diffuse papillomatosis of the entire biliary
tract.

Publication Types: 
    Case Reports
    Research Support, Non-U.S. Gov't

PMID: 14513330 [PubMed - indexed for MEDLINE]

412: Clin Chim Acta. 2003 Oct;336(1-2):123-8.

The effect of endoscopic retrograde cholangiopancreatography on the serum IL-18
and erythrocytes antioxidative capacity in biliary obstructive jaundice.

El-Sayed IH, El kady IM, Badra GA.

Molecular Biology Department, Genetic Engineering and Biotechnology Institute,
Menofiya University, Sadat City, P.O. Box 22857-79, Egypt.
ibrahimelsayed@yahoo.com

INTRODUCTION: Obstructive jaundice is an important clinical problem. It may cause
transient hemolysis and shortened erythrocyte life span as well as cytokine
induction. An increase in lipid peroxidation has been noted as evidence of
oxidative damage in red cells due to cholestasis. The influence of endoscopic
retrograde cholangiopancreatography (ERCP), mechanical lithotrepsy and stone
extraction on the antioxidative capacity of the erythrocyte and immune response
is still unclear. METHODS: Superoxide dismutase (SOD), catalase (CAT) and
glutathione (GSH) content of red blood cells (RBC), and serum interleukin (IL-18)
were measured in 20 patients with calcular obstructive jaundice before and 4
weeks after ERCP intervention and compared with 10 matched healthy volunteers.
RESULTS: A significant decrease (p<0.05) in SOD and CAT activities and
glutathione concentration but a significant increase (p<0.05) in serum IL-18 were
observed in cholestatic patients compared with the healthy control and were
significantly correlated with variable of hepatic dysfunction (alanine
aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin,
alkaline phosphatase (ALP) and gamma glutamyl transferase (GGT). After ERCP,
serum IL-18 and antioxidant capacity of red blood cells were significantly
improved and returned to normal concentration (p<0.05). CONCLUSIONS: In biliary
obstruction, serum IL-18 is increased and antioxidative capacity is decreased,
and have a direct correlation with biochemical markers of liver injury. After
ERCP intervention, the altered antioxidative capacity as well as serum IL-18 was 
completely restored to normal.

PMID: 14500044 [PubMed - indexed for MEDLINE]

413: Surg Endosc. 2003 Oct;17(10):1573-8. Epub 2003 Jul 11.

Laparoscopic treatment for Mirizzi syndrome.

Yeh CN, Jan YY, Chen MF.

Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5,
Fu-Hsing Street, Kwei-Shan, Taoyuan, Taiwan.

BACKGROUND: Mirizzi syndrome is an uncommon complication of longstanding
gallstone disease resulting in obstructive jaundice and remains surgically
challenging. Mirizzi syndrome is generally considered a contraindication to
laparoscopic surgery. We present the surgical experience of 11 consecutive
patients with Mirizzi syndrome who were diagnosed correctly preoperatively and
treated laparoscopically. METHODS: From January 1991 to December 2001, 4,560
patients underwent laparoscopic cholecystectomy for gallbladder lesions, 11
(0.24%) of whom were diagnosed with Mirizzi syndrome. RESULTS: The 11 patients
diagnosed with Mirizzi syndrome included four men and seven women, with ages
ranging from 21 to 72 years (median, 54). There were 10 patients with Mirizzi
syndrome type I (one was caused by gallbladder cancer in the neck), and 1 patient
with type II, according to McSherry's classification. Right upper quadrant
abdominal pain was the most common symptom, occurring in all 11 patients. All 11 
patients were diagnosed correctly preoperatively by endoscopic retrograde
cholangiography (ERCP) with 100% sensitivity. Four of the 11 patients (36.4%)
were converted to open procedure. The postoperative course was uneventful, except
for one patient complicated with a residual common bile duct stone. Hospital stay
ranged from 4 to 33 days (median, 7). CONCLUSIONS: Mirizzi syndrome is an
uncommon disorder. Preoperative suspicion is crucial for correct preoperative
diagnosis. ERCP is the most useful tool for correct preoperative diagnosis and
consequent prevention of common bile duct injury during operation. Should Mirizzi
syndrome be diagnosed, laparoscopic treatment is a feasible and safe procedure,
especially for type I Mirizzi syndrome.

PMID: 12964062 [PubMed - indexed for MEDLINE]

414: Minerva Chir. 2003 Jun;58(3):395-7.

Severe obstructive jaundice in a 90-year-old man caused by an annular pancreas.
Report of a case.

Adamo M, Bonventre S, Tavormina A, Vetri G, Di Gesù G.

Unit of Surgical Physiopathology and Endocrine Surgery, Department of Surgery,
Division of General and Specialistic Surgery, University of Palermo, Palermo,
Italy.

Although the annular pancreas is a rare congenital malformation of the pancreatic
glandular parenchyma, this pathology often remains asymptomatic until the adult
or old age and can represent an incidental finding during an ERCP or an abdominal
Computed Tomography, because the clinical appearance of this condition can be of 
very various kinds. We present a case of an extra-hepatic jaundice in a
90-year-old man, caused by an annular pancreas constricting coledochus.
Description of this case results very interesting and particular for two reasons:
the very old age of the patient, probably the oldest recorded, and the unusual
clinical appearance: obstructive jaundice as beginning one symptom of this
malformation.

Publication Types: 
    Case Reports

PMID: 12955063 [PubMed - indexed for MEDLINE]

415: Scand J Infect Dis. 2003;35(6-7):401-3.

Infectious aetiology of jaundice among pregnant women in Angola.

Strand RT, Franque-Ranque M, Bergström S, Weiland O.

Division of International Health (IHCAR), Department of Public Health Sciences,
Karolinska Institutet, Stockholm, Sweden. rolandstrand@swipnet.se

The contribution of viral hepatitis, human immunodeficiency virus (HIV) infection
and malaria to jaundice among pregnant women in Luanda, Angola, was studied. 20
pregnant women with jaundice (cases) were identified in 2 large maternity
hospitals and compared with 40 pregnant women without jaundice (controls). Among 
the cases 6 patients died, whereas no death occurred in the control group (p <
0.001). Five spontaneous abortions and 6 stillbirths were also noted among the
cases, implying foetal loss in 55% and stillbirth in 30%. One stillbirth was
registered among control women. Of the cases 40% had anti-hepatitis E virus
antibodies compared with 13% of the controls (p = 0.02). Plasmodium falciparum
parasitaemia occurred in 47.5% and 5% of cases and controls, respectively (p <
0.001). There was no difference in the prevalence of antibodies against hepatitis
C or HIV among cases and controls. The carriership of hepatitis B surface antigen
was 10% in both groups. In conclusion, jaundice during pregnancy is often
associated with maternal mortality in Luanda, women suffering from jaundice
during pregnancy have an extremely high case fatality rate, and P. falciparum and
hepatitis E are associated with jaundice in the setting studied.

PMID: 12953953 [PubMed - indexed for MEDLINE]

416: Endoscopy. 2003 Aug;35(8):698-700.

Inflammatory pseudotumor of the common bile duct.

Sobesky R, Chollet JM, Prat F, Karkouche B, Pelletier G, Fritsch J, Choury AD,
Allonier C, Bedossa P, Buffet C.

Dept. of Hepatogastroenterology, Bicêtre Hospital, Paris, France.
rsobesky@club-internet.fr

An exceptional cause of obstructive jaundice is reported in the present case. A
51-year-old woman progressively developed jaundice with pruritus, and abdominal
ultrasonography revealed dilated intra- and extrahepatic bile ducts. Endoscopic
retrograde cholangiography and endoscopic ultrasonography showed a tumor in the
distal common bile duct, but failed to determine the nature of the lesion, and
the patient underwent a pancreaticoduodenectomy. The final diagnosis was an
inflammatory pseudotumor of the common bile duct. Inflammatory pseudotumors are
uncommon, without evident pathogenesis, and are described in many organs. The
localization in the common bile duct is exceptional. The prognosis is good, and a
more conservative approach is possible if the diagnosis is certain before
surgery.

Publication Types: 
    Case Reports

PMID: 12929069 [PubMed - indexed for MEDLINE]

417: Endoscopy. 2003 Aug;35(8):695-7.

Schwannoma of the common bile duct: a rare cause of obstructive jaundice.

Jakobs R, Albert J, Schilling D, Nuesse T, Riemann JF.

Department of Medicine C, Academic Hospital of the University of Mainz,
Ludwigshafen, Germany. jakobsr@klilu.de

The endoscopic diagnosis of bile duct lesions has improved over recent years
through the introduction of cholangioscopy and intraductal ultrasound. Combining 
this with biopsies examined using routinely administered immunohistochemical
markers, the diagnosis of tumors of the extrahepatic bile duct can be improved
substantially. We report a rare case of a schwannoma of the bile duct causing
obstructive jaundice.

Publication Types: 
    Case Reports

PMID: 12929068 [PubMed - indexed for MEDLINE]

418: World J Surg. 2003 Oct;27(10):1161-4. Epub 2003 Aug 18.

Comment in:
    World J Surg. 2005 Jul;29(7):935-6.

Obstructive jaundice alters proliferating cell nuclear antigen expression in rat 
small intestine.

Sheen-Chen SM, Ho HT, Chen WJ, Eng HL.

Department of Surgery, Chang Gung Memorial Hospital, Kaohsiung College of
Medicine, Chang Gung University, 123, Ta-Pei Road, Niao-Sung Hsiang, Kaohsiung
Hsien, Taiwan. smsheen@yahoo.com

Translocation of bacteria and endotoxin has long been documented in obstructive
jaundice, and altered intestinal barrier function is considered to be one of the 
important mechanisms for this phenomenon. Proliferating cell nuclear antigen
(PCNA), also known as cyclin, is an auxiliary protein of DNA polymerase-delta,
and the level of synthesis correlates directly with rates of cellular
proliferation and DNA synthesis. This study was designed with the aim of
evaluating the effect of obstructive jaundice on PCNA expression in small bowel
epithelium. Male Sprague-Dawley rats were randomized to four groups. Group A (n =
10, control group) underwent a sham operation. Group B (n = 9, obstructive
jaundice group for 1 week) underwent common bile duct ligation. Group C (n = 8,
obstructive jaundice group for 2 weeks) underwent common bile duct ligation.
Group D (n = 8, obstructive jaundice group for 2 weeks) underwent common bile
duct ligation with oral glutamine intake. After periods of 7 days and 2 weeks,
segments of small bowel were harvested from groups A & B and groups C & D,
respectively. Nuclear immunohistochemical expression of PCNA in small bowel was
evaluated. The PCNA-labeling index [(PCNA-positive cells/500 cells) x 100] was
quantified. Comparisons among the four groups were performed. The PCNA-labeling
index in small bowel of group B was significantly higher than that of group A
(29.0% vs 21.2%, p = 0.001). After 2 weeks of common bile duct ligation, the
PCNA-labeling index in small bowel of group C was significantly lower than that
of group A (19.4% vs 21.2%, p = 0.045). With oral glutamine intake daily, the
PCNA-labeling index in small bowel of Group D was restored and was significantly 
higher than that of group A (24.5% vs 21.2%, p = 0.002). Obstructive jaundice for
1 week upgraded PCNA expression in rat small intestine. PCNA expression in rat
small intestine later became depressed after obstructive jaundice for 2 weeks.
Oral glutamine intake daily could effectively restore the PCNA expression in
small bowel of rats subjected to obstructive jaundice for 2 weeks.

PMID: 12917765 [PubMed - indexed for MEDLINE]

419: Gastrointest Endosc. 2003 Aug;58(2):220-5.

ERCP in patients 90 years of age and older.

Rodríguez-González FJ, Naranjo-Rodríguez A, Mata-Tapia I, Chicano-Gallardo M,
Puente-Gutierrez JJ, López-Vallejos P, Hervás-Molina AJ, de Dios-Vega JF.

Gastroenterology Department, Hospital Reina Sofía, Córdoba, Spain.

BACKGROUND: Biliary diseases represent particular diagnostic and therapeutic
problems in elderly patients. METHODS: Patients 90 years of age or older who
underwent ERCP from January 1993 to September 2001 were studied retrospectively. 
RESULTS: A total of 126 patients underwent 147 ERCP procedures (range 1-5 per
patient). Twelve additional ERCPs were performed in 9 of the patients during
follow-up because of recurrent symptoms. A total of 159 procedures were,
therefore, available for analysis. The most frequent indications were suspicion
of bile duct stones (46.8%) and obstructive jaundice (35.7%). Midazolam (95.6%)
was used for conscious sedation and hyoscine (74.8%) for duodenal ileus. Patient 
tolerance of the procedure was good in 92.4% of sessions. Diagnoses included bile
duct stones (54%), bile duct dilatation without any apparent obstruction (11.9%),
and malignant stenosis (9.5%). Therapeutic procedures were indicated in 95.6% of 
diagnosed patients and completed in 96.3% of cases. Complications occurred in
association with 2.5% of the ERCP procedures; the procedure-related mortality
rate was 0.7%. CONCLUSIONS: ERCP in elderly patients is practicable. The
complication rate is low, and therapeutic efficacy is good.

PMID: 12872089 [PubMed - indexed for MEDLINE]

420: Inflamm Res. 2003 Jun;52(7):305-10.

Bovine lactoferrin decreases histopathological changes in the liver and regulates
cytokine production by splenocytes of obstructive jaundiced rats.

Zimecki M, Dawiskiba J, Zawirska B, Krawczyk Z, Kruzel M.

Institute of Immunology and Experimental Therapy of Polish Academy of Sciences,
R. Weigla 12, 53-114 Wrocław, Poland. zimecki@immuno.iitd.pan.wroc.pl

OBJECTIVE AND DESIGN: The aim of this study was to evaluate effects of bovine
lactoferrin (BLF) on histopathological changes in the liver of 14 day obstructive
jaundiced (OJ) rats and production of tumor necrosis factor (TNF-alpha) and
interleukin 6 (IL-6) by splenocytes from 7- and 14-day OJ rats. MATERIAL AND
SUBJECTS: In the study 50 male rats of the Buffalo strain (170-270 g, mean 230 g)
were used. TREATMENT: Rats were given 10 mg BLF in 0.5 ml saline daily, using a
stomach tube. BLF was applied 2 days before operation and for 13 days following
operation. METHODS: The specimens of liver were prepared using standard
techniques. Sections, 5 mm thick were stained with hematoxylin and eosin and
reviewed histologically. Microscopic estimation using semiquantitive 4-grade
scale was used for evaluation of liver changes. For cytokine measurement
splenocyte cultures were stimulated with 5 microg/ml lipopolysaccharide (LPS).
After overnight incubation the activities of TNFalpha and IL-6 were determined
using bioassays. For statistical evaluation of data the nonparametric
Mann-Whitney test was applied. RESULTS: In rats with 14-day OJ, treated with BLF,
the pathological changes in the liver were markedly reduced, in particular foci
of necrosis with disseminated lymphocytes, cellular necrobiosis, bile duct
proliferation and dilation. Neither proliferation of fibrous and reticular
connective tissue nor activation of Kupffer cells was revealed. In the 7-day OJ
rats treatment with BLF caused significant inhibition of both spontaneous (mean
253, median 275, vs mean 160, median 148 pg/ml, p=0.002) and LPS-induced
TNF-alpha production (mean 4967, median 4102, vs mean 2291, median 2234 pg/ ml, p
= 0.004) in the splenocyte cultures. The spontaneous (mean 120, median 81, vs
mean 43, median 26 pg/ml, p=0.005) as well as LPS-induced IL-6 production (mean
422, median 378, vs mean 293, median 230 pg/ml, p = 0.025) were also lowered. On 
the other hand, in 14-day OJ, BLF upregulated cytokine production, in particular 
spontaneous (mean 148, median 158, vs mean 338, median 196, p = 0.001) and
LPS-induced TNF-alpha (m ean 1331, median 1507, vs mean 2239, median 1707 pg/ml, 
p = 0.027). CONCLUSION: We conclude that oral administration of BLF is beneficial
in alleviating deleterious effects of OJ.

PMID: 12861396 [PubMed - indexed for MEDLINE]

421: Br J Surg. 2003 Jul;90(7):845-9.

Non-Hodgkin lymphoma presenting with obstructive jaundice.

Ravindra KV, Stringer MD, Prasad KR, Kinsey SE, Lodge JP.

Hepatobiliary Unit, St James's University Hospital, Leeds, UK.

BACKGROUND: Obstructive jaundice is a rare presenting feature of non-Hodgkin
lymphoma (NHL). Lymphomatous masses in the peripancreatic and hepatic hilar
regions are potentially difficult to diagnose. METHODS: A retrospective analysis 
was undertaken of patients presenting with obstructive jaundice secondary to NHL 
at a tertiary care hepatobiliary unit. RESULTS: Over a 7-year period, six adults 
and three children with NHL were managed. The site of the lymphomatous mass was
at the hepatic hilum in six patients and the peripancreatic area in three.
Diagnostic procedures included a laparotomy and biopsy in four patients, hepatic 
trisectionectomy in two, percutaneous biopsy in two and lymph node biopsy in one 
patient. Percutaneous biopsy confirmed the diagnosis in both the patients in whom
it was attempted. One patient died following liver resection. Chemotherapy was
the mainstay of treatment and achieved complete remission in four patients,
partial remission in three and no response in one patient. Two patients
subsequently required operation for a benign biliary stricture after achieving
complete remission. CONCLUSION: NHL must be considered in the differential
diagnosis of obstructive jaundice in adults and children. Attempts must be made
to diagnose the condition using non-operative techniques. Chemotherapy is the
mainstay of treatment. Late benign strictures of the bile duct requiring
operation may develop. Copyright 2003 British Journal of Surgery Society Ltd.
Published by John Wiley & Sons, Ltd.

PMID: 12854111 [PubMed - indexed for MEDLINE]

422: Dig Surg. 2003;20(4):329-31. Epub 2003 Jun 12.

Transhepatic placement of an enteral stent to treat jaundice in a tumor
recurrence obstructed afferent loop after a whipple procedure.

Johnsson E, Delle M, Lundell L, Liedman B.

Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.
eric.johnsson@vgregion.se

Tumour recurrence that obstructs the afferent limb, blocking outflow of bile and 
pancreatic juice, constitutes a major clinical problem after a Whipple procedure.
The endoscopic route is often not a possible alternative. Surgery may be
difficult and perhaps dangerous to the often very sick patient and decompression 
with fine bore catheters may lead to cholangitis. External drainage is
inconvenient to the patient. The present case describes a less invasive method to
provide adequate drainage of the obstructed jejunal limb by insertion of a 22-mm 
enteral Wallstent transhepatically. The patient became and stayed anicteric
during 7 months' follow-up. Copyright 2003 S. Karger AG, Basel

Publication Types: 
    Case Reports

PMID: 12806200 [PubMed - indexed for MEDLINE]

423: Pharmacol Res. 2003 Aug;48(2):139-49.

The effect of PARS inhibition on ileal histopathology, apoptosis and lipid
peroxidation in LPS-induced obstructive jaundice.

Dirlik M, Caglikulekci M, Cinel I, Cinel L, Tamer L, Pata C, Kanik A, Ocal K,
Ogetman Z, Aydin S.

Department of General Surgery, Faculty of Medicine, Mersin University Medical
School, Zeytinlibahçe Caddesi, Eski Otogar Yani 33079, Mersin, Turkey.
musa_dirlik@yahoo.com

In our experimental study, we investigated the protective effect of
3-aminobenzamide (3-AB), the poly (ADP-ribose) synthetase (PARS inhibitor), on
the ileal histopathology and the apoptosis in lipopolysaccharide (LPS)-induced
inflammation in rats with obstructive jaundice (OJ). We randomized 40 rats into
five groups. Group 1: sham group; Group 2: OJ group; Group 3: OJ+LPS; Group 4:
OJ+3-AB+LPS; Group 5: OJ+LPS+3-AB. At the fifth day; the rats were jaundiced. In 
Group 3; 10 mg kg(-1) LPS was injected intraperitoneally at the fifth day and
then after 6h the rats were sacrificed. In Group 4; 10 mg kg(-1) 3-AB was
administrated intraperitoneally at the fifth day and repeated daily for 3 days
and at the eighth day, 10 mg kg(-1) LPS was injected intraperitoneally. In Group 
5, 10 mg kg(-1) LPS was injected intraperitoneally at the fifth day and after 6h 
10 mg kg(-1) 3-AB was administrated intraperitoneally and repeated daily for 3
days. At the eighth day, rats were sacrificed. Blood samples were taken for
detection of serum MDA levels. Ileum samples were taken after relaparotomy for
histopathological examination to evaluate the endotoxin-related intestinal injury
and Caspase-3 apoptosis and for detection of tissue MDA and ATPase activities.
There was marked destruction of villous and crypt epithelial cells and extensive 
apoptosis in Groups 3 and 5 in histopathological examination. In Group 4, the
scores of intestinal mucosal damage and apoptotic cells were reduced
significantly (P<0.05). On the other hand, the scores of intestinal mucosal
damage and apoptotic cells were not improved in Group 5. After the administration
of 3-AB (Group 4), serum and ileal MDA levels decreased, ileal ATPase increased
as compared to Groups 1 and 2. Our study showed that 3-AB prevented the mucosal
damage and apoptotic loss of intestinal epithelial cells significantly if it was 
administrated before LPS. However, 3-AB failed to prevent the mucosal damage and 
apoptotic loss of intestinal epithelial cells significantly if there was
established endotoxemia in OJ.

PMID: 12798666 [PubMed - indexed for MEDLINE]

424: Dig Liver Dis. 2003 Feb;35(2):114-7.

A puzzling jaundice.

Pometta R, Fraquelli AC, Losco A, Conte D.

Postgraduate School of Gastroenterology, IRCCS Ospedale Maggiore, Milan, Italy.

In an adult beta-thalassaemic patient admitted on account of the sudden onset of 
nausea, vomiting and biliary pain, the concomitant jaundice was considered
"obstructive" on the basis of ultrasonographic evidence of cholecysto-choledocal 
stones. However, when the patient was re-evaluated it was found that concomitant 
Gilbert's disease, hepatitis C virus related cirrhosis and dilated cardiomyopathy
had a detrimental effect on clinical and laboratory findings.

Publication Types: 
    Case Reports
    Research Support, Non-U.S. Gov't

PMID: 12747630 [PubMed - indexed for MEDLINE]

425: West Afr J Med. 2002 Jul-Sep;21(3):215-7.

Serum hepatitis C virus and hepatitis B surface antigenaemia in Nigerian patients
with acute icteric hepatitis.

Ola SO, Otegbayo JA, Odaibo GN, Olaleye OD, Olubuyide OL.

Department of Medicine, College of Medicine, University College Hospital, Ibadan,
Nigeria.

Acute hepatitis is common in Nigeria and hepatitis B virus (HBV) infection has
been a major aetiological factor. However, the role of Hepatitis C Virus (HCV)
infection is yet undetermined. Forty-five consecutive Nigerian patients with
Acute Icteric hepatitis (AIH) attending the Medical Clinic of the University
College Hospital, Ibadan, Nigeria and 45 healthy adult Nigerians (controls) were 
studied for evidence of infection with both viruses. Questionnaire on risk
procedures which predispose to acquisition of both HBV and HCV infections were
administered to the patients. Blood samples were collected from all the subjects 
and tested for antibody to HCV (Anti-HCV) and Hepatitis B surface Antigen (HBsAg)
using the second generation Enzyme Linked Immunoassay (Monolisa -R, Sansofi,
Pasteur; France). Anti-HCV was detected in 21(47%) and 17(38%) of the patients
and controls respectively. The corresponding prevalences of HBsAg were 38(84%)
and 11(24%), p < 0.001. Hepatitis B virus infection was found to occur more than 
HCV infection in the patients with AIH but similar among the controls. Combined
HBV and HCV infection occurred more frequently among the patients (42.1%) than in
the control (11%) (; < 0.001). Although there was no significant difference in
the HCV infection between the two groups, isolated HCV infection is commoner in
the control than in the patients with AIH, (p < 0.001). Similarly, single HCV
infection is commoner than lone HBV infection among the control, p < 0.05. In
summary, this study shows that while both HBV and HCV infections are common in
Nigeria, AIH may be more associated with HBV than HCV in the country.

Publication Types: 
    Research Support, Non-U.S. Gov't

PMID: 12744571 [PubMed - indexed for MEDLINE]

426: Eur Surg Res. 2003 May-Jun;35(3):143-7.

Role of oxygen free radical scavengers in acute renal failure complicating
obstructive jaundice.

Kucuk C, Sozuer E, Ikizceli I, Avsarogullari L, Keceli M, Akgun H, Muhtaroglu S.

Department of Surgery, Faculty of Medicine, Erciyes University, Kayseri, Turkey. 
cankucuk@erciyes.edu.tr

Obstructive jaundice is associated with high morbidity and mortality. Major
complications such as pulmonary dysfunction, renal failure and sepsis are
frequently encountered. Recent studies and observations suggest that the free
oxygen radicals (FORs) produced in obstructive jaundice may play a significant
role in the etiopathogenesis of acute renal failure (ARF). Thirty rats were
divided into three groups, as sham, control and treatment groups containing 10
rats each. Laparatomy was performed on each animal in the control and treatment
groups and common bile ducts were ligated. Common bile duct was observed but was 
not ligated for the rats in the sham group. Saline solution injection was begun
on the first day of surgical procedure and repeated once a day during the
following 5 days. The same procedure was performed with oxygen radical scavenger 
dimethyl sulfoxide (1.5 mg/kg/day i.p.) instead of saline in the treatment group.
The rats were sacrificed on the 7th postoperative day. On the 7th postoperative
day, the bilirubin, urea and creatinine levels of the control and treatment
groups were significantly higher in comparison with the sham group (p < 0.01).
Although there was no statistically significant difference between the bilirubin 
levels of the control and treatment groups (p > 0.05), the urea and creatinine
levels in the treatment group were significantly lower (p < 0.01). On the 7th
postoperative day, the erythrocyte superoxide dismutase (SOD) and glutathione
peroxidase (GSH-Px) levels of the control and treatment groups were significantly
lower than those of the sham group (p < 0.01), whereas renal and erythrocyte
malondialdehyde (MDA) levels were significantly higher (p < 0.01). Although SOD
and GSH-Px levels did not differ significantly between the treatment and control 
groups (p > 0.05), renal and erythrocyte MDA levels of the treatment group were
significantly lower than those of the control group (p < 0.01). The
histopathological scores were significantly higher in the control and treatment
groups (p < 0.01); there was no significant difference between the control and
treatment groups (p > 0.05). FORs seem to play a significant role in the
etiopathogenesis of renal failure in obstructive jaundice. Antioxidant treatment 
may decrease oxidative damage due to FORs and may prevent renal failure.
Copyright 2003 S. Karger AG, Basel

PMID: 12740534 [PubMed - indexed for MEDLINE]

427: Clin Chem Lab Med. 2003 Mar;41(3):360-4.

The influence of hemolysis, turbidity and icterus on the measurements of CK-MB,
troponin I and myoglobin.

Kwon HJ, Seo EJ, Min KO.

Department of Clinical Pathology, College of Medicine, The Catholic University of
Korea, St. Paul's Hospital, Seoul, Korea.

To decide on the acceptability of a specimen for the measurement of serum CK-MB, 
troponin I and myoglobin, we investigated the influence of hemolysis, turbidity, 
and icterus on those tests by adding arbitrarily made interferents. A total of 16
cases each for CK-MB and troponin I, and 18 cases for myoglobin tests were
studied to verify the effects of hemolysis, turbidity, and unconjugated
hyperbilirubinemia. A total of 16 cases were studied to clarify the effects of
the conjugated hyperbilirubinemia. We graded the severity of hemolysis,
turbidity, and icterus as mild, moderate, and severe after adding hemolysate,
Intralipos (20% soybean oil), and unconjugated or conjugated bilirubin to sera.
ACS180SE automated chemiluminescence system was used to measure CK-MB, troponin
I, and myoglobin. CK-MB and troponin I were affected by any degree of hemolysis, 
turbidity, unconjugated hyperbilirubinemia, and conjugated hyperbilirubinemia,
while myoglobin was affected only by severe unconjugated hyperbilirubinemia and
conjugated hyperbilirubinemia in the samples with concentration higher than
reference range, resulting in concentration level lower than baseline. In
conclusion, the results of cardiac markers should be carefully interpreted when
the specimens are hemolyzed, turbid or icteric.

Publication Types: 
    Comparative Study
    Research Support, Non-U.S. Gov't

PMID: 12705347 [PubMed - indexed for MEDLINE]

428: Tohoku J Exp Med. 2003 Mar;199(3):193-6.

Transient relief of asthma symptoms during jaundice: a possible beneficial role
of bilirubin.

Ohrui T, Yasuda H, Yamaya M, Matsui T, Sasaki H.

Department of Geriatric and Respiratory Medicine, Tohoku University School of
Medicine, Sendai 980-8574, Japan.

Bilirubin arises from enzymatic reduction by biliverdin reductase of biliverdin, 
a product of heme oxygenase activity. Recent literature describes that bilirubin 
is a major physiologic antioxidant that can protect cells from chemical oxidants 
such as hydrogen peroxide. Recently, it has been reported that oxidative stress
may play a crucial role in the pathogenesis of asthma. We report a case of
complete resolution of persistent difficult-to-control asthma in accordance with 
increased levels of serum bilirubin due to acute hepatitis B. The present case
suggests that anti-oxidative agents might be effective for the treatment of
asthma.

Publication Types: 
    Case Reports

PMID: 12703664 [PubMed - indexed for MEDLINE]

429: Anticancer Drugs. 2003 Apr;14(4):327-9.

Cholestatic jaundice and pseudomembranous colitis following combination therapy
with doxorubicin and docetaxel.

Sundar S, Chan SY.

Department of Oncology, Leicester Royal Infirmary, Leicester, UK.
sundar@oncology.org

We report a case of cholestatic jaundice and pseudomembranous colitis (PMC)
following combination therapy with docetaxel and doxorubicin. This clinical
syndrome has not been previously reported with this combination. In particular,
this is the first report of non-Clostridium difficile-associated PMC with
docetaxel-based chemotherapy. Docetaxel is principally metabolized by the hepatic
cytochrome p450 mixed-function oxidases, in particular by the isoform CYP3A. This
patient was on long-term erythromycin prophylaxis following splenectomy.
Erythromycin is a known inhibitor of CYP3A. We postulate that erythromycin
probably contributed to the observed clinical syndrome. Clinicians should be
aware of potential drug interactions, when unusual toxicities occur with novel
combinations of chemotherapeutic agents.

Publication Types: 
    Case Reports

PMID: 12679738 [PubMed - indexed for MEDLINE]

430: Hepatology. 2003 Apr;37(4):887-92.

A randomized controlled trial of ursodeoxycholic acid in patients with
alcohol-induced cirrhosis and jaundice.

Pelletier G, Roulot D, Davion T, Masliah C, Causse X, Oberti F, Raabe JJ, Van
Lemmens C, Labadie H, Serfaty L; URSOMAF Group.

Department of Gastroenterology of Hôpital Bicêtre, Assistance Publique-Hôopitaux 
de Paris, Paris, France.

The aim of our multicenter study was to assess the efficacy of ursodeoxycholic
acid (UDCA) on the survival of patients with alcohol-induced cirrhosis and
jaundice. We included patients with histologically proven alcohol-induced
cirrhosis and serum bilirubin >50 micromol/L. After randomization, patients
received either UDCA (13-15 mg/kg/d) or a placebo for 6 months. Two hundred
twenty-six patients (113 in each group) were included in 24 centers. There were
139 men and 87 women, mean age of 50.3 years. Seventy-four percent had associated
alcohol-induced hepatitis, and 24% received a corticosteroid therapy. At
inclusion, the 2 groups were comparable for the main clinical and biologic
parameters, but serum bilirubin was higher in the UDCA group than in the placebo 
group (163 micromol/L vs. 145 micromol/L, P <.03). The percentage of patients
lost at follow-up or who resumed their alcoholism during the study was comparable
in the 2 groups. During the study, 55 patients died, 35 in the UDCA group and 20 
in the placebo group. In the intention to treat analysis, the probability of
survival at 6 months (Kaplan-Meier method) was lower in the UDCA than in the P
group (69% vs. 82%, respectively; P =.04, log-rank test). After adjustment on the
bilirubin level at entry (Cox model), the independent predictive value of the
treatment group did not reach the statistical level (RR = 1.64, CI 0.85-2.85; P
=.077). In conclusion, UDCA administered at the dose recommended in primary
biliary cirrhosis has no beneficial effect on the 6-month survival of patients
with severe alcohol-induced cirrhosis. An inappropriate dosage of UDCA cannot be 
excluded as an explanation for the lack of therapeutic benefit.

Publication Types: 
    Clinical Trial
    Multicenter Study
    Randomized Controlled Trial
    Research Support, Non-U.S. Gov't

PMID: 12668982 [PubMed - indexed for MEDLINE]

431: J Huazhong Univ Sci Technolog Med Sci. 2002;22(3):237-40.

The endoscopic retrograde cholangiopancreatographic manifestations of
histopathologically diagnosed hepatocellular carcinoma with obstructive jaundice.

Zhao Q, Gong B, Lu N, Liu N.

Department of Gastroenterology, Tongji Hospital, Tongji Medical College, Huazhong
University of Science and Technology, Wuhan 430030.

To study the manifestations of endoscopic retrograde cholangiopancreatography
(ERCP) in patients of obstructive jaundice associated with HCC, 32 cases of
histopathologically diagnosed HCC with obstructive jaundice were successfully
examined with routine ERCP. 31 patients were demonstrated by ERCP as having
malignant obstructive jaundice. Among them, 19 were hepatic perihilar bile duct
stricture, 7 bile ductile tumorous thrombus, 3 perihilar bile duct stricture
complicated with thrombus, 2 metastasis to hilar lymph node, and 1 common bile
duct stone as proven by sphincterotomy. The malignant perihilar stricture was all
of type III and IV by Bismuth standard of Klastin tumor. In patients identified
as having bile duct tumor thrombus, by the Ueda classification, none was of type 
I and II; 1 type III a; 4 III b; 2 type IV. HCC with obstructive jaundice was
mainly caused by the malignant infiltration of tumor, and most stricture was of
serious nature. When major extra-hepatic bile duct was involved by tumor
thrombus, obstructive jaundice might develop. Malignant perihilar stricture and
tumor thrombus might coexist in some patients. Jaundice was rarely caused by
hepatic hilar lymph node metastasis. Jaundice was not necessarily caused by
tumors and sometimes, it might be caused by common bile stones. Care should be
exercised in differentiation diagnosis in such patients.

PMID: 12658815 [PubMed - indexed for MEDLINE]

432: Scand J Gastroenterol. 2003 Jan;38(1):102-8.

Comment in:
    Scand J Gastroenterol. 2003 Mar;38(3):233-4.

Aetiology and prognostic implication of severe jaundice in surgical trauma
patients.

Labori KJ, Bjørnbeth BA, Raeder MG.

Dept. of Gastroenterological Surgery, Ullevaal University Hospital, Oslo, Norway.

BACKGROUND: Pronounced postoperative jaundice occurs not infrequently in trauma
patients. The aim of this study was to elucidate the implication of early,
pronounced jaundice (serum-bilirubin >100 micromol x l(-1)) for 30-day survival
of such patients. METHODS: From 1995 through 2001, 53 surgical trauma patients
developing pronounced postoperative jaundice were identified. Nine were excluded 
from the study because of major hepatobiliary injury or pre-existing liver
disease. The clinical course and laboratory chemistry profiles of the remaining
44 patients were analysed. RESULTS: Thirty-one patients survived and 13 died
within 30 days of trauma. Non-survivors had higher age, higher injury severity
score (ISS) and lower probability of survival (PS) (P < 0.05) than survivors. ISS
averaged 34 in survivors and 45 in non-survivors. Survivors and non-survivors
received a mean of 46 (range 10-97) and 55 units of blood (range 11-128),
respectively (P = 0.366). Systemic hypotension, local infections and sepsis were 
common in both groups. Bilirubin levels peaked around the 11th day in survivors
(median 189 micromol x l(-1)). In non-survivors, serum bilirubin values rose
progressively, reaching maximum levels at time of death (median 231 micromol x
l(-1)). These patients died in a setting of sepsis and multiple organ failure.
CONCLUSION: Large endogenous production of bilirubin because of rapid breakdown
of transfused and extravasated blood can cause pronounced jaundice in
multitransfused trauma patients. In such patients, serum bilirubin rising >100
micromol x l(-1) does not by itself signal poor outcome. However, progressive
pronounced jaundice outlasting the trauma incident by 10-12 days portends fatal
outcome for the patient.

Publication Types: 
    Comparative Study

PMID: 12608472 [PubMed - indexed for MEDLINE]

433: Scand J Gastroenterol. 2003 Jan;38(1):86-94.

Severe jaundice in Sweden in the new millennium: causes, investigations,
treatment and prognosis.

Björnsson E, Ismael S, Nejdet S, Kilander A.

Dept. of Internal Medicine, Section of Gastroenterology and Hepatology,
Sahlgrenska University Hospital, Gothenburg, Sweden. einar.bjornsson@medic.gu.se

BACKGROUND: The aims of the study were to assess the causes of jaundice in
Gothenburg, Sweden, to study the types of investigations applied in cholestatic
and hepatocellular types of jaundice and treatment and to evaluate the prognosis 
of these patients up to a year from the diagnosis. METHODS: Over a 3-month
period, all adult patients with bilirubin > 100 micromol/l were identified by the
clinical chemistry laboratory serving all three hospitals in Gothenburg. Relevant
clinical information was obtained from medical records. Follow-up was performed
9-12 months later. RESULTS: A total of 173 patients were identified; 40% were
under surgical care while 38% were in the care of internists. The most common
cause of jaundice was malignancy in 58 patients, liver metastases in 20,
cholangiocarcinoma in 16, pancreatic cancer in 13, cancer of papilla Vateri in 2 
and primary liver cancer in 7. Alcoholic liver disease was the second most common
cause, found in 29 patients, followed by bile duct stones (28 patients). Only 3% 
had viral hepatitis. Ultrasound and/or CT were performed in 95% of those with
cholestasis and ultrasound had been performed in 75% of those with hepatocellular
type and CT in almost 50%. Thirty-two patients were operated on, 27 patients were
treated endoscopically and 17 patients required liver transplantation. Total
mortality was 51% and in malignancy 82%. CONCLUSION: Malignancy and alcoholic
liver disease are the most common causes of severe jaundice, whereas viral
hepatitis is a rare cause. Many patients are under surgical care, probably due to
historical reasons as surgery is rarely indicated.

Publication Types: 
    Research Support, Non-U.S. Gov't

PMID: 12608470 [PubMed - indexed for MEDLINE]

434: J Pediatr Surg. 2003 Feb;38(2):256-8.

Obstructive jaundice caused by primary choledochal hydatid cyst mimicking
radiologically choledochal cyst.

Otgün I, Karnak I, Haliloglu M, Senocak ME.

Department of Pediatric Surgery, Hacettepe University Faculty of Medicine,
Ankara, Turkey.

A 12-year-old girl with obstructive jaundice that was initially misinterpreted
radiologically as having choledochal cyst is presented. A primary hydatid cyst in
the wall of the common bile duct causing obstruction was found at operation. The 
authors emphasize that hydatid cyst should be included in the list of
differential diagnoses of obstructive jaundice and cystic lesions located around 
the biliopancreatic junction in children. Copyright 2003, Elsevier Science (USA).
All rights reserved.

Publication Types: 
    Case Reports

PMID: 12596118 [PubMed - indexed for MEDLINE]

435: Am J Med. 2003 Feb 1;114(2):153-5.

Cases from the Osler Medical Service at Johns Hopkins University.

Grow RW, Zaas A.

A 37-year-old woman presented with increasing abdominal pain and jaundice. Six
weeks before admission, she developed persistent diarrhea and jaundice of the
skin. She also bruised easily, and her gums bled. In the subsequent weeks, her
appetite decreased, she was fatigued, and she had nausea, vomiting, and abdominal
distension. She had a history of drinking 1 quart of vodka every day for 20
years, with brief periods of abstinence; she stopped consuming alcohol 11 days
before admission because it no longer provided symptomatic relief. Her past
medical history was also notable for depression, including a suicide attempt 4
years earlier. She did not smoke, use illicit drugs, or have unprotected sexual
intercourse. She had received no blood transfusions and had not traveled
recently. She took no medications, except for occasional ibuprofen.On physical
examination, she was thin and deeply jaundiced, and she trembled and responded
slowly to questions. She was afebrile but tachypneic, and she had orthostatic
hypotension. Her HEENT examination was notable for scleral and sublingual
icterus, as well as crusted blood on her gums and teeth. The jugular veins were
flat. The cardiac examination revealed tachycardia (heart rate, 103 beats per
minute) without murmurs, rubs, or gallops. The abdomen was nontender and
protuberant, with hypoactive bowel sounds; the spleen was not palpable, and there
was no fluid wave or caput medusae. The liver percussed to 18 cm, with a smooth
edge extending 10 cm below the costal margin. She had cutaneous telangiectases on
her chest and bilateral palmar erythema. There was no peripheral edema. The
neurologic examination was notable for asterixis. Her stool was guaiac positive. 
Laboratory studies revealed the following values: hematocrit, 21.2%; white blood 
cells, 17,310/mm(3); ammonia, 42 micromol/L; serum creatinine, 3.9 mg/dL; serum
urea nitrogen, 70 mg/dL; albumin, 2.1 g/dL; total bilirubin, 26.8 mg/dL; alanine 
aminotransferase, 14 U/L; aspartate aminotransferase, 77 U/L; alkaline
phosphatase, 138 U/L; prothrombin time, 103 seconds (international normalized
ratio, 10.6); and urinary sodium, <5 mg/dL. Urinalysis revealed an elevated
specific gravity and numerous muddy granular casts. Hepatitis A, B, and C
serologies were negative. On abdominal ultrasound examination, there was no
ascites, and the liver was echogenic. The portal and hepatic veins were patent,
and the hepatic arteries were normal. The spleen measured 14 cm.What is the
diagnosis?

Publication Types: 
    Case Reports

PMID: 12586238 [PubMed - indexed for MEDLINE]

436: Indian Pediatr. 2002 Dec;39(12):1138-42.

Laparoscopy in diagnosis of prolonged neonatal jaundice.

Shah AA, Sitapara AM, Shah AV.

Department of Pediatric Surgery, V.S. Hospital Ahmedabad, India.

When managing neonatal jaundice, there is no single test or imaging modality that
can reliably define biliary atresia and neonatal hepatitis. Early diagnosis is an
important step for surgical success in extra hepatic biliary atresia. In many
situations, exploratory laparotomy and operative cholangiography may be needed to
settle the definitive diagnosis, with the risk of having negative exploration in 
those high risk patients with medical etiology. The use of laparoscopy may help
in avoiding unnecessary exploration for such group of patients and arriving at a 
definite diagnosis. Six patients with conjugated hyperbilirubinemia were
evaluated with a diagnostic laparoscopy, laparoscopic cholangiography and liver
biopsy. Three of the six patients were diagnosed to have neonatal hepatitis and
so an unnecessary laparotomy was avoided in these cases.

PMID: 12522276 [PubMed - indexed for MEDLINE]

437: Clin Liver Dis. 2002 Nov;6(4):1067-84.

Postoperative jaundice and total parenteral nutrition-associated hepatic
dysfunction.

Chung C, Buchman AL.

Division of Gastroenterology and Hepatology, Northwestern University Medical
School, 676 North St. Clair Street, Suite 880, Chicago, IL 60611, USA.

Postoperative jaundice and TPN-induced hepatic abnormalities represent clinical
situations that stem from multiple and frequently overlapping insults to the
liver. The pattern of LFT abnormalities and appropriate imaging studies provide
clues to the diagnosis. Greater insight into the molecular basis of cholestasis
has shed light on the possible common pathways for the hepatic derangements that 
are seen in diverse situations. TPN-related hepatic dysfunction most likely
involves a combination of nutritional deficiencies, hormonal imbalances,
excessive calories, and possibly bacterial overgrowth in the small bowel. Growing
clinical evidence points to a high incidence of severe liver disease in chronic
TPN-dependent patients. Careful monitoring of patients is warranted in these
circumstances and combined transplantation of the liver and small bowel may be
the only possibility for long-term survival for such patients with progressive
liver disease.

Publication Types: 
    Review

PMID: 12516207 [PubMed - indexed for MEDLINE]

438: Arch Pediatr Adolesc Med. 2002 Dec;156(12):1244-50.

Jaundice noted in the first 24 hours after birth in a managed care organization.

Newman TB, Liljestrand P, Escobar GJ.

Department of Epidemiology and Biostatistics, The University of California, San
Francisco, Campus Box 0560, San Francisco, CA 94143, USA. newman@epi.ucsf.edu

OBJECTIVE: To investigate the significance of jaundice noted in the first 24
hours after birth in a community setting. DESIGN: Supplementary analyses of a
nested case-control study. SETTING: Northern California Kaiser Permanente Medical
Care Program. PATIENTS: Six hundred thirty-one randomly selected newborns
(controls) and 140 cases with total serum bilirubin levels of 25 mg/dL (428 micro
mol/L) or higher from a cohort of 105 384 newborns of at least 2000 g birth
weight and at least 36 weeks' gestational age, born between January 1, 1995, and 
December 31, 1998. MAIN OUTCOME MEASURES: Notations of jaundice in the medical
record, timing and results of bilirubin testing, use of phototherapy, and
development of bilirubin levels of 25 mg/dL or higher. RESULTS: Among the
controls, the cumulative probability of a notation of jaundice (corrected for
early hospital discharge using survival analysis) was 2.8% within 18 hours and
6.7% within 24 hours. In these newborns, cumulative proportions that had
bilirubin levels measured were 38% within 12 hours and 43% within 24 hours of
when jaundice was first noted. About 40% of bilirubin levels measured within 24
hours were above the estimated 95th percentile for age. Compared with newborns
not noted to be jaundiced on the first day, newborns noted to be jaundiced within
24 hours were more likely to receive phototherapy (18.9% vs 1.7%; relative risk, 
10.1; 95% confidence interval, 4.2-24.4) and to develop a bilirubin level of 25
mg/dL or higher (odds ratio, 2.9; 95% confidence interval, 1.6-5.2), but the
absolute risk increase for total serum bilirubin levels of 25 mg/dL or higher was
0.2%. CONCLUSION: Jaundice noted in the medical record in the first 24 hours
after birth was uncommon and often clinically significant in this setting, but
other factors also need to be considered in determining its importance.

PMID: 12444838 [PubMed - indexed for MEDLINE]

439: Am Fam Physician. 2002 Nov 1;66(9):1685-92.

Common issues in the care of sick neonates.

Hashim MJ, Guillet R.

University of Rochester School of Medicine and Dentistry, Rochester, New York,
USA. mjhashim@yahoo.com

Newborn infants may be transferred to a special care nursery because of
conditions such as prematurity (gestation less than 37 weeks), prolonged
resuscitation, respiratory distress, cyanosis, and jaundice, and for evaluation
of neonatal sepsis. Newborn infants' core temperature should be kept above 36.4
degrees C (97.5 degrees F). Nutritional requirements are usually 100 to 120 kcal 
per kg per day to achieve an average weight gain of 150 to 200 g (5 to 7 oz) per 
week. Standard infant formulas containing 20 kcal per mL and maternal breast milk
may be inadequate for premature infants, who require special formulas or
fortifiers that provide a higher calorie content (up to 24 kcal per mL).
Intravenous fluids should be given when infants are not being fed enterally, such
as those with tachypnea greater than 60 breaths per minute. Hypoglycemia can be
asymptomatic in large-for-gestational-age infants and infants of mothers who have
diabetes. A hyperoxia test can be used to differentiate between pulmonary and
cardiac causes of hypoxemia. The potential for neonatal sepsis increases with the
presence of risk factors such as prolonged rupture of membranes and maternal
colonization with group B streptococcus. Jaundice, especially on the first day of
life, should be evaluated and treated. If the infant does not progressively
improve in the special care nursery, transfer to a tertiary care unit may be
necessary.

Publication Types: 
    Review

PMID: 12449267 [PubMed - indexed for MEDLINE]

440: J Viral Hepat. 2002 Nov;9(6):424-8.

The role of lamivudine and predictors of mortality in severe flare-up of chronic 
hepatitis B with jaundice.

Chan HL, Tsang SW, Hui Y, Leung NW, Chan FK, Sung JJ.

Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese
University of Hong Kong, Shatin, Hong Kong. hlychan@hotmail.com

Patients with chronic hepatitis B (CHB) may develop severe disease exacerbations 
(flare) with jaundice, and some may progress to fulminant hepatic failure.
Whether early administration of lamivudine can prevent liver failure and
mortality is uncertain. We investigated the role of lamivudine treatment in
severe hepatitis B virus (HBV) exacerbations. Consecutive patients presented with
severe flare-up of HBV (new onset of jaundice plus alanine aminotransferase
greater than five times upper limit of normal) treated with lamivudine and
historical controls who did not receive lamivudine were studied. All patients had
no hepatic encephalopathy on admission. Univariate analysis and multivariate
logistic regression were performed on various clinical and laboratory factors for
the prediction of mortality. Twenty-eight patients treated with lamivudine and 18
controls were identified. Overall, nine patients died and two other received
liver transplants for fulminant hepatic failure. Six of 28 (21.4%)
lamivudine-treated patients vs five of 18 (27.8%) controls died or received a
liver transplant (P = 0.62). On multivariate analysis, platelet < or = 143 x
10E9/L (odds ratio 22.4, 95% CI 1.8-281.6) and bilirubin > 172 micromol/L (odds
ratio 18.4, 95% CI 1.5-228.5) were independent predictors of liver-related
mortality. The mortality of patients who had thrombocytopenia and high bilirubin,
thrombocytopenia, high bilirubin, and no risk factor were 69.2%, 11.1%, 12.5% and
0% respectively. Hence lamivudine confers no survival benefit to conventional
treatment in severe exacerbations of CHB. Patients with thrombocytopenia and high
bilirubin should be considered for liver transplantation.

Publication Types: 
    Clinical Trial

PMID: 12431204 [PubMed - indexed for MEDLINE]

441: J Indian Med Assoc. 2002 May;100(5):312-4.

Jaundice in falciparum malaria--some prospective observations.

Mazumder R, Mishra RK, Mazumder H, Mukherjee P.

Department of Medicine, Medical College, Kolkata.

The present prospective study of slide positive Plasmodium falciparum patients
revealed a higher (17%) incidence of jaundice. This is much higher than reported 
earlier. Serum transaminases were raised by two to three times the normal value. 
Histologically the most conspicuous finding was reticulo-endothelial cell
proliferation in the liver along with mononuclear cell infiltration. Malarial
parasites were not found in the biopsy specimens. Mortality was high especially
amongst the late presenters. In areas endemic for malaria, awareness of this
entity is important. In a patient with fever and jaundice with or without altered
sensorium, disproportionate hyperbilirubinaemia but with only mild elevation of
liver enzymes could help differentiate these cases from viral hepatitis. The
diagnosis can be confirmed by peripheral blood examination, done if required. As 
the mortality in late presenters is high, early diagnosis in such cases with
institution of specific therapy may be life saving.

PMID: 12418632 [PubMed - indexed for MEDLINE]

442: Bratisl Lek Listy. 2002;103(4-5):174-5.

Current palliative treatment of malignant jaundice.

Hutan M, Salapa M, Poticny V, Bandzak J.

Department of Surgery, Faculty of Medicine, Comenius University, Hospital
Ruzinov, Bratislava, Slovakia. bll@fmed.uniba.sk

When selecting the most suitable palliation of malignant jaundice, the following 
factors are to be considered: 1) patient's overall condition, 2) presumption of
patient's survival, 3) technical, personal, and economic factors, 4)
effectiveness of procedure, 5) morbidity and mortality of palliative treatment.
(Tab. 2, Ref. 3.).

PMID: 12413207 [PubMed - indexed for MEDLINE]

443: J Pediatr Surg. 2002 Nov;37(11):1568-73.

Choledochal cysts: age of presentation, symptoms, and late complications related 
to Todani's classification.

de Vries JS, de Vries S, Aronson DC, Bosman DK, Rauws EA, Bosma A, Heij HA, Gouma
DJ, van Gulik TM.

Department of Surgery, Academic Medical Center and Vrije Universiteit Medical
Center, Amsterdam, The Netherlands.

PURPOSE: The aim of this study was to compare presentation, complications,
diagnosis, and treatment of choledochal cysts in pediatric and adult patients.
METHODS: Forty-two patients were analyzed after subdivision into 3 groups: group 
A, less than 2 years (n = 10); group B, 2 to 16 years (n = 11); group C, greater 
than 16 years (n = 21). RESULTS: The cysts were classified as extrahepatic (n =
33), intrahepatic (n = 5), and combined (n = 4). Seventy-six percent of patients 
presented with abdominal pain, (20 of 21 group C), and 57% with jaundice, (10 of 
10 group A). Cholangiocarcinoma occurred in 6 patients, 4 of whom had previously 
undergone internal drainage procedures. Excision of the extrahepatic cyst was
performed in 27 of 37 patients. Five patients, of whom, 4 had cholangiocarcinoma,
were beyond curative treatment at the time of diagnosis. Six patients had died at
the closure of this study, 5 of them had carcinoma. CONCLUSIONS: Presenting
symptoms are age dependent with jaundice prevailing in children and abdominal
pain in adults. In view of the high risk of cholangiocarcinoma, early resection
and not internal drainage is the appropriate treatment of extrahepatic cysts.
Patients who had undergone internal drainage in the past still should undergo
resection of the cyst. Copyright 2002, Elsevier Science (USA). All rights
reserved.

Publication Types: 
    Comparative Study

PMID: 12407541 [PubMed - indexed for MEDLINE]

444: Am J Gastroenterol. 2002 Oct;97(10):2629-33.

Genotype B hepatitis B virus is associated with severe icteric flare-up of
chronic hepatitis B virus infection in Hong Kong.

Chan HL, Tsang SW, Wong ML, Tse CH, Leung NW, Chan FK, Sung JJ.

OBJECTIVE: We aimed to investigate the association of viral genotype and the
development of icteric flare-up (IF) in chronic hepatitis B virus (HBV)
infection. METHODS: Twenty-one consecutive patients suffering from IF of chronic 
HBV infection, defined as elevation of ALT over five times the upper limit of
normal, together with either bilirubin > 50 IU/L or elevated bilirubin plus PT > 
3 s prolonged, were studied. Patients from three stages of HBV-related chronic
liver disease were studied as controls: 1) asymptomatic carriers (31 patients),
defined as persistent normal ALT for at least 2 yr; 2) active early cirrhosis (49
patients), defined as Child's A liver cirrhosis plus HBV DNA > 106 Eq/ml; and 3) 
decompensated cirrhosis (31 patients), defined as Child's B or C liver cirrhosis 
with complications. Restriction fragment length polymorphism was used for
genotyping. RESULTS: Only genotype B and C HBV were identified in our studied
cohort. Ninety-one percent of patients suffering from IF were infected by
genotype B HBV (p < 0.001 vs asymptomatic carriers, early cirrhosis patients, and
decompensated cirrhosis patients). On the contrary, genotype C HBV was the
predominant strain at different stages of chronic liver disease; no statistical
difference was found on the relative prevalence of genotype B/C HBV among
asymptomatic carriers, early cirrhosis patients, and decompensated cirrhosis
patients. CONCLUSIONS: Genotype B HBV is associated with IF among chronic
HBV-infected patients in Hong Kong, whereas genotype C HBV is more prevalent at
all stages of chronic liver disease. Our findings suggested that the two
different HBV genotypes might have different pathogenic mechanisms of liver
damage.

Publication Types: 
    Research Support, Non-U.S. Gov't

PMID: 12385451 [PubMed - indexed for MEDLINE]

445: J Med Virol. 2002 Dec;68(4):620-7.

Outbreak of jaundice and hemorrhagic fever in the Southeast of Brazil in 2001:
detection and molecular characterization of yellow fever virus.

de Filippis AM, Nogueira RM, Schatzmayr HG, Tavares DS, Jabor AV, Diniz SC,
Oliveira JC, Moreira E, Miagostovich MP, Costa EV, Galler R.

Laboratório de Flavivírus, Departamento de Virologia, Instituto Oswaldo Cruz,
Fiocruz, RJ, Brasil. ambispo@gene.dbbm.fiocruz.br

Between January and March 2001, an outbreak of jaundice and hemorrhagic fever
occurred in the state of Minas Gerais, Southeast region of Brazil, in which a
mortality rate of 53% was reported. Seroconversion, virus isolation,
histopathological and immunohistochemical findings, and reverse
transcription-polymerase chain reaction (RT-PCR) identified yellow fever virus
(YFV) as the etiological agent responsible for the outbreak. Partial nucleotide
sequence analysis from a fragment of the YFV genome spanning parts of
nonstructural (NS) 5 gene and 3' noncoding region (3' UTR) showed that the YFV
involved in this outbreak belongs to South American genotype I and differs from
the Brazilian virus identified in 1996. Copyright 2002 Wiley-Liss, Inc.

Publication Types: 
    Research Support, Non-U.S. Gov't

PMID: 12376973 [PubMed - indexed for MEDLINE]

446: Hear Res. 2002 Nov;173(1-2):82-90.

Immunohistochemical localization of calcium-binding proteins in the brainstem
vestibular nuclei of the jaundiced Gunn rat.

Shaia WT, Shapiro SM, Heller AJ, Galiani DL, Sismanis A, Spencer RF.

Department of Otolaryngology - Head and Neck Surgery, School of Medicine, Medical
College of Virginia Campus, Virginia Commonwealth University Health System,
Richmond 23298-0599, USA.

Vestibular gaze and postural abnormalities are major sequelae of neonatal
hyperbilirubinemia. The sites and cellular effects of bilirubin toxicity in the
brainstem vestibular pathway are not easily detected. Since altered intracellular
calcium homeostasis may play a role in neuronal cell death, we hypothesized that 
altered expression of calcium-binding proteins may occur in brainstem vestibular 
nuclei of the classic animal model of bilirubin neurotoxicity. The expression of 
the calcium-binding proteins calbindin-D28k and parvalbumin in the brainstem
vestibular pathways and cerebellum of homozygous recessive jaundiced (jj) Gunn
rats was examined by light microscopy and immunohistochemistry at 18 days
postnatally and compared to the findings obtained from age-matched non-jaundiced 
heterozygous (Nj) littermate controls. Jaundiced animals exhibited decreased
parvalbumin immunoreactivity specifically in synaptic inputs to superior, medial,
and inferior vestibular nuclei, and to oculomotor and trochlear nuclei, whereas
the neurons retained their normal immunoreactivity. Jaundiced animals also
demonstrated a decrease in calbindin expression in the lateral vestibular nuclei 
and a paucity of calbindin-immunoreactive synaptic endings on the somata of
Deiters' neurons. The involved regions are related to the control of the
vestibulo-ocular and vestibulospinal reflexes. Decreased expression of
calcium-binding proteins in brainstem vestibular neurons may relate to the
vestibulo-ocular and vestibulospinal dysfunction seen with clinical kernicterus, 
and may provide a sensitive new way to assess bilirubin toxicity in the
vestibular system.

Publication Types: 
    Research Support, U.S. Gov't, P.H.S.

PMID: 12372637 [PubMed - indexed for MEDLINE]

447: Rom J Gastroenterol. 2002 Sep;11(3):219-22.

Jaundice after Billroth II resection. A case report.

Culafić D, Kovacević N, Milićević M, Bulajić P.

Institute of Digestive Diseases, Medical Faculty, Belgrade, Yugoslavia.

Ultrasonography is the first line imaging investigation in patients with
jaundice, right upper quadrant pain, or hepatomegaly. Most patients with jaundice
have parenchymal or obstructive jaundice. A 56-year old man was admitted to the
Institute of Digestive Diseases, Belgrade, with severe pains in the epigastrium, 
vomiting, icteric coloration of sclera, white stools and dark urine. The symptoms
had developed 5 days after a Billroth II resection. The functional liver test
indicated a pronounced cholestasis. Real-time ultrasonography showed in the
projection of the pancreas head, a clear bordered unechogenic oval formation,
with a size of 40 x 35 mm. This finding indicated a possibility of an afferent
loop obstruction, accompanied by consecutive obstructive icterus due to
compression on the common bile duct. Ultrasonographic examination was followed by
surgical reintervention. With the development of noninvasive imaging,
transcutaneous ultrasonography, computed tomography and magnetic resonance
imaging, the diagnosis of pancreatic and other cysts in upper abdomen is usually 
straightforward. The important ultrasonographic characteristic of empty organs,
compared to cysts and pseudocyts, is a change in the morphology and size of
organs after a specific time interval. Air bubbles in the organs lumen are like
mobile reflectors, and they are an important sign in identifying segments of the 
gastrointestinal tract.

Publication Types: 
    Case Reports

PMID: 12368942 [PubMed - indexed for MEDLINE]

448: Biol Trace Elem Res. 2002 Sep;88(3):255-69.

Excessive hepatic copper accumulation in jaundiced rats fed a high-copper diet.

Yu S, van der Meer R, Beynen AC.

Department of Nutrition, Faculty of Veterinary Medicine, Utrecht University, The 
Netherlands.

The response of copper metabolism to dietary copper challenge was investigated in
jaundiced rats with elevated plasma concentrations of conjugated bilirubin as a
result of impaired canicular transport of bilirubin glucuronides. Control and
jaundiced rats were fed purified diets with either normal (64 micromol Cu/kg) or 
high (640 micromol Cu/kg) concentration of added copper. Copper loading produced 
a greater increase in hepatic copper concentrations in the jaundiced than in
control rats. The greater dietary-copper-induced increase in hepatic copper in
the jaundiced rats can be explained by the observed smaller rise in biliary
copper excretion and a greater efficiency of dietary copper absorption. In
individual rats, there was a positive relationship between hepatic copper
concentrations and biliary copper concentrations. It is suggested that not the
transport of copper from liver cells to bile but that from plasma to bile is
diminished in the jaundiced rats. The elevated plasma copper concentrations in
the jaundiced rats may support this suggestion.

Publication Types: 
    Research Support, Non-U.S. Gov't

PMID: 12350135 [PubMed - indexed for MEDLINE]

449: Intern Med. 2002 Sep;41(9):701-5.

Repeated jaundice due to YMDD mutant in a patient with prolonged lamivudine
therapy for chronic hepatitis B under prednisolone treatment for Still's disease.

Joh R, Hasegawa K, Torii N, Ogawa M, Kanai N, Naritomi T, Ishikawa K, Iizuka A,
Shizuma T, Hashimoto E, Hayashi N.

Institute of Gastroenterology, Tokyo Women's Medical University.

A 50-year-old woman patient began receiving lamivudine because of acute
exacerbation of chronic hepatitis B. She also suffered from adult-onset Still's
disease and had received prednisolone for 5 years. Lamivudine was effective for
treatment of the first flare. Fifteen months after lamivudine treatment was
started, a breakthrough due to lamivudine-resistant strain M5521 occurred.
Between 10 and 12 months after the breakthrough, flare with jaundice occurred 3
times. We decided interferon would not be suitable, because it could induce
activation of Still's disease. Prolonged lamivudine therapy is only recommended
in cases of hepatitis B in which there is no alternative treatment.

Publication Types: 
    Case Reports

PMID: 12322795 [PubMed - indexed for MEDLINE]

450: Endoscopy. 2002 Oct;34(10):835-7.

Endoscopic removal of a biliary Wallstent with a suture-cutting device in a
patient with primary pancreatic lymphoma.

Levy MJ, Wiersema MJ.

Division of Gastroenterology, The Mayo Clinic, Rochester, Minnesota 55905, USA.
levy.michael@mayo.edu

This report describes the case of a 74-year-old woman who had previously had a
metal stent placed to relieve jaundice resulting from a pancreatic head tumor,
suspected to be adenocarcinoma. The tumor was subsequently found to be a
non-Hodgkin's large-cell lymphoma, which had shown a rapid response to
chemotherapy without tumor recurrence in over 3 years since the diagnosis. She
was referred for management of recurrent jaundice and cholangitis resulting from 
repeated metal stent occlusion, despite multiple endoscopic procedures and failed
surgical removal. This report describes experience with the use of an endoscopic 
suture-cutting device to assist in the removal of the metal stent. It also
highlights the need for proper patient selection before placement of biliary
metal stents.

Publication Types: 
    Case Reports

PMID: 12244508 [PubMed - indexed for MEDLINE]

451: J S Afr Vet Assoc. 2001 Dec;72(4):183-8.

Evaluation of a commercially available molybdate formulation and zinc oxide
boluses in preventing hepatic copper accumulation and thus enzootic icterus in
sheep.

Botha CJ, Shakespeare AS, Gehring R, van der Merwe D.

Department of Paraclinical Sciences, Faculty of Veterinary Science, University of
Pretoria, Onderstepoort, South Africa.

The efficacy of a molybdate formulation and a zinc oxide bolus as prophylactic
agents for enzootic icterus was evaluated in sheep. Before copper loading, liver 
biopsies were performed on 12 male, 6-month-old, Mutton Merino sheep to determine
hepatic copper (Cu) and zinc (Zn) concentrations. The animals were restrictively 
randomised according to liver copper concentrations to 3 treatment groups (n = 4)
to achieve similar mean liver copper concentrations per group. All sheep received
4 ml/kg of a 0.5 % aqueous solution of CuSO4 5H2O intraruminally 7 days per week 
for 10 weeks. On Day 0 the sheep in the Mo-group were injected subcutaneously
with 42 mg molybdenum (Mo) contained in a commercial molybdate formulation. The
animals in the Zn-group each received a zinc oxide bolus, containing 43 g zinc
oxide, via a rumen cannula. Treatment was repeated on Day 42. Four animals served
as untreated controls. Urinary copper excretion, plasma copper concentration,
haematocrit and glutamate dehydrogenase (GLDH) activity were determined
throughout the trial. The animals were sacrificed after 10 weeks and liver
samples were submitted for histopathological examination. Liver and kidney copper
and zinc concentrations were determined. Neither the molybdate treatment nor the 
zinc oxide boluses prevented hepatic copper accumulation. The urinary copper
excretion, plasma copper concentration, haematocrit and GLDH activity were not
significantly different (P > 0.05) from the controls.

Publication Types: 
    Clinical Trial
    Randomized Controlled Trial
    Research Support, Non-U.S. Gov't

PMID: 12219912 [PubMed - indexed for MEDLINE]

452: Arch Dis Child Fetal Neonatal Ed. 2002 Sep;87(2):F137-40.

A comparison of transcutaneous bilirubinometers: SpectRx BiliCheck versus Minolta
AirShields.

Wong CM, van Dijk PJ, Laing IA.

Simpson Memorial Maternity Pavilion, Lauriston Place, Edinburgh EH3 9YW,
Scotland, UK. mae.wong@luht.scot.nhs.uk

BACKGROUND: Two devices are available for making transcutaneous estimates of
serum bilirubin (SBR): the Minolta AirShields JM102 and the new SpectRx
BiliCheck. OBJECTIVES: (a) To measure how well the readings produced by these
devices agree with SBR measured in the laboratory; (b) to estimate for each
device, the proportion of infants with clinical jaundice who would require blood 
sampling if the device was used as a screening tool to detect infants with SBR > 
or = 250 micromol/l. DESIGN: Prospective cohort study of jaundiced infants who
required SBR at < or = 20 days of postnatal age. Those who had received
phototherapy or exchange transfusion were excluded. SETTING: Tertiary neonatal
service in South-East Scotland. INTERVENTIONS: Within 30 minutes of SBR sampling,
transcutaneous bilirubinometry was performed using one Minolta and two SpectRx
devices (designated A and B). RESULTS: Sixty-four neonates were enrolled, 19 of
which were preterm (31-35 weeks). The 95% confidence intervals of a device
reading corresponding to SBR were +/- 66.7, +/- 67.9, and +/- 66.4 micromol/l
respectively. Using the devices to identify all SBR > or = 250 micromol/l would
reduce SBR sampling by 23%, 16%, and 20% respectively. CONCLUSIONS: Given that
SBR levels range from 50 to 400 micromol/l in jaundiced infants, the 95%
confidence intervals of the devices are wide at +/- 67 micromol/l. The SpectRx
can be used as a screening tool for hyperbilirubinaemia but there is no advantage
in using it over the Minolta.

Publication Types: 
    Comparative Study

PMID: 12193523 [PubMed - indexed for MEDLINE]

453: Thromb Res. 2002 Apr 15;106(2):127-30.

Cancer-related thrombotic microangiopathy secondary to Von Willebrand
factor-cleaving protease deficiency.

Blot E, Decaudin D, Veyradier A, Bardier A, Zagame OL, Pouillart P.

Department of Medical Oncology, Institut Curie, 26, rue d'Ulm, 75231 Paris Cedex 
05, France. eblot@rouen.fnclcc.fr

Cancer-related thrombotic microangiopathy (TM) is a serious complication with a
short-term life-threatening prognosis. This complication shares certain
similarities with thrombotic thrombocytopenic purpura and hemolytic uremic
syndrome, both characterized by circulating platelet aggregates containing
ultralarge multimers of Von Willebrand factor (VWF). We report a case of
cancer-related thrombotic microangiopathy secondary to disseminated metastatic
cancer with undetectable serum Von Willebrand factor-cleaving protease activity
and no evidence of serum inhibitory antibody. A concomitant decrease of Ca 19-9
level and hemolysis was observed during chemotherapy, in parallel with
normalization of Von Willebrand factor-cleaving protease activity. The role of
ultralarge multimers of Von Willebrand factor in platelet aggregation in the
context of metastatic disease is discussed with respect to our findings in this
case of cancer-related thrombotic microangiopathy. Copyright 2002 Elsevier
Science Ltd.

Publication Types: 
    Case Reports

PMID: 12182911 [PubMed - indexed for MEDLINE]

454: J Vasc Interv Radiol. 2002 Aug;13(8):845-9.

Palliative percutaneous tube enterostomy in afferent-loop syndrome presenting as 
jaundice: clinical effectiveness.

Kim YH, Han JK, Lee KH, Kim TK, Kim KW, Choi BI.

Department of Radiology and the Institute of Radiation Medicine, Seoul National
University College of Medicine, 28 Yongon-Dong, Chongno-Gu, Seoul 110-744, Korea.

The purpose of this study was to investigate the clinical effectiveness of
percutaneous tube enterostomy in afferent loop syndrome presenting as jaundice.
Tube enterostomy was successfully performed in seven patients without procedural 
complications. The serum bilirubin level normalized in five patients but remained
elevated in the other two, presumably related to more proximal bile duct
obstruction. Percutaneous tube enterostomy is an effective palliative treatment
in afferent loop syndrome presenting as an obstructing jaundice. However,
coexisting biliary obstruction might be problematic for relieving jaundice with
tube enterostomy.

PMID: 12171989 [PubMed - indexed for MEDLINE]

455: BMJ. 2002 Jul 27;325(7357):213-5.

The "jaundice hotline" for the rapid assessment of patients with jaundice.

Mitchell J, Hussaini H, McGovern D, Farrow R, Maskell G, Dalton H.

Gastrointestinal Unit, Royal Cornwall Hospital, Truro TR1 3LJ. jonmitch@clara.net

PROBLEM: Patients with jaundice require rapid diagnosis and treatment, yet such
patients are often subject to delay. DESIGN: An open referral, rapid access
jaundice clinic was established by reorganisation of existing services and
without the need for significant extra resources. BACKGROUND AND SETTING: A large
general hospital in a largely rural and geographically isolated area. KEY
MEASURES FOR IMPROVEMENT: Waiting times for referral, consultation, diagnosis,
and treatment, length of stay in hospital, and general practitioners' and
patients' satisfaction with the service. STRATEGIES OF CHANGE: Referrals were
made through a 24 hour telephone answering machine and fax line. Initial
assessment of patients was carried out by junior staff as part of their working
week. Dedicated ultrasonography appointments were made available. EFFECTS OF
CHANGE: Of 107 patients seen in the first year of the service, 62 had biliary
obstruction. The mean time between referral and consultation was 2.5 days.
Patients who went on to endoscopic retrograde cholangiopancreatography waited 5.7
days on average. The mean length of stay in hospital in the 69 patients who were 
admitted was 6.1 days, compared with 11.5 days in 1996, as shown by audit data.
Nearly all the 36 general practices (95%) and the 30 consecutive patients (97%)
that were surveyed rated the service as above average or excellent. LESSONS
LEARNT: An open referral, rapid access service for patients with jaundice can
shorten time to diagnosis and treatment and length of stay in hospital. These
improvements can occur through the reorganisation of existing services and with
minimal extra cost.

PMID: 12142314 [PubMed - indexed for MEDLINE]

456: Biochim Biophys Acta. 2002 Aug 19;1564(1):219-26.

Binding of bilirubin with albumin-coupled liposomes: implications in the
treatment of jaundice.

Masood AK, Faisal SM, Mushahid MK, Nadeem A, Siddiqui MU, Owais M.

Inter-disciplinary Biotechnology Unit, Aligarh Muslim University, India.

In the present study, we demonstrated the suitability of liposomes as a method of
removing plasma bilirubin in hyperbilirubinemic rats. The liposomes have innate
tendency to bind with bilirubin through hydrophobic interaction. Among different 
types of liposomes, the positively charged liposomes were found to have maximum
affinity to free bilirubin. However, the entrapment or coupling of serum albumin 
on the surface of egg phosphatidylcholine liposomes can render a several-fold
increase in their bilirubin binding capacity. The proteoliposomes were able to
preferentially bind with bilirubin even in the presence of erythrocytes.
Interestingly, these liposomes were found to displace bilirubin bound on the
surface of erythrocytes as well. The results of the present study further
demonstrate that albumin-bearing liposomes were equally effective in removing
plasma bilirubin in experimental jaundiced animals. These observations indicate
that liposome-mediated selective homing of excess plasma bilirubin to the liver
cells (cf. hepatocytes) may help in the development of safer strategy for the
treatment of hyperbilirubinemic conditions in the model animals.

Publication Types: 
    In Vitro
    Research Support, Non-U.S. Gov't

PMID: 12101016 [PubMed - indexed for MEDLINE]

457: Blood Cells Mol Dis. 2002 Mar-Apr;28(2):104-7.

Severe jaundice in a patient with a previously undescribed glucose-6-phosphate
dehydrogenase (G6PD) mutation and Gilbert syndrome.

Beutler E, Gelbart T, Miller W.

Department of Molecular and Experimental Medicine, Division of Hematology, The
Scripps Research Institute, La Jolla, California 92037, USA. beutler@scripps.edu

A patient with chronic hemolytic anemia and G6PD deficiency was noted to be
severely jaundiced and to have a high serum ferritin level. Analysis of his DNA
revealed only heterozygosity for the c.187 C-->G (H63D) mutation of HFE, but
showed that he was homozygous for the UDP glucuronosyltransferase promoter
mutation of Gilbert's disease and that he had a previously undescribed mutation
of G6PD, c.832 T-->C (Ser278Pro). The new variant was named G6PD La Jolla.

Publication Types: 
    Case Reports
    Research Support, Non-U.S. Gov't
    Research Support, U.S. Gov't, P.H.S.

PMID: 12064902 [PubMed - indexed for MEDLINE]

458: J Indian Med Assoc. 2001 Oct;99(10):584-6.

Intra-operative tube stenting, palliation for jaundice in carcinoma gall bladder.

Puneet, Khanna R, Khanna AK.

Department of Surgery, Institute of Medical Science, Banaras Hindu University,
Varanasi.

Majority of patients with advanced carcinoma gall bladder have irresectable
disease and require palliation for jaundice, pruritus and cholangitis. These
cases presenting with jaundice are usually high risk cases to undergo any major
surgical procedure like segment-III hepaticodochojejunostomy. So intra-operative 
tube stenting was attempted in 6 patients of carcinoma gall bladder but
technically, it was possible in 4 cases only. In 2 cases because of massive
locoregional disease it was not possible to cannulate the proximal part of the
bile duct. The distal end of the tube was passed either in the duodenum or
proximal part of the jejunum. Patients were followed up, showed good recovery
from jaundice and pruritus.

Publication Types: 
    Evaluation Studies

PMID: 12018544 [PubMed - indexed for MEDLINE]

459: Dig Dis Sci. 2002 Apr;47(4):929-34.

Bacterial translocation and intestinal morphological findings in jaundiced rats.

Sileri P, Morini S, Sica GS, Schena S, Rastellini C, Gaspari AL, Benedetti E,
Cicalese L.

Division of Transplantation, University of Illinois at Chicago, 60612, USA.

The susceptibility to sepsis in obstructive jaundice may be related to bacterial 
translocation (BT) from the gastrointestinal tract. We evaluated BT to visceral
organs and morphological changes of the intestinal mucosa in a rat model of
obstructive jaundice. Animals were randomly divided into two groups: in group A
the common bile duct was tied and divided, while group B had the bile duct
mobilized but not tied. After seven days, peritoneal swabs and liver, spleen,
pancreas, lung, mesenteric lymph nodes (MLN), cecum, and terminal ileum biopsies 
were obtained for cultures. Light and electron microscopy were performed on
intestinal samples. The TUNEL assay was performed to detect apoptosis. Data were 
analyzed using Fisher exact test and Student t test. Bile duct obliteration
resulted in an increased incidence of BT. Seven days after duct obliteration, BT 
to the peritoneal cavity was evident in 37.5% of the animals in group A and 25%
in group B. The respective BT rates for the two groups were: 42.8% vs 37.5% to
MLN, 71.4% vs 25% to liver, 42.8% vs 12.5% to spleen, 28.6% vs 0% to pancreas and
14.3% vs 0% to lungs. Despite a trend, this was not statistically significant.
Cecal counts did not differ statistically among the groups, while ileal counts
were significantly higher in jaundiced rats (P < 0.05). Structural and
ultrastructural abnormalities were evident only in the mucosa of the terminal
ileum of jaundiced rats. Apoptosis was significantly increased in the terminal
ileum of jaundiced rats (P < 0.002). This study suggests the possible association
of biliary obstruction and BT. The nonspecific physical injury observed may
contribute to breakdown of gastrointestinal barrier function thus promoting BT.

PMID: 11991630 [PubMed - indexed for MEDLINE]

460: Pediatrics. 2002 May;109(5):846-51.

Comment in:
    Pediatrics. 2003 Nov;112(5):1212-3; author reply 1212-3.    Pediatrics. 2003 Nov;112(5):1213-4; author reply 1213-4.

Jaundice as an early diagnostic sign of urinary tract infection in infancy.

Garcia FJ, Nager AL.

Division of Emergency and Transport Medicine, Childrens Hospital Los Angeles, Los
Angeles, California, USA. franciscog@kapiolani.org

OBJECTIVE: Urinary tract infections (UTIs) are a common clinical problem in
febrile infants younger than 8 weeks old, with a prevalence between 5% and 11%.
Previous studies have noted that jaundice may be one of the first signs of a
bacterial infection in infants. Our goal was to determine the incidence of UTIs
in asymptomatic, jaundiced infants younger than 8 weeks old and to determine
which historical and laboratory parameters are associated with UTIs. METHODS: We 
prospectively evaluated asymptomatic, jaundiced infants younger than 8 weeks old 
for evidence of a UTI (defined as >10 000 colony-forming units per milliliter of 
a single pathogen, obtained by bladder catheterization). A serum fractionated
bilirubin level was obtained on all study patients. Detailed questionnaires were 
completed, which included demographic information, prenatal, intrapartum, and
postnatal events. RESULTS: Twelve (7.5%) of 160 infants had a UTI (95% confidence
interval: 3.9%-12.7%). Isolated organisms included Escherichia coli, Enterobacter
cloacae, Enterococcus, Klebsiella pneumoniae, group B Streptococcus,
Streptococcus viridans, and Staphylococcus aureus. Patients with the onset of
jaundice after 8 days of age had a higher incidence of UTI, 6 (50%) of 12 infants
in the positive culture group, versus 15 (10%) of 148 infants in the negative
culture group. Abnormal urinalysis and microscopy results were noted in 5 (42%)
of 12 infants with a UTI, and 6 (55%) of 11 infants had abnormal renal ultrasound
results. CONCLUSION: A UTI was found in 7.5% of asymptomatic, afebrile, jaundiced
infants younger than 8 weeks old. In addition, infants with the onset of jaundice
after 8 days of age or patients with an elevated conjugated bilirubin fraction
were more likely to have a UTI. Therefore, we recommend that testing for a UTI be
included as part of the evaluation in asymptomatic, jaundiced infants presenting 
to the emergency department.

Publication Types: 
    Research Support, U.S. Gov't, P.H.S.

PMID: 11986445 [PubMed - indexed for MEDLINE]

461: Clin Lymphoma. 2002 Mar;2 Suppl 1:S35-9.

Management of hepatic sinusoidal obstruction syndrome following treatment with
gemtuzumab ozogamicin (Mylotarg).

McDonald GB.

Gastroenterology/Hepatology Section, Clinical Research Division, Fred Hutchinson 
Cancer Research Center and the University of Washington School of Medicine,
Seattle, WA 98109-1024, USA. gmcdonal@fhrcrc.org

Gemtuzumab ozogamicin (Mylotarg) therapy may cause sinusoidal obstruction
syndrome (SOS), the mechanism of which probably involves targeting of CD33+ cells
in the sinusoids of the liver, activation of stellate cells, damage to sinusoidal
endothelial cells, sinusoidal vasoconstriction, and ischemic hepatocyte necrosis.
The clinical manifestations of this liver injury are hepatomegaly, weight gain,
ascites, jaundice, and elevation of serum aminotransferase enzymes. An approach
to patient management includes being certain that SOS is the correct diagnosis;
ensuring that liver blood flow is optimized; and managing the accumulation of
fluid in the peritoneal cavity, pleural spaces, and pulmonary interstitium.
Currently, there is no specific therapy that is directed at the sinusoidal
pathology caused by gemtuzumab ozogamicin. There are, however, several rational
therapies that might be tried in patients who exhibit adverse prognostic signs
early in the course of SOS. There is also considerable ongoing hepatology
research dealing with stellate cell and sinusoidal endothelial cell biology and
regulation of sinusoidal blood flow that can be brought to bear on this problem
in the future.

Publication Types: 
    Research Support, U.S. Gov't, P.H.S.
    Review

PMID: 11970769 [PubMed - indexed for MEDLINE]

462: J Gastroenterol Hepatol. 2002 Feb;17(2):190-5.

Incidence and clinical outcome of icteric type hepatocellular carcinoma.

Huang JF, Wang LY, Lin ZY, Chen SC, Hsieh MY, Chuang WL, Yu MY, Lu SN, Wang JH,
Yeung KW, Chang WY.

Department of Internal Medicine, Foo-Yin Institute of Technology Hospital,
Pingtung, Taiwan.

BACKGROUND: To elucidate the incidence of the rare cases of icteric type
hepatocellular carcinoma (IHCC), we conducted a retrospective study. The clinical
outcomes of IHCC cases were also analyzed. METHODS: From January 1986 to December
1997, newly diagnosed HCC cases were evaluated and reviewed from an admission
registration database in a medical center. Patients who had HCC tumors which were
located within biliary tracts, and caused obstructive jaundice as the initial
clinical manifestation of HCC, were defined as cases of IHCC. Besides clinical
manifestations, the outcomes and survival times of various treatment strategies
among the IHCC cases were compared retrospectively. RESULTS: The incidence of
IHCC was 0.53% (10/1897). The median age of the 10 IHCC patients (seven men,
three women) was 56.1 years (range = 41-72 years). Most primary HCC lesions (80%)
were of expansive type: either single nodular type or multinodular type. All the 
patients eventually died of cholangitis and sepsis. Besides biliary drainage,
seven patients of moderate to good liver reserve function received transarterial 
chemoembolization (TACE) for palliative treatment, and three of these received
additional radiotherapy (R/T) because of the limited effect of TACE (total dosage
ranged from 1600 to 5000 cGy). One patient received only radiotherapy (total
dosage 1600 cGy) because of having a single tumor and poor liver reserve
function. The median survival time among those eight patients who received
palliative treatment was 13.4 months (range = 8-26 months), which was
significantly longer than for the other two patients without treatment (2 and 4
months). CONCLUSIONS: Icteric type hepatocellular carcinoma (IHCC) is a rare
presentation of HCC. Palliative treatment strategies, including TACE and/or R/T
showed a beneficial effect in improving the survival time.

PMID: 11966950 [PubMed - indexed for MEDLINE]

463: Indian J Malariol. 2001 Mar-Jun;38(1-2):19-24.

A study on clinical profile of falciparum malaria in a tertiary care hospital in 
south India.

Harris VK, Richard VS, Mathai E, Sitaram U, Kumar KV, Cherian AM, Amelia SM,
Anand G.

Department of Clinical Pathology, Christian Medical College and Hospital,
Vellore-632 004, India.

Malaria continues to be a major problem in tropical countries. To study the
clinical features and complications of malaria in a tertiary care hospital in
south India, records of 183 patients were analysed. Among 86 patients with P.
falciparum and mixed infection, 24 (28 per cent) had cerebral malaria and 32 (37 
per cent) had hyperbilirubinemia. Twenty-three out of 32 (72 per cent) patients
with jaundice had direct hyperbilirubinemia and elevated liver enzymes suggesting
hepatocellular damage. Mortality of the order of 10 per cent was seen only in P. 
falciparum malaria. High incidence of hepatic involvement and hepatorenal failure
were the unusual features observed in the study.

PMID: 11963816 [PubMed - indexed for MEDLINE]

464: Clin Liver Dis. 2002 Feb;6(1):297-310, ix.

Liver imaging. A hepatologist's perspective.

Reddy SI, Grace ND.

Division of Gastroenterology, Brigham and Women's Hospital, Boston,
Massachusetts, USA.

Numerous diagnostic modalities may be employed in the assessment of liver
disease. In this article we outline radiologic approaches to several clinical
problems including the evaluation of abnormal liver function tests and jaundice, 
evaluation of liver masses, and management of the patient with cirrhosis and
portal hypertension.

Publication Types: 
    Review

PMID: 11933595 [PubMed - indexed for MEDLINE]

465: Hong Kong Med J. 2002 Feb;8(1):57-9.

Prolonged jaundice following percutaneous coronary intervention and ticlopidine
therapy.

Tsui PT, Lai ST, Leung WS, Mok NS, Wu CW, Lau ST, Choi YC.

Department of Medicine and Geriatrics, Princess Margaret Hospital, 2-10 Princess 
Margaret Hospital Road, Laichikok, Hong Kong.

Ticlopidine, an adenosine diphosphate receptor blocker, is widely used to prevent
subacute stent thrombosis after percutaneous coronary intervention. Along with
neutropenia and thrombotic thrombocytopenic purpura, cholestatic hepatitis is one
of the most serious potential side-effects of ticlopidine therapy. Four patients 
with prolonged jaundice after ticlopidine therapy, including one fatal case, are 
presented. Alternative antithrombotic therapy for subsequent percutaneous
coronary intervention is also described. Clopidogrel therapy was found to be safe
and effective in two patients with a history of ticlopidine-related cholestatic
hepatitis.

Publication Types: 
    Case Reports

PMID: 11861996 [PubMed - indexed for MEDLINE]

466: Niger J Med. 2001 Jul-Sep;10(3):130-1.

Hepatic ultrasonographic findings in Nigerians with acute icteric hepatitis.

Otegbayo JA, Ola SO, Agunloye AM.

Department of Medicine, University College Hospital, Ibadan, Nigeria.

Forty five consecutive patients with acute icteric hepatitis in the University
College Hospital, Ibadan were recruited for clinical assessment of the liver.
Ultrasonographic assessment of the liver was also carried out with Siemens
Sonoline ultrasound machine with 3.5 MHz sector probe. Eighty two percent of the 
patients had no liver abnormality on ultrasonography. No significant difference
was found between ultrasonographic and clinical estimation of hepatic size.
Thickened gallbladder wall was found in 6.7% of the patients while gallstones
were found in 4.4%. Fine echoes and reduced parenchyma echoes were found in 2.2% 
of the patients. There were no ultrasonographic differences on account of viral
status or transaminase levels. It is recommended that ultrasonographic assessment
of the liver be considered in routine work-up of patients with acute icteric
hepatitis to exclude structural causes of obstructive jaundice.

PMID: 11806013 [PubMed - indexed for MEDLINE]

467: Am J Trop Med Hyg. 2001 Dec;65(6):834-6.

Helminth infections are associated with protection from malaria-related acute
renal failure and jaundice in Thailand.

Nacher M, Singhasivanon P, Silachamroon U, Treeprasertsuk S, Vannaphan S, Traore 
B, Gay F, Looareesuwan S.

Unité INSERM 511, Immunobiologie Cellulaire et Moléculaire des Infections
Parasitaires, Faculté de medecine Pitié-Salpétrière, Paris, France.

Following studies showing an association between helminth infections and
protection from cerebral malaria, we compared 22 patients with malaria-associated
acute renal failure with 157 patients with moderately severe malaria. Helminths
were associated with protection from renal failure (adjusted odds ratio [AOR],
0.16 [0.03-0.85], P = 0.03). Helminth-infected controls were less likely to have 
jaundice (AOR, 0.39 [0.16-0.96], P = 0.04) or to have peripheral mature schizonts
(AOR, 0.2 [0.07-0.62], P = 0.005) than controls without helminths. This suggested
that preexisting helminth infections may have been protective by influencing
sequestration and obstructive jaundice, 2 possible determinants of acute tubular 
necrosis.

Publication Types: 
    Research Support, Non-U.S. Gov't

PMID: 11791982 [PubMed - indexed for MEDLINE]

468: AIDS Read. 2001 Nov;11(11):577-80.

Comment in:
    AIDS Read. 2002 Apr;12(4):171.

Optimal treatment of nevirapine-associated hepatotoxicity remains uncertain.

Bundow D, Rosoff L, Aboulafia DM.

Division of Gastroenterology, Virginia Mason Medical Center, Seattle, USA.

The cases of 2 patients with nevirapine-associated hepatotoxicity in conjunction 
with rash and eosinophilia are reported here. Both patients' conditions improved 
following withdrawal of nevirapine. Previous case reports have described a
variety of interventions other than drug withdrawal that might have contributed
to resolution of drug-induced hepatitis. Until a better understanding of the
clinical spectrum and pathophysiology of nevirapine-associated hepatotoxicity is 
realized, treatment will remain largely empiric.

Publication Types: 
    Case Reports

PMID: 11789021 [PubMed - indexed for MEDLINE]

469: Indian J Pediatr. 2001 Oct;68(10):977-80.

Jaundice in the newborn.

Agrawal R, Aggarwal R, Deorari AK, Paul VK.

Division of Neonatology, Department of Pediatrics, All India Institute of Medical
Sciences, Ansari Nagar, New Delhi, India.

Hyperbilirubinemia is the commonest morbidity in the neonatal period and 5-10% of
all newborns require intervention for pathological jaundice. Neonates on
exclusive breast-feeding have a different pattern of physiological jaundice as
compared to artificially fed babies. Guidelines from American Academy of
Pediatrics (AAP) for management of jaundice in a normal term newborn have been
included in the protocol. Separate guidelines have been provided for the
management of jaundice in sick term babies, preterm and low birth weight babies, 
for jaundice secondary to hemolysis and for prolonged hyperbilirubinemia.
Although hour specific bilirubin charts are available, these have to be validated
in Indian infants before they are accepted for widespread use.

Publication Types: 
    Review

PMID: 11758137 [PubMed - indexed for MEDLINE]

470: Am J Gastroenterol. 2001 Nov;96(11):3186-9.

Jaundice caused by a clinically undetectable T-cell lymphoma infiltrating the
sphincter of Oddi.

Weinstock LB, Swanson PE, Bennett KJ, Van Amburg A, Wald SM, Shah NB.

Department of Medicine, Barnes-Jewish Hospital, Washington University Medical
Center, St. Louis, Missouri, USA.

Malignant lymphoma rarely presents with jaundice. We describe a patient who had a
unique etiology for painless jaundice, dilated ducts, and a normal ampulla of
Vater. A Whipple's procedure was performed for the suspicion of pancreatic
cancer, and initial pathological review detected only mild focal chronic
pancreatitis. Seven months later, the patient developed ascites, retroperitoneal 
mass, and splenomegaly caused by a T-cell lymphoma. Reevaluation of the Whipple's
specimen revealed previously unrecognized microscopic infiltration and fibrosis
of the sphincter of Oddi by atypical T-lymphocytes. Obstructive jaundice caused
by a clinically undetectable primary duodenal T-cell lymphoma has not been
previously reported and is contrasted with other causes of jaundice associated
with malignant lymphoma and ampullary lesions.

Publication Types: 
    Case Reports
    Research Support, Non-U.S. Gov't
    Review

PMID: 11721770 [PubMed - indexed for MEDLINE]

471: J Immunol. 2001 Dec 1;167(11):6559-67.

Forced expression of murine IL-17E induces growth retardation, jaundice, a
Th2-biased response, and multiorgan inflammation in mice.

Pan G, French D, Mao W, Maruoka M, Risser P, Lee J, Foster J, Aggarwal S,
Nicholes K, Guillet S, Schow P, Gurney AL.

Department of Molecular Oncology, Genentech, Inc., South San Francisco, CA 94080,
USA. jgpan@gene.com

IL-17 is a proinflammatory cytokine, and its in vivo expression induces
neutrophilia in mice. IL-17E is a recently described member of an emerging family
of IL-17-related cytokines. IL-17E has been shown to bind IL-17Rh1, a protein
distantly related to the IL-17R, suggesting that IL-17E probably possesses unique
biological functions. In this study, we have identified the murine ortholog of
IL-17E and developed transgenic mice to characterize its actions in vivo.
Biological consequences of overexpression of murine (m)IL-17E, both unique to
IL-17E and similar to IL-17, were revealed. Exposure to mIL-17E resulted in a
Th2-biased response, characterized by eosinophilia, increased serum IgE and IgG1,
and a Th2 cytokine profile including elevated serum levels of IL-13 and IL-5 and 
elevated gene expression of IL-4, IL-5, IL-10, and IL-13 was observed in many
tissues. Increased gene expression of IFN-gamma in several tissues and elevated
serum TNF-alpha were also noted. In addition, IL-17E induces G-CSF production in 
vitro and mIL-17E-transgenic mice had increased serum G-CSF and exhibit
neutrophilia, a property shared by IL-17. Moreover, exposure to mIL-17E elicited 
pathological changes in multiple tissues, particularly liver, heart, and lungs,
characterized by mixed inflammatory cell infiltration, epithelial hyperplasia,
and hypertrophy. Taken together, these findings suggest that IL-17E is a unique
pleiotropic cytokine and may be an important mediator of inflammatory and immune 
responses.

PMID: 11714825 [PubMed - indexed for MEDLINE]

472: Emerg Med J. 2001 Nov;18(6):504-5.

Occult splenic injury: delayed presentation manifesting as jaundice.

Simpson RA, Ajuwon R.

Accident and Emergency Department, The John Radcliffe Hospital, Headley Way,
Oxford OX3 9DU, UK. dr-rob@dr-rob.co.uk

Delayed splenic rupture, though uncommon, is a recognised clinical condition and 
is associated with a significant mortality rate. In the vast majority of cases
the patient re-presents with abdominal symptoms and/or signs of acute
intraperitoneal haemorrhage. A case is presented of delayed splenic rupture
presenting with jaundice attributable to intra-abdominal clot lysis.

Publication Types: 
    Case Reports

PMID: 11696518 [PubMed - indexed for MEDLINE]

473: Am J Trop Med Hyg. 2001 Oct;65(4):318-24.

Epidemiology of acute hepatitis in the Stann Creek District of Belize, Central
America.

Bryan JP, Reyes L, Hakre S, Gloria R, Kishore GM, Tillett W, Engle R, Tsarev S,
Cruess D, Purcell RH.

Department of Preventive Medicine and Biometrics, Uniformed Services University
of the Health Sciences, Bethesda, Maryland 20814-4799, USA.

Hepatitis is common in the Stann Creek District of southern Belize. To determine 
the etiologies, incidence, and potential risk factors for acute jaundice, we
conducted active surveillance for cases. Cases of jaundice diagnosed by a
physician within the previous 6 weeks were enrolled. Evaluation included a
questionnaire and laboratory tests for hepatitis A, B, C, D, and E, a blood film 
for malaria, and a serologic test for syphilis. Etiologies of jaundice among 62
evaluable patients included acute hepatitis A, 6 (9.7%), acute hepatitis B, 49
(79.0%), hepatitis non-A-E, 2 (3.2%), and malaria, 5 (8.1%). There were no cases 
of acute hepatitis E. One patient each with antibody to hepatitis C and D were
detected. The annualized incidence of hepatitis A was 0.26 per 1,000. All cases
of hepatitis A were in children 4-16 years of age. The annualized incidence of
hepatitis B, 2.17 per 1,000, was highest in adults aged 15-44 years (4.4 per
1,000) and was higher in men (36 cases; 3.09 per 1,000) than women (13 cases;
1.19 per 1,000). Four (31%) of the women with hepatitis B were pregnant. The
annualized incidence was significantly higher in Mestizo (6.18 per 1000) and Maya
(6.79 per 1,000) than Garifuna (0.38 per 1,000) or Creole (0.36 per 1,000).
Persons with hepatitis B were significantly more likely to be born outside of
Belize (82%), had been in Belize < 5 years (73%), and lived and worked in rural
areas (96%) than was the general population. Of those > or = 14 years of age with
hepatitis B, only 36% were married. Few persons admitted to transfusions,
tattoos, IV drug use, multiple sexual partners, visiting prostitutes, or sexually
transmitted diseases. Only 1 of 49 had a reactive test for syphilis. Six patients
were hospitalized (including 3 with acute hepatitis B and one with hepatitis A), 
and none to our knowledge died. Acute hepatitis B is the most common cause of
viral hepatitis in the Stann Creek District, but the modes of transmission remain
obscure. Infants, women attending prenatal clinics, and new workers are potential
targets for immunization with hepatitis B vaccine.

Publication Types: 
    Research Support, U.S. Gov't, Non-P.H.S.

PMID: 11693876 [PubMed - indexed for MEDLINE]

474: J Clin Gastroenterol. 2001 Oct;33(4):319-22.

Do steroids help jaundice caused by primary sclerosing cholangitis?

Parkes M, Booth JC, Pillai G, Mee AS.

Department of Gastroenterology, Royal Berkshire Hospital, Reading, United
Kingdom.

The management of jaundice in patients with primary sclerosing cholangitis (PSC) 
is clinically challenging. In patients in whom the recognized precipitants for
jaundice have been excluded, the outlook is uncertain at best. Some improve
spontaneously, but the only treatment demonstrated to be effective is liver
transplantation--which may not always be appropriate. We report three cases of
jaundice in patients with PSC in whom corticosteroid therapy appeared to be
beneficial.

Publication Types: 
    Case Reports

PMID: 11588548 [PubMed - indexed for MEDLINE]

475: Am J Gastroenterol. 2001 Aug;96(8):2494-6.

Severe hepatotoxicity with jaundice associated with paroxetine.

Odeh M, Misselevech I, Boss JH, Oliven A.

Department of Internal Medicine B and Pathology, Bnai Zion Medical Center, Haifa,
Israel.

Hepatotoxicity due to paroxetine, a selective serotonin reuptake inhibitor, is
very rare, and to the best of our knowledge, only five cases of liver injury in
association with paroxetine have previously been reported in the medical
literature. We describe the clinical, biochemical, and pathological findings in a
patient with paroxetine hepatotoxicity, which was reversed after withdrawal of
the drug. The present case and the others previously reported suggest that
hepatotoxicity should be taken into account as a rare complication, sometimes
severe, that may occur with paroxetine.

Publication Types: 
    Case Reports

PMID: 11513198 [PubMed - indexed for MEDLINE]

476: Biol Neonate. 2001 Aug;80(2):158-62.

Auditory brainstem response and unbound bilirubin in jaundiced (jj) Gunn rat
pups.

Ahlfors CE, Shapiro SM.

Division of Neonatology, California Pacific Medical Center, San Francisco, CA,
USA. cahlfors@pns.cpmc.org

The role of plasma bilirubin-albumin binding in the pathogenesis of kernicterus
in human newborns is controversial. Kernicterus in the jaundiced (jj) Gunn rat
pup, an animal model for kernicterus, prolongs interwave intervals and decreases 
wave amplitude in the auditory brainstem response (ABR). Plasma total bilirubin
concentration (TBC), albumin concentration, and unbound bilirubin concentration
(UBC), a measure of bilirubin-albumin binding, were measured in 16-day-old jj
Gunn rat pups (n = 21) and compared with ABR wave latencies, interwave intervals,
and wave amplitudes by linear correlation. The UBC, but not the TBC or
TBC/albumin ratio, correlated positively and significantly with ABR I-II and
I-III interwave intervals (r = 0.55, p = 0.009, and r = 0.60, p = 0.004,
respectively). The UBC, but not the TBC or TBC/albumin ratio, predicts bilirubin 
toxicity, as measured by bilirubin-induced ABR changes in jj Gunn rat pups.

PMID: 11509817 [PubMed - indexed for MEDLINE]

477: Jpn J Thorac Cardiovasc Surg. 2001 Jun;49(6):388-90.

Jaundice after surgery for an aortic arch aneurysm.

Onoguchi K, Hachiya T, Sasaki T, Hashimoto K, Takakura H, Takeuchi S.

Department of Cardiovascular Surgery, Saitama Cardiovascular and Respiratory
Center, Saitama, Japan.

A 57-year-old patient who developed hyperbilirubinemia after surgery for an
aortic arch aneurysm subsequently suffered pseudomonas sepsis. Low-volume biliary
drainage from the common bile duct was colorless. A disturbance in the liver's
excretory system caused jaundice. Sepsis and jaundice were resolved when hepatic 
excretory function recovered.

Publication Types: 
    Case Reports

PMID: 11481845 [PubMed - indexed for MEDLINE]

478: Ann Clin Biochem. 2001 Jul;38(Pt 4):323-8.

Relationships between serum (ZZ)-bilirubin, its subfractions and biliverdin
concentrations in infants at 1-month check-ups.

Itoh S, Kondo M, Imai T, Kusaka T, Isobe K, Onishi S.

Department of Pediatrics, Kagawa Medical University, Kitagun, Japan.
sitoh@kms.ac.jp

In 150 infants, including those with breast milk jaundice, who were brought to
our hospital for their 1-month check-ups, the serum concentrations of
(ZZ)-bilirubin, its subfractions and biliverdin were measured by high-performance
liquid chromatography and the relationships among them investigated.
(ZZ)-Bilirubin was found to have the highest serum concentration, followed by
(ZE)-bilirubin, accounting for 14.0 (geometric mean) % of (ZZ)-bilirubin.
Biliverdin had a serum concentration of 0.95% of (ZZ)-bilirubin. There was only a
small amount of total (di- and mono-) glucuronosyl bilirubin, 0.42% of
(ZZ)-bilirubin. (ZE)-Bilirubin, (EZ)-bilirubin, (EZ)-cyclobilirubin. biliverdin, 
diglucuronosyl bilirubin and monoglucuronosyl bilirubin (C-8 and C-12) showed
positive logarithmic correlations with (ZZ)-bilirubin (R2=0.16 or above, P<0.05).
(ZE)-Bilirubin showed a significant positive logarithmic correlation with
(ZZ)-bilirubin (R2=0.863, P<0.0001). Furthermore, (EZ)-cyclobilirubin, the most
important photoisomer in phototherapy for neonatal hyperbilirubinaemia, was
detected in very small amounts in approximately half of the neonates (84 of 150) 
when they were in conditions of only weak ambient light. The relationship between
total glucuronosyl bilirubin and (ZZ)-bilirubin concentrations fitted a model of 
saturation kinetics of bilirubin UDP-glucuronosyltransferase.

Publication Types: 
    Research Support, Non-U.S. Gov't

PMID: 11471872 [PubMed - indexed for MEDLINE]

479: Lancet. 2001 Jul 14;358(9276):91-7.

Erratum in:
    Lancet 2001 Jul 28;358(9278):336.    Lancet 2001 Sep 22;358(9286):1018. Papaiordanou, CM [corrected to Papaiordanou,
PM].

Comment in:
    Lancet. 2001 Dec 1;358(9296):1907-8.    Lancet. 2001 Jul 14;358(9276):84-5.

Serious adverse events associated with yellow fever 17DD vaccine in Brazil: a
report of two cases.

Vasconcelos PF, Luna EJ, Galler R, Silva LJ, Coimbra TL, Barros VL, Monath TP,
Rodigues SG, Laval C, Costa ZG, Vilela MF, Santos CL, Papaiordanou PM, Alves VA, 
Andrade LD, Sato HK, Rosa ES, Froguas GB, Lacava E, Almeida LM, Cruz AC, Rocco
IM, Santos RT, Oliva OF; Brazilian Yellow Fever Vaccine Evaluation Group.

Instituto Evandro Chagas/Fundação Nacional de Saúde (FUNASA), Belém, Brazil.
pedrovasconcelos@iec.pa.gov.br

BACKGROUND: The yellow fever vaccine is regarded as one of the safest attenuated 
virus vaccines, with few side-effects or adverse events. We report the occurrence
of two fatal cases of haemorrhagic fever associated with yellow fever 17DD
substrain vaccine in Brazil. METHODS: We obtained epidemiological, serological,
virological, pathological, immunocytochemical, and molecular biological data on
the two cases to determine the cause of the illnesses. FINDINGS: The first case, 
in a 5-year-old white girl, was characterised by sudden onset of fever
accompanied by headache, malaise, and vomiting 3 days after receiving yellow
fever and measles-mumps-rubella vaccines. Afterwards she decompensated with
icterus and haemorrhagic signs and died after a 5-day illness. The second
patient-a 22-year-old black woman-developed a sore throat and fever accompanied
by headache, myalgia, nausea, and vomiting 4 days after yellow fever vaccination.
She then developed icterus, renal failure, and haemorrhagic diathesis, and died
after 6 days of illness. Yellow fever virus was recovered in suckling mice and
C6/36 cells from blood in both cases, as well as from fragments of liver, spleen,
skin, and heart from the first case and from these and other viscera fragments in
case 2. RNA of yellow fever virus was identical to that previously described for 
17D genomic sequences. IgM ELISA tests for yellow fever virus were negative in
case 1 and positive in case 2; similar tests for dengue, hantaviruses,
arenaviruses, Leptospira, and hepatitis viruses A-D were negative. Tissue
injuries from both patients were typical of wild-type yellow fever.
INTERPRETATION: These serious and hitherto unknown complications of yellow fever 
vaccination are extremely rare, but the safety of yellow fever 17DD vaccine needs
to be reviewed. Host factors, probably idiosyncratic reactions, might have had a 
substantial contributed to the unexpected outcome.

Publication Types: 
    Case Reports
    Research Support, Non-U.S. Gov't

PMID: 11463409 [PubMed - indexed for MEDLINE]

480: Lancet. 2001 Jun 16;357(9272):1945-6.

Genetic determinants of jaundice and gallstones in haemoglobin E beta
thalassaemia.

Premawardhena A, Fisher CA, Fathiu F, de Silva S, Perera W, Peto TE, Olivieri NF,
Weatherall DJ.

Chronic hyperbilirubinaemia, gallstone formation, and gall bladder disease are
unusually common in people with haemoglobin E beta thalassaemia in Sri Lanka. To 
determine whether this has a genetic basis we compared the bilirubin levels and
frequency of gallstones in patients with different alleles of the UGT*1 gene.
There was a significantly higher bilirubin level in those with the 7/7 genotypes 
compared with 6/6 and 6/7 genotype (p=0.032 and 0.0015 respectively), who also
appeared more prone to gallstone formation. These results suggest that the UGT*1 
genotpe is of importance in the genesis of gallstones in this population of
patients.

PMID: 11425418 [PubMed - indexed for MEDLINE]

481: J Am Coll Surg. 2001 Jun;192(6):726-34.

The effect of preoperative biliary drainage on postoperative complications after 
pancreaticoduodenectomy.

Sewnath ME, Birjmohun RS, Rauws EA, Huibregtse K, Obertop H, Gouma DJ.

Department of Surgery, Academic Medical Center Amsterdam, University of
Amsterdam, The Netherlands.

BACKGROUND: The benefit of preoperative biliary drainage in jaundiced patients
undergoing pancreaticoduodenectomy for a suspected malignancy of the
periampullary region is still under debate. This study evaluated preoperative
biliary drainage in relation to postoperative outcomes. STUDY DESIGN: At the
Academic Medical Center, Amsterdam, the Netherlands, a cohort of 311 patients
undergoing pancreaticoduodenectomy from June 1992 up to and including December
1999 was studied. Of this cohort 21 patients with external or surgical biliary
drainage were excluded and 232 patients who had received preoperative internal
biliary drainage were divided into three groups corresponding with severity of
jaundice according to preoperative plasma bilirubin levels: < 40 microM (n =
177), 40 to 100 microM (n = 32), and > 100 microM (n = 23) were designated as
groups 1, 2, and 3, respectively. These groups were compared with patients who
underwent immediate surgery (n = 58) without preoperative drainage. RESULTS: The 
median number of stent (re)placements was 2 (range 1 to 6) with a median drainage
duration of 41 days (range 2 to 182 days) and a stent dysfunction rate of 33%.
Although patients in group 1 were better drained than patients in groups 2 and 3 
(median reduction of bilirubin levels 82%, 57%, and 37%, respectively, p < 0.01),
there was no difference in overall morbidity among the drained groups (50%, 50%, 
and 52%, respectively). There was no significant difference in overall morbidity 
between patients with and without preoperative biliary drainage (50% and 55%,
respectively). CONCLUSIONS: Preoperative biliary drainage did not influence the
incidence of postoperative complications, and although it can be performed safely
in jaundiced patients it should not be used routinely.

Publication Types: 
    Comparative Study

PMID: 11400966 [PubMed - indexed for MEDLINE]

482: Am J Gastroenterol. 2001 May;96(5):1571-4.

Jaundice and hepatocellular damage associated with nevirapine therapy.

Prakash M, Poreddy V, Tiyyagura L, Bonacini M.

Division of Infectious Diseases, Keck School of Medicine, Los Angeles,
California, USA.

OBJECTIVE: Nevirapine is a nonnucleoside reverse transcription inhibitor that is 
used as part of highly active antiretroviral therapeutic combinations. Nevirapine
has been associated with a skin rash in 32 to 48% of patients. Recent reports
indicate that hepatic toxicity also occurs. METHODS: We describe four instances
of reversible hepatocellular damage associated with the use of nevirapine in
patients with HIV infection. Two of the four patients were also coinfected with
the hepatitis C virus. RESULTS: Evidence of malaise, skin rash, and icteric
hepatitis with pruritus occurred 4-6 wk after the beginning of nevirapine
therapy. No evidence of metabolic acidosis was present in any of our patients. In
all cases, liver test results declined to normal or near normal levels, and
pruritus disappeared 4-6 wk after discontinuation of the medication. No patient
was rechallenged with the drug. CONCLUSION: Nevirapine can be associated with
icteric hepatitis, which appears to be reversible after withdrawal of the drug.

Publication Types: 
    Case Reports

PMID: 11374701 [PubMed - indexed for MEDLINE]

483: Surg Today. 2001;31(2):174-6.

Pleural dissemination as a complication of preoperative percutaneous transhepatic
biliary drainage for hilar cholangiocarcinoma: report of a case.

Uenishi T, Hirohashi K, Inoue K, Tanaka H, Kubo S, Shuto T, Yamamoto T, Kaneko M,
Kinoshita H.

Second Department of Surgery, Osaka City University Medical School, Osaka, Japan.

One potential risk of percutaneous transhepatic biliary drainage is tumor seeding
along the catheter tract. A 57-year-old woman with obstructive jaundice due to
hilar cholangiocarcinoma underwent an extended left hepatic lobectomy, a regional
lymph node dissection, and a right hepaticojejunostomy 2 weeks after percutaneous
transhepatic biliary drainage. Multiple right pleural masses were found on a
chest radiogram 14 months after the operation. No recurrent lesions were detected
in the abdominal cavity. A right panpleuropneumonectomy was performed; however,
the patient died of respiratory failure due to tumor recurrence 9 months after
the second operation. Preoperative percutaneous transhepatich biliary drainage
was considered to have resulted in pleural implantation.

Publication Types: 
    Case Reports

PMID: 11291716 [PubMed - indexed for MEDLINE]

484: Biochem Pharmacol. 2001 Apr 1;61(7):843-9.

Role of cytochrome P450 1A2 in bilirubin degradation Studies in Cyp1a2 (-/-)
mutant mice.

Zaccaro C, Sweitzer S, Pipino S, Gorman N, Sinclair PR, Sinclair JF, Nebert DW,
De Matteis F.

Department of Pharmacology, University of Turin Medical School, Via P. Giuria 13,
10125, Turin, Italy.

In congenital jaundice, which is due to defects of bilirubin gluruconidation,
bilirubin is degraded by an alternative pathway into unidentified products.
Previously, it was shown that plasma bilirubin levels can be decreased in rats
with this defect by inducers of CYP1A enzymes. Here, liver microsomes from rats
or mice treated with beta-naphthoflavone (BNF) or 3-methylcholanthrene (3 MC) had
increased activity for bilirubin degradation. The activity was further stimulated
by addition of the coplanar molecule 3,4,3',4'-tetrachlorobiphenyl (TCB). There
was more stimulation of bilirubin degradation by TCB in microsomes from
BNF-treated rats than in microsomes from BNF-treated mice. CYP1A1 to CYP1A2
ratios were greater in rats treated with BNF. In Cyp1a2 (-/-) mutant mice, 3-MC
treatment did not increase the rate of bilirubin degradation, but TCB increased
this degradation severalfold. Between SWR and C57BL/6 inbred mouse strains that
have a 2-fold difference in hepatic constitutive CYP1A2 levels, there was also a 
2-fold difference in bilirubin degradation; TCB did not stimulate in either
strain. We conclude that CYP1A2 is responsible for microsomal bilirubin
degradation in the absence of TCB. TCB was required for bilirubin degradation by 
CYP1A1. Manipulation of CYP1A2 may be of therapeutic benefit in patients with
these diseases of bilirubin conjugation.

Publication Types: 
    Research Support, Non-U.S. Gov't
    Research Support, U.S. Gov't, Non-P.H.S.
    Research Support, U.S. Gov't, P.H.S.

PMID: 11274970 [PubMed - indexed for MEDLINE]

485: J Clin Gastroenterol. 2001 Mar;32(3):255-8.

Jaundice caused by a pancreatic mass: an exceptional presentation of Crohn's
disease.

Reynaert H, Peters O, Van der Auwera J, Vanstapel MJ, Urbain D.

Department of Gastroenterology, University Hospital, Free University of Brussels,
Belgium. gasrth@az.vub.ac.be

It is well known that Crohn's disease can involve the pancreas. However,
granulomatous inflammation of the pancreas causing jaundice is extremely rare. In
this report, we describe a patient presenting with jaundice in whom a Whipple
procedure was performed because of the suspicion of a malignant pancreatic tumor.
However, on histologic examination a benign granulomatous pancreatic mass was
found. Further investigations revealed no other organ involvement and no
underlying disease could be identified. Therefore, the tentative diagnosis of an 
idiopathic inflammatory pseudotumor was made. Only 6 months later, when the
patient developed bloody diarrhea, Crohn's disease was diagnosed. This case
stresses that, especially in young patients, Crohn's disease should be included
in the differential diagnosis of benign common bile duct strictures even if no
other symptoms of Crohn's disease are present.

Publication Types: 
    Case Reports

PMID: 11246358 [PubMed - indexed for MEDLINE]

486: Cancer. 2001 Feb 15;91(4):660-3.

Treatment of the jaundiced patient with breast carcinoma: case report and
alternate therapeutic strategies.

Gurevich I, Akerley W.

Department of Medicine of Brown University School of Medicine, Providence, Rhode 
Island, USA.

BACKGROUND: Breast carcinoma in the setting of liver metastases and jaundice
raises a complex therapeutic dilemma. Not only is the prognosis poor but toxicity
related to treatment can be unpredictable due to altered drug clearance.
Guidelines built around dose reduction have been suggested but often do not
address the varied presentations in clinical medicine. Bilirubin exceeding 5.0
mg% often is considered an absolute contraindication to the administration of
chemotherapeutic agents dependent on hepatic metabolism. METHODS: A 55-year-old
woman with metastatic breast carcinoma to the liver and hyperbilirubinemia was
treated with sequential, empiric chemotherapy agents with the goal of preventing 
severe toxicity through dose reduction, avoidance of combination therapy, divided
doses (weekly therapy), and selection of drugs less dependent on hepatic
clearance. Several attempts did not yield a regimen with a successful response,
but toxicity was minimal. Eventually, a successful schedule and dose of an agent 
cleared by liver metabolism was individualized for the patient. RESULTS: After
eight cycles of low dose weekly doxorubicin chemotherapy, the patient's symptoms 
resolved, bilirubin level normalized, and performance status returned to
baseline. The patient remained on treatment and was alive 12 months later.
CONCLUSIONS: The authors propose that altering a drug schedule by dividing doses 
may minimize toxicity, maintain dose intensity, and represent an alternative
strategy for the treatment of patients with hepatic impairment. Copyright 2001
American Cancer Society.

Publication Types: 
    Case Reports

PMID: 11241231 [PubMed - indexed for MEDLINE]

487: Methods Inf Med. 2000 Dec;39(4-5):311-8.

Validation of ICTERUS, a knowledge-based expert system for Jaundice diagnosis.

Molino G, Marzuoli M, Molino F, Battista S, Bar F, Torchio M, Lavelle SM, Corless
G, Cappello N.

Laboratory of Clinical Informatics, San Giovanni Battista Hospital of Turin,
Turin, Italy. gmolino@molinette.piemonte.it

The study aimed to describe an example of the assessment and validation of
knowledge-based clinical expert systems. The paper focuses on ICTERUS, an expert 
system for jaundice diagnosis. It describes system design, the methodology
applied for upgrading and validating the program, and the most important outcomes
of the validation procedure. The clinical validation of the system on a very
large European database (Euricterus Project) shows that diagnostic conclusions
are reliable in about 70% of eligible cases. This figure appears acceptable for a
system which provides decision support only on the basis of clinical data,
assuming that the final decision is achieved under user responsibility. Expected 
biases, limitations and inconsistencies in the practical application of the
system are discussed.

Publication Types: 
    Research Support, Non-U.S. Gov't

PMID: 11191699 [PubMed - indexed for MEDLINE]

488: Gut. 2001 Mar;48(3):409-13.

Comment in:
    Gut. 2002 Oct;51(4):613-4; author reply 614.

The causes of obvious jaundice in South West Wales: perceptions versus reality.

Whitehead MW, Hainsworth I, Kingham JG.

Department of Gastroenterology, Singleton Hospital, Sketty, Swansea SA2 8QA, UK.

AIMS: (1) A prospective analysis of clinically obvious jaundice (bilirubin >120
micromol/l) in South Wales to determine accuracy of diagnosis, referral pattern, 
treatment, and outcome. (2) To compare British gastroenterologists' and local
general practitioners' perceptions of common causes of jaundice with our study
findings. METHODS: Over a seven month period all patients with bilirubin >120
micromol/l (excluding neonates with physiological jaundice) were identified by a 
biochemistry laboratory serving three general hospitals and the community.
Clinical data were recorded prospectively. Sixty nine consultant
gastroenterologists and 67 local general practitioners (GPs) were asked to cite
the commonest causes of bilirubin >120 micromol/l in their experience. RESULTS: A
total of 121 patients were identified of whom 95 were admitted to hospital
because of jaundice, 22 developed jaundice while in hospital, and four remained
in the community. Causes of jaundice were: malignancy 42, sepsis/shock 27,
cirrhosis 25, gall stones 16, drugs 7, autoimmune hepatitis 2, and viral
hepatitis 2. One in five was wrongly diagnosed, often as viral hepatitis.
Although 30% were under surgical care only 4% required surgery. Overall mortality
was high (31%) and greatest in sepsis/shock (51%). Gastroenterologists and GPs
both perceived malignancy and gall stones to be the commonest causes of marked
jaundice followed by viral hepatitis and cirrhosis; sepsis/shock was hardly
mentioned. CONCLUSIONS: There are important discrepancies between
gastroenterologists' and GPs' perceptions of likely causes of jaundice and the
actual causes we have shown. In particular, sepsis/shock is common in hospital
practice but is overlooked whereas viral hepatitis is rare but perceived as
common and overdiagnosed. Gall stones usually cause mild jaundice with bilirubin 
levels less than 120 micromol/l. Many patients are referred to surgical services 
for historical reasons yet rarely require surgery and are usually treated by
physicians or endoscopists.

Publication Types: 
    Comparative Study

PMID: 11171834 [PubMed - indexed for MEDLINE]

489: Accid Emerg Nurs. 2000 Jan;8(1):20-3.

Hepatorenal problems presented in an urban high dependancy unit in a user of
ecstasy and cocaine.

Jones C, Little K.

Accident and Emergency Department, Aintree Complex, Aintree Hospital, Longmoor
Lane, Liverpool, UK.

A case is presented of a young man aged 25 years who had an episode of jaundice
and renal failure after using a small amount of ecstasy and cocaine. There is a
discussion of the issues raised by the case as well as some points of interest
for research and health education.

Publication Types: 
    Case Reports

PMID: 11147017 [PubMed - indexed for MEDLINE]

490: Epidemiol Infect. 2000 Oct;125(2):367-75.

Community studies on hepatitis B in Rajahmundry town of Andhra Pradesh, India,
1997-8: unnecessary therapeutic injections are a major risk factor.

Singh J, Bhatia R, Patnaik SK, Khare S, Bora D, Jain DC, Sokhey J.

National Institute of Communicable Diseases, Delhli, India.

In Rajahmundry town in India, 234 community cases of jaundice were interviewed
for risk factors of viral hepatitis B and tested for markers of hepatitis A-E.
About 41% and 1.7% of them were positive for anti-HBc and anti-HCV respectively. 
Of 83 cases who were tested within 3 months of onset of jaundice, 5 (6%), 11
(13.3%), 1 (1.2%), 5 (6%) and 16 (19.3%) were found to have acute viral hepatitis
A-E, respectively. The aetiology of the remaining 60% (50/83) of cases of
jaundice could not be established. Thirty-one percent (26/83) were already
positive for anti-HBc before they developed jaundice. History of therapeutic
injections before the onset of jaundice was significantly higher in cases of
hepatitis B (P = 0.01) or B-D (P = 0.04) than in cases of hepatitis A and E
together. Other potential risk factors of hepatitis B transmission were equally
prevalent in two groups. Subsequent studies showed that the majority of
injections given were unnecessary (74%, 95% CI 66-82%) and were administered by
both qualified and unqualified doctors.

PMID: 11117960 [PubMed - indexed for MEDLINE]

491: Gastroenterology. 2000 Nov;119(5):1348-57.

A replication-deficient rSV40 mediates liver-directed gene transfer and a
long-term amelioration of jaundice in gunn rats.

Sauter BV, Parashar B, Chowdhury NR, Kadakol A, Ilan Y, Singh H, Milano J,
Strayer DS, Chowdhury JR.

Department of Medicine, Seaver Institute of Human Genetics, Albert Einstein
College of Medicine, New York, New York, USA.

BACKGROUND & AIMS: In the quest for a recombinant viral vector for liver-directed
gene therapy that would permit both prolonged and efficient transgene expression 
in quiescent hepatocytes in vivo and repeated administration, we evaluated a
recombinant simian virus 40 (rSV40). METHODS: The rSV40 was generated through
replacement of the DNA encoding for the T antigens (Tag) by the coding region of 
human bilirubin-uridine 5'-diphosphate-glucuronosyl-transferase (BUGT)
complementary DNA (SV-hBUGT). Helper-free rSV40 units were generated at
infectious titers of 5 x 10(9) to 1 x 10(10) infectious units (IU)/mL in a
Tag-producing packaging cell line (COS-7 cells). RESULTS: After 1, 3, or 7 daily 
infusions of 3 x 10(9) IU of SV-hBUGT through an indwelling portal vein catheter 
in bilirubin-UGT-deficient jaundiced Gunn rats, mean serum bilirubin
concentrations decreased by 40%, 60% and 70%, respectively, in 3 weeks and
remained at those levels throughout the duration of the study (40 days). Results 
of liver biopsies from SV-hBUGT-treated Gunn rats, but not from controls, were
positive for human BUGT DNA, messenger RNA, and protein. Bilirubin-UGT activity
in liver homogenates was 8%-12% of normal, and bilirubin glucuronides were
excreted in bile. Immunostaining showed that >50%-60% of hepatocytes stably
expressed the transgene. Portal vein infusion of an rSV40 expressing hepatitis B 
surface antigen (HBsAg) in a naive Gunn rat and a Gunn rat that had received 7
injections of SV-BUGT resulted in approximately equal levels of hepatic
expression of HBsAg, indicating that multiple inoculations of SV-BUGT did not
elicit neutralizing antibodies. Plasma alanine aminotransferase levels and liver 
histology remained normal despite repeated injections of rSV40. CONCLUSIONS:
rSV40 vectors may represent a significant advance toward gene therapy for
metabolic diseases.

Publication Types: 
    Research Support, Non-U.S. Gov't
    Research Support, U.S. Gov't, P.H.S.

PMID: 11054394 [PubMed - indexed for MEDLINE]

492: Gut. 2000 Nov;47(5):717-20.

Co-amoxiclav jaundice: clinical and histological features and HLA class II
association.

O'Donohue J, Oien KA, Donaldson P, Underhill J, Clare M, MacSween RN, Mills PR.

Department of Gastroenterology, Gartnavel General Hospital, Glasgow G12 0YN, UK. 
john.o'donahue@uhl.nhs.uk

BACKGROUND AND AIMS: Jaundice associated with co-amoxiclav has been increasingly 
recognised. We aimed to characterise its clinical and histological features and
to investigate linkage with human leucocyte antigen class II haplotypes. METHODS:
We identified cases in the west of Scotland in the period 1991-1997 and performed
polymerase chain reaction amplification and oligonucleotide probing on whole
blood. RESULTS: Twenty two cases were identified (10 male, mean age 59.1 years). 
Jaundice occurred a median of 17 days after drug commencement, with a median peak
bilirubin level of 225 micromol/l (range 84-598) and median duration of jaundice 
69 days (range 29-150). Two patients had primary biliary cirrhosis and two other 
patients had persistently abnormal liver biochemistry on follow up. One death
occurred in a frail elderly woman despite resolving jaundice. The frequency of
jaundice was 1 in 78 209 co-amoxiclav prescriptions. Liver biopsy, available in
12 patients, showed perivenular bilirubinostasis, accompanying reactive ceroid
laden macrophages, and portal inflammation with focal injury to interlobular bile
ducts. Fourteen of 20 patients had DRB1*1501 compared with 27 of 134 controls
(p<2.5 x 10(-6); odds ratio (OR) 9.25; relative risk (RR) 6.43). Of these, seven 
patients were homozygous for DRB1*1501(p< 10(-8); OR 35.54; RR=8.68) compared
with two of 134 controls. All patients with DRB1*1501 had the extended haplotype 
DRB1*1501-DRB5*0101-DQA1*0102-DQB1*0602. There were no clinical or histological
differences between genotypes. CONCLUSIONS: Co-amoxiclav associated
hepatotoxicity may have a genetic basis and be delayed, severe, and prolonged,
although complete recovery is usual.

PMID: 11034591 [PubMed - indexed for MEDLINE]

493: J Ethnopharmacol. 2000 Nov;73(1-2):313-6.

Plant sources for the treatment of jaundice in the tribals of Western Madhya
Pradesh of India.

Samvatsar S, Diwanji VB.

School of Life Sciences, Devi Ahilya Vishwa Vidyalaya, Khandwa Road Campus,
452001, Indore, India. microb@mantraunline.com

A survey of the tribals of Western Madhya Pradesh of India for the treatment of
jaundice has yielded 13 plants for this purpose. Part of the plant used, dosage, 
duration, restriction on intake of food etc. has been reported.

Publication Types: 
    Research Support, Non-U.S. Gov't

PMID: 11025171 [PubMed - indexed for MEDLINE]

494: Trans R Soc Trop Med Hyg. 2000 May-Jun;94(3):243-6.

A survey on community perceptions of jaundice in east Delhi: implications for the
prevention and control of viral hepatitis.

Singh J, Shakya N, Jain DC, Bhatia R, Bora D, Pattanayak PK, Gupta S, Datta KK,
Sokhey J.

Epidemiology Division, National Institute of Communicable Diseases, Delhi, India.

Using senior health professionals as interviewers, a 30-cluster sampling survey
was carried out to investigate community perceptions of pilia (the local word for
jaundice) in east Delhi (India). Of 416 persons (mostly mothers of children aged 
< 2 years) interviewed, 339 (81%) were aware of pilia as an illness. Only 322
(77%), 164 (39%), 73 (18%) and 71 (17%) people knew about correct symptoms,
dangers, causes and prevention of pilia. Most of the correct responses were
related to the faeco-orally transmitted viral hepatitis. Literate respondents
were significantly more aware of pilia (chi 2 52.81, P < 0.0001), its symptoms
(chi 2 48.88, P < 0.0001), causes (chi 2 39.34, P < 0.0001), dangers (chi 2 19.3,
P = 0.0007), and prevention (chi 2 60.8, P < 0.0001). However, age of the
respondents had no significant bearing (P > or = 0.05) on the correctness of
responses. About 293 (70%) subjects considered pilia as a treatable illness; of
them, 193 (66%) and 77 (26%) respectively expressed their preference for the
'modern' and indigenous systems of medicine for its treatment. In contrast, 110
(38%) respondents said that they would prefer faith healers for the treatment of 
pilia. Although only 31 (7%) persons were aware of a vaccine against pilia
(hepatitis B vaccine), virtually all agreed to have their children immunized if
such a vaccine were made available. The study underscores the usefulness of pilia
in lay-reporting of viral hepatitis and epidemiological studies on
jaundice-associated illnesses and the need for educating the community about its 
causes and prevention to increase people's participation in controlling viral
hepatitis and other diseases that mainly manifest as jaundice.

Publication Types: 
    Research Support, Non-U.S. Gov't

PMID: 10974987 [PubMed - indexed for MEDLINE]

495: Eur J Surg Oncol. 2000 Jun;26(4):428-9.

Ampullary carcinoid and jejunal stromal tumour associated with von
Recklinghausen's disease presenting as gastrointestinal bleeding and jaundice.

Karatzas G, Kouraklis G, Karayiannakis A, Patapis P, Givalos N, Kaperonis E.

Second Department of Propedeutic Surgery, University of Athens Medical School,
Athens, Greece.

We report a very rare case of a 36-year-old woman with von Recklinghausen's
disease, synchronous carcinoid of the ampulla of Vater and stromal tumour of the 
jejunum, who presented with gastrointestinal bleeding and jaundice. Copyright
2000 Harcourt Publishers Ltd.

Publication Types: 
    Case Reports

PMID: 10873367 [PubMed - indexed for MEDLINE]

496: Int J Artif Organs. 2000 May;23(5):312-8.

Biochemical assessment and clinical evaluation of a non-ionic adsorbent resin in 
patients with intractable jaundice.

Pazzi P, Scagliarini R, Puviani AC, Lodi G, Morsiani E, Gullini S.

Department of Gastroenterology S. Anna Hospital and University of Ferrara, Italy.
pzp@unife.it

We investigated in vitro and in vivo the ability of a non-ionic adsorbing resin
(styrenedivinylbenzene copolymer) to remove bilirubin and bile acids from human
plasma. In preliminary experiments, human plasma from healthy donors, enriched in
conjugated bile acids and bilirubin, and pooled plasma from jaundiced patients
were recirculated through the resin column. The removal of bilirubin and bile
acids was evaluated at two different flow rates (200 ml/min and 40 ml/min), and
compared to an activated charcoal column. Four patients with severe jaundice were
subsequently treated by 4-hour plasmaperfusion through the resin. The in vitro
studies showed that after 1 hour the removal of bile acids was almost complete
and bilirubin level decreased significantly, reaching a plateau after 4 hours. In
the in vivo study, all treatments were well tolerated. After plasmaperfusion,
serum bile acid levels decreased by 64.9-94.6% and total bilirubin by 35.3-57.7%.
No clinical or biochemical side effects were observed. Our data suggest that
plasmaperfusion through this resin is safe and efficient for removal of bilirubin
and bile acids in jaundiced patients. Thus, it may serve as a method of
artificial liver support in the treatment of cholestatic syndromes.

PMID: 10872849 [PubMed - indexed for MEDLINE]

497: J Pediatr. 2000 Jun;136(6):771-4.

A new blue light-emitting phototherapy device: a prospective randomized
controlled study.

Seidman DS, Moise J, Ergaz Z, Laor A, Vreman HJ, Stevenson DK, Gale R.

Department of Obstetrics and Gynecology, Chaim Sheba Medical Center,
Tel-Hashomer, Israel.

OBJECTIVE: To evaluate the efficacy of a new phototherapy light source with a
narrow luminous blue spectrum. The device, made with high-intensity gallium
nitride light-emitting diodes (LEDs), was compared with conventional phototherapy
at similar light intensities. SETTING: Two university-affiliated community
hospitals in Jerusalem. DESIGN: Prospective open randomized study. PARTICIPANTS: 
Sixty-nine jaundiced, but otherwise healthy, term infants who met the entry
criteria for phototherapy set by the American Academy of Pediatrics' Practice
Parameter. MAIN OUTCOME MEASURES: The duration of phototherapy and the rate of
decrease in total serum bilirubin (TSB) concentration. RESULTS: The mean TSB
concentrations at initiation and termination of treatment did not differ between 
newborns receiving LED and those receiving conventional phototherapy. The
duration of phototherapy and the rate of decrease in TSB concentration were not
statistically different in the 2 groups. The average rate of decrease in TSB
after adjustment by a linear regression analysis for confounding factors was
-3.16 micromol/L/h (95% confidence limits -4.81, -1.51) in newborns receiving LED
phototherapy compared with -2.19 micromol/L/h (-3.99, -0.40) in those treated
with conventional phototherapy (P <.14). No side effects were noted in any of the
newborns. CONCLUSIONS: The blue gallium nitride LED device is as effective as
conventional phototherapy and is readily accepted by nursing staff. Future LED
phototherapy devices can provide much higher irradiance, and thus greater
efficacy, and offer a new highly versatile approach to the treatment of jaundice.

Publication Types: 
    Clinical Trial
    Randomized Controlled Trial
    Research Support, Non-U.S. Gov't
    Research Support, U.S. Gov't, P.H.S.

PMID: 10839875 [PubMed - indexed for MEDLINE]

498: Scand J Gastroenterol. 2000 Apr;35(4):438-45.

Objective assessment of the contribution of each diagnostic test and of the
ordering sequence in jaundice caused by pancreatobiliary carcinoma.

de Bree E, Tsiftsis DD, Santos RM, Lavelle SM, Cuervas-Mons V, Gauthier A, Gips
C, Malchow-Moeller A, Molino G, Rohr G, Theodossi A, Tsantoulas D.

Dept. of Surgical Oncology, University Hospital, Herakleion, Crete, Greece.

BACKGROUND: Computer-assisted diagnostic systems are not substantially more
accurate than the clinician in the differential diagnosis of jaundice but may
help in optimal selection and sequencing of tests. The present study aimed to
assess with an electronic diagnostic tool the pattern of ordering tests and the
diagnostic contribution and related financial cost of each test in jaundiced
patients with pancreatobiliary carcinoma, in an effort to make the clinician's
diagnostic behaviour more efficient and economical. METHODS: Clinical and
diagnostic test data were prospectively gathered from 356 jaundiced patients with
pancreatobiliary carcinoma and entered in a Bayesian diagnostic programme. The
test results were added to the existing diagnostic evidence, and the programme
calculated the diagnostic contribution of each test. RESULTS: A total of 1804
diagnostic tests were ordered. Quantitative assessment of the diagnostic
contribution of each test showed that percutaneous transhepatic cholangiography
and computed tomography were associated with the highest provision of
information. The most cost-effective tests were ultrasonography and liver
function tests. CONCLUSIONS: It is possible to determine objectively the
diagnostic contribution of each test in establishing the diagnosis of
pancreatobiliary carcinoma. The observed physician behaviour in ordering the
various diagnostic tests might be improved with regard to its efficacy and its
cost-effectiveness profile.

PMID: 10831270 [PubMed - indexed for MEDLINE]

499: Acta Neuropathol. 2000 Apr;99(4):393-401.

Expression of the alpha and beta subunits of Ca2+/calmodulin kinase II in the
cerebellum of jaundiced Gunn rats during development: a quantitative light
microscopic analysis.

Conlee JW, Shapiro SM, Churn SB.

Department of Veteran Affairs Medical Center, Salt Lake City, UT 84148, USA.

The homozygous (jj) jaundiced Gunn rat model for hyperbilirubinemia displays
pronounced cerebellar hypoplasia. To examine the cellular mechanisms involved in 
bilirubin toxicity, this study focused on the effect of hyperbilirubinemia on
calcium/calmodulin-dependent kinase II (CaM kinase II). CaM kinase II is a
neuronally enriched enzyme which performs several important functions.
Immunohistochemical analysis of alternating serial sections were performed using 
monoclonal antibodies for the alpha and beta subunits of CaM kinase II.
Measurements were made of the total numbers of stained cells in each of the deep 
cerebellar nuclei and of Purkinje and granule cell densities in cerebellar
lobules II, VI, and IX. The beta subunit was present in Purkinje cells and deep
cerebellar nuclei of both groups at all ages, but only granule cells which had
migrated through the Purkinje cell layer showed staining for beta subunit;
external granule cells were completely negative. Many Purkinje cells had
degenerated in the older animals, and the percent of granule cells stained for
beta subunit was significantly reduced. The alpha subunit was found exclusively
in Purkinje cells, although its appearance was delayed in the jaundiced animals. 
Sulfadimethoxine was administered to some jj rats 24 h or 15 days prior to
sacrifice to increase brain bilirubin concentration. Results showed that
bilirubin exposure modulated both alpha and beta CaM kinase II subunit expression
in selective neuronal populations, but sulfadimethoxine had no acute effect on
enzyme immunoreactivity. Thus, developmental expression of the alpha and beta
subunits of CaM kinase II was affected by chronic bilirubin exposure during early
postnatal development of jaundiced Gunn rats.

Publication Types: 
    Research Support, U.S. Gov't, P.H.S.

PMID: 10787038 [PubMed - indexed for MEDLINE]

500: J Pediatr Hematol Oncol. 2000 Mar-Apr;22(2):154-7.

Jaundice caused by the vanishing bile duct syndrome in a child with Hodgkin
lymphoma.

Yusuf MA, Elias E, Hübscher SG.

Shaukat Khanum Memorial Cancer Hospital & Research Centre, Lahore, Pakistan.

The authors report a 5-year-old boy with Hodgkin disease and cholestatic jaundice
that predated the start of treatment for his lymphoma. His clinical course was
punctuated by relentless progression of jaundice, characterized by obstructive
pattern liver function tests, severe pruritus, intermittent fever, and marked
hypercholesterolemia with development of palmar xanthomata. The jaundice was
found to be attributable to vanishing bile duct syndrome (VBDS). The extent of
hepatic dysfunction precluded appropriate treatment of the lymphoma with
chemotherapy, and the boy died of liver failure. In the differential diagnosis of
jaundice in children with Hodgkin disease, VBDS should be considered.

Publication Types: 
    Case Reports

PMID: 10779030 [PubMed - indexed for MEDLINE]

501: Acad Emerg Med. 2000 Feb;7(2):146-56.

Evaluation of the physician's ability to recognize the presence or absence of
anemia, fever, and jaundice.

Hung OL, Kwon NS, Cole AE, Dacpano GR, Wu T, Chiang WK, Goldfrank LR.

Department of Emergency Medicine, Bellevue Hospital Center, New York University
Medical Center, New York 10016, USA. olhung@pol.net

OBJECTIVE: The evaluation of the patient through a comprehensive history and
physical examination is considered the cornerstone of medical diagnosis, but many
studies suggest that physicians have inadequate physical examination skills. It
is unknown whether these skills are reliable and whether they can be adequately
acquired through training. The objective of this study was to evaluate the
ability of the clinician to detect the presence and discriminate the extent of
clinical anemia, fever, and jaundice in an ED or hospitalized patient. METHODS:
This was a prospective observational study of a convenience sample of patients
presenting to the ED or admitted to the hospital who had a rectal temperature
measurement within 30 minutes prior to the observation, serum hematocrit
measurement on the day of observation, or serum bilirubin measurement one day
prior to the day of observation. Observers' (emergency medicine attending
physicians', resident physicians', and rotating medical students') estimated
serum hematocrit, rectal temperature, and serum bilirubin values were obtained
after each observation. Sensitivity, specificity, positive predictive value,
negative predictive value, and mean absolute difference between actual and
estimated values were calculated for each observer. RESULTS: The physicians
detected the presence or absence of anemia, fever, and jaundice in patients with 
sensitivities and specificities of approximately 70%. Their predictions varied
from the measured value on average by 6.0 +/- 4.6% for serum hematocrit, 1.3 +
1.1 degrees F for rectal temperature, and 3.4 +/- 5.3 mg/dL for serum bilirubin. 
Observer accuracy decreased when evaluating patients with high and low measured
values. CONCLUSIONS: The ability to correctly perform and interpret the physical 
examination appears to be independent of the observer level of training, patient 
ethnicity, or patient gender. The examination for pallor, warmth, and jaundice is
unreliable in predicting the corresponding laboratory or electronic measurement. 
Certain anemic, febrile, or jaundiced patients may not be reliably detected
solely by a focused physical examination.

PMID: 10691073 [PubMed - indexed for MEDLINE]

502: Radiographics. 2000 Jan-Feb;20(1):173-95.

US approach to jaundice in infants and children.

Gubernick JA, Rosenberg HK, Ilaslan H, Kessler A.

Department of Radiology, Albert Einstein Medical Center, Philadelphia, PA
19141-3098, USA.

High-resolution real-time ultrasonography (US) serves as an important tool for
differentiation of obstructive and nonobstructive causes of jaundice in infants
and children, independent of liver function. Unconjugated hyperbilirubinemia
occurs in approximately 60% of normal term infants and in 80% of preterm infants.
Persistence of neonatal jaundice beyond 2 weeks of age demands US evaluation to
differentiate between the three most common causes: hepatitis, biliary atresia,
and choledochal cyst. In all three conditions, the hepatic echotexture is
diffusely coarse and hyperechoic, but this appearance may be seen in a variety of
hepatic inflammatory, obstructive, and metabolic processes. Thus, hepatic
scintigraphy and at times percutaneous liver biopsy are necessary to narrow the
differential diagnosis and to identify patients who require more invasive
techniques (eg, intraoperative cholangiography). US is useful for demonstrating
inspissated bile and biliary duct stones. In infants, stones are usually
secondary to obstructive congenital anomalies of the biliary tract, total
parenteral nutrition, furosemide treatment, phototherapy, dehydration, infection,
hemolytic anemia, and short-gut syndrome, whereas in older children, stones are
usually associated with sickle cell disease, bowel resection, hemolytic anemia,
and choledochal cyst. Jaundice in infants and children may also be due to
cirrhosis, benign strictures, and neoplastic processes.

Publication Types: 
    Review

PMID: 10682780 [PubMed - indexed for MEDLINE]

503: Anesth Analg. 2000 Feb;90(2):489-93.

Interference of cerebral near-infrared oximetry in patients with icterus.

Madsen PL, Skak C, Rasmussen A, Secher NH.

Departments of Anesthesia and Transplantation, Rigshospitalet, Copenhagen,
Denmark. fyrrevang11@dadlnet.dk

Near-infrared spectrophotometry assesses cerebral oxygen saturation (ScO(2))
based on the absorption spectra of oxygenated and deoxygenated hemoglobin and the
translucency of biological tissue in the near-infrared band. In patients with
icterus, however, bilirubin can potentially hinder cerebral oximetry. In 48
patients undergoing orthotopic liver transplantation, we related total plasma
bilirubin to ScO(2) as determined from spectrophotometry with wavelengths of 733 
and 809 nm. Before surgery, ScO(2) was 59% (15%-78%) (median with range) and
bilirubin was 71 (6-619) micromol/L with a negative correlation (r = -0.72; P <
0.05). The 95% prediction interval included the lowest measurable ScO(2) of 15%
at a bilirubin level of 370 micromol/L. During reperfusion of the grafted liver, 
the ScO(2) increased by 7% (-8% to 17%) (P < 0.05), and bilirubin did not
influence this increase. In one patient, the ScO(2) remained below 15% despite a 
decrease in bilirubin from 619 to 125 micromol/L, suggesting that tissue
pigmentation deposits also absorb light. In conclusion, bilirubin dampens the
spectrophotometry-determined cerebral oxygen saturation at 733 and 809 nm. A
bilirubin level of 370 micromol/L, tissue pigment deposits, or both, may render
determination of cerebral oxygen saturation impossible. Even at high bilirubin
values, changes in cerebral perfusion may be visible. IMPLICATIONS: In 48
patients undergoing liver transplantation, the interference of icterus on
cerebral oximetry by near-infrared light was investigated. Bilirubin absorbed the
near-infrared light and lowered the measured cerebral oxygen saturation. Even at 
high bilirubin values, changes in cerebral oxygenation, as seen during
reperfusion of the grafted liver, may be visible.

Publication Types: 
    Clinical Trial
    Research Support, Non-U.S. Gov't

PMID: 10648345 [PubMed - indexed for MEDLINE]
