Comparative Study on Presentation of Biliary Ascariasis with Dead and Living Worms

Background/Aim:

Ascariasis is a common parasitic infestation in Asia and Latin America. The most serious presentation is biliary and pancreatic ascariasis (BPA). The aim of the present study was to compare the clinical presentation of BPA with dead worms with that with living worms.

Materials and Methods:

We included 138 consecutive cases of BPA that occured during the period January 2005 to July 2009. All the patients had endoscopically proven BPA consisting of living or dead worms. Comparison was done by chi-square and independent t tests.

Results:

The age (mean ± SD) of the patients was 36.8 ± 16.1 years. Prevalence ratio between male and female patients was 1:5. Ninety eight patients contained living worms and 40 had dead worms. Males were more prone to develop dead worm BPA. The commonest presentation was biliary colic (131; 94.9%); others were acute cholangitis (30; 21.7%), obstructive jaundice (19; 13.8%), choledocholithiasis (20; 14.5%), acute pancreatitis (10; 7.2%), acute cholecystitis (6; 4.3%), liver abscess (2; 1.4%), hepatolithiasis (3; 2.2%), stricture of common bile duct (2; 1.4%), pancreatic abscess (1; 0.7%) and cirrhosis of liver (1; 0.7%). Choledocholithiasis, hepatolithiasis, liver abscess and cirrhosis were associated only with dead worms. We could successfully remove all the worms with endoscopic interventions, but 5 patients required surgical intervention as there were strictures and stones within the biliary tree or Ascaris were in gallbladder. Recurrences of stone and cholangitis occurred only in those with dead worms.

Conclusion:

Biliary ascariasis with dead worms is more dangerous than that with living worms. Endoscopic or surgical intervention may be required repeatedly in those with dead worms.     

Hypocholesterolemia in Patients with an Amebic Liver Abscess

Background/Aims

Many parasites induce changes in the lipid profiles of the host. Cholesterol increases the virulence of Entamoeba histolytica in animal models and in vitro culture. This study aimed to determine, in patients with an amebic liver abscess, the correlation between cholesterol and other features, such as the size and number of abscesses, standard hematological and serum chemistry profiles, liver tests, and duration of hospital stay.

Methods

A total of 108 patients with an amebic liver abscess and 140 clinically healthy volunteers were investigated. Cholesterol and triglycerides were measured in the sera. The data from medical observations and laboratory tests were obtained from the clinical records.

Results

A total of 93% of patients with an amebic liver abscess showed hypocholesterolemia not related to any of the studied parameters. Liver function tests correlated with the size of the abscess. The most severe cases of amebic liver disease or death were found in patients whose cholesterol levels continued to decrease despite receiving antiamebic treatment and hospital care.

Conclusions

Our results show that the hypocholesterolemia observed in patients with an amebic liver abscess is not related to any of the clinical and laboratory features analyzed. This is the first study relating hypocholesterolemia to severity of hepatic amebiasis.     

Liver storage disease in Iran: a ten year study of liver biopsies in Children Medical Center Hospital in Tehran-Iran

Background

Liver storage diseases are rare biochemical and inherited diseases that affect multiorgan systems.

Objectives

This study was performed to determine the rate of storage diseases and their types in liver pathology specimens of subjects who were referred to a tertiary pediatric center.

Patients and Methods

Two pathologists evaluated 2216 pathology specimens (stained with hematoxylin and eosin and periodic acid-Schiff) from subjects who were referred to the largest pediatric tertiary referral center in Iran between 1996 and 2007. Baseline data and clinical and laboratory manifestations were retrieved from the patients'' files.

Results

We identified 117 patients who had storage diseases. A combination of clinical and laboratory findings was used to assess the final diagnosis. Glycogen storage disease (GSD) was observed in 85 of cases, compared with lysosomal storage diseases (LSD) in 31 patients and mucopolysaccharidoses in 1 case. LSD was more prevalent in those aged between 1 month and 1 year, whereas GSD was more frequent in those aged between 1 and 6 years. Most of the patients aged between 1 and 6 years. Most patients with LSD and GSD had unknown types of the disease. The most common known types in the LSD and GSD groups were Niemann-Pick disease and GSD type I respectively. The most common clinical and laboratory manifestation was hepatomegaly and abnormal liver enzymes, respectively.

Conclusions

Most of our patients with storage diseases had Gaucher disease. Hepatomegaly and elevated transaminase levels were the most striking finding. However, with regard to the limitations of our methodology, further studies that collect more accurate data are warranted.     

Prevalence of Microscopic Colitis in Patients with Chronic Diarrhea in Egypt: A Single-center Study

Background/Aim:

Microscopic colitis (MC) is diagnosed when a patient with chronic watery non-bloody diarrhea (CWND) has an endoscopically normal colon, but colonic biopsies show unique inflammatory changes characteristic of lymphocytic or collagenous colitis. MC is a disorder of unknown etiology. Studies comparing the prevalence of the disease in developing countries as compared to developed countries may shed more light on the possibility of a post-infectious etiology. Most data on the incidence and prevalence of MC are from developed countries where it accounts for 4-13% of cases of CWND. There are only a few reports from developing countries. Two studies from Peru and Tunis, with high prevalence of infectious gastroenteritis, revealed MC in 40% and 29.3% of cases of CWND, respectively. The aim of this study was to investigate the prevalence of MC in patients presenting with CWND in Egypt.

Materials and Methods:

A total of 44 patients with CWND of unexplained etiology who had undergone full colonoscopy with no macroscopic abnormalities between January 2000 and January 2010 were assessed retrospectively.

Results:

The histological appearance of MC was identified in 22 (50%) patients. Twelve (55%) patients were male and 10 (45%) female. Mean age was 40 years (range: 20-65 years). Twenty (91%) of MC cases had lymphocytic colitis and 2 (9%) had collagenous colitis.

Conclusions:

The prevalence of MC in Egyptian patients with CWND is high when compared to that in developed countries. MC mainly affects young and middle-aged patients and it is more commonly of the lymphocytic type.     

Long-term Follow up of Mesenchymal Hamartoma of Liver- Single Center Study

Background/Aim:

Mesenchymal hamartoma of liver (MHL) is a rare liver tumor of childhood. About 200 cases have been reported till now. Most of the work on MHL is limited to case reports and there are not many long term follow-up studies. We present our 20 years of experience with this uncommon entity. This study aims to highlight clinical features, diagnosis and treatment of MHL.

Materials and Methods:

All patients with a diagnosis of MHL in last 20 years were included in this retrospective study. The patients were evaluated clinically, radiologically and pathologically.

Results

The total number of patients with a diagnosis of MHL was nine. Mean age of the patients was 19.89 ± 2.75 months. Right lobe was involved in eight patients. The prominent clinical features were distension of abdomen and anorexia. Surgical options used were hepatic lobectomy, wedge resection and enucleation. Histopathology of the specimens showed cysts of variable size with normal hepatocytes, bile ducts and connective tissue stroma. Overall mortality was one (11.11%).

Conclusion:

MHL is a benign tumor that can present with various clinical features. It should be differentiated carefully from other liver masses especially malignant ones. The diagnosis can be made with the help of radiology and histopathology. Adequate resection is curative in most of the cases and long-term follow up is satisfactory.     

Cholangiocarcinoma Secondary to Primary Sclerosing Cholangitis in Explanted Livers: A Single-Center Study in the South of Iran

Background:

Primary sclerosing cholangitis (PSC) is a chronic disease, characterized by chronic inflammation and fibrosis of bile duct epithelial cells. This is a significant contributory factor to the development of malignancy, most commonly cholangiocarcinoma (CCA), which is the second most common malignant liver tumor.

Objectives:

For the first time in Iran, we intend to describe our experience with cases of PSC, with and without CCA, in explanted livers, and compare our results with those found in other areas of the world.

Patients and Methods:

The study population comprised 181 individuals with a diagnosis of PSC who had undergone liver transplantation in the main liver transplant center of Iran, the largest center of hepatobiliary surgery in the south of that country, over a 3-year period between 2012 and 2014. All explanted livers, with and without CCA, were evaluated.

Results:

Of the 181 patients, 16 were found to have CCA, two of whom had been diagnosed after pathologic study of the explanted livers. Therefore it appeared that 8.8% of the patients with PSC in our center had developed CCA before liver transplantation.

Conclusions:

A comparison of our results with those obtained from other centers in both Western and Asian countries (which reported CCA in 3.6% - 36.5% of patients with PSC), shows that the incidence of CCA in the patients we studied is intermediate.     

Lack of Knowledge About Hepatitis C Infection Rates Among Patients With Inherited Coagulation Disorders in Countries Under the Eastern Mediterranean Region Office of WHO (EMRO): A Meta-Analysis

Context

Hepatitis C virus (HCV) infection is a public health problem. HCV alone is responsible for 90% cases of acute hepatitis among multiply transfused patients who are at risk of cirrhosis and hepatocellular carcinoma (HCC).

Objectives

To provide a clear picture of available data, we performed a systematic review of the epidemiological characteristics of HCV infection among patients with inherited coagulation disorders in the countries under the Eastern Mediterranean Region Office (EMRO).

Evidence Acquisition

Meta-analysis was carried out on the basis of results of electronic and manual search. This analysis included studies in English, French, and Persian that met with the following criteria: (1) appropriate study design: cross-sectional, case-control, and cohort; (2) studies reporting HCV prevalence according to enzyme immune assay; (3) studies in which the sample population was enrolled from EMRO countries. According to the results of the heterogeneity tests, we used fixed-effect/random-effect model for our meta-analysis, with the “Metan” command.

Results

We included 30 studies, most of which were from Iran. The mean age of the subjects ranged from 13 to 27.1 years. The majority of the patients were male (range, 81% to 100%). The pooled estimate of HCV infection among patients with inherited coagulation disorders was 48.07% (95% confidence interval [CI], range: 27.39–55.68) in Iran, 36.03% (95% CI, range: 4.466–67.598) in Pakistan, and 48.27% (95% CI, range: 36.12–60.43) in all the EMRO countries taken together.

Conclusions

In Iran and other EMRO countries, the HCV infection rate among patients with inherited coagulation disorders is high. Our study shows that there is a lack of knowledge about infections in such patients in most of the EMRO countries. It is the responsibility of health-policy makers to address this knowledge gap and provide safe and adequate treatment for patients in high-risk groups.     

Biliary Ascariasis in the Indian Subcontinent: A Study of 42 Cases

Background/Aim:

History of ascariasis is known to stretch back many centuries. One quarter of the world''s population is known to be infected by ascariasis. It is endemic in various parts of the Indian subcontinent and the gangetic plain of West Bengal is one of them. We aimed to study the various types of clinical presentations, complications and different diagnostic tools and to assess various options for the management of biliary ascariasis.

Materials and Methods:

Forty-two cases of hepatobiliary ascariasis were studied over a period of 3 years. All the patients were adults aged between 20 and 50 years and all but two were admitted with acute upper abdominal pain.

Results:

In this study, biliary ascariasis was found to be more common in females, 73.8% (31 patients). The most common presentation was upper abdominal pain in 95.2% of the patients (40 patients). Complications observed were obstructive jaundice in 28.56% (12 patients), cholangitis in 16.7% (seven patients), acute pancreatitis in 2.4% (one patient) and hepatic abscess in 2.4% (one patient). History of worm emesis was present in 38.1% (16 patients). History of previous cholecystectomy was present in 16.7% (seven patients) and endoscopic sphincterotomy in 4.8% (two patients). Ultrasound was the diagnostic tool of choice with 100% results. Conservative management was successful in 83.3% (35 patients). During follow-up, worm reinvasion of the biliary system occurred in 7.1% (three patients).

Conclusion:

In endemic countries, ascariasis should be suspected in patients with biliary disease, especially if a cholecystectomy or sphincterotomy has been performed in the past. Most of the patients respond to conservative management.     

Distribution and risk factors of hepatitis B virus infection in the general population of Central Iran

Background

Hepatitis B is the most common chronic viral infection in humans and the most common cause of death among viral hepatitis. As 70% to 80% of chronic hepatitis cases are caused by HBV in Iran, this virus alone is considered the most important cause of liver diseases and the major cause of mortality arising from viral hepatitis cases in Iran.

Objectives

We planned this study to determine the prevalence of hepatitis B in the general population of Qom, central Iran.

Patients and Methods

The present study is a cross-sectional study. A total of 3690 samples were collected from 7 rural clusters and 116 urban clusters. Ten teams, each consisting of 2 trained members, were assigned to conduct the sampling and fill the questionnaires. The data were analyzed using SPSS.

Results

The prevalence rate of hepatitis B infection in Qom Province was 1.3%. The mean age of the patients with hepatitis B was 44.17 years. The prevalence of hepatitis B was 1.6% in men and 1.1% in women. Moreover, the prevalence of hepatitis B correlated positively with age, tattooing, and literacy level.

Conclusions

The prevalence rate of hepatitis B in Qom is 1.3%. It is possible to prevent the disease by increasing public awareness. Further investigation on clinical presentations and a determination of the genotype of the virus are suggested.     

Platelet count/bipolar spleen diameter ratio for the prediction of esophageal varices: The special Egyptian situation: Noninvasive prediction of esophageal varices

Background

Esophageal variceal hemorrhage is a devastating complication of portal hypertension that occurs in approximately one-third of cirrhotic patients.

Objectives

We assessed the value of the platelet count/ bipolar spleen diameter ratio as a noninvasive parameter for the prediction of esophageal varices (EVs) in Egyptian cirrhotic patients.

Patients and Methods

Laboratory and ultrasonographic and imaging variables were prospectively evaluated in 175 patients with liver cirrhosis. All patients underwent upper gastrointestinal endoscopy. Patients with active gastrointestinal bleeding at the time of admission were excluded.

Results

The platelet count/ bipolar spleen diameter ratio in patients with EVs was significantly lower than in patients without EVs. In an analysis of the receiver operating characteristic curves (ROCs), we calculated an optimal cutoff value of 939.7 for this ratio, which gave 100% sensitivity and negative predictive values, 86.3% specificity, a 95.6% positive predictive value, and an area under the ROC curve of 0.94 ± 0.02, reflecting its overall diagnostic accuracy. These findings were extended to a subset analysis of compensated cirrhotic patients.

Conclusions

The platelet count/ bipolar spleen diameter ratio has excellent accuracy in the noninvasive assessment of EVs in patients with compensated or decompensated liver cirrhosis. It is easy to calculate and can lower the financial and sanitary burdens of endoscopy units, especially in developing countries.     

Role of Albendazole in the Management of Hydatid Cyst Liver

Background/Aim:

Hydatidosis has a worldwide distribution and the liver is the most common organ involved. Hydatid cysts of the liver can be managed either by nonoperative or operative methods. Nonoperative methods include chemotherapy and percutaneous treatment. The study aimed at understanding the effect of albendazole therapy on the viability of protoscoleces and recurrence rate of hydatid disease of the liver.

Patients and Methods:

The study was conducted at Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar, Kashmir, India, over a period of 2 years from January 2002 to December 2003, with further follow-up of 5 years. The study included 72 cases in the age group of 17-66 years, comprising 39 males and 33 females. The patients were randomized into two groups of 36 patients each. In group A, patients were directly subjected to surgery, while in group B, patients were administered albendazole for 12 weeks preoperatively, followed by a further postoperative course for 12 weeks.

Results:

Of patients who received albendazole therapy, no patient had viable cysts at the time of surgery, as compared to 94.45% of the patients who did not receive any preoperative albendazole (P<0.01). In patients who did not receive any albendazole therapy, recurrence rate was 16.66%, while no recurrence was seen in patients who received albendazole therapy (P≤0.05).

Conclusion:

We conclude that albendazole is an effective adjuvant therapy in the treatment of hydatid liver disease.     

Autoimmune Hepatitis: Single-center Experience of Clinical Presentation, Response to Treatment and Prognosis in Saudi Arabia

Background /Aim:

Autoimmune hepatitis (AIH) is a common cause of end-stage liver disease worldwide. It is a disease prevalent in children and adults, with female predominance and variable clinical presentations. AIH has favorable responses to steroids and immunomodulators. Diagnosis of AIH is based on clinical and laboratory criteria, as suggested by the International Autoimmune Hepatitis Group. Data on the disease pattern of AIH from the Middle East countries is scarce.

Materials and Methods:

In this retrospective analysis, we studied clinical and laboratory features, immunological data, radiological findings, liver biopsy findings and response to therapy in patients with AIH from the hepatology clinics of King Abdul Aziz, University Hospital, Jeddah, from 1994 to 2008.

Results:

We diagnosed 41 patients with AIH, and 33 were included in the analysis. The mean age was 32.3 years, with female predominance of 75.7%. De-compensated cirrhosis at presentation was found in 45.5% of the patients. Acute hepatitis was associated with significantly higher levels of the serum ALT and bilirubin (P=0.001 and P=0.03, respectively). All our patients had type 1 AIH. Treatment with prednisolone and azathioprine resulted in complete or partial remission in majority of the patients (54.8%). However, patients with advanced disease showed a poorer response to treatment (P=0.016). Six patients with poor compliance had relapse of AIH. Two patients had a flare of the disease during pregnancy, and they responded well with prednisolone. The longest follow-up was 14 years and the shortest was 2 months. Four patients died from liver disease.

Conclusion:

AIH patients in Saudi Arabia are likely to present with advanced disease at a young age and would have a poorer response to therapy as compared with patients in other countries worldwide.     

Cardiovascular complications in newly diagnosed rheumatic heart disease patients at Mulago Hospital,Uganda

Background

Complications of rheumatic heart disease are associated with severe morbidity and mortality in developing countries where the disease prevalence remains high. Due to lack of screening services, many patients present late, with severe valve disease. In Uganda, the disease and its complications are still not well studied.

Objective

To profile and describe cardiovascular complications in newly diagnosed rheumatic heart disease patients attending the Mulago National Referral Hospital in Uganda.

Methods

This was a cross-sectional study where consecutive, newly diagnosed rheumatic heart disease patients were assessed and followed up for complications, such as heart failure, pulmonary hypertension, atrial fibrillation, recurrence of acute rheumatic fever, and stroke.

Results

A total of 309 (115 males and 196 females) definite rheumatic heart disease patients aged 15–60 years were enrolled in the study and analysed. Complications occurred in 49% (152/309) of the newly diagnosed rheumatic heart disease cases, with heart failure (46.9%) the most common complication, followed by pulmonary arterial hypertension (32.7%), atrial fibrillation (13.9%), recurrence of acute rheumatic fever (11.4%), infective endocarditis (4.5%) and stroke (1.3%). Atrial fibrillation and acute rheumatic fever were the most common complications associated with heart failure.

Conclusion

In this study we found that about 50% of newly diagnosed rheumatic heart disease patients in Uganda presented with complications. Heart failure and pulmonary arterial hypertension were the most commonly observed complications.     

Clinical features and long term outcome of 102 treated autoimmune hepatitis patients

Background

There is limited data on the natural history of autoimmune hepatitis (AIH) and on the long-term follow-up of AIH patients who have been referred for regular medical attention.

Objectives

We evaluated the clinical presentation and natural history of AIH in a large cohort of type I AIH patients from Iran.

Patients and Methods

Between 1997 and 2008, 102 patients were enrolled in the study. Patients were diagnosed using the International Autoimmune Hepatitis Group criteria and were followed up for an average of 60 months. Clinical and biochemical data were gathered from all the patients at both the beginning and the end of the follow-up period. Liver biopsy was performed in all patients before treatment, and the biopsies were performed in 28 patients after treatment.

Results

Biochemical remission was achieved by 80 (79.4%) patients. Of these, 53 (66.5%) showed near-normal liver histology or liver function test results and sonogram. The remaining 27 (33.5%) patients also achieved clinical and biochemical remission, but developed compensated cirrhosis. After a period of remission, 24 patients (32.5%) relapsed. Among the 22 (21.6%) patients who showed ultimate treatment failure, 6 underwent orthotopic liver transplantation and 3 died of liver failure while awaiting a transplant. Sixteen (72.7%) of the 22 patients who did not respond to therapy were non-compliant with medications and had irregular follow-up. The overall 10-year survival rate in the cohort was 96%.

Conclusions

Long-term survival in AIH patients is very good. Prompt diagnosis and appropriate first-line and salvage therapy that includes close follow-up will make liver transplantation a rare necessity in the treatment of this disease.     

Cytologic Comparison Between Malignant and Regenerative Nodules in the Background of Cirrhosis

Background

Incidence of hepatocellular carcinoma has been increased as the sixth most common cancer in the world. Improvement in imaging techniques has decreased the need for tissue confirmation in diagnosis of hepatocellular carcinoma (HCC). Meanwhile, false negative and positive cases are present. Fine needle aspiration (FNA) biopsy can be helpful to identify well-differentiated HCCs with low risk of vascular invasion and better prognosis following transplantation.

Objectives

We conducted this study to find useful criteria for cytological differential diagnosis between nodules of well differentiated hepatocellular in the background of cirrhosis and pure cirrhotic regenerative nodules in cytology smears.

Materials and Methods

140 fine needle aspirations (FNA) of fresh cirrhotic hepatectomy specimens were studied (100 pure regenerative nodules and 40 HCC nodules). All slides were reviewed by two expert pathologists. The most useful criteria were selected and evaluated in 560 cytology smears stained by Pap and Wright methods.

Results

None of the smears from cirrhotic patients showed mitosis, transgressing endothelium, eccentric nuclei, and scant cytoplasm, but thick nuclear membrane, spindle cells and abundant, thick and monotonous cytoplasm were found in many cases with cirrhosis. Large nucleoli (2 %), multiple nucleoli (6 %), increased N/C ratio (4 %), and broad cores (2 %) were found very rarely in the smears of regenerative nodules, but they were present in 50 %, 72.5 %, 87 %, and 77.5 % of HCC nodules, respectively.

Conclusions

Combination of cytologic criteria can be helpful for differential diagnosis between HCC and regenerative nodules.     

A Retrospective Study of Two-port Appendectomy and its Comparison with Open Appendectomy and Three-port Appendectomy

Background/Aims:

To establish the efficacy of two-port appendectomy as an alternative to standard laparoscopic and open appendectomy in the management of acute appendicitis.

Materials and Methods:

Of the 151 patients included in the study, 47 patients were in the open group, 61 in two-port and 43 patients were included in the three-port group. Only patients with uncomplicated acute appendicitis were included in the study. Patients with complicated appendicitis like perforated appendix, appendicular lump and appendicular abscess were excluded from the study. Patients converted to open procedure after initial diagnosis and patients with other pathology in addition to appendicitis were also excluded. Patients with recurrent appendicitis and chronic appendicitis were excluded. The total number of excluded cases was 50. Data were compared with cases of open and three-port appendectomy.

Results:

The mean operative time was 43.94, 35.74, and 59.65 min (SD: 18.91, 11.06, 19.29) for open, two-port, and three-port appendectomy groups respectively. Mean length of stay in days was 3.02, 1.93, and 2.26 (SD: 1.27, 1.04,1.09) for open, two-port, and three-port appendectomy groups respectively. Surgical site infection was significantly lower (P = 0.03) in laparoscopy group as compared to that in open appendectomy group. Seven patients (4.63%) developed surgical site infection, 5 (10.63%) in the open and 2 (1.92%) in the laparoscopy group. Surgical site infection was 1.63% and 2.32% in two-port and three-port appendectomy groups respectively.

Conclusions:

For uncomplicated appendicitis, the two-port appendectomy technique significantly reduces operative time as well as length of hospital stay. It also reduces surgical site infection as compared to open appendectomy group.     

Pepsin and Bile Acid Concentrations in Sputum of Mustard Gas Exposed Patients

Background/Aim:

Gastro-esophageal reflux has been suggested to be associated with several pulmonary complications such as asthma, and post-transplant bronchiolitis obliterans (BO). Pepsin or bile salts in the sputum is shown to be an optimal molecular marker of gastric contents macro/micro aspiration. In this study, we investigated sputum pepsin as a marker of micro-aspiration in sulfur mustard (SM) exposed cases compared to healthy controls.

Materials and Methods:

In a case controlled study, 26 cases with BO and 12 matched healthy controls were recruited and all cases were symptomatic and their exposure to SM was previously documented during Iran-Iraq conflict. Pepsin levels in sputum and total bile acids were measured using enzymatic assay. The severity of respiratory disorder was categorized based upon the spirometric values.

Result:

The average concentration of pepsin in sputum was higher in the case group (0.29 ± 0.23) compared with healthy subjects (0.13 ± 0.07; P ± 0.003). Moreover, the average concentration of bile acids in the sputum cases was not significantly different in comparison to the controls (P = 0.5).

Conclusion:

Higher pepsin concentrations in sputum of SM exposed patients compared with healthy control subjects indicate the occurrence of significantly more gastric micro-aspiration in SM exposed patients.     

Analysis of Elevated Liver Enzymes in an Acute Medical Setting: Jaundice May Indicate Increased Survival in Elderly Patients with Bacterial Sepsis

Background/Aim:

It has been shown previously that in primary care settings in UK abnormal liver enzymes are not adequately investigated and followed up; hence potentially treatable chronic liver diseases remain undiagnosed. No such published data is available with regard to secondary care settings. The aims of this audit were, to determine if the current practice in our hospital with regards to investigation, management and follow-up of patients with elevated liver enzymes is in accordance with American Gastroenterology Association (AGA) guidelines and to analyze the effect of age and elevated parameters of liver blood tests on mortality in patients with bacterial sepsis.

Materials and Methods:

A total of 4816 patients were admitted to our acute medical receiving unit during a period of 6 months, of which 378 were with elevated liver enzymes.

Results and Conclusion:

The common conditions that resulted in elevated liver enzymes were sepsis (123) and alcohol-related liver diseases (120). All patients with elevated parameters of liver function tests (LFTs) were fully investigated, managed and followed up in accordance with AGA guidelines. In addition, in patients with bacterial sepsis, old age was associated with increased mortality, while development of jaundice in elderly patients with bacterial sepsis was associated with increased survival.     

Prevention of Bile Leak after Liver Surgery: A Fool-proof Method

Background/Aim:

Bile leak is not uncommon after liver surgeries. There is no adequate method described to prevent this morbid complication.

Materials and Methods:

At the end of the liver procedure, transcystic normal saline was injected under pressure with distal clamping. Leaking saline on the cut surface of the liver was sutured. The process was repeated till no leaking was observed. A suction drain was kept for any bile leak.

Results:

Open liver resection and hydatid cyst surgery cases were included. There were 24 cases, with 13 males and 11 females. The age range was from 4 to 80 years, with a mean of 48 years (SD ± 17.7). The number of leak sites that could be sutured were 0-4 (mean of 2.3 ± 0.5). None had bile leak postoperatively.

Conclusion:

Transcystic injection under pressure with distal clamping demonstrates the leak sites. Suturing them prevents the postoperative bile leak.     

A prospective review of acute coronary syndromes in an urban hospital in sub-Saharan Africa

Objectives

To determine the epidemiology of acute coronary syndromes (ACS) in sub-Saharan Africa.

Methods

A prospective survey was carried out of all patients with a diagnosis of ACS who were admitted to the critical care unit of a tertiary teaching hospital over a 25-month period. Demographics, presentation, management and outcomes were subsequently recorded.

Results

A total of 111 (5.1% of all hospitalisations) patients were recruited, with 56% presenting with ST-elevation myocardial infarction (STEMI) and the rest non-ST-elevation myocardial infarction (NSTEMI) or unstable angina (UA). Chest pain was the most common presenting symptom, and up to one-third of all STEMI patients did not receive any form of reperfusion therapy, primarily due to late presentation. As in the developed world, diabetes, hypertension and cigarette smoking still account for the most common predisposing risk-factor profile, and the mortality associated with ACS is about six to 10% in our unit.

Conclusions

ACS, contrary to common belief, is increasingly more prevalent in sub-Saharan Africa, with similar risk profiles to that in the developed world. Late presentation to hospital is common and accounts for the increased mortality associated with this condition.