Factors contributing to adverse maternal outcomes in patients with HELLP syndrome

Objective: To determine the prognostic factors for adverse maternal outcomes in women with complete HELLP syndrome.

Methods: A retrospective cohort study was carried out by searching the hospital data for the diagnosis of HELLP syndrome according to Tennessee classification from January 2007 to January 2014. Data included a total of 171 patients between January 2007 and January 2014. The data were collected from the hospital records including demographic data variables, presence of preeclampsia/chronic hypertension, gestational age at the time of diagnosis, and adverse maternal outcomes in terms of eclampsia, disseminated intravascular coagulopathy, acute renal failure (ARF), pulmonary edema, abruptio placentae placental abruption, pleural effusion, ascites, transfusion, and death were determined as adverse maternal outcomes. Independent prognostic factors for each complication with adverse maternal outcome were determined.

Results: A total of 171 patients between January 2007 and January 2014 were included in the study. Clinical and laboratory parameters of 171 patients were analyzed. Risk factors for adverse maternal outcomes were as follows; aspartate amino transferase (AST)?>?316?U/L, alanine aminotransferase (ALT)?>?217?U/L, total bilirubin >2.0?mg/dL, lactate dehydrogenase (LDH)?>?1290?U/L, blood urea nitrogen (BUN)?>?44?mg/dL, and low platelets (<50,000/mm³). The risk of eclampsia increased 4.1 times and 3.4 times in the presence of LDH >1290?U/L and headache, respectively. Younger maternal age also increased the risk of eclampsia. Risk of ARF increased 15 times at the levels of bilirubin >2.0.

Conclusions: Younger age, headache, bilirubin >2.0?mg/dL, LDH >1290?U/L, and low platelets (<50,000/mm³) were independent prognostic risk factors for predicting adverse maternal outcomes.     

Adjunctive choledochoduodenostomy to choledocholithotomy in the treatment of calculous biliary tract disease.

Between 1986 and 1991, 16 selected patients with calculous biliary tract disease (CBTD) underwent side-to-side choledochoduodenostomy (CDS) as an adjunct to either primary (10 patients) or secondary (six patients) choledocholithotomy. Patients selected for adjunctive CDS were those with common bile duct dilatation > or = 1.5 cm in size. All operations were elective procedures. The stoma of the CDS was about 3.0 cm in size, measured directly. There were no operative deaths. There were no early complications related to the CDS procedure itself, except for two (12.5%) wound infections. CDS significantly eliminates bile stasis which is indicated by a fall in both the serum levels of alkaline phosphatase (from 228 +/- 118 to 72 +/- 22 IU/L, p < 0.01) and total bilirubin (from 4.7 +/- 4.7 to 0.9 +/- 0.2 mg/dL, p < 0.01) postoperatively. Late complications (ascending cholangitis or sump syndrome) of CDS or recurrent symptoms of CBTD were not encountered during the average follow-up period of 21 +/- 18 months. From our clinical results, we suggest that adjunctive CDS to choledocholithotomy is a safe and effective procedure in the treatment of selected patients with CBTD.     

Incidence of common bile duct stones in patients with acute and chronic cholecystitis

In this study, a series of 705 patients with chronic cholecystitis and 203 with acute cholecystitis were surgically treated. The age distribution for the two groups was similar. Operative cholangiography was performed upon 661 patients (94.0 per cent) with chronic cholecystitis and upon 182 patients (90 per cent) with acute cholecystitis. The common bile duct was explored in 146 patients (20.7 per cent) with chronic cholecystitis and in 41 patients (20.1 per cent) with acute cholecystitis, and bile duct calculi were found in 106 patients (15 per cent) with chronic cholecystitis and in 29 patients (14.2 per cent) with acute inflammation of the gallbladder. The total number of postoperative complications and the operative mortality were similar for the two groups. It is concluded that the incidence of common bile duct stones in patients with acute cholecystitis is the same as for those with chronic cholecystitis.     

Signet-ring cell carcinoma of the ampulla of Vater.

Carcinomas of the ampulla of Vater are uncommon, and signet-ring cell carcinoma is rare. We report a case of signet-ring cell carcinoma of the ampulla of Vater with obstructive jaundice in a 53-year-old man. Abdominal ultrasonography and abdominal computed tomographic scan revealed dilatation of the common bile duct, intrahepatic duct, and main pancreatic duct, with the obstruction level in the distal common bile duct near the ampulla of Vater. Duodenoscopy displayed an ampullary tumor protruding from the papilla of Vater with an erythematous and sloughing surface. Endoscopic biopsy of the tumor showed a signet-ring cell carcinoma. The patient received percutaneous transhepatic cholangiographic drainage, and the jaundice gradually improved. A Whipple operation including pancreatoduodenectomy and hemigastrectomy was performed. Pathological examination confirmed signet-ring cell carcinoma of the ampulla of Vater with direct invasion of the periampullary duodenum and distal common bile duct. No gastric lesion or nodal metastasis was found. The postoperative course was uneventful. The patient was alive with no recurrent disease during a follow-up period of 25 months.     

Marcadores del laboratorio clínico en pacientes con preeclampsia severa admitidas en una unidad de cuidados intensivos

ObjectiveTo measure the frequency of positive results for clinical laboratory markers in patients with severe preeclampsia (SP) admitted in an intensive care unit (ICU).DesignCross-sectional study.SettingICU of the High-Specialty Medical Unit, Hospital of Gynecology and Obstetrics No. 3, National Medical Center La Raza, Mexican Institute of Social Security, Mexico City, Mexico.Patients212 pregnant patients with SP admitted to the ICU between June 1 and December 31, 2016.InterventionsLaboratory results were consulted to identify the percentage of positive markers of SP.Variables of interestSP markers: hemoglobin (Hb) < 10 g/dL, platelet count (Plat) < 100,000 platelets/μL, glucose ? 180 mg/dL, serum creatinine (Cr) > 1.1 mg/dL, uric acid (Ua) > 4.0 mg/dL, aminotransferase aspartate (AST) > 70 U/L, lactic deshydrogenase (LDH) > 600 U/L, blood pH < 7.32, deficit of base of extra cellular fluid (DB ecf) > 8 mmol/L and lactate > 4 mmol/L.ResultsPositive markers 93.39% (n = 198) with the following distribution: Ua ? 4 mg/dL, 88.48% (n = 169, mean 6.2 ± 1.04 mg/dL); AST ? 70 U/L, 25.13% (n = 48, mean 180.4 ± 73.08 U/L); Plat < 100,000 platelets/μL, 24.08% (n = 46, mean 71,600 ± 22,970 platelets/μL); LDH ? 600 U/L, 21.98% (n = 42, mean 1,021.3 ± 476 U/L); Cr ? 1.1 mg/dL, 13.08% (n = 25, mean 1.33 ± 0.34 mg/dL); blood pH < 7.32, 7.32% (n = 14, mean 7.30 ± 0.01); DB ecf ? 8 mmol/L, 6.28% (n = 12, mean 9 ± 0.2 mmol/L); glucose ? 180 mg/dL, 3.30% (n = 7, mean 187.85 ± 2.67 mg/dL); lactate ? 4 mmol/L, 1.04% (n = 2), and Hb ? 10 g/dL, 0%.ConclusionsThe most frequent positive markers of SP were Ua, AST, Plat, LDH and Cr.     

血浆置换在治疗妊娠期急性脂肪肝中的应用价值

目的探讨血浆置换在治疗妊娠期急性脂肪肝的中的应用价值。 方法对2010年1月至2013年12月中山大学附属第三医院产科收治的17例采用血浆置换治疗妊娠期急性脂肪肝患者的临床资料进行回顾性分析,分析患者治疗前后的临床症状、体征、肝肾功能、凝血等指标,以及血浆置换出现的副作用。 结果(1)患者治疗前后各项检查指标的比较：白细胞(20.2±9.1)×10⁹/L与(15.2±5.9)×10⁹/L、天冬氨酸转氨酶(304.3±312.6)U/L与(81.4±99.5)U/L、丙氨酸转氨酶(332.5±348.3)U/L与(116.7±198.9)U/L、总胆红素(130.5±113.6)μmol/L与(84.3±35.5)μmol/L、凝血酶原时间(22.5±6.3)s与(19.6±6.7)s、尿素(9.6±7.8) mmol/L与(7.6±4.2)mmol/L、尿酸(515.3±167.0)μmol/L与(380.0±219.4)μmol/L,均得到明显改善(P值均<0.05);(2)血浆置换副作用小,未出现因不良反应而终止血浆置换治疗的病例。 结论血浆置换用于治疗妊娠期急性脂肪肝具有安全、有效等特点,在及时终止妊娠后使用血浆置换可有效遏制病情的发展。     

Immune defects in active mycobacterial diseases in patients with primary immunodeficiency diseases (PIDs)

Natural human immunity to the mycobacteria group, including Mycobacterium tuberculosis, Bacille Calmette-Guérin (BCG) or nontuberculous mycobacteria (NTM), and/or Salmonella species, relies on the functional IL-12/23-IFN-γ integrity of macrophages (monocyte/dendritic cell) connecting to T lymphocyte/NK cells. Patients with severe forms of primary immunodeficiency diseases (PIDs) have more profound immune defects involving this impaired circuit in patients with severe combined immunodeficiencies (SCID) including complete DiGeorge syndrome, X-linked hyper IgM syndrome (HIGM) (CD40L mutation), CD40 deficiency, immunodeficiency with or without anhidrotic ectodermal dysplasia (NEMO and IKBA mutations), chronic granulomatous disease (CGD) and hyper IgE recurrent infection syndromes (HIES). The patients with severe PIDs have broader diverse infections rather than mycobacterial infections. In contrast, patients with an isolated inborn error of the IL-12/23-IFN-γ pathway are exclusively prone to low-virulence mycobacterial infections and nontyphoid salmonella infections, known as Mendelian susceptibility to the mycobacterial disease (MSMD) phenotype. Restricted defective molecules in the circuit, including IFN-γR1, IFN-γR2, IL-12p40, IL-12R-β1, STAT-1, NEMO, IKBA and the recently discovered CYBB responsible for autophagocytic vacuole and proteolysis, and interferon regulatory factor 8 (IRF8) for dendritic cell immunodeficiency, have been identified in around 60% of patients with the MSMD phenotype. Among all of the patients with PIDs referred for investigation since 1985, we have identified four cases with the specific defect (IFNRG1 for three and IL12RB for one), presenting as both BCG-induced diseases and NTM infections, in addition to some patients with SCID, HIGM, CGD and HIES. Furthermore, manifestations in patients with autoantibodies to IFN-γ (autoAbs-IFN-γ), which is categorized as an anticytokine autoantibody syndrome, can resemble the relatively persistent MSMD phenotype lacking BCG-induced diseases.     

Excretion of cefuroxime in biliary disease

Cefuroxime is a broad spectrum B-lactamase stable cephalosporin antibiotic. An intravenous injection of cefuroxime sodium 1.5 grams was administered to 45 patients after induction of anesthesia for cholecystectomy. Twenty-five patients had elective operations for chronic cholecystitis and 20 underwent urgent operations for acute cholecystitis. Of the 25 patients who underwent elective treatment, the cystic duct was patent in 13 and obstructed in 12. Antibiotic concentrations were measured by microbiologic assay in plasma, common bile duct bile, gallbladder bile and gallbladder wall. Organisms grown from the bile (Escherischia coli, eight; Proteus morganii, one; Streptococcus species, three, and Staphylococcus aureus, one) were sensitive to cefuroxime with the exception of one instance of Streptococcus faecalis. Cefuroxime levels were the same in specimens of patients with chronic or acute cholecystitis and reached therapeutic levels in the gallbladder wall, the main site of the inflammatory reaction. There was no difference in bile levels from gallbladders with patent or obstructed cystic ducts, suggesting that cefuroxime diffuses into the gallbladder and bile from the blood stream. There were no wound infections in this study when only a single dosage of antibiotic was administered intravenously.     

Predictors of adverse perinatal outcomes in intrahepatic cholestasis of pregnancy with dichorionic diamniotic twin pregnancies

Objective: The aim of our study was to investigate the predictors of adverse perinatal outcomes in intrahepatic cholestasis of pregnancy (ICP) with dichorionic diamniotic (DCDA) twin pregnancies.

Methods: This study was a retrospective study of women diagnosed with ICP and DCDA twin pregnancies in Chengdu’s women and children’s central hospital. These patients were subdivided into mild and severe ICP groups according to total bile acid (TBA) level. The clinical characteristics and perinatal outcomes were collected and compared between the two groups. Logistic regression analysis was developed to evaluate predictors of adverse perinatal outcomes.

Results: About 134 cases were included in the study. Eighty-four cases were in the mild ICP group, and the other 50 cases were in the severe ICP group. Level of alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), total bilirubin (TBIL), and direct bilirubin (DBIL) in the severe ICP group were significant higher than those in the mild ICP group. The rate of delivery before 34 gestational weeks, meconium-stained amniotic fluid, and composite adverse neonatal outcome were higher in the severe ICP group than those in the mild ICP group. After adjusting for confounders, ICP onset gestational age (GA)?<30 weeks and AST >200U/l were associated with GA at delivery <34 weeks. ALP >400U/l was an independent risk factor of meconium-stained amniotic fluid. ICP onset GA <30 weeks was an independent risk factor of composite adverse neonatal outcome.

Conclusion: ICP onset GA <30 weeks, TBA >40 µmol/l, AST >200U/l, and ALP >400U/l were associated with composite adverse perinatal outcomes in ICP with DCDA twin pregnancies. For those patients with these characteristics, fetal surveillance and treatment should be enhanced.     

Laparoscopic cholecystectomy: the first 50 patients]

Laparoscopic cholecystectomy (LC) has rapidly gained wide acceptance in the United States. The applicability, safety and efficacy of this new procedure for the treatment of cholelithiasis in Taiwan, however, needs evaluation. We performed LC in 50 out of 98 cases of cholelithiasis at Cathay General Hospital from 28 December 1990 to 28 April 1991. We found that the applicability rate was 51%. The reasons for not selecting LC in the 48 open cases were: acute and gangrenous cholecystitis (13), common bile duct stones (11), concomitant intra-abdominal malignancy (5), intrahepatic stones (5), multiple upper abdominal incisions (4), pancreatitis or pancreatic abscesses (3) and other causes (7). In the LC group, there were 44 patients with symptomatic chronic calculus cholecystitis, 3 patients with acute calculus cholecystitis and 3 patients with gall bladder polyps. The age of the patients ranged from 27 to 79. There were 14 males and 36 females. All of the patients had a detailed preoperative workup including complete liver function test and sonographic examination of the hepatobiliary system. Additional pre-operative endoscopic retrograde cholangiopancreatographies were done in 3 and operative cholangiograms were done in another 3 to confirm the absence of common bile duct stones or to delineate anatomy. Although we encountered a few problems during the operations, such as severe adhesion, bleeding, difficult dissection, CO2 leakage, difficult insufflation, or large stones, all of the 50 patients completed the LC successfully without conversion to open cholecystectomy. The average operation time was 60 minutes, ranging from 30 to 135 minutes. Drain tubes were used in 7 cases.(ABSTRACT TRUNCATED AT 250 WORDS)     

Complications of laparoscopic cholecystectomy: an analysis of 200 cases.

Complications of the initial 200 cases of laparoscopic cholecystectomy (LC) at the Cathay General Hospital within a period of 11 months were reviewed from video documents of the operations and clinical records. The major complication rate was 3.5%, including one common bile duct (CBD) injury (0.5%), three retained CBD stones (1.5%), one subphrenic fluid accumulation (0.5%), one liver abscess (0.5%) and one cystic duct stump bile leakage (0.5%). All major complications were cholecystectomy-related, and only one of the seven occurred in cases of acute cholecystitis. Age and sex were not related to its occurrence. The rate of minor complications ranged from 0.5% to 10%; they were: shoulder and back pain (10%), gall bladder perforation (10%), retained stones in the abdominal cavity (5%), transient nausea and diarrhea (5%), extension of umbilical port to a mini-laparotomy (3.5%), prolonged operation time > three hours (2%), subcutaneous emphysema (1.5%), wound infection (1.5%) and prolonged ileus (0.5%). The minor complications occurred largely in patients with acute cholecystitis. The complications occurred mostly during the early period of our study, indicating a learning period phenomenon. These could have been avoided if we had had a thorough knowledge of the potential complications and had strictly followed the principles of laparoscopic surgery. We conclude that LC is safe and the complication rate is not higher than that for open cholecystectomy. Most of the complications are preventable if LC is performed by qualified biliary surgeons following strict precautions.     

Effects of human immunodeficiency virus 1 infection on microbial origins of pelvic inflammatory disease and on efficacy of ambulatory oral therapy

OBJECTIVE: This study was undertaken to determine the effects of human immunodeficiency virus 1 infection on the clinical presentation, severity, causal organisms, and response to ambulatory therapy of pelvic inflammatory disease. STUDY DESIGN: Women 18 to 40 years old with lower abdominal pain for <1 month were recruited. Participants underwent a standardized questionnaire, physical examination, screening for human immunodeficiency virus 1 and other sexually transmitted infections, and endometrial biopsy to detect plasma cell endometritis. Reevaluations were performed at 1 and 4 weeks to assess response to therapy. RESULTS: Among 162 women with adequate endometrial biopsy specimens 63 (39%) had histologically confirmed endometritis. Endometritis was more frequent among women who were seropositive for human immunodeficiency virus 1 than among women who were seronegative (odds ratio, 3.0; 95% confidence interval, 1.5-5.9). Infections with either Neisseria gonorrhoeae or Chlamydia trachomatis, or both, were least common and bacterial vaginosis was most common among human immunodeficiency virus 1-infected women with CD4 T-lymphocyte counts <400 cells/microL (P <. 04, P <.03, respectively). After oral antibiotic therapy, similar proportions of both women who were seropositive and women who were seronegative for human immuno-deficiency virus 1 had a >/=75% reduction in clinical severity score (81% vs 86%). CONCLUSION: Outpatient treatment of pelvic inflammatory disease was successful regardless of human immunodeficiency virus 1 serostatus.     

Cholelithiasis: Presentation and Management

Cholelithiasis affects approximately 15% of the US population. Rising trends in obesity and metabolic syndrome have contributed to an increase in diagnosis of cholelithiasis. There are several risk factors for cholelithiasis, both modifiable and nonmodifiable. Women are more likely to experience cholelithiasis than are men. Pregnancy, increasing parity, and obesity during pregnancy further increase the risk that a woman will develop cholelithiasis. The classic presentation of persons experiencing cholelithiasis, specifically when gallstones obstruct the common bile duct, is right upper quadrant pain of the abdomen that is often elicited upon palpation during physical examination and documented as a positive Murphy's sign. Referred pain to the right supraclavicular region and/or shoulder, nausea, and vomiting are also frequently reported by persons with cholelithiasis. Cholelithiasis can result in complications, including cholecystitis (inflammation of the gallbladder) and cholangitis (inflammation of the bile duct). Lack of physical examination findings does not rule out a diagnosis of cholelithiasis. Laboratory tests such as white blood cell count, liver enzymes, amylase, and lipase may assist the clinician in diagnosing cholelithiasis; however, ultrasonography is the gold standard for diagnosis. Management is dependent on severity and frequency of symptoms. Lifestyle and dietary modifications combined with medication management, such as use of gallstone dissolution agents, may be recommended for persons who have a single symptomatic episode. If symptoms become severe and/or are recurrent, laparoscopic cholecystectomy is recommended. It is recommended that individuals with an established diagnosis of cholelithiasis be referred to a surgeon and/or gastroenterologist within 2 weeks of initial presentation regardless of severity or frequency of symptoms.     

先天性胆总管囊肿的特点及危险因素

目的探讨先天性胆总管囊肿的临床特点及危险因素。方法本研究为回顾性研究。研究对象为广东省妇幼保健院2013年1月至2018年8月收治的胎儿期确诊先天性胆总管囊肿,于生后手术治疗,临床资料完整的52例患儿。根据孕期囊肿增大的程度,分为进展型组(≥15 mm,22例)和稳定型组(<15 mm,30例)。分析2组患儿产前产后超声、MRI的特点。比较2组术前、术后的临床表现、生化检查结果,术中囊液淀粉酶水平、胆道造影和探查、肝脏活检,以及术后随访等资料。采用t(或t')或χ^2检验,以及Pearson相关分析等统计学方法分析数据。结果(1)52例患儿手术年龄为46(7~822)d。囊肿均在孕19~21周首次发现。>34孕周产前检查时,进展型组囊肿最大径明显大于稳定型组[孕31~34、>34周和术前,2组分别为(31.1±8.4)与(23.1±6.6)mm,t=3.911;(36.1±6.8)与(27.1±7.3)mm,t=4.557;(51.8±18.0)与(34.0±15.6)mm,t=3.809;P值均<0.01]。(2)进展型组产前MRI显示囊肿形态不规则,逐步增大,肝总管及肝内胆管可见,至产后逐渐明显扩张,胆总管远端呈逐渐变窄的圆锥样改变,胆总管末端逐渐闭塞,产后囊肿内可见沉淀物形成。稳定型组产前MRI显示囊肿形态不规则,其中5例可见肝总管及肝内胆管扩张,产后扩张加重,胆总管远端无圆锥样改变,产后囊肿内偶有沉淀物形成,胆总管末端可见。(3)25例开腹手术治疗的先天性胆总管囊肿患儿中,7例囊液淀粉酶高于正常水平,其中4例为正常值上限的2~5倍(进展型组1例,稳定型组3例);另3例均为稳定型组患儿,其囊液淀粉酶水平是正常值上限的10倍以上。进展型组术前直接胆红素水平高于稳定型组[18.40(2.50~113.30)与8.70(0.00~16.80)μmol/L,u=2.400,P<0.05]。(4)52例患儿中,Ⅰ型囊肿37例(71.1%),Ⅳ型14例(26.9%),Ⅴ型1例(2.0%)。所有病例术后均定期随访半年至1年,肝功能和胆红素可降至正常水平,患儿生长发育情况与同龄儿童相当。(5)52例患儿中的46例(88.5%)有不同程度的肝纤维化及炎症。进展型组手术年龄较大的患儿,肝纤维化及炎症程度较重。稳定型组手术干预时间对肝脏纤维化及炎症程度无显著影响。进展型组肝纤维化及炎症较稳定型组更严重(肝纤维化分级:χ^2=14.260,P=0.006;炎症活动程度分级:χ^2=9.904,P=0.019)。结论孕期首次检查时肝门部囊肿较大(≥30 mm)或者随孕期明显增大(≥15 mm),是先天性胆总管囊肿的危险因素,应警惕早期胆总管末端狭窄或闭塞,生后需密切追踪随访。对于产后合并大便颜色变浅、黄疸及肝功能损害的患儿建议生后早期(1~2月)外科干预,一般不超过3个月,以解除胰胆管合流解剖异常及肝脏病理状态,同时排除囊肿型胆道闭锁可能。     

Differential expression of CD40 and CD95 in ovarian carcinoma

PURPOSE: The role of CD95 (Fas) as a mediator of apoptosis has been well documented. CD40 ligation has been recently shown to initiate apoptosis and modulate CD95 mediated apoptosis in normal and some neoplastic tissues. Here we report the expression of CD95 and CD40 in cryopreserved cell suspensions from ovarian cancer associated ascites, fresh primary and recurrent ovarian carcinoma (OVCA) specimens, and ten established ovarian cancer cell lines. The effect of CD95 and CD40 receptor binding on apoptosis is described in two cell lines. EXPERIMENTAL DESIGN: Ascites specimens, fresh primary and recurrent OVCA specimens were dissociated to single cell suspensions. Expression of CD95 and CD40 was analyzed using flow cytometry. Apoptosis was determined via annexin uptake by flow cytometry following incubation with anti-CD95 antibody, CH11 and trimeric CD40L. RESULTS: Ascites showed the highest expression of both CD95 and CD40. Recurrent OVCA, in contrast, expressed low levels of CD95 and CD40. Primary OVCA showed moderate expression of both receptors. CD40 expression in ascites was significantly greater when compared to solid specimens (p < 0.05). Both CD40 and CD95 were strongly expressed in eight of ten cell lines studied. Binding of CD40L did not influence CD95 mediated apoptosis. CONCLUSIONS: CD40 is ubiquitously expressed in ovarian carcinomas and expression differs between ascites and solid tumor. There may be differential expression of both CD40 and CD95 in recurrent vs primary ovarian carcinoma, which may contribute to increased clinical malignancy of recurrent disease. In contrast to other epithelial malignancies, CD40 ligation does not appear to modulate CD95 mediated apoptosis.     

Lithotomy of intrahepatic and choledochal stones with Yag laser

Eight patients with intrahepatic bile duct stones and three with choledochal stones were treated by Yag laser using a choledochofiberscope. A choledochoscope was inserted through a T-tube fistula in five patients or a percutaneous transhepatic cholangiodrainage fistula in six patients. In one patient, right partial lobectomy of the liver was performed after most of the stones were withdrawn, since some stones in the extremely narrow bile duct had not been removed. Most of the intrahepatic bile duct stones and choledochal stones will be withdrawn using the Yag laser and a choledochofiberscope, when they were bilirubin stones.     

Endotoxemia and cholestasis

Endotoxemia has been incriminated as a major cause of morbidity and mortality in patients with obstructive jaundice. It has been postulated that absence of gastrointestinal bile salt flow in cholestasis enhances portal absorption of bacterial endotoxin from the intestine, thereby predisposing the host to endotoxemia and its complications. This study re-evaluates this pathologic mechanism, using new quantitative chromogenic and conventional qualitative limulus techniques for the detection of bacterial endotoxin. Female Sprague-Dawley rats underwent either ligation of bile duct or sham operation. Serum total bilirubin, serum bile acid and intestinal bile acid concentrations were determined seven, 14 and 21 days after operation. Chromogenic and conventional qualitative limulus lysate endotoxin determinations were simultaneously performed on post-operative days two, seven, 14 and 21. Serum total bilirubin and bile acid concentrations were elevated and intestinal bile acid levels depressed at days seven, 14 and 21 (p less than 0.05). Results of quantitative and qualitative limulus studies failed to demonstrated the coexisting development of portal or systemic endotoxemia in rats with the bile duct ligated after diminution of flow of gastrointestinal bile salt. These data refute the hypothesis that flow of gastrointestinal bile salt enhances portal absorption of intestinally derived endotoxin and suggest alternative mechanisms are involved in the pathogenesis of endotoxemia in obstructive jaundice.     

Chronic hepatitis B virus infection and dyslipidemia.

BACKGROUND AND PURPOSE: The association of chronic hepatitis B virus (HBV) infection and decreased levels of high-density lipoprotein cholesterol (HDL-C) has been well documented. However, the relationship between dyslipidemia and asymptomatic chronic HBV infection is still unclear. METHODS: In 1997, 1330 medical center employees (405 men and 925 women) were recruited to evaluate the effects of chronic HBV infection on serum lipid profile, including total cholesterol (TC), HDL-C, low-density lipoprotein cholesterol, and triglycerides (TG). Among these patients, 195 were found to have chronic HBV infection and 35 (17.9%) of them were found to have elevated alanine aminotransferase (ALT). Multiple linear regression analyses were used to evaluate the effects of chronic HBV infection on serum lipids. RESULTS: The most significant finding was that levels of TC and HDL-C were decreased by 5.8 and 2.7 mg/dL respectively, among patients with asymptomatic chronic HBV infection (serum ALT < 40 U/L). After controlling for other determinants, male gender, old age, higher body mass index (BMI) and waist-to-hip ratio, current smoking, and hepatitis B surface antigen-negative status with ALT > or = 40 U/L were associated with lower serum HDL-C and higher TG levels. However, moderate to heavy alcohol drinking, physically active lifestyle, and lower BMI were associated with higher levels of HDL-C. CONCLUSIONS: Asymptomatic chronic HBV infection was associated with lower serum levels of TC and HDL-C. Elevation of ALT was also an indicator of lower levels of HDL-C in patients with chronic hepatitis B and lower serum HDL-C and higher TG levels in patients without HBV infection. These findings also indicated the need to monitor the risk of atherosclerotic diseases in patients with asymptomatic chronic HBV infection, especially those with lower HDL-C levels.     

Biliary tract disease in Thailand

One hundred and eighty-nine patients were documented as having biliary tract disease. Two hundred and nine lesions were found. The prevalence of malignant disease of the biliary tract was represented by 30.1 per cent, and cholangiocarcinoma was a leading cause. The carcinogenesis of cholangiocarcinoma has been speculated. Acute cholecystitis represented 55 per cent of biliary tract disease in Thailand, which consisted of acute calculous cholecystitis and acute noncalculous cholecystitis, 94.8 and 5.2 per cent, respectively. Among acute calculous cholecystitis, the prevalence of cholelithiasis, choledocholithiasis and intrahepatic stones were 58.5, 68.8 and 15.6 per cent, respectively. The high prevalence of choledocholithiasis and intrahepatic stones requires elucidation. In the remaining surgical disease of the biliary tract, opisthorchiatic cyst was the most common cause. The diagnosis of opisthorchiatic cyst was made roentgenologically in association with the identification of Opisthorchis ova in the aspirated bile. Opisthorchiatic cyst appears to be a unique clinical entity, differing from other types of intrahepatic cysts. Another form of presentation of biliary tract opisthorchiasis is through obstruction of the common bile duct by an aggregated mass of dead worms. This condition is cured by surgical removal of the worms. It is worth while to mention that, among 189 patients with biliary tract disease, there were three documented instances of choledochal cysts. This probably indicates a high prevalence of choledochal cysts when compared with that for the United States. In the present study, a 36 year old female with a diagnosis of Caroli's disease, ascariasis of the common bile duct and choledocholithiasis is presented.     

过氧化物酶增殖体激活受体α、氧固醇7α羟化酶及雌激素受体间调控关系及其与孕鼠肝内胆汁淤积发生的相关性

目的 探讨过氧化物酶增殖体激活受体α(PPARα)、氧固醇7α羟化酶(CYP7B1)、雌激素受体(ER)α及ERβ之间的调控关系与孕鼠肝内胆汁淤积发生的相关性.方法 选择清洁级SD孕鼠80只,随机分为4组,每组20只,自孕第13天起:对照组孕鼠皮下注射精制植物油2.0ml·kg-1·d-1;低剂量组孕鼠皮下注射17-α-乙炔雌二醇(1.0 mg·kg-1·d-1);中剂量组孕鼠皮下注射17-α-乙炔雌二醇(1.25 mg·lg-1·d-1);高剂量组孕鼠皮下注射17-α-乙炔雌二醇(1.5 mg·kg-1·d-1).4组孕鼠于妊娠第21天处死后提取肝脏组织.应用酶联免疫吸附试验检测各组孕鼠血清中丙氨酸转氨酶(ALT)、门冬氨酸转氨酶(AST)、总胆酸(TBA)及胆红素(BIL)水平;应用实时定量PCR技术检测各组孕鼠肝脏组织中PPARα mRNA、CYP7B1 mRNA、ERα mRNA及ERβ mRNA的表达水平.结果 (1)生化指标:对照组孕鼠ALT、AST、TBA及BIL水平分别为(41.1±2.8)U/L、(44.4±3.6)U/L、(26.4±5.6)μmol/L、(2.8±0.2)U/L,低剂量组孕鼠分别为(48.2±3.4)U/L、(47.9±3.7)U/L、(36.4±4.2)μmol/L、(4.2±0.2)U/L,中剂量组孕鼠分别为(70.4±5.3)U/L、(68.4±5.6)U/L、(64.3±3.8)μmol/L、(6.2±1.2)U/L,高剂量组孕鼠分别为(72.4±7.6)U/L、(70.2±3.8)U/L、(72.4±7.8)μmol/L、(8.2±2.2)U/L.低剂量组、中剂量组、高剂量组孕鼠ALT、AST、TBA、BIL水平明显高于对照组(P<0.05);中剂量组、高剂量组孕鼠各生化指标水平明显高于低剂量组(P<0.05).(2)ERαmRNA及ERβmRNA表达水平:ERαmRNA的表达水平在低剂量组(0.76±0.02)、中剂量组(0.99±0.04)和高剂量组(1.21±0.01)孕鼠肝脏组织中呈逐渐升高趋势(P<0.05),并明显高于对照组(0.65±0.01),分别与对照组比较,差异均有统计学意义(P<0.05);ERβ表达水平在4组孕鼠间分别比较,差异均无统计学意义(P>0.05).(3)CYP7B1 mRNA及PPARα mRNA表达水平:CYP7B1 mRNA的表达水平在低剂量组(0.93±0.01)、中剂量组(0.99±0.06)和高剂量组(1.22±0.04)孕鼠肝脏组织中呈逐渐升高趋势(P<0.05),并明显高于对照组(0.75±0.02),分别与对照组比较,差异均有统计学意义(P<0.05);PPARα mRNA表达水平在低剂量组(0.83±0.05)、中剂量组(0.71±0.02)和高剂量组(0.64±0.03)孕鼠肝脏组织中呈逐渐降低趋势(P<0.05),并明显低于对照组(1.35±0.05),分别与对照组比较,差异均有统计学意义(P<0.05).结论 随着雌激素剂量的增加,PPARα表达水平降低,对CYP7B1表达的抑制作用解除,而导致CYP7B1表达水平升高;而CYP7B1有促进ERα高表达的作用,最终由ERα介导了雌激素诱导的肝内胆汁淤积的发生.提示PPARα、CYP7B1及ER的异常表达,是调控雌激素诱导孕鼠肝内胆汁淤积的发生机制之一.