Liver function tests in children with blunt abdominal traumas.

BACKGROUND: Previous studies have suggested that there are cut-off values for liver function tests (LFTs) beneath which significant liver injury can be excluded after blunt abdominal trauma in children. Our objective is to test this hypothesis in our patient population. METHODS: The LFTs of all consecutive patients admitted in Geneva from January 1, 2001 to December 31, 2004 following blunt abdominal trauma were analysed and compared to radiological (ultrasound and/or computed tomography scan) findings and final outcome. RESULTS: Of 115 patients identified, sixteen had radiological evidence of liver injury. These patients had significantly (p < 0.01) increased aspartate aminotransferase (AST) and alanine aminotransferase (ALT) values (474 +/- 369 IU/l and 442 +/- 383 IU/l, respectively) compared to patients without liver injury (AST 88 +/- 161 IU/l and ALT 68 +/- 137 IU/l). Among the sixteen patients with liver injury, ten (63 %) had AST < 450 IU/l and seven (44 %) had ALT < 250 IU/l. Two patients had radiological evidence of OIS grade 3 liver injury with AST as low as 95 and 92, and ALT of 80 and 86, below all cut-off values recommended in the literature. CONCLUSION: In our experience, low LFT values at admission could not rule out significant liver injury. The diagnosis of such lesions still relies on clinical and radiological findings, as do other intra-abdominal organ injuries.     

Re-evaluation of liver transaminase cutoff for CT after pediatric blunt abdominal trauma

Purpose

Current guidelines for computed tomography (CT) after blunt trauma were developed to capture all intra-abdominal injuries (IAI). We hypothesize that current AST/ALT guidelines are too low leading to unnecessary CT scans for children after blunt abdominal trauma (BAT).

Methods

Patients who received CT of the abdomen after blunt trauma at our Level I Pediatric Trauma Center were stratified into a high risk (HR) (liver/spleen/kidney grade ≥III, hollow viscous, or pancreatic injuries) and low risk (LR) (liver/kidney/spleen injuries grade ≤II, or no IAI) groups.

Results

247 patients were included. Of the 18 patients in the HR group, two required surgery (splenectomy and sigmoidectomy). Transfusion was required in 30% of grade III and 50% of grade IV injuries. Eleven (5%) patients in LR group were transfused for indications other than IAI, and none were explored surgically. Both AST (r = 0.44, p < 0.001) and ALT (r = 0.43, p < 0.001) correlated with grade of liver injury. Using an increased threshold of AST/ALT, 400/200 had a negative predictive value of 96% in predicting the presence of HR liver injuries.

Conclusion

The current cutoff of liver enzymes leads to over-identification of LR injuries. Consideration should be given to an approach that aims to utilize CT in pediatric BAT that identifies clinically HR injury.

     

The value of routine follow-up imaging in pediatric blunt liver trauma

Purpose. To evaluate the utility of routine follow-up computed tomography (CT) and/or ultrasound (US) scans in children with blunt hepatic trauma initially managed non-operatively. Materials and methods. Review of the records of 66 children with proven blunt liver injury on initial CT scan, who were initially managed non-operatively during the period January 1991 to December 1996. Follow-up CT and US studies were analyzed and correlated with clinical outcome. Results. Of the 66 children, 30 were not followed with any imaging study, 26 were followed with US only, 7 with CT only and 3 with US and CT. Disappearance of the liver lesion(s) was seen in 25 patients (range: 6 days – 14 months) and decrease in size was noted in 10. In one patient, who developed abdominal and right shoulder pain 10 days after presentation with subsequent hemoglobin drop, CT showed contrast medium extravasation into a hepatic hematoma from portal vein injury that required surgery. Conclusion. Our series suggests that in asymptomatic patients, US and CT follow-up studies do not provide the additional information needed for patient management. Therefore, we believe that in asymptomatic children with blunt hepatic trauma who are clinically stable, routine follow-up imaging studies are of very limited value. Received: 13 September 1999 Accepted: 6 March 2000     

Serum transaminase elevations in infants with rotavirus gastroenteritis

Over a 6-week period, 35 (41%) of 86 infants admitted with diarrhea and dehydration were found to have human rotavirus (HRV) gastroenteritis, using the Rotazyme (RTZ) test. Serum transaminase levels were measured on 44 infants on admission and 72 infants during the first 3 days of hospitalization. On admission, RTZ-positive (RTZ+) infants had higher mean and median alanine aminotransferase (ALT) levels [mean 87.5 U/L in RTZ+ vs. 50.0 U/L in RTZ-negative (RTZ-), p = 0.001; medium 60 U/L in RTZ+ vs. 41 U/L in RTZ- infants, p = 0.002], and higher mean and median aspartate aminotransferase (AST) levels (mean 64.3 U/L in RTZ+ vs. 44.0 U/L in RTZ- infants, p = 0.008; median 67.5 U/L vs. 42.0 U/L, respectively, p = less than 0.05). On admission, 72% of RTZ+ vs. 19% of RTZ- infants had ALT levels greater than 50 U/L (p = 0.0004). Maximum ALT levels from the first 3 days were also higher in the RTZ+ group (67.7% of RTZ+ vs. 34.1% of RTZ- having levels greater than 50 U/L, p = 0.005). Transaminase elevations did not correlate with dehydration of any electrolyte abnormalities. These findings suggest that transaminase elevations are common in infants hospitalized with HRV enteritis.     

Blunt bowel and mesenteric injuries in children: Do nonspecific computed tomography findings reliably identify these injuries?

OBJECTIVE: Abdominal computed tomography has proven accurate for the detection of pediatric solid organ injuries following blunt abdominal trauma but is less reliable in detecting blunt bowel and mesenteric injuries (BBMI). The purpose of this study was to determine the significance of nonspecific findings on abdominal computed tomography (CT) scan in children at risk for BBMI. DESIGN: Retrospective chart review. SETTING: Regional pediatric trauma center. PATIENTS: All patients who received an abdominal CT scan as part of their evaluation following blunt abdominal trauma over a 10-yr period (September 1991 to September 2001). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Individual records were reviewed by one of the authors and analyzed for age, gender, mechanism of injury, diagnostic studies and procedures, results of initial CT scan, treatment, surgical procedures, complications, and outcome. Patients were excluded if they suffered penetrating trauma, had an abdominal CT scan performed at another institution, had a surgical procedure before CT scan, or had incomplete records. A total of 2,114 patients met inclusion criteria. Sixty-five percent were male and ages ranged from 3 wks to 18 yrs. There were 178 patients who had at least one nonspecific finding on abdominal CT scan suggestive of BBMI; 151 patients had one finding, 24 patients had two findings, and three had three findings. The risk of BBMI increased with the number of nonspecific findings (positive predictive value = 11% with at least one finding and 44% with two or more findings). This increase in positive predictive value, however, was accompanied by a reduction in sensitivity (62% and 37%, respectively). A total of 32 patients had surgically proven BBMI. Of these, eight had a single nonspecific finding on CT scan, ten had two findings, and two had three findings (12 patients had no CT findings suggestive of BBMI). There were complications in four of the 32 patients with BBMI and one death (due to laceration of the superior mesenteric artery). The complications appeared to occur independent of the time to surgical intervention. CONCLUSIONS: The presence of multiple nonspecific findings on abdominal CT scan does not reliably predict BBMI in children. Children also appear to suffer complications from BBMI less frequently than adults, regardless of the time to surgery. Therefore, nonspecific findings alone do not warrant surgical exploration. The decision to operate should instead be based on clinical data that include serial physical examinations.     

Pediatric abdominal trauma: evaluation by computed tomography

When indications for immediate laparotomy are not present, CT of the abdomen and pelvis can be used to evaluate pediatric blunt abdominal trauma. During 2-year period, the medical records and abdominal/pelvic CT scans of 100 consecutive pediatric patients who were evaluated for blunt abdominal trauma were retrospectively reviewed. The scans appeared normal for 73 children. Of these children, 30 had severe head injuries and a depressed sensorium. A total of 27 abdominal/pelvic CT scans were interpreted as abnormal. Findings included nine splenic fractures, six renal contusions, nine hepatic lacerations, one duodenal hematoma, one traumatic pancreatitis, four bony injuries, six miscellaneous abnormalities, and one intraperitoneal bleed. Only two of these 27 patients required abdominal surgery. The remaining 25 patients were treated conservatively based upon a stable clinical state and CT delineation of the extent of injury. No mortality resulted. CT is the radiographic examination of choice for hemodynamically stable pediatric patients with blunt abdominal trauma. CT provided a reliable adjunct examination technique when a physical examination could not be performed and a complete history could not be obtained. The extent of abdominal/pelvic injuries is well delineated and can often be followed by diagnostic imaging, usually allowing for conservative therapy.     

Hepatic dysfunction in childhood malaria.

Hepatic function of 80 children aged under 3 years with Plasmodium vivax malaria were studied during the acute attack and 6 weeks after antimalarial treatment. Raised levels of serum aspartate transaminase (serum AST; SGOT), serum alanine transaminase (serum ALT; SGPT), and alkaline phosphatase were observed in 68%, 39% and 46% of cases respectively. AST levels were higher than ALT ones and the mean level of both enzymes was much higher in patients with hepatomegaly. The hepatic dysfunction which these observations reflect is transient, as these enzymes were found to be at their normal levels 6 weeks after treatment. A transient derangement of liver function is thus a common feature of childhood malaria, and hepatic dysfunction takes place to a significant degree even in P. vivax malaria.     

Hepatic toxicity during chemotherapy for severe tuberculosis meningitis

The possible development of hepatotoxic effects as a result of high dosages of isoniazid, rifampin, pyrazinamide, and ethionamide was assessed in 56 young children (median age, 22 months) treated for severe tuberculous meningitis (TBM). Only one of the 56 children became jaundiced, probably as result of hepatitis A infection. Of 33 children observed for at least eight weeks, only five (15%) had normal serum aspartate aminotransferase (AST), alanine aminotransferase (ALT), and gamma-glutamyl transferase levels throughout, but in only three patients were AST or ALT values greater than 200 U/L, and enzyme levels tended to normalize toward the end of the period. In this group of 33 children, those at stage III TBM had higher enzyme levels than did those at stage II. The remaining 23 children were observed for a mean period of only four weeks, and 18 (75%) had at least one abnormal liver function test result.     

Markers for occult liver injury in cases of physical abuse in children.

Children suffering physical abuse are at risk for abdominal trauma. When the abdominal trauma is not evident clinically and remains occult, the child's condition can rapidly deteriorate before the diagnosis is made, and delay may occur in the activation of child protective services. The use of markers for abdominal trauma in the evaluation of cases of child physical abuse was examined. Children younger than 12 years presenting to the Emergency Department at the Children's Hospital of Buffalo from August 1989 through April 1990 for the evaluation of suspected physical abuse were prospectively entered in the project. All patients had a complete history and physical examination performed. Those patients who did not show any signs of abdominal injury had the following laboratory tests done: (1) levels of liver transaminases, lactate dehydrogenase, and alkaline phosphatase; (2) amylase level; and (3) uranlysis. Of 49 patients without clinical signs of abdominal trauma, 4 children had elevated transaminase levels. Three of these 4 patients had liver lacerations documented by subsequent abdominal computed tomographic scans. A new finding of transaminase levels as markers of occult liver injury in children suffering physical abuse is reported.     

Elevation of serum stem-cell factor in postoperative biliary atresia

BACKGROUND: Biliary atresia (BA) is one of the most common causes of neonatal cholestasis. Stem-cell factor (SCF) has been implicated in the development of fibrosis in various diseases. The objective of the present study was to examine the significant role of SCF in BA. METHODS: Fifty-seven pediatric patients with BA after Kasai operation and 30 healthy children were recruited. The mean ages of BA patients and controls were 6.1 +/- 0.6 years and 6.1 +/- 0.7 years, respectively. The patients were categorized into two groups according to their serum levels of total bilirubin (TBil < 2 mg/dL, no jaundice vs TBil > or = 2 mg/dL, persistent jaundice) and alanine aminotransferase (ALT < 100 vs ALT > or = 100 U/L). The serum SCF levels were determined on commercially available enzyme-linked immunosorbent assay. RESULTS: The mean serum SCF level of the BA children was higher than that of normal controls (748.3 +/- 17.9 pg/mL vs 582.2 +/- 17.3 pg/mL; P < 0.001). Subsequent analysis demonstrated that the BA patients with serum ALT > or = 100 U/L had significantly greater levels of serum SCF compared to those with serum ALT < 100 U/L (796.5 +/- 22.6 pg/mL vs 694.7 +/- 25.0 pg/mL, respectively; P = 0.002). In addition, serum SCF levels were significantly elevated in the patients with portal hypertension (PH) compared with those without PH (810.0 +/- 18.8 pg/mL vs 634.1 +/- 20.1 pg/mL, P < 0.001). CONCLUSION: The current study showed that BA patients had higher serum SCF levels compared with controls. The significant elevation in SCF levels is associated with the presence of PH and the degree of hepatic injury. These findings suggest that SCF may play a part in the pathogenesis of hepatic fibrosis in BA patients after Kasai procedure.     

二氧化碳气腹对幼兔肝肾功能影响的实验研究

目的 观察CQ气腹对幼兔肝肾功能的影响,为临床新生儿腹腔镜外科气腹的选择提供参考.方法 32只健康新西兰幼兔(3周龄,体重0.8～1.0 kg)按随机数字表法平均分为4组:对照组(单纯腹腔麻醉)、开腹手术组(麻醉后行开腹手术)、低压力组(腹腔压力维持在6 mmHg)、高压力组(腹腔压力维持在12 mmHg),采用10％水合氯醛3ml/kg腹腔麻醉,术中追加用4％水合氯醛1 ml.麻醉时间持续4h.麻醉4h后每组随机取4只处死,余4只复苏后继续饲养7d后处死,均切取肝肾组织浸泡福尔马林,行HE染色,观察组织学改变.分别于麻醉前30 min、麻醉后4h及术后7d取幼兔静脉血3 ml,-80℃保存.收集血清,进行肝肾生化指标检测,包括:谷丙氨酸氨基转移酶(ALT)、天门冬氨酸氨基转移酶(AST)、总胆红素(TBIL)、直接胆红素(DBIL)、谷氨酰转肽酶(GGT)、肌酐(CR)、尿素氮(BUN)和尿酸(UA).结果 四组幼兔麻醉前和麻醉后4h、术后7d血清CR、BUN、UA、AST、TBIL及DBIL变化差异均无统计学意义(P＞0.05).气腹高压力组麻醉后4h和术后7d血清ALT值分别为(81.24 U/L,59.87 U/L),两者相比,差异无统计学意义(P＞0.05);与本组麻醉前30 min(8.14 U/L)比较,差异有统计学意义(P＜0.05);且与对照组、开腹手术组及气腹低压力组麻醉后4h血清ALT值(8.50、9.09和9.40 U/L)及术后7d血清ALT值(13.07、8.58和12.83 U/L)比较,差异有统计学意义(P＜0.05).气腹高压力组麻醉后4h和术后7d血清GGT值分别为193.72 U/L和156.74 U/L,两者比较,差异无统计学意义(P＞0.05);与本组麻醉前30 min血清GGT值14.85 U/L比较,差异有统计学意义(P＜0.05);且与对照组、开腹手术组及气腹低压力组麻醉后4h血清GGT值(20.31、15.11和15.98 U/L)及术后7d血清GGT值(22.26、14.70和27.44 U/L)比较,差异有统计学意义(P＜0.05).HE染色显示高压组幼兔麻醉后4h和术后7d均可见弥漫肝淤血,且术后7d无明显改善,肾无明显组织形态学改变.结论 幼兔可良好耐受6 mmHg和12 mmHg的气腹压力,术后可存活.气腹压力为6 mmHg时肝肾功能均不受显著影响,12 mmHg时肾功能影响不显著,但肝出现了肝淤血改变,且术后7d无明显恢复.     

A comparison between scintigraphy and computed abdominal tomography in blunt liver and spleen injuries in children

Fifty consecutive paediatric patients with objective clinical signs of blunt abdominal trauma underwent both computed abdominal tomography (CT) and liver-spleen scintigraphy (LSS). All were managed non-operatively with no morbidity or mortality. Five splenic and 13 liver injuries were visualised on CT while LSS revealed 9 splenic and 29 liver injuries. Where injury to either organ was detected by both modalities, there was good correlation anatomically and also as to the extent of injury. LSS demonstrated injuries not shown on CT, which appeared to detect only more extensive injuries. We conclude that scintigraphy may be the more sensitive and therefore more appropriate method when blunt injury to the liver and spleen alone is clinically suspected. Abdominal CT remains the early investigation of choice in patients with clinical evidence of haemoperitoneum associated with shock or multiple injuries, particularly when injury to the kidneys as well as to the liver and spleen is suspected or when a concomitant brain scan is indicated. Offprint requests to: D. H. Bass     

Comparison between serum alpha-glutathione S-transferase and aminotransaminases in detecting cytolysis in hepatitis C-infected children.

BACKGROUND: alpha-Glutathione S-transferase (alphaGST) has been proposed as a more sensitive indicator than serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) in detecting hepatocellular damage due to chronic hepatitis C virus (HCV) infection. METHODS: The accuracy of alpha-GST was compared with that of ALT and AST in detecting cytolysis in 103 blood samples issued from 31 children positive for HCV RNA. RESULTS: alpha-GST had a lower sensitivity than ALT or AST (32% vs. 54.4% for each aminotransferase). The sensitivity of ALT and/or AST was 60.2%, whereas that of ALT and/or alpha-GST and AST and/or alpha-GST was lower (58.3% and 57.3%, respectively). Among 41 serum samples with negative ALT and AST, only 2 had positive alpha-GST, whereas alpha-GST failed to detect cytolysis in 31 samples with elevated ALT and/or AST. No correlation was found between alpha-GST, ALT, or AST and the Knodell score. CONCLUSIONS: The combination of ALT with AST is actually the best compromise in detecting cytolysis in untreated HCV-infected patients.     

Vitamin E treatment of nonalcoholic steatohepatitis in children: a pilot study

AIM: To determine whether supplemental oral vitamin E is effective in lowering serum aminotransferase and alkaline phosphatase levels in children with nonalcoholic steatohepatitis (NASH) associated with obesity. STUDY DESIGN: Open-label pilot study enrolling all children <16 years old with chronically elevated serum aminotransferase (alanine aminotransferase and aspartate aminotransferase) levels for greater than 3 months, who demonstrated a diffusely echogenic liver on ultrasonography, had no demonstrable reason for abnormal serum chemistry values other than obesity, and therefore were diagnosed to have NASH. Patients were prescribed oral vitamin E between 400 and 1200 IU per day. Serum chemistry values were monitored monthly during treatment. RESULTS: Eleven subjects with a mean age of 12.4 years were enrolled; treated patients were followed up for 4 to 10 months. The body mass index did not change significantly before and after treatment (32.8 +/- 3.8 kg/m(2) vs 32.5 +/- 4.4 kg/m(2), respectively). Serum alanine aminotransferase decreased from 175 +/- 106 IU/L to 40 +/- 26 IU/L (P <.001, paired Student t test), serum aspartate aminotransferase decreased from 104 +/- 61 IU/L to 33 +/- 11 IU/L (P <.002), and alkaline phosphatase decreased from 279 +/- 42 IU/L to 202 +/- 66 IU/L (P <.003) during treatment. Serum aminotransferase levels remained normal during treatment but returned to abnormal in those electing to stop treatment. Serum alpha-tocopherol levels were within the normal range before the commencement of therapy and increased significantly with supplementation. The liver remained diffusely echogenic during therapy, at the time serum aminotransferase levels were reduced. CONCLUSIONS: Daily oral vitamin E administration normalized serum aminotransferase and alkaline phosphatase levels in children with NASH. Obese children with NASH should be encouraged to lose weight as part of a comprehensive weight reduction program and to consider taking supplemental alpha-tocopherol.     

肾上腺素对内毒素致大鼠炎症性肝损害的保护作用

目的 探讨肾上腺素(Epi)对内毒素（脂多糖，LPS）致大鼠炎症性肝损害的保护作用及其作用机制。方法 50只SD大鼠随机分为5组（每组各10只）：对照组：静脉滴注生理盐水2.4 mL·kg-1·h-1；LPS组：静脉注射LPS 6 mg·kg-1后，静脉滴注生理盐水2.4 mL·kg-1·h-1；低、中和高剂量Epi组：静脉注射LPS 6 mg·kg-1后，分别静脉滴注Epi 0.12、0.3和0.6 μg·kg-1·min-1。在LPS注射前、注射后2和6 h 3个时点取血，检测血清ALT、AST、TNF-α、IL-1β和IL-10水平，并在6 h时点观察肝脏的组织病理学改变。结果 LPS组注射LPS后2、6 h血清AST和ALT水平较对照组显著升高，同时血清TNF-α、IL-1β和IL-10水平亦较对照组显著升高（P<0.05）。病理检查结果示：LPS组肝窦扩张、充血，局灶性肝细胞坏死。高剂量Epi可显著降低血清AST和ALT水平，减轻肝脏病理损伤，并显著可降低TNF-α水平和升高IL-10水平 (vs LPS组，P均<0.05)，但对IL-1β水平无影响。中、低剂量Epi对LPS致炎症性肝损害无明显保护作用。结论 Epi可通过抗炎作用减轻LPS诱导的炎症性肝损害。     

腹部闭合伤致儿童胰腺外伤的诊治探讨

目的 探讨儿童腹部闭合性损伤导致胰腺外伤的病因及诊断和治疗方法.方法 回顾性分析我院1999年1月至2008年5月间收治14例闭合性腹部损伤导致胰腺外伤患儿的临床资料.结果 男11例,女3例,男∶女=3.7∶1.致伤原因依次为自行车把致伤5例、交通事故4例、踢伤或殴伤3例、跌伤2例.临床表现有腹痛、腹部压痛、白细胞及血清淀粉酶升高和发热.实验室检查14例均有不同程度白细胞升高.10例(71.5%)血清淀粉酶升高,二者升高水平与胰腺损伤程度无关;重复血清淀粉酶值测定对胰腺外伤具有诊断意义.11例(78.6%)CT检查发现胰腺损伤6例(54.5%),5例CT检查正常但剖腹探查胰腺外伤2例;12例B超检查发现胰腺损伤8例;内镜逆行胰胆管造影(ERCP)检查1例.保守治疗成功9例,包括轻微损伤6例,远端胰管损伤1例,入院时有胰管损伤但未发现2例.剖腹探查及胰腺外引流术5例.胰腺假性囊肿形成后手术4例.结论 胰腺外伤在儿童腹部闭合性损伤中并不常见.诊断以血清淀粉酶升高、CT及B超检查为主,少数需剖腹探查.白细胞及血清淀粉酶升高水平与胰腺损伤程度无关.重复血清淀粉酶测定及CT检查对胰腺外伤具有诊断意义.大多数胰腺创伤包括胰管近端损伤儿童可以先保守治疗而不是冒风险手术干预,如果形成假性囊肿再后期引流.胰管远端损伤(Ⅲ级)最好选择保脾胰尾切除术.剖腹探查术中发现轻微胰腺损伤而采用腹部闭式引流措施意义不大.     

Management of blunt hepatic injury in children: usefulness of emergency transcatheter arterial embolization

We reviewed our experience to determine the usefulness of emergency transcatheter arterial embolization (TAE) for severe blunt hepatic injury (BHI) in children. Between 1978 and 2000, 21 children with BHI (14 boys and 7 girls, ranging in age from 2 to 14 years) were managed according to our protocol. The patients who were hemodynamically stable, and had no other associated injury requiring laparotomy, regardless of the hepatic injury grade, were managed nonsurgically. Emergency angiography and TAE performed after a CT scan revealed extravasation of the contrast medium. Of the 21 patients, 3 underwent emergency laparotomy; 2 due to hemodynamic instability despite fluid resuscitation (1 died), and the 3rd patient because of associated injury. The other 18 patients (86%) were initially managed nonsurgically; however, 2 underwent delayed laparotomy because of complications (1 each of suspected delayed hepatic hemorrhage and liver abscess). Nonsurgical management was completed in the remaining 16 (89%) with no morbidity and mortality. Two of the 16 returned to a hemodynamically stable condition with fluid resuscitation, but were compromised with persistent hepatic hemorrhage, and were successfully treated with emergency TAE. We propose that emergency TAE should be considered as an initial treatment for severe BHI in children.     

Laparoscopic diagnosis of blunt abdominal trauma in children

This study evaluates the safety and role of laparoscopy in the diagnosis of blunt abdominal trauma in children. Laparoscopy was performed in five patients aged 3 to 13 years because of persistent abdominal pain after blunt trauma. A laparotomy was not indicated from the physical examination, laboratory data, or radiologic findings. With the patient under general anesthesia, a 10-mm trocar was inserted through the umbilical fossa and the intra-abdominal organs were observed for 10–60 min under an insufflation pressure of 10–12 mmHg. The patients remained hemodynamically stable without pneumothorax development. Three patients underwent laparatomies: one, who had blood in the omental sac, had a duodenal injury with hemorrhagic necrosis and underwent a resection; one with ascites and high amylase levels had an injury of the main pancreatic duct and underwent resection of the pancreatic tail; and one who had fresh blood in the upper abdomen and Douglas' pouch had a splenic hemorrhage and underwent hemostasis. The other two had serous or serosanguinous ascites and recovered without surgery. In patient 1, the same amount of information might have been obtained from a barium study. In patient 2, the pancreatic transection might have been diagnosed from ascites shown on serial computed tomograms. Patient 3 might also have been treated successfully non-surgically. It hus appears that laparoscopy may be a safe diagnostic method for blunt abdominal trauma in children, however, this small series has yielded insufficient information to assess its usefulness in making the diagnosis and the decision for laparotomy. Further studies are required to ascertain whether it will make any significant difference in the form of management.     

Elevated serum nitric oxide metabolites in biliary atresia

Biliary atresia (BA) remains one of the most intractable liver diseases in children. The aim of this study was to investigate the possible roles of nitric oxide (NO) in BA. Serum levels of nitrite and nitrate (NO production) were determined using a colorimetric method from 65 post-operative BA patients and 12 healthy children. The patients were categorized into two groups according to their jaundice status, and serum alanine aminotransferase (ALT, a marker for liver injury). Unpaired t tests were used. Data are expressed as mean and SD in terms of μmol/l. Age and gender between BA patients and controls were comparable. Serum NO metabolites of BA patients was higher than the controls (79.77±21.22 vs. 65.75±9.44, P=0.001). Subgroup analysis revealed that there was no difference in serum nitrate/nitrite levels of BA patients without jaundice compared to those with jaundice (78.85±23.23 vs. 80.90±18.76, P=0.70). However, patients with serum ALT≥100 IU/l had higher levels of serum NO metabolites compared to those with serum ALT<100 IU/l. In conclusion, NO production was elevated in BA patients compared to normal controls. Serum NO was associated with serum ALT levels, but not with jaundice status, in BA patients. These suggest that NO plays a role in the pathophysiology of liver injury in post-operative BA.     

Hepatic damage in biliary-obstructed rats is ameliorated by leflunomide treatment

Cholestasis, or impaired bile flow, occurs in a wide variety of liver diseases and causes hepatic damage by retention and accumulation of toxic hydrophobic bile salts inducing persistent inflammation and oxidative stress. In the present research, we studied the effect of leflunomide, a novel immunosuppressive and anti-inflammatory agent against autoimmune disease, on hepatic damage produced by double ligature of the extrahepatic biliary duct in Wistar Albino rats. Cholestasis was done by double ligature and section of the extrahepatic biliary duct (BDL). Leflunomide was given i.g. 10 mg/kg/day. The severity of cholestasis and hepatic injury was determined by changes in the plasma enzyme activities of alanine aminotransferase (ALT), aspartate aminotransferase (AST) and levels of direct bilirubin. Malondialdehyde (MDA), protein carbonyl (PC), nitric oxide (NO), catalase (CAT) and superoxide dismutase (SOD) were determined to the oxidative status in the liver tissue. Myeloperoxidase (MPO) activity and levels of tissue hydroxyproline (HPR) were determined to neutrophil activation and collagen accumulation, respectively. Further, histological changes were studied. Treatment with leflunomide markedly reduced serum transaminase activities as compared to BDL rats. At the same time leflunomide significantly inhibited increases in liver MDA, PC and NO levels and also attenuated the depletion of CAT and SOD in the liver after bile duct ligation. Similarly, increase in tissue MPO activity and HPR due to BDL was also attenuated by leflunomide treatment. These findings were supported by histopathological findings. These findings suggested that leflunomide can attenuate hepatic damage in extrahepatic cholestasis by prevention of oxidative stress and inflammatory process.