Inhibition of the liver expression of arylalkylamine N-acetyltransferase increases the expression of angiogenic factors in cholangiocytes

Background and aims

Reduction of biliary serotonin N-acetyltransferase (AANAT) expression and melatonin administration/secretion in cholangiocytes increases biliary proliferation and the expression of SR, CFTR and Cl^–/HCO₃^– AE2. The balance between biliary proliferation/damage is regulated by several autocrine neuroendocrine factors including vascular endothelial growth factor-A/C (VEGF-A/C). VEGFs are secreted by several epithelia, where they modulate cell growth by autocrine and paracrine mechanisms. No data exists regarding the effect of AANAT modulation on the expressions of VEGFs by cholangiocytes.

Methods

In this study, we evaluated the effect of local modulation of biliary AANAT expression on the cholangiocytes synthesis of VEGF-A/C.

Results

The decrease in AANAT expression and subsequent lower melatonin secretion by cholangiocytes was associated with increased expression of VEGF-A/C. Overexpression of AANAT in cholangiocyte lines decreased the expression of VEGF-A/C.

Conclusions

Modulation of melatonin synthesis may affect the expression of VEGF-A/C by cholangiocytes and may modulate the hepatic microvascularization through the regulation of VEGF-A/C expression regulating biliary functions.     

An animal model of benign bile-duct stricture,sclerosing cholangitis and cholangiocarcinoma and the role of epidermal growth factor receptor in ductal proliferation

Objective

To adapt an animal model of benign bile-duct stricture, sclerosing cholangitis and cholangiocarcinoma in order to determine if the expression of epidermal growth factor receptor (EGFr) could be used to differentiate these lesions.

Design

A prospective control study with blinded interpretation of liver biopsy histology and immunohistochemical staining as the criterion standards.

Setting

A university-affiliated research centre.

Subjects

Male Syrian Golden hamsters (40 for benign duct stricture, 29 for sclerosing cholangitis and 27 for cholangiocarcinoma).

Interventions

Ligation of the common bile duct with 6-0 catgut for benign duct stricture; injection of the biliary tree with 0.15 mL of formalin for sclerosing cholangitis; and weekly subcutaneous injections of 500 mg/kg of di-isopropanolnitrosamine for 10 weeks followed by ligation of the common bile duct with 6-0 catgut for cholangiocarcinoma. Routine histologic preparation of liver biopsies obtained at autopsy 10 weeks postoperatively then immunohistochemical staining of specimens for EGFr.

Main Outcome Measures

The development of benign or atypical biliary ductal proliferation, including adenoma and carcinoma formation. The presence or absence of immunohistochemical staining for EGFr.

Results

Benign ductal proliferation without atypia was seen in 15 of 21 animals in the bile-duct-stricture group that were sacrificed, in 15 of 24 animals in the sclerosing cholangitis group and in 17 of 18 animals in the cholangiocarcinoma group. Atypical proliferation was seen in 13 of 18 animals with cholangiocarcinoma but not in the other two groups. The differential occurrence of atypical ductal proliferation was statistically significant (p < 0.00001) for both groups. No evidence of EGFr expression was found in any group.

Conclusion

Although the animal model was valid histologically for comparing benign and malignant biliary disease, EGFr does not play a role in biliary ductal proliferation and so cannot be used to differentiate between benign and malignant lesions.     

The role of cyclic AMP in canine secretin-stimulated bile flow.

Cyclic nucleotide secretion rates in bile during the physiologic stimulation of ductular bile flow in dogs was evaluated by measurement of bile cyclic AMP concentration during the stimulation of secretin release by infusion of acid into the duodenum of dogs with chronic bile fistulas. The effects of PGA₁ and theophylline on secretin-stimulated bile flow and cyclic AMP secretin rates were also evaluated. Endogenous secretin stimulated bicarbonate-rich bile flow and decreased bile cyclic AMP concentration. PGA₁ significantly decreased secretin-stimulated bile flow but not bile cyclic AMP secretion. Theophylline did not alter secretin-stimulated bile flow or cyclic AMP secretion rates. These data indicate that based on cyclic AMP content in bile, secretin-stimulated ductular bile flow is unrelated to cyclic AMP metabolism.     

Optimal surgical technique, use of intra-operative cholangiography (IOC), and management of acute gallbladder disease: the results of a nation-wide survey in the UK and Ireland

INTRODUCTION

There is debate on optimal techniques that reduce bile duct injury during laparoscopic cholecystectomy (LC). A national survey of Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland (AUGIS) members was carried out to determine current surgical practice for gallstones, including the use of intra-operative cholangiography (IOC) or critical view of safety to reduce the risk of bile duct injury.

SUBJECTS AND METHODS

An anonymous postal survey was sent to all 417 AUGIS members. Data on grade of surgeon, place of work (district general hospital, teaching), subspecialty, number LC per year, use of IOC, critical view of safety, and management of stones detected during surgery were collated.

RESULTS

There was a 36% (152/417) response – 134 (88%) from consultant surgeons (36, HPB; 106,OG; 64, DGH; 88, teaching hospital). Of these, 38% performed > 100 LC per year, 36% 50–100 LC per year, and 22% 25–50 LC per year. IOC was routine for 24%; and selective for 72%. Critical view of Calot''s triangle was advocated by 82%. Overall, 55% first clip and divide the cystic artery, whereas 41% first clip and divide the cystic duct. Some 39% recommend IOC and 23% pre-oper-ative MRCP if dilated common bile duct (CBD) is noted on pre-operative ultrasound. When bile duct stones are identified on IOC, 61% perform laparoscopic CBD exploration (LCBDE), 25% advise postoperative ERCP, and 13% perform either LCBDE or ERCP. Overall, 88% (n = 134) recommend index cholecystectomy for acute pathology, and this is more likely in a teaching hospital setting (P= 0.003). Laparoscopic CBD exploration was more likely to be performed in university hospitals (P< 0.05).

CONCLUSIONS

A wide dissection of Calot''s triangle to provide a critical view of safety is the technique most commonly recommended by AUGIS surgeons (83%) to minimise risk of bile duct injury, in contrast to 24% that recommend routine IOC. The majority (88%) of AUGIS surgeons advise index admission cholecystectomy for acute gallbladder disease.     

Dynamic study of pancreaticobiliary reflux using secretin-stimulated magnetic resonance cholangiopancreatography in patients with choledochal cysts

Background/Purpose

Refluxes through pancreaticobiliary maljunctions play an important role in the pathophysiology of choledochal cysts. Dynamic studies of the pancreaticobiliary tract were performed using secretin-stimulated magnetic resonance cholangiopancreatography.

Methods

Six patients with choledochal dilation were recruited for this study. Four patients exhibited cystic and 2 exhibited fusiform dilatation of the common bile duct (CBD). Magnetic resonance cholangiopancreatography images were obtained every minute during the 15-minute period after secretin stimulation. The sequential morphological changes in the biliary trees, pancreas, and duodenum were assessed, and the total pixel values of these organs were measured for each image, then plotted as a ratio against the baseline image.

Results

In 2 cases involving cystic dilatation, the intensity of bile duct images continued to rise after secretin stimulation. In a case involving fusiform dilatation, a transitory elevation in CBD intensity was observed. In 3 cases involving fusiform or cystic dilatation, the intensity of CBD did not change notably. In all cases, the duodenum was filled well after secretin stimulation.

Conclusions

The sustained elevation in bile duct intensity after secretin stimulation indicates reflux and bile stasis. Transitory elevation may indicate reflux without stasis. This method allows assessment of the dynamics of pancreatic and bile fluid under more physiologic condition.     

Spontaneous biliary peritonitis,or delayed bile leak?

Introduction

Spontaneous biliary peritonitis is a rare cause of acute abdominal pain. Whilst usually of extrahepatic origin, here we describe an even rarer perforation of an intrahepatic duct.

Presentation of Case

A 31 year old woman presented with acute onset epigastric abdominal pain on a background of cholecystectomy four years prior. Laparoscopy demonstrated bilious fluid but failed to identify the site of bile leak. Subsequent ERCP localised the leak to an anomalous radical of the right hepatic duct.

Discussion

Spontaneous biliary peritonitis is a rare diagnosis. Most cases are extrahepatic and the pathogenesis of intrahepatic ductal rupture has been difficult to define. Whilst acute bile leak is a recognised complication of cholecystectomy, bile leak four years following operation has not been described previously.

Conclusion

Spontaneous biliary peritonitis remains as a rare cause of acute abdominal pain. Within the context of cholecystectomy, the surgeon should always be alert to the possibility of delayed bile leak.     

Surgical Management of Boerhaave's Syndrome in a Tertiary Oesophagogastric Centre

INTRODUCTION

The aim of this study was to review the management and outcome of patients with Boerhaave''s syndrome in a specialist centre between 2000–2007.

PATIENTS AND METHODS

Patients were grouped according to time from symptoms to referral (early, < 24 h; late, > 24 h). The effects of referral time and management on outcomes (oesophageal leak, reoperation and mortality) were evaluated.

RESULTS

Of 21 patients (early 10; late 11), three were unfit for surgery. Of the remaining 18, immediate surgery was performed in 8/8 referred early and 6/10 referred late. Four patients referred late were treated conservatively. Oesophageal leak (78% versus 12.5%; P < 0.05) and mortality (40% versus 0%; P < 0.05) rates were higher in patients referred late. For patients referred late, mortality was higher in patients managed conservatively (75% versus 17%; not significant).

CONCLUSIONS

The best outcomes in Boerhaave''s syndrome are associated with early referral and surgical management in a specialist centre. Surgery appears to be superior to conservative treatment for patients referred late.     

Laparoscopic Management of Common Bile Duct Stones: Transpapillary Stenting or External Biliary Drainage?

Background:

To date, the management of common bile duct stones (CBDs) is still controversial. If laparoscopic exploration is performed and biliary decompression is needed after stone removal, the placement of a laparoscopic transpapillary stent shows promising results in avoiding T-tube–related complications.

Methods:

Between January 2007 and May 2012, a series of 48 patients who underwent biliary decompression after laparoscopic common bile duct exploration (LCBDE) to treat choledocholithiasis was retrospectively analyzed. The results in patients with transpapillary stent placement (TS=35) were compared with those who had an external biliary drainage (EBD=13).

Results:

LCBDE and TS placement was achieved either by a choledochotomy or through the cystic duct. There was no mortality in our series. Patients with an external biliary drainage (EBD) had more surgery-related complications (P<.0001) and a longer hospital stay (P=.03). Postoperative ERCP to remove the TS was successful in all cases.

Conclusion:

Laparoscopic TS is a safe method in the treatment of selected patients with CBD stones that can be achieved without having to perform a choledochotomy. Because of the lower morbidity and the shorter hospital stay compared with EBD, it should be considered as a first approach whenever biliary decompression is needed after LCBDE.     

Closed retrograde multiple intramedullary Kirschner wires fixation for humeral shaft fractures with the limb flexed over an articulated support

Objective

To evaluate the results of multiple closed intramedullary Kirschner wiring via a supracondylar entry point for humeral shaft fractures.

Patients and methods

The charts of 37 patients with humeral shaft fractures treated with the Hackethal''s technique between January 2007 and December 2011 were reviewed retrospectively. The operation was performed with the patient lying in supine (n = 22) or lateral (n = 15) position. The elbow was flexed over an articulated support with the arm kept in a vertical position. Thirty-three patients were available for final evaluation with a mean follow-up delay of 14 (range, 6–24) months. We were concerned about fracture union, range of motion of the shoulder and the elbow, and complications. Final evaluation used the criteria by Qidwai.

Results

Bone union rate was 94%. Restriction of ranges of motion of the shoulder more than 20° was noticed in two patients due to protruding wires. Three patients developed limitation of elbow extension owing to backing out of the wires. The overall results were excellent (n = 26; 79%), good (n = 4; 12%), and poor (n = 3; 9%).

Conclusion

Closed Hackethal''s technique using K-wires gives satisfactory results in terms of bone union and elbow and shoulder function in selected humeral shaft fractures. The articulated support precludes the transolecranon traction.     

Role of Vascular Endothelial Growth Factor in Protection of Intrahepatic Cholangiocytes Mediated by Hypoxic Preconditioning After Liver Transplantation in Rats

Objective

To investigate the effect on intrahepatic cholangiocytes mediated by hypoxic preconditioning (HP) after liver transplantation and the role of vascular endothelial growth factor (VEGF).

Materials and Methods

This experiment was based on a model of rat orthotopic liver autotransplantation. Sprague-Dawley rats were randomly divided into 3 groups: normal control, autotransplantation (AT), and HP. The HP group was subjected to 8% oxygen atmosphere for 90 minutes before surgery. At 6, 12, 24, and 48 hours after autotransplantation, the rats were killed for testing .Serum total bilirubin, direct bilirubin, and alkaline phosphatase concentrations were determined. The microstructure of cholangiocytes and the ultramicrostructure of cholangioles were determined. Immunohistochemistry was used to detect the expression of VEGF and the proliferation rate of cholangiocytes.

Results

Total bilirubin, direct bilirubin, and alkaline phosphatase concentrations in the AT group increased considerably more than in the HP group during the entire interval (P < .05). Light microscopy demonstrated that the microstructure of cholangiocytes in the AT group was damaged more seriously than in the HP group. At transmission electron microscopy, the ultramicrostructure of cholangioles was changed more obviously than in the HP group. The expression of VEGF on cholangiocytes and the proliferation rate of cholangiocytes were higher in the HP group than in the AT group over the entire experiment (P < .05).

Conclusion

Hypoxic preconditioning has a protective effect on cholangiocytes after liver autotransplantation. The mechanism may be related to HP-induced overexpression of VEGF on cholangiocytes.     

Protective effect of polyunsaturated phosphatidylcholine on liver damage induced by biliary obstruction in rats

Background/purpose: Persistent inflammatory response secondary to congenital or acquired biliary choleastasis plays an important role in the pathophysiology of hepatic tissue damage. The polyunsaturated fatty acids (PUFA) have been shown to suppress the inflammatory reactions in vivo and in vitro. PUFA has been shown also to protect againts various types of experimental liver damage in animal models and isolated hepatocytes. Therefore, the aim of this study was to investigate the protective effect of PUFA administration on liver damage using the rat chronic biliary obstruction model.Methods: Swiss albino rats of either sex were divided into 4 groups as follows: control group (group 1, 10 rats); rats with sham operation and treated with saline group 2, 10 rats); rats with biliary obstruction (group 3, 15 rats); and polyunsaturated phophatidylcholine (PPC)-treated rats with biliary obstruction (Group 4, 15 rats). Biliary obstruction was induced by double ligation and division of the common bile duct. PUFA treatment was started 2 weeks later from biliary obstruction in doses of 50 mg/d per rat and continued for 2 weeks. All animals were killed after 4 weeks of common bile duct ligation or sham operation. Liver damage and cholestasis were determined by biochemical and histologic examinations.Results: The data showed a decrease in plasma bilirubin level (both conjugated and unconjugated) and liver enzyme levels (AST, ALT, AP, GGT, 5′-NT) in group 4, when compared with group 3 (P < .05). Tissue levels of malondialdehyde (MDA) in group 4 was 20.00 ± 2.93 compared with that in group 3, 27.12 ± 2.96 (P < .05). Administration of PUFA to the biliary obstructed rats resulted in inhibition of collagen accumulation (P < .05) and ductal proliferation (P < .05).Conclusions: PUFA reduced liver damage, ductular proliferation, and fibrosis in biliary obstructed rats. These effects suggest that it might be a useful agent to preserve liver function in patients with biliary obstruction such as biliary atresia.     

Treatment of hepatic hydatid disease complications using endoscopic retrograde cholangiopancreatography procedures

Background

Liver hydatidosis may lead to serious morbidity due to biliary complications, the management for which endoscopic sphincterotomy (ES) and biliary drainage are very efficient. We evaluated the effectiveness of endoscopic treatment for complications of hepatic hydatid disease.

Methods

We retrospectively reviewed endoscopic retrograde cholangiopancreatography (ERCP) procedures performed between January 2000 and December 2009 and compared laboratory findings, localization of the lesions and ERCP procedures applied between patients with and without jaundice.

Results

In all, 70 ERCP procedures were performed in 54 patients (24 men, 30 women). Of the 70 procedures, 24 were performed to treat jaundice. All patients with biliary fistulas and jaundice were managed with endoscopic procedures. The 70 ERCP procedures included sphincterotomy only (n = 40); sphincterotomy and stent placement (n = 7); stent placement only (n = 4); sphincterotomy and membrane extraction (n = 9); sphincterotomy, membrane extraction and pus drainage (n = 5); and sphincterotomy and pus drainage (n = 5). Laboratory results improved in 3–7 days, and bile leakage ceased in 2–21 days.

Conclusion

Endoscopic retrograde cholangiopancreatography is a safe and effective way to manage biliary complications of hepatic echinococcal disease. In most patients, ES is the most efficient treatment of postoperative external biliary fistulas, jaundice and accompanying cholangitis, as it enables clearing the bile ducts of hydatid remnants; ES should be performed since it accelerates the healing process by decreasing pressure in the choledochus.     

The Relationship between Spinal Stenosis and Neurological Outcome in Traumatic Cervical Spine Injury: An Analysis using Pavlov's Ratio, Spinal Cord Area, and Spinal Canal Area

Background

This study examined the relationship between four radiological parameters (Pavlov''s ratio, sagittal diameter, spinal cord area, and spinal canal area) in patients with a traumatic cervical spine injury, as well as the correlation between these parameters and the neurological outcome.

Methods

A total of 212 cervical spinal levels in 53 patients with a distractive-extension injury were examined. The following four parameters were measured: Pavlov''s ratio on the plain lateral radiographs, the sagittal diameter, the spinal cord area, and the spinal canal area on the MRI scans. The Pearson correlation coefficients between the parameters at each level and between the levels of each parameter were evaluated. The correlation between the radiological parameters and the spinal cord injury status classified into four categories, A (complete), B (incomplete), C (radiculopathy), and D (normal) was assessed.

Results

The mean Pavlov''s ratio, sagittal diameter, spinal cord area and spinal canal area was 0.84, 12.9 mm, 82.8 mm² and 236.8 mm², respectively. An examination of the correlation between the radiological spinal stenosis and clinical spinal cord injury revealed an increase in the values of the four radiological parameters from cohorts A to D. Pavlov''s ratio was the only parameter showing statistically significant correlation with the clinical status (p = 0.006).

Conclusions

There was a correlation between the underlying spinal stenosis and the development of neurological impairment after a traumatic cervical spine injury. In addition, it is believed that Pavlov''s ratio can be used to help determine and predict the neurological outcome.     

Modified Weil Osteotomy for the Treatment of Freiberg's Disease

Background

Numerous metatarsal osteotomies have been developed for the treatment of Freiberg''s disease. The purpose of this study was to evaluate the clinical outcomes of modified Weil osteotomy in the treatment of Freiberg''s disease.

Methods

From November 2001 to July 2008, nineteen patients (twenty feet), treated surgically for Freiberg''s disease, were included in this study. The average age of the patients was 33.6 years (range, 17 to 62 years), the mean follow-up period was 71.6 months (range, 41 to 121 months). Clinical outcomes were evaluated according to visual analogue scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) lesser metatarsophalangeal-interphalangeal scale, the patients'' subjective satisfaction and range of motion (ROM) of metatarsophalangeal (MTP) joint. In the radiologic evaluation, initial metatarsal shortening by Freiberg''s disease compared to opposite site, metatarsal shortening after modified Weil osteotomy compared with preoperative radiography and term for radiologic union were observed.

Results

VAS showed improvement from 6.2 ± 1.4 to 1.4 ± 1.5 at last follow-up (p < 0.0001). Points of AOFAS score increased from 63.3 ± 14.9 to 80.4 ± 5.6 (p < 0.0001). ROM of MTP joints also improved from 31.3 ± 10.1 to 48.3 ± 13.0 degrees at last follow-up (p < 0.0001). According to Smillie''s classification system, there was no significant improvement of VAS, AOFAS score and ROM between early stages (stage I, II, and III) and late stages (stage IV and V). Out of twenty cases, nineteen (95%) were satisfied, reporting excellent or good results.

Conclusions

Modified Weil osteotomy is believed to be a useful method for the treatment of Freiberg''s disease, not only in the early stages but also in the late stages. It relieves pain and improves function via shortening of metatarsals and restoration of MTP joint congruency.     

Revisit of Broden's View for Intraarticular Calcaneal Fracture

Background

This study was performed to investigate the relationship between coronal computed tomography (CT) and Broden''s view in terms of location of the fracture line and fracture pattern.

Methods

Forty-five feet of 45 patients with intraarticular calcaneal fractures were evaluated. The mean age of the patients was 46.3 years (standard deviation, 18.1; range, 15 to 80 years), and there were 34 men and 11 women. The Broden''s views were acquired using the ray sum projection, reviewed, and correlated with the coronal CT image to determine the location of the fracture on the posterior facet and fracture pattern described by the Sanders classification. The quantified location of the fracture line was defined as the distance between the medial margin of posterior facet and the fracture line divided by the whole length of the posterior facet, which was expressed as a percentage.

Results

The fracture line on the Broden''s view was positioned at 22.3% (standard deviation, 29.6) laterally compared to that on coronal CT (p < 0.01). Although all cases showed posterior facet involvement on the CT scan, the fracture line was positioned lateral to the posterior facet in 6 cases (13.3%) in the Broden''s view. The coronal CT and Broden''s view showed a low level of agreement in the fracture pattern according to the Sanders classification, with kappa values of 0.23.

Conclusions

Surgeons should consider that the fracture line on the Broden''s view shows positioning laterally compared to coronal CT and they should consider that the fracture line at the lateral to posterior facet on the Broden''s view might be an intraarticular fracture line. There are some limitations when applying the Sanders classification with the Broden''s view.     

Hyperamylasaemia and ischaemic colitis

INTRODUCTION

Ischaemic colitis is a differential diagnosis to be considered in patients who have a high cardiovascular risk. Presentation of severe ischaemia is usually that of an acute abdomen with passage of fresh blood per rectum, and hyperamylasaemia.

PRESENTATION OF CASE

A 66-year-old gentleman was admitted to A&E with a short history of central abdominal pain, nausea, vomiting and fresh bleeding per rectum. A diagnosis of ischaemic colitis was made by the computed tomography (CT) scan findings of colonic thickening and pneumatosis, in addition to colonoscopy demonstrating sloughy mucosa and ulceration. Symptoms did not resolve with conservative management, therefore laparotomy + Hartmann''s procedure was performed. Histology showed extensive areas of both partial and full thickness ischaemia with stricture.

DISCUSSION

Amylase is an indicator of intra-abdominal inflammatory processes. Hyperamylasaemia (normal <100 U/l) is most frequently associated with pancreatitis; however, causation is not exclusive and other differentials including bowel ischaemia must be considered, although amylase is not a specific marker for ischaemic colitis. It is important to distinguish between ischaemic and ulcerative colitis.

CONCLUSION

Intestinal ischaemia is a serious acute abdominal pathology that is associated with hyperamylasaemia, and frequently requires prompt surgical intervention to prevent subsequent mortality.     

Amyloid goiter related with Crohn's disease: A rare association: Amyloid goiter secondary to Crohn's disease

INTRODUCTION

Amyloid goiter (AG) is characterized by enlargement of the thyroid gland as a result of extensive amyloid deposition in a bilateral and diffuse manner.

PRESENTATION OF CASE

A 58-year-old male patient was diagnosed of Crohn''s Disease (CD). He was admitted to our clinic with complaint of respiratory distress and rapid growth swelling in the neck. Ultrasound examination revealed huge multinodular goiter on both sides of thyroid gland. We performed bilateral total thyroidectomy. Pathological evaluation revealed AG.

DISCUSSION

Amyloid leads to degeneration in tissues, thereby disrupts the function of the relevant organs. It is important to distinguish AG from other reasons of goiter, particularly thyroid medullary cancer that can cause amyloid deposition in thyroid gland. Secondary amyloidosis frequently involves thyroid gland at microscopic level, but rarely causes goiter. An analysis of current literature revealed that only few cases of AG occurred secondary to CD. Herein we presented a case of AG who has rapidly growing goiter that associated with CD.

CONCLUSION

AG must be kept in mind in case of rapidly growing goiter, especially in patients with chronic inflammatory bowel diseases.     

Melatonin regulation of biliary functions

The intrahepatic biliary epithelium is a three-dimensional tubular system lined by cholangiocytes, epithelial cells that in addition to modify ductal bile are also the targets of vanishing bile duct syndromes (i.e., cholangiopathies) such as primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC) that are characterized by the damage/proliferation of cholangiocytes. Cholangiocyte proliferation is critical for the maintenance of the biliary mass and secretory function during the pathogenesis of cholangiopathies. Proliferating cholangiocytes serve as a neuroendocrine compartment during the progression of cholangiopathies, and as such secrete and respond to hormones, neurotransmitters and neuropeptides contributing to the autocrine and paracrine pathways that regulate biliary homeostasis. The focus of this review is to summarize the recent findings related to the role of melatonin in the modulation of biliary functions and liver damage in response to a number of insults. We first provide a general background on the general function of cholangiocytes including their anatomic characteristics, their innervation and vascularization as well the role of these cells on secretory and proliferation events. After a background on the synthesis and regulation of melatonin and its role on the maintenance of circadian rhythm, we will describe the specific effects of melatonin on biliary functions and liver damage. After a summary of the topics discussed, we provide a paragraph on the future perspectives related to melatonin and liver functions.     

Sigmoid endometriosis and a diagnostic dilemma - A case report and literature review

Introduction

Intestinal endometriosis is often an infrequently considered diagnosis in female of childbearing age by general surgeon. There is a delay in diagnosis because of constellation of symptoms and lack of specific diagnostic modalities. Patients suffer from intestinal endometriosis for many years before they are diagnosed. Often, such patients are labelled with irritable bowel syndrome. Intestinal endometriosis has a diagnostic time delay of 8–11 years due to its non-specific clinical features and multi-system involvement.

Presentation of Case

Our patient was a 32 years old Caucasian female who was referred to us with features of intestinal obstruction. Despite repeated clinical assessments and use of different diagnostic modalities the diagnosis was still inconclusive even after 21 days of her first presentation to primary care physician. She had an exploratory laparotomy, sigmoid colectomy, and Hartmann''s procedure with a temporary colostomy with us. Histopathology confirmed endometriosis and also showed melanosis coli. She was referred to the gynaecological team for review and follow up.

Discussion

Intestinal endometriosis should be considered as a differential diagnosis in female patients of childbearing age group presenting with non-specific gastrointestinal signs and symptoms. Our patient manifested intestinal endometriosis and melanosis coli on histopathology suggesting symptoms of long duration.

Conclusion

Bowel endometriosis is a less considered and often ignored differential diagnosis in acute and chronic abdomen. This condition has considerable effect on patient''s health both physically and psychologically.Abbreviations: bpm, beats per minutes; CA-125, tumour marker for ovarian carcinoma; cm, centimetre; COCPs, combined oral contraceptive pills; CRP, C-reactive protein, an inflammatory marker; CT scan, computerised tomographic scan; e.g., an abbreviation for the Latin phrase exempli gratia. When you mean “for example,” use e.g.; g, gram; g/dl, gram per decilitre; GnRH, gonadotropic releasing hormone; L, litre; mg, milligram; MRI, magnetic resonance imaging; NSAIDs, non steroidal anti-inflammatory drugs; WBC, white blood cell; %, percentage