Jaundice

Jaundice is the clinical finding of yellow discolouration of the body tissues usually observed in the skin secondary to excess bilirubin in the serum (hyperbilirubinemia). Jaundice occurs due to an imbalance between production and clearance of bilirubin; therefore, it is important to understand the pathophysiology of jaundice to understand its aetiology. Clinically a careful history, physical examination, together with appropriate urine and blood tests will guide further investigations to obtain an appropriate diagnosis. Often the pathophysiological effects of jaundice and the underlying aetiology can cause sepsis, dehydration, electrolyte imbalance and clotting abnormalities. It is therefore important to assess and address associated effects to reduce morbidity prior to instituting any treatment plan. Treatment plans often involve specialists from the multidisciplinary team.     

Jaundice

Jaundice is yellow discolouration of the skin, sclera and mucous membranes due to raised plasma bilirubin. Jaundice occurs due to an imbalance between the production and clearance of bilirubin and thus an understanding of bilirubin metabolism is required to evaluate a jaundiced patient. Jaundice can be classified as pre-hepatic, hepatic or post-hepatic according to the site of disruption of bilirubin metabolism. Following history, examination and initial blood tests, an abdominal ultrasound scan is usually the next investigation, with sequentially more invasive tests being undertaken as required. Jaundiced patients usually require management by a multidisciplinary team.     

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.     

金属支架治疗恶性梗阻性黄疸伴十二指肠梗阻47例

目的:探讨经内镜置入十二指肠金属支架治疗恶性梗阻性黄疸合并十二指肠梗阻的作用.方法:恶性梗阻性黄疸合并十二指肠梗阻病例47例.经内镜置入47个十二指肠自膨式金属支架,观察临床疗效.结果:47例病人十二指肠金属支架置入均成功,随访期间,病人术后均能正常进半流质事物,黄疸基本消退,疗效满意,本组未发生严重并发症发生.结论:内镜置入金属内支架是一种简单、有效的治疗方法,对不能手术的恶性梗阻性黄疸合并十二指肠梗阻有很好的缓解作用.     

Evaluation of Pringle Maneuver During Liver Resection in a Rat Model of Surgical Obstructive Jaundice

Temporary portal triad clamping (Pringle maneuver) during liver resection reduces intraoperative blood loss. A normal liver can safely tolerate normothermic ischemia for up to 60 min. However, its safety in patients with surgical obstructive jaundice (SOJ) is not known. Therefore, we investigated the effect of hepatic ischemia in an experimental rat model of SOJ created by ligating the bile duct. Four groups of rats were created: Group I (sham operation, 10 days later, liver resection); Group II (sham operation, 10 days later, liver resection with 5 min of hepatic ischemia); Group III (bile duct ligation, 10 days later, liver resection); and Group IV (bile duct ligation, 10 days later, liver resection with 5 min of hepatic ischemia). The ischemic injury was assessed by the survival of rats, liver tissue malondialdehyde and total glutathione (markers of free radical injury), serum alanine aminotransferase, aspartate aminotransferase, and liver histology. The results showed decreased survival (47.6% vs. 90% [p =. 046]), increased liver tissue malondialdehyde (161 ± 35 vs. 129 ± 33 μg/gm liver tissue [p ≤. 05]), and decreased liver tissue total glutathione (565 ± 169 vs. 1075 ± 276 nmol/gm liver tissue [p ≤. 05]) in rats with SOJ subjected to hepatic ischemia when compared to nonjaundiced rats. The changes in serum aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase showed an increasing trend in the SOJ group but were not statistically significant. Ischemic changes in liver histology were seen more often in the SOJ group but were not statistically significant. These data suggest that temporary portal triad clamping in an experimental model of SOJ is detrimental to the outcome of liver resection.     

华支睾吸虫所致胆道梗阻的诊断和治疗

目的 探讨华支睾吸虫所致胆道梗阻的诊断及治疗。方法 对36例华支睾吸虫所致胆道梗阻进行回顾性分析。结果 本组36例中34例术前未能确诊,仅2例术前怀疑为寄生虫团块阻塞。36例患者经手术切开胆总管取虫和术后驱虫治疗,全部治愈出院。30例随访1～3年,无复发。结论 对病人有长期食鱼生史,出现胆道梗阻症状和体征,B超示胆总管无回声团块,CT示胆总管中等密度团块状肿物,应首先考虑诊断为华支睾吸虫引起胆道梗阻的可能。胆总管切开取虫,胆道反复用生理盐水冲洗,术后驱虫治疗,必要时用胆道镜取虫,可取得满意的疗效。     

The role of peribiliary cysts in biliary obstruction

Peribiliary cysts are cystic dilatations of the extramural glands of the intrahepatic biliary tree. This disorder is uncommon and is usually asymptomatic. However, it may cause extrinsic biliary compression and consequently, obstructive jaundice. This paper describes 2 such cases presenting with jaundice. The etiology, natural history, investigation findings and treatment of this disorder are also discussed.     

The Effects of Dimethylsulfoxide in Experimental Obstructive Jaundice

Material and methods: Thirty rats were divided into three groups, as sham, control and DMSO groups. Laparatomy was performed on each animal in the control and DMSO groups and common bile ducts were ligated. Common bile duct was observed but was not ligated for the rats in the sham group. Saline solution injection (1.5 mg/kg/intraperitoneally (ip)) was begun on the first day of surgical procedure and repeated once a day for the next 5 days. The same procedure was performed with DMSO (1.5 mg/kg/ip) instead of saline in the DMSO group. The rats were sacrificed on the postoperative seventh day, at which time venous blood and liver tissue specimens were taken. Main outcome measurements: On the 7^th postoperative day, the bilirubin, AST, ALT, ALP and GGT levels of the control and DMSO groups were significantly higher in comparison with the sham group (p < 0.01). On the 7^th postoperative day, the erythrocyte superoxide dismutase (SOD) and glutathione peroxidase (GSH-Px) levels of the control and DMSO groups were significantly lower than those of the sham group (p < 0.01), but there was no statistical difference between the two groups (p > 0.05). Erythrocyte and liver malondialdehyde (MDA) levels in the control and DMSO groups were significantly higher compared with the sham group (p < 0.01). However, the MDA levels were significantly lower in the DMSO group compared to the control group (p < 0.01).

Conclusion: It is stated that free oxygen radicals seem to play a role in the liver tissue injury, secondary to obstructive jaundice. In our experimental study, exogenic DMSO seems to have decreased lipid peroxidation and to have improved some of the parameters of liver tissue injury due to the obstructive jaundice in rats.     

Therapeutic Effect of Plasma Exchange with the Biliary Drainage in the Treatment of Obstructive Jaundice

The effect of therapeutic plasmapheresis combined with biliary drainage was evaluated in obstructive jaundice animal models. Plasma exchange (PE) using fresh-frozen plasma was carried out with biliary drainage (BD) on a canine jaundice model created by the ligation and resection of bile duct. Routine biochemical analyses were done following PE and BD. The result was compared with that of a BD only group. Plasma bilirubin level abruptly dropped after PE and was kept at a lower level, whereas the bilirubin level of the drainage alone group decreased gradually. Decreased plasma mitochondrial GOT level in the PE group suggests improvement of liver cell damage in obstructive jaundice. Mitochondrial function of liver tissue was evaluated following partial hepatectomy, which was carried out 2 days after PE along with BD in jaundice rat. Mitochondrial respiratory control ratio and ADP/O ratio following hepatectomy were improved in the PE group. The results suggest the improvement of hepatic functional reservoir by a single PE treatment in addition to BD treatment. These results show that PE can shorten the icteric period and may improve the hepatic functions after the treatment of malignant obstructive lesion in the biliary tract.     

Obstructive putty-like cast of the biliary tree

A 62-year-old woman was presented at the emergency department with cholangiosepsis. She had a history of liver metastases for which she had a left hemihepatectomy and loco regional recurrence at the liver hilum for which she received chemoradiation therapy MR-imaging of the liver showed multiple intrahepatic fluid collections/abscesses, together with significantly dilated intrahepatic bile ducts. For her significant hepatic function impairment she received antibiotic treatment and percutaneous drainage. The differential diagnosis was local tumor recurrence or post radiation fibrosis causing outflow obstruction centrally in the liver hilum. During the admission the serum bilirubin values kept rising. During surgery surgeons decided to perform a hepatotomy and connect a loop of the jejunum directly on the liver parenchyma, in order to allow better drainage. Intra operatively, after the hepatotomy, we encountered green-brownisch putty-like material. By traction a ‘cast’ of a large part of the biliary tree was removed.     

Preoperative Biliary Drainage in Patients with Obstructive Jaundice: History and Current Status

Rationale  Preoperative biliary drainage (PBD) has been introduced to improve outcome after surgery in patients suffering from obstructive jaundice due to a potentially resectable proximal or distal bile duct/pancreatic head lesion. In experimental models, PBD is almost exclusively associated with beneficial results: improved liver function and nutritional status; reduction of systemic endotoxemia; cytokine release; and, as a result, an improved immune response. Mortality was significantly reduced in these animal models. Human studies show conflicting results. Findings  For distal obstruction, currently the “best-evidence” available clearly shows that routine PBD does not yield the appreciated improvement in postoperative morbidity and mortality in patients undergoing resection. Moreover, PBD harbors its own complications. However, most of the available data are outdated or suffer from methodological deficits. Conclusion  The highest level of evidence for PBD to be performed in proximal obstruction, as well as over the preferred mode, is lacking but, nevertheless, assimilated in the treatment algorithm for many centers. Logistics and waiting lists, although sometimes inevitable, could be factors that might influence the decision to opt for PBD, as well as an extended diagnostic workup with laparoscopy (on indication) or scheduled preoperative chemotherapy.     

胆汁回输对梗阻性黄疸患者红细胞免疫功能的影响

目的探讨梗阻性黄疸患者行胆道外引流术后胆汁回输对红细胞免疫功能的影响。方法将行胆道外引流的梗阻性黄疸患者分为胆汁回输组(n=24)和单纯外引流组(n=27)，并随机选择同期无黄疸的胆囊切除术患者(n=25)作为对照组。观察手术前、后红细胞C3b受体花环试验(C3bRRT)、红细胞免疫复合物花环试验(ICRT)、红细胞cab受体花环促进率(RFER)和红细胞cab受体花环抑制率(RFIR)的变化。结果术前，胆汁回输组及单纯引流组患者C3bRRT和RFER均明显低于对照组．ICRT及RFIR活性均明显高于对照组；术后第14天胆汁回输组C3bRRT明显高于单纯引流组(P＜0．05)。结论梗阻性黄疸患者红细胞免疫功能被抑制，在胆道外引流术后行胆汁回输有利于红细胞免疫功能的恢复。     

Solitary Extra-Hepatic Hilar Peribiliary Cyst Presenting with Obstructive Jaundice: A Case Report

Peribiliary cyst is a poorly recognized and under-reported clinico-pathologic entity around the biliary tree. Peribiliary cysts are cystic dilatations of obstructed peribiliary glands, which are normal elements of the biliary tract. They are generally asymptomatic and rarely cause biliary obstruction. They are usually discovered incidentally at autopsy or in explants following liver transplantation.

A 59-year-old male patient presenting with obstructive jaundice due to a large extra-hepatic hilar peribiliary cyst is reported here. We briefly discuss its differential diagnoses such as bile duct cyst, liver cyst or lymph cyst, and its management.

Radiological imaging demonstrated a solitary large (5 cm) well-defined, smooth, thin walled cystic lesion at the porta hepatis paralleling but not communicating with the bile duct. A wide cyst de-roofing was performed and histological examination of the cystic wall revealed an inflammatory cyst.

The patient made an uneventful recovery and remained asymptomatic with normal liver function tests 36 months post-operatively.     

Effects of the administration of pentoxifylline and prednisolone on the evolution of portal fibrogenesis secondary to biliary obstruction—an experimental study in growing animals

Background

Many chronic liver diseases lead to progressive hepatic fibrosis, a condition that can ultimately result in loss of organ function and severe portal hypertension necessitating hepatic transplantation. Within the last few decades, studies have been conducted to demonstrate the possibility of drug modulation of hepatic fibrogenesis. Regarding biliary obstruction, it has been suggested that administration of corticosteroids could promote better late outcomes for children with biliary atresia submitted to Kasai's portoenterostomy. Models used to test potential antifibrogenic drugs such as pentoxifylline (PTX) have not included growing animals.

Methods

In this experimental study, 119 young rats (21st or 22nd days) were submitted to laparotomy and common bile duct ligation (CBDL) or to sham surgery (SHAM). Animals were allocated into 5 groups, according to surgical procedure, and administered the following solutions: (1) CBDL + distilled water, (2) SHAM + distilled water, (3) CBDL + PTX, (4) CBDL + prednisolone (PRED), and (5) CBDL + PTX + PRED (PTX + PRED). Each group was further divided into 2 subgroups according to the length of the experiment (15 or 30 days). At the end of the defined period, animals were weighed, and a hepatic fragment was collected from each one for analyses.

Results

The PTX animals exhibited increased weight gain compared to animals in the PRED or PTX + PRED groups. Animals from the 3 therapeutic groups (PTX, PRED, and PTX + PRED) showed diminished collagen-filled area in portal spaces. Total portal space area was increased in the PTX group.

Conclusions

Hepatic fibrosis induced by bile duct ligation in young rats could be modulated by pharmacologic interventions. Administration of PTX or PRED, or the combination of both, resulted in diminished collagen-filled areas in portal spaces.     

The Effect of Calcium Dobesilate on Liver Damage in Experimental Obstructive Jaundice

Purpose/Aim of the study: Inflammation and oxidative stress are two significant factors affecting the degree of liver damage in obstructive jaundice. The aim of this study was to evaluate the effect of calcium dobesilate (CaDob), an effective antioxidant and anti-inflammatory drug, on damage to liver caused by experimental obstructive jaundice. Materials and Methods: 30 rats in total were randomly placed into three groups, each group consisting of 10 rats. The sham group (Group 1) only received solely laparotomy. In the control group (Group 2), ligation was applied to the biliary tract and no treatment was implemented. In the CaDob group (Group 3), following ligation of the biliary tract, 100 mg/kg/day CaDob was implemented via an orogastric tube for a 10–day period. Liver tissue and blood samples were taken for histopathological and biochemical examination. Results: The CaDob group had significantly lower test values for serum liver functions when compared to the control group. Statistically lower levels of tissue malondialdehyde (MDA) and fluorescent oxidation products (FOP) were detected in the CaDob group, and the CaDob group had significantly higher levels of sulfydryl (SH) than the control group. Histopathological scores in the CaDob group were found out to be statistically less than the scores the control group received (p < 0.05). Conclusions: CaDob treatment repaired the histpatological changes induced by bile duct ligation. The hepatoprotective effects of CaDob can be associated with its antioxidant properties of the drug.     

Jaundice: applying lessons from physiology

Jaundice is a common presentation in medical and surgical gastroenterology practice. Knowledge of the physiology of bilirubin metabolism will help the clinician to understand the mechanisms of development of jaundice. This along with clinical evaluation, laboratory investigation and non-invasive imaging will help when making a firm diagnosis. Further management may require advanced imaging and/or invasive techniques, which should be chosen in the light of the given clinical scenario based on the risk-benefit ratio, local availability and expertise.     

Jaundice: applying lessons from physiology

Jaundice is a common presentation in medical and surgical gastroenterology practice. Knowledge of the physiology of bilirubin metabolism will help the clinician to understand the mechanisms of development of jaundice. This along with clinical evaluation, laboratory investigation and non-invasive imaging will help when making a firm diagnosis. Further management may require advanced imaging and/or invasive techniques, which should be chosen in the light of the given clinical scenario based on the risk-benefit ratio, local availability and expertise.     

梗阻性黄疸肝内增生胆管上皮细胞凋亡的实验研究

目的：研究梗阻性黄疸肝内胆管上皮细胞凋亡对增生胆管的影响。方法：应用末端脱氧苷酸转移酶介导的脱氧三磷酸尿苷（dUTP）缺口末端标记技术（TUNEL）观察大鼠胆道梗阻及胆肠内引流术后肝内胆管上皮细胞凋亡与胆管增生的关系。结果：胆道梗阻后，肝内胆管明显增生，胆管上皮细胞凋亡明显增加；早期胆肠内引流术后，增生的胆管及胆管上皮细胞凋亡明显减少。结论：胆道梗阻胆管上皮细胞凋亡增加可能与清除过度增生的胆管有关，是机体维持自身组织稳定的一种重要机制；早期胆肠内引流术后，随着增生的胆管减少，胆管上皮细胞凋亡明显减少。     

ERCP检查在胆囊切除术后阻塞性黄疸诊断中的应用

３６例胆管切除术后阻塞性黄疸患者行ＥＲＣＰ检查、结果显示：胆总管结石９例，肝内外胆管结石１５例，医源性胆管损伤５例，毛细胆管性肝炎３例，胰头肿瘤１例，十二指肠乳头肿瘤２例。文章还论述了ＥＲＣＰ检查在阻塞性黄疸诊断中的优点及其局限性。