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Jaundice icterus [keywords]
- Establishment of an orthotopic pancreatic cancer mouse model: Cells suspended and injected in Matrigel. [Journal Article]
- World J Gastroenterol 2014 Jul 28; 20(28):9476-85.
To establish an orthotopic mouse model of pancreatic cancer that mimics the pathological features of exocrine pancreatic adenocarcinoma.Pan02 cells were suspended in low-temperature Matrigel and injected into the parenchyma of pancreatic tails of C57BL/6 mice, with cells suspended in phosphate buffered saline (PBS) serving as a control. Primary and implanted tumors were confirmed pathologically. The rate of tumor formation and intraperitoneal implantation in the two groups were compared at different time points after injection. Leakage and intra-abdominal dispersion of Matrigel and PBS, both dyed with methylene blue, were compared after injection into the parenchyma of the pancreas. We observed adherence and proliferation in Pan02 cells suspended in Matrigel in vitro. We also compared the pathological manifestation of this orthotopic pancreatic cancer model in the head and tails of the pancreas. The characteristics of the origin of epithelial cells and exocrine markers of established orthotopic pancreatic tumors were confirmed using immunohistochemistry.Diluted Matrigel could form a gel drip in the pancreatic parenchyma, effectively preventing leakage from the injection site and avoiding dispersion in the abdominal cavity. Pan02 cells were able to adhere to a dish, proliferate, and migrate in the gel drip. The tumor formation rate in the Matrigel group was 100% at both 2 and 3 wk after injection, whereas it was 25.0% and 37.5% in the PBS group at 2 and 3 wk, respectively (P < 0.05). The intraperitoneal tumor implantation rate was 75.0% in the PBS group after 3 wk of injection, while it was 12.5% in the Matrigel group (P < 0.05). Hepatoduodenal ligament and duodenal invasions with obstructive jaundice and upper digestive obstruction with mesenteric lymph node metastasis were observed in the pancreatic head group. In the pancreatic tail group, spleen and gastric invasion were dominant, leading to retroperitoneal lymph nodes metastasis. Positive immunohistochemical staining of cytokeratin and negative staining of vimentin and chromogranin A confirmed that the orthotopic pancreatic tumor injected with Pan02 cells suspended in Matrigel was of epithelial origin and expressed exocrine markers of cancer.This method of low-temperature Matrigel suspension and injection is effective for establishing an orthotopic mouse model of pancreatic cancer.
- Atypical causes of cholestasis. [REVIEW]
- World J Gastroenterol 2014 Jul 28; 20(28):9418-9426.
Cholestatic liver disease consists of a variety of disorders. Primary sclerosing cholangitis and primary biliary cirrhosis are the most commonly recognized cholestatic liver disease in the adult population, while biliary atresia and Alagille syndrome are commonly recognized in the pediatric population. In infants, the causes are usually congenital or inherited. Even though jaundice is a hallmark of cholestasis, it is not always seen in adult patients with chronic liver disease. Patients can have "silent" progressive cholestatic liver disease for years prior to development of symptoms such as jaundice and pruritus. In this review, we will discuss some of the atypical causes of cholestatic liver disease such as benign recurrent intrahepatic cholestasis, progressive familial intrahepatic cholestasis, Alagille Syndrome, biliary atresia, total parenteral nutrition induced cholestasis and cholestasis secondary to drug induced liver injury.
- Managing malignant biliary obstruction in pancreas cancer: Choosing the appropriate strategy. [REVIEW]
- World J Gastroenterol 2014 Jul 28; 20(28):9345-9353.
Most patients with pancreatic cancer develop malignant biliary obstruction. Treatment of obstruction is generally indicated to relieve symptoms and improve morbidity and mortality. First-line therapy consists of endoscopic biliary stent placement. Recent data comparing plastic stents to self-expanding metallic stents (SEMS) has shown improved patency with SEMS. The decision of whether to treat obstruction and the means for doing so depends on the clinical scenario. For patients with resectable disease, preoperative biliary decompression is only indicated when surgery will be delayed or complications of jaundice exist. For patients with locally advanced disease, self-expanding metal stents are superior to plastic stents for long-term patency. For patients with advanced disease, the choice of metallic or plastic stent depends on life expectancy. When endoscopic stent placement fails, percutaneous or surgical treatments are appropriate. Endoscopic therapy or surgical approach can be used to treat concomitant duodenal and biliary obstruction.
- Effective Biliary Drainage and Proper Treatment Improve Outcomes of Hepatocellular Carcinoma with Obstructive Jaundice. [JOURNAL ARTICLE]
- Gut Liver 2014 Jul 25.
: We investigated the treatment outcomes and prognostic factors of hepatocellular carcinoma (HCC) with obstructive jaundice.: Among 2,861 patients newly diagnosed with HCC between 2002 and 2011, a total of 63 patients who initially presented with obstructive jaundice were analyzed. Only four patients presented with resectable tumors and underwent curative resection. In the other patients who presented with unresectable tumors, 5, 8, 9, and 18 patients received transarterial chemoembolization (TACE), chemotherapy, radiotherapy, and combined treatment, respectively. Both the clinical and the treatment factors that affect overall survival (OS) were analyzed.: The median OS was 4 months, and the 1-year OS rate was 23%. Patients who received treatment for HCC had a significantly improved OS rate compared with the patients who received supportive care only (1-year OS, 32% vs 0%; p<0.01). Responders to treatment showed a better OS than nonresponders (1-year OS, 52% vs 0%; p<0.01). TACE and radiotherapy resulted in relatively good treatment responses of 64% and 67%, respectively. In multivariate analyses, treatment of HCC (p=0.02) and the normalization of serum bilirubin by biliary drainage (p=0.02) were significantly favorable prognostic factors that affected the OS.: Unresectable HCC with obstructive jaundice has a poor prognosis. However, effective biliary drainage and treatment of HCC such as with TACE or radiotherapy improves survival.
- Autoimmune pancreatitis: A surgical dilemma. [JOURNAL ARTICLE]
- Cir Esp 2014 Jul 24.
Autoimmune pancreatitis (AIP) is defined as a particular form of pancreatitis that often manifests as obstructive jaundice associated with a pancreatic mass or an obstructive bile duct lesion, and that has an excellent response to corticosteroid treatment. The prevalence of AIP worldwide is unknown, and it is considered as a rare entity. The clinical and radiological presentation of AIP can mimic bilio-pancreatic cancer, presenting difficulties for diagnosis and obliging the surgeon to balance decision-making between the potential risk presented by the misdiagnosis of a deadly disease against the desire to avoid unnecessary major surgery for a disease that responds effectively to corticosteroid treatment. In this review we detail the current and critical points for the diagnosis, classification and treatment for AIP, with a special emphasis on surgical series and the methods to differentiate between this pathology and bilio-pancreatic cancer.
- Initial presentations and final outcomes of primary pyogenic liver abscess: a cross-sectional study. [JOURNAL ARTICLE]
- BMC Gastroenterol 2014 Jul 28; 14(1):133.
Although pyogenic liver abscess (PPLA) fatalities are decreasing owing to early diagnosis and effective treatments, PPLA-associated complications still exist. The purpose of this study was to analyze the characteristic features of initial presentations and final outcomes of PPLA caused by different pathogens.This retrospective study collected and analyzed information regarding initial presentations and final outcomes in patients diagnosed with PPLA at admitted at Changhua Christian Hospital from January 1 to December 31, 2010.During the study period, we analyzed the records of a total of 134 patients with documented PPLA. There were no significant causative pathogen-related differences in symptoms at initial presentation. Compared with the survivor group, patients in the mortality group were characterized by male gender (p < 0.001), malignancy (p < 0.001), respiratory distress (p =0.007), low blood pressure (p = 0.024), jaundice (p = < 0.001), rupture of liver abscess (p < 0.001), endophthalmitis (p = 0.003), and multiple organ failure (p < 0.001). No patients received liver transplantation or were diagnosed with HIV during the study period. According to univariate logistic regression analysis, gender (OR = 1.185, 95% CI: 0.284-11.130, p = 0.006), malignancy (OR = 2.067, 95% CI: 1.174-13.130, p = 0.004), respiratory distress (OR = 1.667, 95% CI: 1.164-14.210, p = 0.006), low blood pressure (OR = 2.167, 95% CI: 2.104-13.150, p = 0.003), jaundice (OR = 1.9, 95% CI: 1.246-3.297, p = 0.008), rupture of liver abscess (OR = 5.167, 95% CI: 2.194-23.150, p = 0.003), endophthalmitis (OR = 2.167, 95% CI: 1.234-13.140, p = 0.005), and multiple organ failure (OR = 3.067, 95% CI: 1.184-15.150, p = 0.001) differed significantly between the mortality and survivor groups.Although the initial presentations of PPLA caused by different pathogens were similar, there were significant differences in mortality in cases involving: (1) male patients, (2) malignancy, (3) initial respiratory distress, (4) initial low blood pressure, (5) jaundice, (6) rupture of liver abscess, (7) endophthalmitis, , and (8) multiple organ failure. We strongly recommend using a severity score of the disease to determine the risk of mortality for each patient with PPLA. In order to prevent complications and reduce mortality, more attention must be paid to high-risk PPLA patients.
- Outcome analysis of jaundice fast-track system implementation in Thammasat University Hospital. [Journal Article]
- J Med Assoc Thai 2014 May; 97(5):500-5.
Infants who were readmitted with high level of bilirubin (more than 20 mg/dl) should be treated as an acute medical emergency to prevent acute and chronic bilirubin encephalopathy.To determine causes of severe neonatal hyperbilirubinemia, risk factors for exchange transfusion and outcomes of neonate after implementation of the jaundice fast-track system in Thammasat hospital.The medical records of neonates presenting with clinically significant hyperbilirubinemia to the outpatient department or emergency department after implementation of the jaundice fast-track system at Thammasat university from October 1, 2010 through september 30, 2012, were retrospectively reviewed.There were 76 infants included in the study. One infant had neurological abnormalities consistent with acute bilirubin encephalopathy at presentation. all infants received intensive phototherapy. Eight infants (10.5%) underwent an exchange transfusion. a cause of hyperbilirubinemia was identified in 66 cases (86%). Breastfeeding jaundice was the most common cause (47%). The mean peak MB level was higher in the exchange transfusion group than the phototherapy group (25.0 +/- 2.9 mg/dl vs. 21.2 +/- 1.8 mg/dl, p < 0.001). Three infants in the exchange transfusion group had sepsis on admission compared to none in the phototherapy group, (p < 0.001). Infant diagnosed as cephalhematoma underwent an exchange transfusion. The median (range) length of stay was significantly longer in the exchange transfusion group than the phototherapy group (9 (2-15) days vs. 2 (1-12) days, p < 0.001). There were no statistical differences between the two groups in age at readmission and time to phototherapy. All infants in this study were discharged as no neurological abnormalities. Infants presented with peak MB > or = 24 mg/dl had the greatest risk of exchange transfusion (or = 26.6; 95% ci = 4.6, 153.7).Initiating phototherapy within an hour of admission in infants who were readmitted with high levels of bilirubin is effective to prevent bilirubin encephalopathy. Physicians' early recognition of the risk factors to exchange transfusion is, therefore, crucial.
- Vitiligo, jaundice and cholestasis in a middle aged woman: a case report. [Journal Article]
- Bol Asoc Med P R 2014; 106(2):37-41.
Primary biliary cirrhosis with autoimmune hepatitis (PCB/AIH) overlap is characterized by uncertain behavior and no standardized treatment. A 35 year-old-woman with vitiligo, jaundice and cholestasis fulfilled serological, biochemical and histological criteria for PBC/AIH overlap. Treatment was initiated with conventional doses of corticosteroid and ursodeoxycholic acid. Her condition worsened with poor biochemical hepatic response. The course of action was altered to institute high doses of ursodiol, azathioprine and corticosteroids for extended periods of time. This case illustrates how increased understanding of the overlap PBC/AIH leads to new interventions. Recognition of these variant forms is critical for institutional management of both disease entities.
- Liver transplantation following the Kasai procedure in treatment of biliary atresia: a single institution analysis. [JOURNAL ARTICLE]
- Pediatr Surg Int 2014 Jul 27.
This study aimed to assess outcomes of liver transplantation (LTx) in patients with biliary atresia (BA).The Kasai procedure was performed for 358 patients at Tohoku University Hospital between January 1955 and December 2013; 64 (17.9 %) required LTx. These 64 patients were divided into 4 groups according to their age at the time of transplantation: Group 1, aged <2 years (n = 27); Group 2, aged 2-9 years (n = 16); Group 3, aged 10-19 years (n = 11); and Group 4, aged ≥20 years (n = 10). Clinical parameters were evaluated retrospectively.Both living-donor (n = 57) and deceased-donor (n = 7) LTx were performed. Indications were irreversible jaundice (n = 53), intractable cholangitis (n = 3), hepatopulmonary syndrome (n = 6), portopulmonary hypertension (n = 1), and intestinal bleeding (n = 1). Jaundice occurred more frequently in Groups 1 and 2 than in Groups 3 and 4 (p = 0.031). Survival rates were 81.5, 100, 90.9, and 80 % in Groups 1, 2, 3, and 4, respectively.Although the overall LTx survival rate was satisfactory, some adult recipients experienced LTx-related difficulty. Close follow-up, meticulous assessment of physical and social conditions, presence of a multidisciplinary support system, and appropriate time course for LTx are all essential factors in the treatment of BA.
- Experience of treating biliary atresia with three types of portoenterostomy at a single institution: extended, modified Kasai, and laparoscopic modified Kasai. [JOURNAL ARTICLE]
- Pediatr Surg Int 2014 Jul 27.
Generally, open portoenterostomy (PE) involves a wide extended anastomosis and all sutures are deep [extended PE (EP)]. In contrast, the anastomosis in Kasai's PE (KP), our modified open Kasai PE (MK), and our laparoscopic modified Kasai PE (lapMK) involve shallow suturing, especially at the 2 and 10 o'clock positions where the right and left bile ducts would be normally. We compared outcomes of 36 consecutive biliary atresia (BA) patients treated by three types of PE at a single institution during the period 2005-2014; EP (n = 13), MK (n = 11), and lapMK (n = 12).We compared age at PE, time taken to become jaundice-free (total bilirubin ≤1.2 mg/dL; JF time), proportion of JF subjects [JF ratio (JFR)], steroid dosage, incidence of cholangitis, postoperative liver function and CRP, presence of hypersplenism, requirement for liver transplantation (LTx), and JF survival with the native liver (JF+NL) as indicators of outcome.Patient demographics, steroid dosage, JF time, incidence of cholangitis, presence of hypersplenism, operating time, blood loss and postoperative biochemistry were similar for all groups. However, JFR was significantly higher for lapMK (100 %) versus EP (46.2 %) (p < 0.05), but not for MK (81.8 %) versus EP. Kaplan-Meier analysis showed survival with NL was significantly higher for lapMK (10/12: 83.3 %: JF in 9; not JF in 1) and MK (9/11: 81.8 %: JF in all) versus EP (3/13: 23.1 %: JF in all) (p < 0.05, respectively), but not for lapMK versus MK. JF+NL in both lapMK (9/12: 75.0 %) and MK (9/11: 81.8 %) were significantly higher compared with EP (3/13: 23.1 %) (p < 0.05, respectively). Intraperitoneal adhesions were less pronounced at LTx in lapMK compared with MK or EP.This study would suggest that depth of suturing during PE would appear to influence post-PE outcome. LapMK should be reconsidered as a valid treatment option for BA.