Cases Of Jaundice Research Articles

Non-a, non-b hepatitis: identification of hepatitis-B-like virus particles in serum and liver.

Hepatitis B virus-like particles including: small spheres and filaments 15--25 nm in diameter together with a 35--40 nm Dane particle-like virion have been identified in sera of patients with non-A, non-B hepatitis. In a coded serological study, such particles were detected transiently in 3/4 acute, and persistently in 7/8 chronic cases of non-A, non-B hepatitis with non-A, non-B antigenemia. Only 2/12 similar cases without non-A, non-B antigens (Ag) in serum had detectable particles but neither patients with drugs, or type A hepatitis, nor cases of obstructive jaundice. The particles did not express hepatitis B surface (HBs) or non-A, non-B Ag at their surface but were associated, in three patients, with significant endogenous DNA polymerase activity. Furthermore, particles similar to hepatitis B cores (BHc) and also associated with DNA polymerase activity were demonstrated by sucrose gradient ultracentrifugation of a liver homogenate obtained from a patient who had died of non-A, non-B hepatitis. The non-A, non-B hepatitis virion described here appears, therefore, as a hepatitis B-like virus. The exact kinship between these two agents is currently being investigated.

Defect in Plasma Clearance of Bromsulphthalein in Papua New Guineans with Systemic Infections

One hundred and one Papua New Guineans, most of whom had systemic infections, received 5 mg kg body-weight-1 bromsulphthalein (BSP) intravenously after an overnight fast; serial venous blood BSP concentrations were measured for up to 2 hours. Many of those with infections had a reduction in plasma BSP disappearance rate and 30-minute retention. However, 15 per cent of 86 with infection had a secondary rise in plasma BSP concentration after 30 minutes, and in those followed serially a secondary peak was observed; that returned to normal after treatment and was not seen in 12 who were free of infection. Liver-biopsy specimens taken from four who had that defect in clearance did ot show Dubin-Johnson pigment. BSP curves with an exactly similar secondary rise after 30 minutes have previously been considered specific for the Dubin-Johnson syndrome, which is probably inherited as a Mendelian recessive; it seems possible that in the present study systemic infections have exposed the forme fruste of the condition. The present finding might explain some cases of jaundice associated with systemic infection commonly seen in Papua New Guinea. It might explain some toxic therapeutic reactions, because plasma concentrations of agents excreted in bile are likely to be abnormally elevated. If this abnormality in excretion proves to have a genetic basis it might prove valuable in mapping gene dispersal in South-east Asia and the Pacific.

Plasma bile pigment conjugation modalities in icterus syndromes of various origin.

Plasma azopigments derived from conjugated bilirubin were analyzed by thin-layer chromatography according to HEIRWEGH et al. in 14 cases of obstructive jaundice and in 11 of acute hepatitis. The chromatographic patterns were compared with those obtained from azopigments derived from 8 normal bile samples. The plasma pigment patterns did not differ from those of the bile in number and chromatographic mobility of the spots. However, the quantitative percentages of the plasma azopigments were significantly modified: the alpha 0 fraction (free azodipyrrolic pigment) increased in both icteric syndromes, while the delta fraction (mainly glucuronide azopigment) decreased. Moreover, the behavior of two closed components of the delta group showed significant differences in both icteric syndromes. It can be postulated that the synthesis of bilirubin diconjugates decreases both in hepatocellular and cholestatic jaundice, while monoglucuronidated as well as saccharide and glucoside conjugates increase. In cholestatic jaundice the conjugation with glucuronic acid mainly takes place in the normal way, whereas compounds with different features are formed in hepatitis.

Vitamin D metabolism in acute and chronic cholestasis

To study the effects of acute and chronic cholestasis on vitamin D metabolism we investigated six cases of acute extrahepatic obstructive jaundice and eight cases of primary biliary cirrhosis (PBC) (three supplemented with vitamin D). Plasma 25-hydroxyvitamin D (25OHD) was low in the patients with PBC unsupplemented with vitamin D but normal in obstructive jaundice. None of the patients with PBC showed radiological or histological evidence of osteomalacia. In PBC, dietary intake of vitamin D was low but response to ultra-violet irradiation of the skin was normal even in those with a considerably raised serum bilirubin. Patients with PBC or obstructive jaundice had low levels of 25 hydroxyvitamin D binding protein which correlated with the serum albumin. The half-life of intravenously injected (3)H vitamin D(3) ((3)HD(3)) and the subsequent production of (3)H 25OHD were normal in all the patients with obstructive jaundice and in most with PBC. The two patients with PBC who produced less (3)H 25OHD than expected were receiving vitamin D supplements. The urinary tritium ((3)H) excretion after the injection of (3)HD(3) correlated with the serum bilirubin. After the injection of (3)H 25OHD(3) the urinary excretion of (3)H was minimal and did not correlate with the serum bilirubin, suggesting that the radioactivity appearing in the urine after the (3)H vitamin D(3) injection was associated with vitamin D metabolites other than 25OHD. Factors contributing to the low plasma 25OHD in primary biliary cirrhosis may be a low dietary intake of vitamin D, inadequate exposure to ultra-violet light, and a tendency to urinary wastage of vitamin D metabolites.

Our experience in the management of neonatal jaundice

Two hundred (200) cases of neonatal jaundice were treated in this hospital (CH CC) with phenobarbitone and phototherapy as a single agent and with a combination of phototherapy and phenobarbitone.

Prevalence of intrahepatic cholestasis of pregnancy in La Paz, Bolivia

A past history of intrahepatic cholestasis of pregnancy—either as cholestatic jaundice or as pruritus gravidarum—was inquired in 304 pregnant women examined in La Paz, Bolivia. Pruritus gravidarum was detected in 9.2% of them but no cases of cholestatic jaundice of pregnancy were found in the sample studied. This prevalence rate of pruritus gravidarum is considerably greater than that reported in European and North American populations (0.2–3.0%) but smaller than in Araucanian Indian-mixed (22.1%) and in Caucasoids (12.6%) previously studied in Chile. No significant differences in prevalence rates of pruritus gravidarum were found between the four ethnic groups (Aimara Indian. Quechua Indian, Indian-mixed and Caucasoids) in which Bolivian women were classified. Bolivian and Chilean Caucasoids showing a greater degree of ethnic admixture with South American Indian groups in their ancestry, had a greater prevalence and recurrence rate of intrahepatic cholestasis of pregnancy than Caucasoid women showing a smaller degree of ethnic admixture with native Indian groups. We propose that the prevalence of intrahepatic cholestasis of pregnancy in Bolivia and in Chile is influenced by a genetic predisposition related to ethnic admixture with some South American Indian groups. Still unidentified environmental factors may modify the expressivity of the disease.

Hepatobiliary imaging: the use of 99Tcm-pyridoxylidene glutamate scanning in jaundiced adults and infants.

99Tcm-pyridoxylidene glutamate (99Tcm-PG) scans have been carried out in 24 jaundiced adults (mean total bilirubin 255 mumol/l and 11 infants with prolonged obstructive jaundice (mean total bilirubin 165 mumol/l). Absence of radioactivity in the gut was interpreted as complete biliary obstruction which was the cause of jaundice in ten adults and six infants. Using this criterion occlusion or patency of the bile ducts was correctly determined in 21 adults and eight infants. False-negative gut images were found in one adult and two infants, and three scans were inconclusive (two adults, one infant). The scan was unable to show details of the site of obstruction or pathology but the technique was simple and atraumatic and was safely performed in patients with serious complications, e.g. renal failure, coagulation defects, septicaemia. In infants the 99Tcm-PG scan compared well with the 131I rose bengal faecal excretion test and with liver biopsy in the investigation of prolonged obstructive jaundice. Repeat scans in infants with biliary atresia were used to assess postoperative bile drainage. It is suggested that 99Tcm-PG scanning is useful screening test in difficult cases of jaundice. It is especially useful in frail patients, and patients with complications.

Jaundice, Choledocholithiasis, and a Nondilated Common Duct

In two cases of jaundice due to choledocholithiasis, the biliary tree was not dilated on skinny-needle transhepatic cholangiography. Visualization of the biliary tree before arriving at a diagnosis in certain cases of jaundice is needed.

Occupational hazards to reproduction and health in anaesthetists and paediatricians.

A mail questionnaire was sent to Finnish anaesthetists and paediatricians to evaluate the risks of reproductive, teratogenic and health complications related to the professions. The incidence of diagnosed spontaneous miscarriages in anaesthetists' families was 10.2% of all pregnancies and it was 13.2% in paediatricians' families. Smoking seemed to increase markedly the incidence of spontaneous miscarriages, which was 22.9% in smoking female anaesthetists and 17.2% in smoking female paediatricians. The gestation times in cases of both full-term pregnancies and miscarriages were shorter in the anaesthetist group than those in the paediatrician group. Congenital abnormalities appeared at an equal rate in both anaesthetist and paediatrician groups, but strikingly, there were nine musculoskeletal abnormalities in the anaesthetists' children compared to no such defects in paediatricians' children. Serious diseases occurred at low frequencies, but three cases of hepatic jaundice and three cases of viral myocarditis in anaesthetists indicate possible infectious hazards to health in anaesthetic work. Different infectious diseases to the respiratory and urinary tracts were commonest among paediatricians. Cancer was not reported in the anaesthetist group. The study does not indicate that gas pollution in operating rooms is harmful to the personnel.

Massive hepatic necrosis associated with dantrolene therapy

Hepatic toxicity associated with dantrolene sodium is generally believed to be mild and unusual. Despite the large number of patients treated for spastic conditions with this drug, reports of this complication are few. Side effects associated with dantrolene sodium are mainly drowsiness, dizziness, weakness, and headache (2-5). Abnormalities of liver function have been reported, but have usually been mild and have not necessitated withdrawal of the drug (2, 4, 6). Recently, Schneider and Mitchell described a case of jaundice they felt was due to dantrolene sodium in which needle biopsy of the liver showed cytotoxic effects and cholestasis. They urged caution if this drug is used in patients with liver disease (7). In this communication the authors report what they believe to be the first death from liver damage in a patient being treated with dantrolene sodium.

Erythromycin Estolate Hepatotoxicity

A recent review of erythromycin 1 stated that of 506 cases of cholestatic jaundice following erythromycin estolate administration reported between 1961-1973, only 12 (2%) occurred in children younger than 12 years of age. During the same period an estimated 30 million courses of therapy with a liquid form of estolate were prescribed. We report the case of a child in whom cholestatic jaundice developed and who was seen as an acute surgical emergency after erythromycin estolate administration. A percutaneous liver biopsy specimen demonstrated changes consistent with a hypersensitivity drug reaction. Report of a Case .—A 7-year-old boy was hospitalized with abdominal pain, rash, and fever of two days' duration. Four weeks prior to admission to the hospital his mother administered two 250-mg tablets of erythromycin estolate for treatment of a sore throat. Three days prior to admission an upper respiratory infection again developed and the patient was given erythromycin estolate

Percutaneous transhepatic drainage of the biliary tract: Technique and results in 104 cases

A two-step procedure for percutaneous transhepatic drainage (PTD) of the biliary tract is described. This technique was applied on a total of 105 cases of obstructive jaundice, 84 with malignant and 21 with benign lesions, and was successful in 104. Decompression effect was adequate and reduction in serum bilirubin level was quick. Operative mortality, which used to be high in jaundiced patients with serum bilirubin levels above 10 mg per dl, has been significantly reduced with this procedure employed as the first step in a two-stage operation for malignant biliary obstruction. PTD proved to be very useful in the management of acute obstructive suppurative cholangitis and ensuing liver abscesses. Continuous drainage was also achieved by PTD in inoperable cases, and 1 patient with a hilar carcinoma was kept alive for 2 years and 1 month by PTD alone. With the improvement in the diagnosis of biliary tract disease this procedure will assume an important position in the management of obstructive jaundice.

EARLY ULTRASOUND EXAMINATION IN ANTENATAL CARE

Ultrasound examination was done on 442 women early in pregnancy. If there was a discrepancy the date of delivery calculated from ultrasound readings was preferred to that calculated by traditional means. As a result of this policy induction or planned cæsarean section was postponed or cancelled in 10·4% of cases. In 9·7% of women the menstrual history was unreliable and the ultrasound measurement was used to estimate the date of delivery. Thus in 21·1% of pregnancies the early ultrasound measurement decided when or whether labour was to be induced. In women induced for postmaturity there was no increase in prolonged labour or need for cæsarean section. There were no cases of neonatal respiratory distress and neonatal jaundice was less common than it was when the onset of labour was spontaneous. This evidence suggests that neonatal jaundice is not caused by induction of labour or by the agents used. The low frequency of jaundice in this series is thought to be due to accurate prediction of the expected date of delivery and consequent exclusion of premature babies born to "postmature" women.

Bile leakage following percutaneous transhepatic cholangiography with the Chiba needle.

Percutaneous transhepatic cholangiography (PTC) for jaundice of undetermined etiology was performed with the Chiba needle in 30 patients. Successful visualization of the biliary ductal system was accomplished in 26 patients (86.7%); two of six patients (33.3%) with normal biliary systems had ducts visualized, and the ducts were visualized in the 24 patients (100%) with obstruction. Bile leakage of 50 to 500 ml (average, 200 ml) was observed at laparotomy or autopsy in 12 patients (40%), nine (30%) of whom had symptoms of peritonitis. Six (20%) of these were transient and three (10%) progressed to an acute abdomen. Bacteremia occurred in seven patients (23.3%), in three (10%) it progressed to septic shock, with one death (3.3%). There were no complications in patients with nonobstructed ducts. This study suggests that PTC with the Chiba needle has little advantage over the larger sheathed needles, and surgical standby is indicated in suspected cases of obstructive jaundice.

Ultrasound

Evaluation of the jaundiced patient's condition frequently can be difficult. Clinical history, physical examination, liver function tests, and other laboratory data are often inconclusive in differentiating extrahepatic obstruction (surgical jaundice) from intrahepatic cholestasis (medical jaundice). During a 14-month period, we have evaluated 40 cases of jaundice of unknown causes. Ultrasound was able to correctly diagnose pathologically proved extrahepatic obstruction in 23 of 24 patients and intrahepatic cholestasis in 15 of 16 patients. There was one false-positive and one false-negative result in this series. (<i>JAMA</i>238:221-223, 1977)

Ultrasound. A new diagnostic approach to the jaundiced patient.

Evaluation of the jaundiced patient's condition frequently can be difficult. Clinical history, physical examination, liver function tests, and other laboratory data are often inconclusive in differentiating extrahepatic obstruction (surgical jaundice) form intrahepatic cholestasis (medical laundice). During a 14-month period, we have evaluated 40 cases of jaundice of unknown causes. Ultrasound was able to correctly diagnose pathologically proved extrahepatic obstruction in 23 of 24 patients and intrahepatic cholestasis in 15 of 16 patients. There was one false-positive and one false-negative result in this series.

Occurrence of disseminated intravascular coagulation (DIC) in obstructive jaundice and its relation to biliary tract infection

Coagulation studies were done on 78 consecutive cases of obstructive jaundice with or without biliary tract infection. Among 26 cases with biliary tract infection 20 cases showed no bleeding tendency but remarkable hypercoagulability with decreased fibrinolytic activity. Other six cases developed diffuse bleeding tendency in addition to the signs of hypotension and multiorgan dysfunction such as oliguria, respiratory distress and mental confusion. Most showed marked coagulation defects characterized by thrombocytopenia, decreased fibrinogen, antithrombin III and plasminogen levels and narrowing of maximal amplitude in thrombelastogram as well as the increase of fibrin degradation products and positive soluble fibrin monomer complexes. All except one died and three cases were autopsied. In two cases postmortem examination revealed multiple fibrin thrombi in lungs and other organs. A cause of the development of bleeding tendency in obstructive jaundice presently observed may likely to be due to the occurrence of disseminated intravascular coagulation (DIC), i.e. hypercoagulability caused by the biliary tract infection is responsible.

Unexpected hepatic dysfunction found by multiple laboratory screening.

During a 1-year period, 7620 elective surgical admissions were given multiple laboratory screening (SMA-18) determinations. Of these, 11 healthy patients, aged 10 to 54, with a pretest classification of ASA 1 (no systemic disease) were found to have clearly abnormal elevations of the SGOT, SGPT, and LDH levels. The proposed elective surgical procedures and anesthesia were canceled. All 11 patients proved to have overt liver pathology by further testing, and 3 later became clinically jaundiced. No cases of unexplained postsurgical jaundice occurred in any of the other 7609 operated cases during the 1-year study. The incidence of clearly elevated enzyme levels in voluntary hospital surgical admissions is approximately 1/700 and the incidence of clinical jaundice is approximately 1/2540. There appears to be a seasonal variation, with the preponderance of elevated enzyme levels in the winter and spring months.

Phenobarbital-Induced Hepatic Dysfunction

Phenobarbital has infrequently been reported to cause hepatitis. The previously reported cases of barbiturate-induced jaundice are reviewed and data from two previously unreported cases are presented. A discussion of mechanisms of iatrogenic hepatotoxicity is presented with emphasis on idiosyncratic mechanisms. Hepatitis secondary to phenobarbital administration appears to be due to a hypersensitivity reaction. This mechanism seems most likely because of the commonly seen clinical picture of rash, fever and eosinophilia. Speculation is made that phenobarbital hepatitis is possibly more common than the small number of reported cases would indicate. Criteria for the assessment and treatment of this iatrogenic disease are presented.

The Urinary Excretion of Glucosiduronates of Cortisol and Cortisone

Cortisol and cortisone glucosiduronic acids were synthesised in a 14C-labelled from and utilised in a double-isotope derivative procedure for the analysis of cortisol glucosiduronate (FG) and cortisone glucosiduronate (EG) in human urine. Normal adults were found to excrete between 16 and 100 mug/24 h of FG (n = 14) and between 55 and 120 mug/24 h of EG (n = 15). Elevated values were observed in subjects with Cushing's syndrome and following ACTH stimulation. Abnormal excretion was noted in one patient with hepatic cirrhosis and in one case of cholestatic jaundice. The ratio FG/EG was markedly increased after ACTH stimulation and, in the normal group, was positively correlated to a highly significant degree (P less than 0.001) with FG excretion. These two observations suggest that EG excretion is less sensitive than FG excretion to variations in cortisol production.