Initial Bilirubin Level Research Articles

Machine learning to predict completion of treatment for pancreatic cancer.

Chemotherapy enhances survival rates for pancreatic cancer (PC) patients postsurgery, yet less than 60% complete adjuvant therapy, with a smaller fraction undergoing neoadjuvant treatment. Our study aimed to predict which patients would complete pre- or postoperative chemotherapy through machine learning (ML). Patients with resectable PC identified in our institutional pancreas database were grouped into two categories: those who completed all intended treatments (i.e., surgery plus either neoadjuvant or adjuvant chemotherapy), and those who did not. We applied logistic regression with lasso penalization and an extreme gradient boosting model for prediction, and further examined it through bootstrapping for sensitivity. Among 208 patients, the median age was 69, with 49.5% female and 62% white participants. Most had an Eastern Cooperative Oncology Group (ECOG) performance status of ≤2. The PC predominantly affected the pancreatic head. Neoadjuvant and adjuvant chemotherapies were received by 26% and 47.1%, respectively, but only 49% completed all treatments. Incomplete therapy was correlated with older age and lower ECOG status. Negative prognostic factors included worsening diabetes, age, congestive heart failure, high body mass index, family history of PC, initial bilirubin levels, and tumor location in the pancreatic head. The models also flagged other factors, such as jaundice and specific cancer markers, impacting treatment completion. The predictive accuracy (area under the receiver operating characteristic curve) was 0.67 for both models, with performance expected to improve with larger datasets. Our findings underscore the potential of ML to forecast PC treatment completion, highlighting the importance of specific preoperative factors. Increasing data volumes may enhance predictive accuracy, offering valuable insights for personalized patient strategies.

Is primary biliary cholangitis still a challenge? Experience of Hassan II University Hospital FES Morocco

Introduction: Primary biliary cholangitis is a chronic autoimmune hepatopathy and the leading cause of intrahepatic cholestasis. Treatment is mainly based on ursodesoxycholic acid. The aim of our work is to study the epidemiological, clinical and evolutionary profile of PBC, and to determine the factors predictive of a poor response to UDCA in our context. Materials and methods: This is a retrospective descriptive and analytical study of all cases of PBC followed in our training program from June 2012 to February 2023. Results: We recorded all clinical, diagnostic, therapeutic and evolutionary aspects of 70 cases of PBC. Ninety-two percent ( n= 65) were women. The mean age was 57.3 [24-83] years. The circumstances of discovery were dominated by pruritus, and jaundice. M2-type anti-mitochondrial antibodies were positive in 91.4% of cases. 52.14% of cases had associated autoimmune diseases. Treatment was based on UDCA in all cases, combined with corticosteroids and immunosuppressants for patients with overlap syndrome. A biochemical response after one year of treatment according to Paris II criteria was found in 62.85% (44 cases). In univariate analysis, the factors associated with poor response to treatment were : Discovery of cirrhosis at diagnosis , Decompensated cirrhosis , presence of overlap syndrome , poor compliance with UDCA due to non-availability of medication , initial bilirubin level above 30 mg/l , hypoalbuminemia below 35 g/l. Conclusion: Our study shows the frequency of cirrhosis in PBC, which may explain the low response rate to UDCA, a drug that remains difficult to obtain in our Moroccan context, making prognosis poor and management difficult.

Dynamic three-dimensional liver volume assessment of liver regeneration in hilar cholangiocarcinoma patients undergoing hemi-hepatectomy.

For patients with hilar cholangiocarcinoma (HC) undergoing hemi-hepatectomy, there are controversies regarding the requirement of, indications for, and timing of preoperative biliary drainage (PBD). Dynamic three-dimensional volume reconstruction could effectively evaluate the regeneration of liver after surgery, which may provide assistance for exploring indications for PBD and optimal preoperative bilirubin value. The purpose of this study was to explore the indications for PBD and the optimal preoperative bilirubin value to improve prognosis for HC patients undergoing hemi-hepatectomy. We retrospectively analyzed the data of HC patients who underwent hemi-hepatectomy in the First Affiliated Hospital of China Medical University from 2012 to 2023. The liver regeneration rate was calculated using three-dimensional volume reconstruction. We analyzed the factors affecting the liver regeneration rate and occurrence of postoperative liver insufficiency. This study involved 83 patients with HC, which were divided into PBD group (n=36) and non-PBD group (n=47). The preoperative bilirubin level may be an independent risk factor affecting the liver regeneration rate (P=0.014) and postoperative liver insufficiency (P=0.016, odds ratio=1.016, β=0.016, 95% CI=1.003-1.029). For patients whose initial bilirubin level was >200 μmol/L (n=45), PBD resulted in better liver regeneration in the early stage (P=0.006) and reduced the incidence of postoperative liver insufficiency [P=0.012, odds ratio=0.144, 95% confidence interval (CI)=0.031-0.657]. The cut-off value of bilirubin was 103.15 μmol/L based on the liver regeneration rate. Patients with a preoperative bilirubin level of ≤103.15 μmol/L shown a better liver regeneration (P<0.01) and lower incidence of postoperative hepatic insufficiency (P=0.011, odds ratio=0.067, 95% CI=0.008-0.537). For HC patients undergoing hemi-hepatectomy whose initial bilirubin level is >200 μmol/L, PBD may result in better liver regeneration and reduce the incidence of postoperative liver insufficiency. Preoperative bilirubin levels ≤103.15 μmol/L maybe recommended for leading to a better liver regeneration and lower incidence of postoperative hepatic insufficiency.

Predictive Factors of Chemotherapy Initiation after Biliary Drainage for Advanced Biliary Tract Cancer: A Retrospective Multicenter Study

Background and Aims: In unresectable biliary tract cancers, the management of biliary obstruction is often the first step before introduction of chemotherapy. Our aim was to study the predictive factors of chemotherapy initiation after biliary drainage in a series of patients presenting with advanced biliary tract cancer and obstructive jaundice.&#x0D; Methods: Data of all patients treated for unresectable biliary tract cancer with initial biliary obstruction requiring a drainage in six institutions, from January 2009 to January 2019, were retrospectively collected.&#x0D; Results: Among 82 patients included in this study (median age 68 years, men 61%), 48 (59%) received chemotherapy. Median overall survival was 4.9 months (0.2-38.7) in the group of patients who did not receive chemotherapy and 12.2 months (1.9-61.0) in chemotherapy group (HR=2.93; 95%CI: 1.6-5.3; p&lt;0.0001). In univariate analysis, younger age, male gender, Eastern Cooperative Oncology Group (ECOG) score ≤2, high albumin level, low C-reactive protein level, and endoscopic drainage were significantly associated with introduction of chemotherapy. In multivariate analysis, only ECOG score ≤2 at diagnosis (HR=70.4; 95%CI: 4.6-1097.6; p=0.002) and male gender (HR=5; 95%CI: 1.5-16.5; p=0.009), were significant independent predictive factors of chemotherapy introduction. Age and bilirubin level at diagnosis were not significant factors in multivariate analysis.&#x0D; Conclusions: ECOG score ≤ 2 and male gender were the only independent predictive factors of chemotherapy introduction in unresectable biliary tract cancers. Age or initial bilirubin level were not predictors for chemotherapy introduction. These results might help defining the initial therapeutic strategy.

The CHOP Study – Cholestatic Influence on Portal Vein Embolization (PVE) Induced Future Liver Remnant (FLR) Hypertrophy – A Maastricht Aachen Analysis

Introduction: Experimentally induced hepatocellular bile salt accumulation impairs liver function and regeneration. Portal Vein Embolisation (PVE) is the current standard to induce FLR hypertrophy. The impact of cholestasis on PVE-induced FLR hypertrophy however remains unclear. We hypothesized that cholestasis impairs PVE induced FLR hypertrophy and compared PVE hypertrophic response between patients with and without cholestasis. Methods: Patients with perihilar cholangiocarcinoma or colorectal liver metasases, who had undergone PVE before a major hemihepatectomy in Uniklinik RWTH Aachen or Maastricht University Medical Center between 2016 and 2019, were enrolled. Clinical and laboratory variables were recorded and volume of segment 2 and 3 on pre- and post-embolization CT-scans were assessed. Diameters of left and right hepatic bile ducts was measured on pre-embolization scans. Bilirubin was used as a clinical marker of cholestasis. The degree of hypertrophy (DH) as a percentage and kinetic growth rate (KGR) as percentage/week were used to assess the increase of the liver volume. Results: In this study,142 patients were enrolled. Sequential pre- and post-CT-scans were available for 53 patients (32 for CRLM, 21 for pCCA). Liver segment II and III volumes increased significantly after PVE in both groups (P < 0.001). pCCA patients with cholangitis (n=4) had an almost blunted DH (P = 0.042). DH and KGR did not differ (P = 0.719 and P = 0.968, respectively) between drained and undrained pCCA patients. Higher initial bilirubin level before biliary drainage was correlated with less PVE-induced DH (ρ=-0.727, P = 0.007). The bilirubin level and bile duct diameter before PVE was not associated with DH and KGR. Conclusion: Initial bilirubin levels before biliary drainage were negatively correlated with PVE-induced liver hypertrophy in patients with pCCA. Biliary duct diameter and bilirubin level right before PVE seems less of influence on PVE induced hypertrophy.

Characteristics of Bilirubin According to the Results of the Direct Antiglobulin Test and Its Impact in Hemolytic Disease of the Newborn.

Hyperbilirubinemia, which is a sign of hemolytic disease of the newborn (HDN), can irreversibly damage the central nervous system. To determine the etiology of HDN in affected patients and characterize the changing pattern of bilirubin using direct antiglobulin testing (DAT). We collected clinical data from newborns who underwent perinatal DAT and from their mothers, between August 2008 and July 2017. Among 303 neonates, 37 (12.2%) showed positive DAT results. The positive predictive values (PPVs) and negative predictive values (NPVs) based on DAT results were 75.7% and 28.9%, respectively, for starting phototherapy. Bilirubin levels increased more rapidly in the DAT-positive group, compared with the DAT-negative group. The initial bilirubin level differed significantly according to the etiology of hyperbilirubinemia. Further, neonates with anti-D showed higher delta bilirubin per day than neonates with other antibodies. Our results may help to determine the measurement period for bilirubin according to DAT results and etiology.

Noradrenaline for reverting hepatorenal syndrome: a prospective, observational, single-center study.

ObjectiveTo evaluate the effectiveness of noradrenaline for the treatment of hepatorenal syndrome (HRS).BackgroundHRS represents the development of renal failure in cirrhotic patients. The standard treatment for HRS is terlipressin, which, as opposed to noradrenaline, is more expensive and less accessible in most tertiary care centers.Patients and methodsThirty consecutive patients with HRS type 1 received noradrenaline (1–4.0 mg/hour) and albumin for 14 days. The parameters recorded were: serum creatinine levels, creatinine clearance, mean arterial pressure (MAP), urine output, and serum sodium levels evaluated at baseline and on treatment days 1, 3, 7, and 14.ResultsMost patients achieved serum creatinine levels <1.5 mg/dL and were considered responders (22/30, 73%), whereas eight patients (27%) were nonresponders. At baseline, responders and nonresponders differed only regarding initial bilirubin levels and international normalized ratio values. Treatment duration was 7.5±3.2 days. Responders experienced a significant (p<0.05) decrease in serum creatinine levels (from 3.26±0.48 to 1.28±0.14 mg/dL), as well as a significant increase (p<0.05) in creatinine clearance (from 21±4.1 to 67.7±12.1 mL/min), urine output (from 583±41.1 to 1163±105 mL/day), MAP (from 79.2±2.94 to 93.9±2.34 mmHg), and serum sodium levels (from 125±2.01 to 132.3±1.39 mEq/L). In nonresponders, the MAP increased, but serum creatinine levels also increased, reflecting a decrease in creatinine clearance and urine output, with no significant change in serum sodium levels over the duration of the treatment.ConclusionIn most patients, noradrenaline treatment induced systemic vasoconstriction resulting in HRS reversal, with acceptable safety, in agreement with previously reported outcomes of terlipressin treatment.

Tu1464 Dose Initial Bilirubin Level Prior to Endoscopic Drainage Predicts the Ability to Start Folfirinox Regimen in Patients With Periampullary Malignancies

Tu1464 Dose Initial Bilirubin Level Prior to Endoscopic Drainage Predicts the Ability to Start Folfirinox Regimen in Patients With Periampullary Malignancies

Preoperative defining system for pancreatic head cancer considering surgical resection.

To provide appropriate treatment, it is crucial to share the clinical status of pancreas head cancer among multidisciplinary treatment members. A retrospective analysis of the medical records of 113 patients who underwent surgery for pancreas head cancer from January 2008 to December 2012 was performed. We developed preoperative defining system of pancreatic head cancer by describing "resectability - tumor location - vascular relationship - adjacent organ involvement - preoperative CA19-9 (initial bilirubin level) - vascular anomaly". The oncologic correlations with this reporting system were evaluated. Among 113 patients, there were 75 patients (66.4%) with resectable, 34 patients (30.1%) with borderline resectable, and 4 patients (3.5%) with locally advanced pancreatic cancer. Mean disease-free survival was 24.8 mo (95%CI: 19.6-30.1) with a 5-year disease-free survival rate of 13.5%. Pretreatment tumor size ≥ 2.4 cm [Exp(B) = 3.608, 95%CI: 1.512-8.609, P = 0.044] and radiologic vascular invasion [Exp(B) = 5.553, 95%CI: 2.269-14.589, P = 0.002] were independent predictive factors for neoadjuvant treatment. Borderline resectability [Exp(B) = 0.222, P = 0.008], pancreatic head cancer involving the pancreatic neck [Exp(B) = 9.461, P = 0.001] and arterial invasion [Exp(B) = 6.208, P = 0.010], and adjusted CA19-9 ≥ 50 [Exp(B) = 1.972 P = 0.019] were identified as prognostic clinical factors to predict tumor recurrence. The suggested preoperative defining system can help with designing treatment plans and also predict oncologic outcomes.

Initial Serum Bilirubin Level as a Predictor of Clinical End Points in Primary Sclerosing Cholangitis

Initial Serum Bilirubin Level as a Predictor of Clinical End Points in Primary Sclerosing Cholangitis

Neonatal Hyperbilirubinemia Due to ABO Incompatibility

Aim: ABO incompatibility is a common condition occurring in about 15-25% of all maternal/fetal pairs. The features of ABO incompatibility range from asymptomatic through to severe hemolysis with hyperbilirubinemia and anemia. The aim of this study is to assess the clinical course of ABO incompatibility and to evaluate the effect of blood groups on the severity of neonatal jaundice. Material and Methods: Neonates with ABO hemolytic disease of newborn were retrospectively studied. Risk factors for the severity of jaundice were recorded. Demographic, clinic, and laboratory features were compared in infants with blood groups A and B. Results: Within 13 months, 165 term infants with neonatal jaundice were treated. 32 (19.4%) of these patients had jaundice due to maternal-fetal ABO incompatibility. The O-A group included 23 infants (71.9%) while the O-B group included for 9 infants (28.1%). All the infants received phototherapy while none of the cases required exchange transfusion. Mean total bilirubin level was 15.6p4.5 mg/dl on the 2.9p2.1 days of mean age after the initiation of treatment. There were no differences between the infants with blood group A or B in terms of demographics, initial bilirubin level, anemia in first 24 hours, the rate of hemolysis, and direct Coombs test. Conclusion: ABO incompatibility may have risks of significant hyperbilirubinemia and hemolysis in infants. Neonatal jaundice due to ABO incompatibility can be successfully managed with early admission of intensive phototherapy through close follow-ups. Blood type has no effect on the severity of jaundice. Key words: Neonate; Jaundice; ABO Incompatibility; Blood Group; Phototherapy.

Demographic and Clinico-Pathological Characteristics of Egyptian Patients with Cholangiocarcinoma

A study was conducted to identify the characteristic demographic and clinico-pathological features of Egyptian patients with CCA, in order to improve both early diagnosis and ultimate prognosis. We collected and reviewed the demographic, clinical, laboratory data and cholangiographic studies and treatment modalities of patients admitted with CCA in the National Liver Institute (NLI), Menoufiya University, Egypt between April 2008 and March 2010. In order to evaluate the life expectancy of patients, follow up analysis was done from the time of diagnosis until the end of the study march 2012. Results of the study showed that Ninety-two patients were admitted with CCA in the above mentioned period. The median age was 52.2 years. The patients constituted 52.2% distal CCA, 37% hilar CCA and 10.8% intrahepatic CCA. The prevalence of HCV antibody was 31%. ERCP and PTD were the main procedures for palliative drainage, Surgery was done for 14 cases: Whipple’s operation was done for 8 cases of distal CCA, surgical by pass for two cases of distal CCA, Hepatic resection was done for 4 cases of hilar CCA The mean survival time was 298 days with no significant difference in mean survival time between patients with different types of CCA. Cox’ proportional hazard model showed that the presence of liver cirrhosis was independent risk factors for worse survival with hazard ratio of 6.8. Age, sex, initial bilirubin level and type of the tumor were not significant factors affecting survival. Therefore, Egyptian patients with CCA presented at a younger age and had higher bilirubin level than other patients. They presented late, so that curative surgical resection was rarely feasible.

Clinical efficacy of malignant obstructive jaundice treated by domestic biliary metallic stent insertion

To evaluate the clinical efficacy of implanted biliary metallic stents in the management of malignant obstructive jaundice (MOJ). Percutaneous transhepatic cholangiography and stent insertion were performed in 241 consecutive patients to treat malignant biliary obstruction between December 1998 and February 2009. The study end point was patient death. All patients were followed-up until death or until February 2010. The therapeutic efficacy was determined by statistical analysis of life span and pre- and post-operative laboratory indices. All 241 patients were successfully stented. The level of bilirubin descended obviously within four weeks of implantation (P less than 0.05), and the early mortality rate was 4.56% (11/241). Two-hundred-and-two patients were followed-up (range: 8-193 weeks post-transplantation) and showed a median survival of 43.55 weeks. The survival rates at 13, 26, 39 and 52 weeks post-transplantation were 87%, 66%, 56%, and 41%, respectively. The stent patency rates at 13, 26, 39 and 52 weeks post-transplantation were 70%, 46%, 36% and 24%, respectively; the mean stent patency was 27.57 weeks. Cox regression analysis identified the strong predictors of improved survival as an initial bilirubin level of less than 221 mumol/L (P = 0.01) and a stent-induced bilirubin reduction of more than 50% (P = 0.002). Transhepatic metallic biliary stenting is a safe and effective therapeutic intervention for malignant biliary obstruction. Significant periods of survival and palliation of jaundice can be achieved with this method. Hyperbilirubinemia and a stent-induced bilirubin reduction of less than 50% are independent predictive factors for the survival of MOJ patients.

1326 Comparison of Intensive Light-Emitting Diode and Intensive Compact Fluorescent Phototherapy in Non-Hemolytic Jaundice

In severe and rapidly increasing jaundice, the use of high-intensity phototherapy provides greater effectiveness and a faster decrement in bilirubin levels. The aim of this study is compare the effectiveness...

Multicenter study evaluating factors for stent patency in patients with malignant biliary strictures: development of a simple score model

Self-expanding metal stents (SEMS) are known to have a significantly higher patency rate than plastic stents. We aimed to identify prognostic factors, besides stent type, for stent patency and to develop a score model that could further aid in guiding stent choice for the palliation of a malignant biliary stricture. A retrospective multicenter study was conducted. Data on consecutive patients who had a stent placed between January 2002 and July 2009 were collected. Cumulative stent occlusion rates were analyzed by Kaplan-Meier curves and log rank testing, and prognostic factors were assessed by Cox regression analysis. A total of 690 stents (512 plastic stents, 174 SEMS) were endoscopically placed in 390 patients. At 8weeks, stent occlusion had occurred in 32% of the plastic stents and 11% of the SEMS. Multivariate analysis indicated that plastic stents (hazard ratio [HR] 2.5, 95% confidence interval [CI] 1.9-3.5), a tight stricture requiring preceding dilation (HR 1.8, 95% CI 1.3-2.5), and a high initial bilirubin level (>50μmol/L (HR 1.3, 95% CI 1.0-1.7) were independently associated with an increased risk of stent occlusion. A score model based on these 3 factors was able to distinguish between stent procedures with a relatively high and low risk of stent occlusion (median 14 vs. 26weeks, respectively). Besides plastic stents, stricture severity requiring preceding dilation, and initial higher bilirubin level were associated with a shorter period of stent patency. A simple score model based on these factors was able to predict stent occlusion and may aid in choosing the most appropriate stent type in individual patients.

Su1441 The Rate of Decline in the Levels of Bilirubin and Alkaline Phosphatase After Therapeutic ERCP for the Relief of Common Bile Duct Obstruction

The Rate of Decline in the Levels of Bilirubin and Alkaline Phosphatase After Therapeutic ERCP for the Relief of Common Bile Duct Obstruction Kian Makipour, Mandeep Singh, Anil K. Vegesna, Larry S. Miller Temple University, Philadelphia, PA Background: In certain clinical situations it is important to know the rate of change of bilirubin and alkaline phosphatase. For example when a CBD stone is removed or a stent placed the levels of bilirubin and/or alkaline phosphatase should decrease at a certain rate. If they do not drop at that rate it may be assumed that the bile duct remains fully or partially obstructed. However, the rate of change in bilirubin and alkaline phosphatase is not clear. Purpose: To evaluate the rate of change in bilirubin and alkaline phosphatase after therapeutic ERCP for the relief of common bile duct obstruction. Methods: A retrospective review of 86 patients (52Yrs, 32M, 54F, 27Caucasian, 25African American, 33Hispanic and 1Asian) with CBD obstruction and elevated bilirubin and/or alkaline phosphatase was performed to determine the rate of change of the levels of bilirubin and alkaline phosphatase during the CBD obstruction and after relief of the CBD obstruction. 86 patients with CBD obstruction had either a stone removed (86 patients) and or a stent placed (20 patients) to relieve the obstruction. Levels of alkaline phosphatase and bilirubin were followed for up to five days or until the patient was discharged from the hospital. Results: The initial alkaline phosphatase, total bilirubin and direct bilirubin levels were 232 IU, 5 mg/dl and 3 mg/dl respectively. The rate of change for alkaline phosophtase, total bilirubin and direct bilirubin levels were -7.28 IU/L, -0.59 mg/ dl and -0.36 mg/dl per day respectively (graph 1 and 2). Conclusions: We measured the rate of change of alkaline phosphatase and bilirubin after relief of CBD obstruction. The rate of change in alkaline phosphatase levels was greater than the rate of change in bilirubin levels after relief of CBD obstruction. We plan to use these rates of change in the future to monitor patients after relief of CBD obstruction.

Hepaticojejunal Anastomotic Stricture With Presentation as Biliocutaneous Fistula

Purpose: Background: Hepaticojejunal anastomotic stricture (HAS) is a late complication of biliary diversion surgery. The most common presentation of HAS is either abdominal pain or abnormal liver enzymes. We present an unusual case of HAS presenting as a biliocutaneous fistula. Case: A 59 year old man was transferred to our facility after presenting with jaundice and drainage of bile from a papule on the right abdomen at the mid-axillary line. He had a history of chronic pancreatitis and had undergone a Whipple procedure 8 years prior. He reported 2 prior episodes of jaundice and cholangitis which had been treated with percutaneous biliary drainage two years earlier. He had no further complaints until presenting with 1 week of progressive right-sided abdominal pain, jaundice, and a raised skin lesion on his right side. This was incised by an outside provider, resulting in drainage of bile. Initial bilirubin level was 9.0 mg/dL. He was admitted, and imaging with computed tomography revealed a fluid-filled sinus tract extending from the skin to the dome of the liver. Following transfer he underwent single balloon enteroscopy with endoscopic retrograde cholangiogram (ERC). A stenotic hepaticojejunal anastomosis was encountered, and cholangiogram revealed diffusely dilated intrahepatic ducts. Following cannulation and balloon dilation of the stricture to 8mm, multiple stones were swept from the biliary tree and two 7 French biliary stents were placed. The patient's bilirubin failed to improve and 2 days later the procedure was repeated with dilation to 9 mm and placement of two 8.5 French stents. He experienced no further drainage from the fistula site. At the time of his follow-up ERC 3 months later, his total bilirubin level had decreased to 1.6 mg/dL. The anastomosis had partially restenosed. The biliary stents were removed, followed by endoscopic sphincteroplasty and further dilation of the anastomosis. The patient has had no recurrent symptoms over the past 7 months of follow-up. Conclusions: This case illustrates the unusual presentation of HAS with spontaneous biliary decompression via a biliocutaneous fistula. The fistula followed the course of a previously closed percutaneous biliary drain tract. The case also demonstrates the therapeutic capability of ERC via single balloon enteroscopy in treating HAS via dilation and endoscopic stricturoplasty.

Safety of Yttrium-90 Microsphere Radioembolization in Patients with Biliary Obstruction

There are few data on radioembolization in the setting of biliary obstruction. The present study was performed to assess the safety of yttrium-90 ((90)Y) radioembolization in the setting of tumor-related biliary obstruction and total bilirubin levels of 2 mg/dL or lower. Twelve patients with liver tumors underwent 19 treatment sessions with (90)Y to the obstructed liver lobe or segment. Initial bilirubin level was 2 mg/dL or lower in all cases. Measured outcomes included pre- and posttreatment white blood cell (WBC) count, total bilirubin level, and alkaline phosphatase (ALP) level. Bilirubin toxicities and biliary complications were assessed according to Common Toxicity Criteria, version 3.0. Lobar or segmental (90)Y was successful in all cases. Pre- and posttreatment median WBC counts (5.3 vs 5.3; P = .490), bilirubin levels (1.0 vs 1.1; P = .460), and ALP levels (195 vs 146; P = .712) showed no differences. One case of grade 3 bilirubin toxicity was noted in a patient with liver hilar nodal progression and subsequent biliary obstruction requiring external drainage. Complete resolution of biliary obstruction was seen after (90)Y treatment in one case of metastatic colorectal carcinoma at 1 month follow-up. No biliary complications (infection, sepsis, biliary necrosis, biloma formation, abscess development, or biliary stricture) were encountered in this cohort during an overall median follow-up time of 22.9 months. The use of (90)Y glass microspheres demonstrated a good safety profile in the setting of tumor-related biliary obstruction in patients with normal or near-normal bilirubin levels in this series, without evidence of therapy-related progressive leukocytosis, bilirubin increase, or infectious or biliary complications after treatment.

Important Elements for the Diagnosis of Drug-Induced Liver Injury

Drug-induced liver disease is the leading cause of acute liver failure in the United States. Accurate reporting of drug-induced liver injury is essential for early detection of hepatotoxicity and for developing reliable, interpretable literature. We assessed the extent to which published case reports of drug-induced liver disease include sufficient clinical data for interpreting the cause of toxicity. We developed a list of 42 predetermined, specific minimal elements necessary in evaluating causality of drug-induced liver injury. We then analyzed 97 published case reports or series studies of hepatotoxicity from 6 drugs (from 3 classes): amoxicillin/clavulanic acid (n = 35), troglitazone (n = 32), rosiglitazone (n = 10), pioglitazone (n = 8), zafirlukast (n = 8), and montelukast (n = 4). Patient age, sex, primary disease, and drug name were reported in most, if not all, published case reports. However, many elements were underreported; some publications did not mention initial bilirubin levels (12%), many did not provide initial alkaline phosphatase levels (58%), and others provided vague descriptions of how certain diagnoses were excluded, that is, tests for hepatitis A, B, and C were negative. Data on abnormal results from serial liver tests frequently were absent. Exclusions of competing viral etiologies were reported in less than 50% of the studies. Reports of drug-induced liver diseases often do not provide the data needed to determine the causes of the adverse effects. Efforts to promote and include a list of essential diagnostic elements in research articles could increase the quality and clinical utility of published case reports of drug toxicity.

Outcomes in percutaneous stenting of non-hepato-biliary/pancreatic malignant jaundice

The aim of this study is to review the practice and outcomes at our institution of percutaneous transhepatic placement of metallic biliary stents for non-hepato-biliary/pancreatic (non-HBP) malignant obstructive jaundice. A retrospective review was performed of the records of all patients undergoing transhepatic stenting for non-HBP malignant obstructive jaundice over a 7-year period. A total of 25 patients were successfully stented and linear regression analysis of a variety of demographic, clinical and laboratory markers against survival was performed. Survival after stenting varied from 1 to 1354 days (median 58, mean 152). An initial bilirubin level less than 300 micromol/L (P=0.01) and a reduction of greater than 50% in bilirubin post stenting (P=0.02) were strong predictors of improved survival. Older patients survived longer than younger ones (P<0.01). There was a weak association of survival with an albumin>30 g/L (P=0.06), but no statistically significant correlation with creatinine or haemoglobin levels or active tumour treatment after stenting. There were few major complications from the procedures. Transhepatic metallic biliary stenting for non-HBP malignant biliary obstruction is a safe and effective procedure, and with careful patient selection, significant periods of survival and palliation of jaundice can be achieved.