Severe Obstructive Jaundice Research Articles

Ultrasound-guided percutaneous transhepatic biliary drainage for distal biliary malignant obstructive jaundice

The main cause of distal biliary malignant obstructive jaundice (DBMOJ) is the stricture of the extrahepatic biliary tract by malignant tumors, including pancreatic head and uncinate process cancer, low-grade cholangiocarcinoma, duodenal cancer, papillary duodenal cancer and other malignant tumors. The most effective treatment is radical pancreaticoduodenectomy. However, preoperative obstructive jaundice can affect the patient’s liver function and blood coagulation function, increase local inflammation and oedema, and make surgery more difficult. Patients with severe obstructive jaundice require preoperative biliary drainage, which can be achieved by various methods, including ultrasound endoscopic biliary drainage (EUS-EBD) and endoscopic retrograde biliary drainage (ERBD). The latter is mainly divided into endoscopic nasobiliary drainage and endoscopic biliary stent. Some patients underwent percutaneous transhepatic biliary drainage (PTBD) when ERBD and EUS-EBD failed. In this study, we aimed to identify PTBD in DBMOJ and to further investigate the role of the puncture pathway in DBMOJ. The relationship between PTBD and bile duct internal diameter was confirmed by analysing and collating clinical data. In this study, DBMOJ was grouped according to bile duct internal diameter and liver function was used as an indicator to examine the improvement in liver function with PTBD in patients undergoing DBMOJ. Analysis of puncture complications showed that PTBD puncture was safe. DBMOJ with different bile duct internal diameters had different rates of liver function improvement after PTBD. The right-side approaches had significantly lower alanine aminotransferase (ALT) and alanine transaminase (AST) than the left-side approaches. This study showed that PTBD for DBMOJ is associated with a low complication rate and good reduction of jaundice. Liver function recovery was faster in patients with DBMOJ treated with PTBD in the right-sided approach compared with the left-sided approach. PTBD is an effective tool to be used in patients who have failed ERBD and EUS-EBD.

Value of preoperative biliary drainage in pancreatic head cancer patients with severe obstructive jaundice: A multicenter retrospective study.

Pancreatic head cancer accompanied by obstructive jaundice is a common clinical situation. The aim of this study was to assess the impact of preoperative biliary drainage (PBD) on clinical outcomes in patients with severe obstructive jaundice. Patients with a bilirubin level of ≥250 μmol/L at diagnosis who underwent PBD were included. The primary endpoints and secondary endpoints were the postoperative severe complications rates. Secondary endpoints were the degree of improvement in general condition, predictors of severe postoperative complications, and the impact of PBD on patients with bilirubin levels >300 μmol/L. In total, 289 patients were included, and 188 patients (65.1%) underwent PBD. The patients who met the American Society of Anesthesiologists (ASA) classification II-III stages decreased from 119 to 100 ( P = 0.047) after PBD. The overall severe complications were significantly more frequent in the direct surgery (DS) group than in the PBD group (34.7% vs. 22.9%, P = 0.031), especially the postoperative hemorrhage (6/43 [14.0%] vs. 9/35 [25.7%], P = 0.038) and intra-abdominal infection (6/43 [14.0%] vs. 10/35 [28.6%], P = 0.018). The ASA classifications II-III (odds ratio [OR]=2.89, 95% confidence interval [CI]: 1.38-4.31), P = 0.01) and DS (OR = 3.65, 95% CI: 1.45-7.08; P = 0.003) were independently associated with severe postoperative complications. The occurrence rate of severe postoperative complications in patients with a bilirubin level >300 μmol/L who underwent PBD was significantly lower than in patients who underwent DS (25.6% vs. 40.6%, P = 0.028), but the benefit of PBD was not observed in patients who had a bilirubin level between 250 and 300 μmol/L. PBD is useful in reducing severe postoperative complications, especially in patients with bilirubin levels >300 μmol/L.

Cytochrome P450 3A4 activity and genetic variants as predictors of liver failure in patients with obstructive jaundice

Liver failure in patients with obstructive jaundice is a significant contributor to mortality within this patient cohort. The exact mechanism and triggers of this occurrence are yet to be fully understood. With this in mind, our study aimed to assess the correlation between the urinary 6 β-OHC/C ratio and various biochemical parameters of liver function. Furthermore, we conducted genotyping of CYP3A4*22 (rs35599367), CYP3A5*3 (rs776746) polymorphic markers to investigate the potential effects of their variants on the probability of liver failure in obstructive jaundice. Our study included 75 patients diagnosed with severe obstructive jaundice. All test subjects underwent functional liver tests, and control blood tests were administered on the seventh day following biliary decompression. Patients were categorized into two groups: group 1 - patients without liver failure (n = 60) and group 2 - patients with liver failure (n = 15). Laboratory indexes such as 6 β –OHC concentration and 6 β- OHC/cortisol ratio can serve as significant predictors of liver failure in patients with moderate and severe degree obstructive jaundice after biliary decompression. Based on the study of “wild” and polymorphic variants of CYP3A4*22 (CC and CT) and polymorphism of CYP3A5*3A6986G (GG, GA, AA), it was discovered that liver failure in the CYP3A4*22 variant may be associated with the CC genotype, and in the CYP3A5*3 variant - with the GA genotype. Hence, the determination of 6β- OHC concentration and 6β- OHC/C ratio, as well as the analysis of polymorphic and “wild” variants of CYP3A4*22 (CC and CT) and CYP3A5*3 polymorphism A6986G (GG, GA, AA), may play a crucial role in predicting liver failure in patients with obstructive jaundice.

Identifying and validating molecular subtypes of biliary atresia using multiple high-throughput data integration analysis.

Biliary atresia (BA) is the most common form of severe neonatal obstructive jaundice. The etiology and pathogenesis of BA are multifactorial, and different factors may interact to produce heterogeneous pathological features and clinical outcomes. Despite different pathological features, all patients received the same treatment strategy. This study performed integrative clustering analysis based on multiple high-throughput datasets to identify the molecular subtypes of BA and provide a new treatment strategy for personalized treatment of the different subtypes of BA. The RNA sequence dataset GSE122340 in the Gene Expression Omnibus (GEO) database was downloaded; 31 BA and 20 control normal liver tissues were collected at our center for transcriptome sequencing, and clinical and follow-up data of BA patients were available. Molecular subtypes were identified using integrated unsupervised cluster analysis involving gene expression, biliary fibrosis, and immune enrichment scores based on the transcriptome dataset, and the results were validated using independent datasets. Based on the results of the integrated unsupervised clustering analysis, four molecular subtypes were identified: autoimmune, inflammatory, virus infection-related, and oxidative stress. The autoimmune subtype with a moderate prognosis was dominated by autoimmune responses and morphogenesis, such as the Fc-gamma receptor and Wnt signaling pathway. The biological process of the inflammatory subtype was mainly the inflammatory response, with the best prognosis, youngest age at surgery, and lowest liver stiffness. The virus infection-related subtype had the worst prognosis and was enriched for a variety of biological processes such as viral infection, immunity, anatomical morphogenesis, and epithelial mesenchymal transition. The oxidative stress subtype was characterized by the activation of oxidative stress and various metabolic pathways and had a poor prognosis. The above results were verified independently in the validation sets. This study identified four molecular subtypes of BA with distinct prognosis and biological processes. According to the pathological characteristics of the different subtypes, individualized perioperative and preoperative treatment may be a new strategy to improve the prognosis of BA.

Optimization of surgical approach for the treatment of gallstone disease complicated by obstructive jaundice

An elevated morbidity rate due to gallstone disease (GSD) is accompanied by a 35% increase in the frequency of complication occurrence. Surgical treatment of GSD complicated by obstructive jaundice (OJ) is an urgent problem due to a relatively high percentage of complications and lethal outcomes. To improve the surgical treatment outcomes of patients with GSD complicated by OJ by introducing a differentiated approach to the choice of surgical intervention tactics. The surgical treatment outcomes of 384 patients operated for cholelithiasis complicated by mechanical jaundice in the period from 2016 to 2020 were analysed in this work. The performed study demonstrates that minimally invasive interventions and their sequence in this category of patients should be defined based on the severity of OJ. Minimally invasive surgery positively affects LPO indices and significantly decreases MDA (1.2-fold in subgroups with mild and moderate OJ (p < 0.0001), 1.4-fold (p < 0.0001) - with severe OJ). Compared to conventional surgery, catalase activity increased 1.1-fold in the subgroups with mild to moderate OJ (p < 0.0001) and 1.3-fold in those with severe OJ (p < 0.0001). The illness severity-differentiated surgical approach for GSD complicated by OJ allows the optimal minimally invasive surgical intervention to be chosen in patients with this pathology.

A Pancreatic Head Mass and Extreme Elevation of CA 19-9; a Benign Masquerade of Cholangiocarcinoma

Background: Carbohydrate antigen 19-9 (CA 19-9) is a specific tumour marker for pancreatic and biliary malignancy. Immunoglobulin G4-related disease (IgG4-RD) is an immune-mediated condition in which IgG4 infiltrates are found in various organs, including the biliary tract and can present as pseudotumours. Method: This case report describes of an extreme elevation of CA 19-9 level of 3295 kU/L, in an 83-year-old woman presenting with severe obstructive jaundice and weight loss. An MRCP revealed a mass at the head of pancreas, amputating the biliary tree. Liver function tests revealed a significant cholestatic pattern and severe hyperbilirubinaemia (289umol/L). IgG4 level was found to be elevated 7.97g/L (normal titres 0.04-0.86g/L). Treatment high dose corticosteroids were commenced. Two months later a repeat MRCP revealed complete disappearance of the pancreatic head mass. There was also normalisation of the bilirubin and a dramatic decrease of CA 19-9 to 154 kU/L. Results: This case reports the highest published benign elevation of Ca19.9 level in the setting of IgG4 disease. In IgG4-RD, IgG4 histopathologic infiltrates are found in various organs. Immunoglobulin G4 sclerosing cholangitis and associated pseudotumours, biliary manifestations of IgG4-RD, are a recently described disease processes. Complicating diagnosis of IgG4-RD is the potential for dual pathology in patients; that being the presence of both cholangiocarcinoma as well as IgG4-RD. Conclusion: Differentiation between cholangiocarcinoma and IgG4-RD is extremely important, as the treatment is vastly different. This case illustrates that extreme elevation of Ca19.9 cannot be equated with malignant diagnosis in the setting of IgG4 disease.

Clinical utility of 3D magnetic resonance elastography in patients with biliary obstruction.

Three-dimensional magnetic resonance elastography (3D-MRE) allows for multiparametric modeling of both elastic and viscous tissue characteristics. Our aim was to compare 3D-MRE with conventional liver shear stiffness assessment in gauging obstructive jaundice (OJ), predicting the adequacy of biliary decompression after drainage, and discriminating OJ from liver fibrosis. Patients with no histories of liver disease (n = 201) were studied in retrospect, grouped by bilirubin levels as no jaundice (NJ ≤ 2 mg/dL; n = 75), mild OJ (>2 mg/dL and ≤ 4 mg/dL; n = 56), and severe OJ (> 4 mg/dL; n = 70). For comparison, another 75 patients with chronic hepatitis B and C infections and histologically proven liver fibrosis were similarly analyzed. Each patient underwent spin-echo echo-planar-imaging MRE at 60Hz with 3D wave postprocessing. Logistic regression and ordinary regression models were used to compare the 3D-MRE model with liver shear stiffness. Liver shear stiffness, loss modulus, and damping ratio were incorporated into a 3D-MRE model, which significantly outperformed shear stiffness in predicting OJ severity (accuracy: 0.801 vs 0.672; p < 0.001). Both the 3D-MRE model and liver shear stiffness performed equally well in predicting the outcome of biliary drainage procedure (C-statistics: 0.852 vs 0.847; p = 0.48). The 3D-MRE model also demonstrated significantly better C-statistics than that of liver shear stiffness in discriminating mild OJ from F1-F2 liver fibrosis (0.765 vs 0.641; p = 0.005) and severe OJ from F3-F4 liver fibrosis (0.750 vs 0.635; p = 0.031). 3D-MRE is an innovative imaging method for gauging OJ severity, predicting the outcome of biliary drainage procedure, and discriminating OJ from liver fibrosis. • 3D-MR elastography achieved promising results for predicting the severity of obstructive jaundice. • Advanced parameters of 3D-MR elastography demonstrated significantly better performance than that of shear stiffness of 2D-MR elastography in discriminating obstructive jaundice from liver fibrosis caused by chronic hepatitis B/C. • Both 3D-MR elastography and 2D-MR elastography were equivalent in predicting the outcome of biliary drainage procedure.

Interventional radiology in rendezvous technique for choledocholitiasis in elderly patients

Aim. Define the safety and effectiveness of rendezvous technique for choledocholithiasis.Material and methods. We performed a retrospective and prospective analysis of the results in percutaneous transhepatic access to the bile ducts and endoscopic intervention in the rendezvous technique for choledocholithiasis in 100 elderly patients. The patients were divided into 2 groups for 50 people. The implementation of the rendezvous began from the antegrade stage in patients from group I; in patients of group II – from the retrograde stage. Postmanipulation complications and failures were When analyzed. The control point of the study is the identification of complications associated with manipulation from the next stages of the rendezvous technique.Results. We revealed a direct dependence of the results in sequence of rendezvous technique for elderly patients with choledocholithiasis and obstructive jaundice. This fact allows recommending percutaneous transhepatic access before endoscopic intervention for these patients with statistical significance. The frequency of complications and failures in patients of group I was 18%, in group II – 52%. This allows for such patients percutaneous transhepatic access before endoscopic intervention in the rendezvous technique. The frequency of complications and failures in patients of group I was 18%, in group II – 52%.Conclusion. Dilatation of intrahepatic segmental and subsegmental 2 and 3 biliary ducts with moderate and severe obstructive jaundice is a predictor of complications with ineffective endoscopic approach. In such situations, preventive antegrade drainage of the biliary tract with rendezvous technique makes possible to prevent cholangitis, effectively eliminate biliary hypertension, clarify the severity of stenosis of the papilla with antegrade balloon revision, and also secure delayed endoscopic resolution of biliary pathology.

Which patients benefit from preoperative biliary drainage in resectable pancreatic cancer?

ABSTRACT Recent studies have indicated that preoperative biliary drainage (PBD) should not be routinely performed in all patients suffering from obstructive jaundice before pancreatic surgery. The severity of jaundice that mandates PBD has yet to be defined. The evaluated paper examines the impact of PBD on intra-operative, and post-operative outcomes in patients initially presenting with severe obstructive jaundice (bilirubin ≥250 μmol/L). In this key paper evaluation, the impact of PBD versus a direct surgery (DS) approach is discussed. The arguments for and against each approach are considered with regards to drainage associated morbidity and mortality, resection rates, survival and the impact of chemotherapy and malnutrition. Concentrating on resectable head of pancreas tumors, this mini-review aims to scrutinize the authors’ recommendations, alongside those of prominent papers in the field.

Biliary decompression in patients with obstructive jaundice

Aim. Evaluation of the biliary tract decompression methods and their use results, in patients with obstructive jaundice of various etiologies on the basis of our own clinical material.Material and Methods. A retrospective analysis of the biliary tract drain results in 6935 patients with obstructive jaundice with benign and tumor etiology. In 87% cases there was B Class of obstructive jaundice. In 93% we observed mild (A Class) obstructive jaundice. For the biliary tract drainage we used laparoscopic or open surgical access. The retrograde drain we used in sixty-seven percent cases with obstructive jaundice B Class. In sixty-six percent cases of obstructive jaundice C Class, we used antegrade drain.Results. The biliary decompression was effective in 98%. Regarding the rate and timing of bilirubin reduction, all the applied methods showed a similar result, however, the greatest number of complications and fatalities we recorded in patients after antegrade percutaneous drain of the biliary tract and transabdominal access. In 36% the performed interventions became the final treatment option, and the sixty-one percent of patients underwent two-stage treatment. The overall mortality rate was 3%.Conclusion. The use of percutaneous drainage is justified for obstructive jaundice with tumor origin, and possible radical surgical treatment. Transabdominal access drainage for benign etiology of obstructive jaundice in compensated patients can be safely used. Transduodenal endoscopic drain is an alternative to other methods biliary tract drain in severe and medium obstructive jaundice of benign etiology. The same drain method can be used for drainage of biliary tract in patients with tumors of the hepatopancreatobiliary zone organs, as a palliative treatment.

Электронная микроскопия эритроцитов пациентов с механической желтухой доброкачественного генеза тяжелой степени тяжести

Электронная микроскопия эритроцитов пациентов с механической желтухой доброкачественного генеза тяжелой степени тяжести

One-Step Surgery in Pancreatic Head Cancer Complicated by Obstructive Jaundice

Objective: to analyze short-term and long-term results of one-step surgery in resectable pancreatic head cancer (PHC), complicated by obstructive jaundice. Material and methods. The retrospective analysis of 123 consecutive cases of the surgical treatment of PHC has been performed. Group I (N = 33) consisted of patients with the total bilirubin level up to 100 µmol/l, group II (N = 31) - with the level of total bilirubin of 100-287 µmol/l who had undergone the one-step surgery. Group III (N = 59) included patients having undergone the surgical treatment with preoperative biliary drainage (PBD) in the form of the biliodigestive anastomoses or external drainage, with the total bilirubin level of 125-720 µmol/l. The frequency of postoperative complications, 90-day lethality and the overall survival rate were assessed by the Kaplan-Meier method. Results. The frequency of complications in the patients of groups I, II and III was 42.4, 48.4 and 35.6 %, lethality - 3.0, 3.2 and 6.8 %, respectively (P &gt; 0.05); the 5-year survival rate - 39.7 ± 8.8 %, 30.1 ± 11.8 % and 4.9 ± 3.1 % (P = 0.004). Conclusion. The one-step surgical treatment of PHC with moderately severe obstructive jaundice was not accompanied with the increased frequency of postoperative complications and mortality. The overall survival rates were significantly higher in the patients undergoing the one-step surgery and did not correlate with the total bilirubin levels. The two-step surgery was accompanied by extremely low survival rates. The cancellation of the routine PBD procedure can be considered as one of the ways to improve the long-term outcomes of the PHC treatment.

The Application of Intravoxel Incoherent Motion Diffusion-Weighted Imaging in the Diagnosis of Hilar Obstructive Jaundice.

The aim of this study was to investigate the potential of intravoxel incoherent motion diffusion-weighted imaging in diagnosing hilar obstructive jaundice. Fifty-nine patients diagnosed with hilar obstructive jaundice were enrolled in our hospital form January 2017 to January 2018. All the patients received scanning by a 3.0-T nuclear magnetic resonance scanner. The values of apparent diffusion coefficient (ADC)slow, ADCfast, and f were obtained and analyzed by 2 experienced radiologists. The differences between patients with hilar biliary obstruction and healthy volunteers in ADCslow, ADCfast, and f values were analyzed. Moreover, the differences between benign and malignant obstructive jaundice in ADCslow, ADCfast, and f values were analyzed. According to the serum levels of total bilirubin, patients were divided into 3 groups: mild, moderate, and severe obstructive jaundice. The differences between the 3 groups in ADCslow, ADCfast, and f values were also analyzed. The ADCfast values were obviously lower in patients with hilar obstructive jaundice than in healthy controls, whereas no significant difference in the values of ADCslow and f was found between both groups. The optimal cutoff value for ADCfast was 0.0341. The ADCfast values were significantly different between patients with benign and malignant hilar obstructive jaundice. The ADCfast values were negatively associated with the severity of hilar obstructive jaundice. Intravoxel incoherent motion diffusion-weighted imaging was a promising method for diagnosing hilar biliary obstruction jaundice.

A Case of Severe Obstructive Jaundice due to Gallbladder Hemorrhage

A Case of Severe Obstructive Jaundice due to Gallbladder Hemorrhage

Experience in treating patients with severe obstructive jaundice with benign cause

Experience in treating patients with severe obstructive jaundice with benign cause

PO-106 Anisochronous aerobic exercise improves glucose and lipid metabolism of obstructive jaundice by activating Akt signaling pathway

Objective To observe the effect of moderate intensity and different interval aerobic exercise on hepatic injury and AKT signaling pathway induced by severe obstructive jaundice in mice.&#x0D; Methods 40 male KM mice were randomly divided into 4 groups: sham operation (OJ) group, model (OM) group, 3-week exercise (ST) group and 6-week exercise (SU) group. Mice in OM group, ST group and SU group all adopted the orthotopic hanging choledochotomy method modified by this study group to construct the animal model of obstructive jaundice. The slope of group ST and group SU were 0% and the speed was 10m/min. After the above 6 weeks of intervention, HE staining was used to observe the morphological changes of hepatocytes. Methods of automatic biochemical analyzer test serum total bilirubin (TBIL), alanine aminotransferase (ALT), aspertate aminotransferase (AST), liver function and fasting plasma glucose (GLU), glycosylated hemoglobin (HbA1c), glycosylated serum protein (GSP), total cholesterol (TC), triglyceride (TG) and high-density lipoprotein cholesterol (HDL - C) of sugar, lipid metabolism and biochemical indexes such as detection; Immunohistochemical staining and qrt-pcr technology were used to observe the expression changes of AKT related molecules such as SREBP-1c, LDL-C, gsk-3β, GCK and G6Pase in liver tissues.&#x0D; Results HE staining showed that the liver cell cords of the normal group were orderly. In the model group, the hepatocytes of the rats were fibrosed in large amounts, which showed degeneration, necrosis and even disordered structure of hepatocytes. In the 3-week exercise group, a small number of hepatic cells were found with patchy necrosis, hepatic lobule structure was changed, and hepatic cords were not well arranged. There was no obvious tissue necrosis in the 6-week exercise group, the hepatic lobule structure was basically normal, and the liver cord was arranged in order. Serological results showed that the levels of TG, TC, LDL-C, HDL - C and GLU in the 6-week exercise group were significantly lower than those in the model group (P &lt; 0.01), and the levels of TG and TC in the 3-week group were also significantly decreased (P &lt; 0.05). In liver tissues, the mRNA and protein expression of related molecules of AKT pathway such as SREBP-1c, LDL-C, gsk-3β, GCK and G6Pase were significantly decreased. &#x0D; Conclusions Moderate intensity aerobic exercise can regulate glucose and lipid metabolism in mice with severe liver injury caused by obstructive jaundice. The underlying mechanism may be related to regulating the AKT pathway.

Polybromo-1 loss in cholangiocarcinoma development: Expressional analysis

Dear editor, the cholangiocarcinoma is a deadly hepatobiliary cancer. It results in high fatality in affected persons in endemic Southeast Asia. The patient usually manifests at large stage of cancer and has severe obstructive jaundice. The underlying genetic pathophysiology of cholangiocarcinoma is very interesting. As a cancer, the mutation can be expected (such as KRAS mutation). In a recent publication by Luchini et al., the loss of Polybromo-1 (PBRM1) was observed during the development of cholangiocarcinoma. The similar finding was also reported by another Japanese scientist group. Here, the authors use the standard gene ontology technique to assess the effect of PBRM1 loss comparing to the naïve case. The protocol for gene ontology analysis is the same as previously gene ontology analysis studied. According to analysis, the identified main affected function due to PBRM1 loss is “regulation of chromatin association.” This implies that loss of PMB1 during cholangiocarcinoma development is the important pathobiological process that promotes the abnormal cell division and might stimulate the cancer development. In fact, the loss of PBRM1 is proposed as an important predictor for poor outcome in several cancers such as renal cancer.

Predictors of hepatic insufficiency in obstructive jaundice

To develop predictive model for hepatic insufficiency in obstructive jaundice. Obstructive jaundice was modeled by the author's method on 48 mini pigs, while morpho-functional features of erythrocytes were studied by using of INTEGRA Aura atomic force microscope (NT-MDT, Zelenograd, Russia). Histological specimens were stained with hematoxylin and eosin. Discriminant analysis was used to create predictive model for hepatic insufficiency. Mathematical model of hepatic insufficiency prediction has been developed. Sensitivity and specificity of this model were 94.1% and 74.2% respectively. Total percentage of correct predictions was 81.3%. Severe obstructive jaundice contributes erythrocyte's transformation from biconcave to dome-shaped followed by changes of its physical properties. Erythrocyte's volume and activity of cytolysis enzymes are the most informative to predict hepatic insufficiency. Our model allows us to diagnose this complication at early stages and to correct pre-, intra- and postoperative therapy.

Hemophagocytic Lymphohistiocytosis Masquerading as Cholangitis

Hemophagocytic lymphohistiocytosis (HLH) is a rare syndrome of unchecked immune activation leading to multi-organ damage with a high mortality. It can be hereditary or triggered by an inflammatory process. Mild hepatitis is present in the majority of patients with HLH, but obstructive jaundice has not been reported. We present the case of a 60 year old male who presented with severe obstructive jaundice from HLH triggered by an underlying lymphoma. A 60 y/o male with a history of DM, CAD and CKD presented with severe jaundice, high fevers and fatigue. His bilirubin was 22 with 20.1 of direct; ALT 33, AST 87, and Alk phos of 114. WBC was 12.4 with left shift. CT abdomen showed mild prominence of CBD and fatty liver without lymphadenopathy. Suspecting cholangitis, antibiotics were started. An MRCP did not show any evidence of biliary dilation or choledocholithiasis and an ERCP showed esophagitis and gastritis but again, no evidence of biliary obstruction. Further work up found a ferritin of 2165 and LDH of 1434. With no lab evidence of hemolytic anemia, a bone marrow biopsy was done, which was inconclusive. Due to progressive liver failure, a liver biopsy was done which showed hemophagocytic histiocytes with evidence of large B cell lymphoma. He had intrahepatic cholestasis due to HLH caused by the lymphoma. Unfortunately with worsening liver and eventual renal failure, he could not receive appropriate chemotherapy, and succumbed to the disease. HLH was considered to be a rare disease in adults; however recently its being increasingly reported, likely due to awareness, rather than rise in incidence. Diagnosis of HLH is a challenge due to nonspecific features mimicking SIRS. Liver injury with mild elevation of transaminases is seen in 85% patients with HLH and about half have hyperbilirubinemia. Florid liver failure is rare, and Post hepatic form of injury mimicking cholangitis has not been reported so far. Prognosis of adult HLH is very poor, with mortality of 41-75% and Delayed diagnosis is considered the most important factor related to treatment failure. Early diagnosis and timely treatment with the HLH-2004 protocol has been shown to improve survival in adult patients with HLH, thus highlighting the importance of recognizing rare presentations of this disease. In patients with liver failure with intrahepatic cholestasis and unclear etiology, HLH should be strongly suspected as timely diagnosis with a Bone marrow or liver biopsy could be life saving.

EFFECTS OF SALVIA MILTIORRHIZAE ON THE KIDNEY OF RATS WITH SEVERE ACUTE PANCREATITIS AND OBSTRUTIVE JAUNDICE.

Background:Severe acute pancreatitis (SAP) and obstructive jaundice (OJ) are frequent recurring diseases that bring about huge threat to human health. Some reports have demonstrated that Salviae miltiorrhizae can protect multiple organs of SAP and OJ model animals or patients, but their related mechanisms were not clear. In this study, we observed the effects of Salvia miltiorrhizae injection on apoptosis and NF-κB expression in kidney and explored the protective effect and mechanism of Salvia miltiorrhizae on the kidney of SAP or OJ rats. The results obtained will provide a theoretical basis for clinical application of Salvia miltiorrhizae.Material and Methods:A total of 288 rats were used for SAP -and OJ-associated experiments. The mortality rates of rats, the contents of serum BUN and CREA, the expression levels of Bax, NF-κB proteins and the apoptosis index were observed, respectively.Results:The pathological changes in the kidney of SAP or OJ rats in treated group were mitigated to varying degrees. At 6 and 12 hours after operation in SAP rats or on 21 and 28 days after operation in OJ rats, the contents of serum CREA in treated group were significantly lower than those in model control group; At 3 and 6 hours after operation, the staining intensity of Bax protein of kidney in treated group was significantly lower than that in model control group; on 14 days after operation, the apoptosis index in the kidney of OJ rats in treated group was significantly lower than that in model control group.Conclusion:Salvia miltiorrhizae can exert protective effects on the kidney of SAP and OJ rats.