Complications of a severe autoimmune hemolytic anemia crisis: transfusional iron overload and gangrenous cholecystitis.

BACKGROUND: Evans syndrome is a rare autoimmune disorder that is defined by the simultaneous or sequential presence of two or more cytopenias without an obvious underlying precipitating cause. Evans syndrome usually follows a chronic relapsing and remitting course and is quite rare, making it difficult to evaluate in clinical studies. CASE REPORT: A 66-year-old male patient with a 17-year history of Evans syndrome presented with fulminant autoimmune hemolytic anemia (AIHA). He presented with a markedly elevated C-reactive protein (CRP; 46 mg/L [normal, 0-5 mg/L]) before onset of a decrease in hemoglobin. He required the transfusion of 20 units of red blood cells while awaiting response to aggressive immunosuppressive therapy including high-dose corticosteroids, intravenous immunoglobin therapy, and rituximab. He achieved a complete hematologic response. RESULTS: His postdischarge course was complicated by acute cholecystitis requiring laparoscopic cholecystectomy. In addition, his transfusional iron overload requiring 16 phlebotomies to reduce his ferritin level from 4933 µg/L to 326 µg/L, with phlebotomies ongoing every 2 weeks to achieve a ferritin level of less than 100 µg/L. CONCLUSION: Neither transfusional iron overload nor acute cholecystitis are well-recognized complications of a severe episode of AIHA. An elevated CRP has been recently recognized as an important prognostic marker in patients with immune thrombocytopenic purpura and this case suggests a need to evaluate its utility in AIHA.

[Chronorehabilitation of the patients suffering from chronic cholecystitis with concomitant gallbladder dysfunction and opisthorchiasis]. / Khronoreabilitatsiia bol'nykh khronicheskim kholetsistitom s disfunktsiei zhelchnogo puzyria i opistorkhozom.

The importance of the development of the effective rehabilitative measures for the patients suffering from chronic cholecystitis with concomitant gallbladder dysfunction and opisthorchiasis is beyond question. The adequate methods for the rehabilitation of the patients after an intensive de-worming remain to be developed. It is known that de-worming is not infrequently followed by the immediate amplification of the manifestations of the stagnation of bile in the gallbladder that become even more pronounced than before the de-worming procedure. With the purpose of improving the effectiveness of the spa and health resort-based rehabilitation and prevention of the complications, it is recommended to make use of the modern therapeutic physical factors to be prescribed taking into consideration the characteristics of the biological rhythms in the functional activity of the biliary system in the individual patients. The most effective rehabilitation methods for the treatment of the pathology in question include the application of the therapeutic physical factors known to produce the beneficial effect on the functional state of the biliary system and exert the normalizing influence on the structure of the biological rhythms of the functional activity of various organs and systems. We used a range of approaches for the treatment of 123 patients with chronic cholecystitis and concomitant gallbladder dysfunction plus opisthorchiasis including extremely high-frequency electromagnetic irradiation (EHF therapy) in the combination with the oral intake of the choleretic herbal remedies followed by the transverse galvanization of the epigastric region with due regard for the phase of the rhythm of the functional activity of the gallbladder. The results of such treatment gave evidence of the positive dynamics of all the studied indicators of the functional activity of the biliary system and the organism as a whole which suggests the highest therapeutic effect (87.9%) of the proposed treatment that was maintained during 6 to 12 months.

[The contingency of the therapeutic effectiveness with the peculiarities of the non-pharmacological treatment of the patients presenting with chronic cholecystitis]. / Sopryazhennost' terapevticheskoi effektivnosti s osobennostyami nemedikamentoznogo lecheniya bol'nykh khronicheskim kholetsistitom.

The elaboration of new technologies for the medical rehabilitation of the patients presenting with chronic cholecystitis in combination with chronic opisthorchiasis is a topical problem facing modern clinical gastroenterology. The application of up-to-date non-pharmacological therapeutic modalities, such as ultrahigh-frequency (UHF) therapy concomitantly with group chronophysiotherapy makes it possible to significantly improve the final outcome of the treatment. The results of clinical studies give evidence of the favourable influence of the combined chronorehabilitative treatment including UHF therapy on the characteristics of the functional state of the biliary-hepatic system and of the organism as a whole. The positive dynamics of these characteristics is suggestive of the high (up to 87,5%) therapeutic effectiveness of the proposed treatment. The investigations into the relationship between this effect and the peculiarities of the combined therapeutic modalities have demonstrated their correlation (χ2=104,13; p=0,0001; V-Kramer´s coefficient =0,35) and showed that the use of combined chronorehabilitation including UHF therapy based on the application of phone resonance radiation guarantees (and is a predictor of) high therapeutic effect (percent concordance =95,6%; standard coefficient=2,13; p=0,001) of the treatment of the patients with chronic cholecystitis in combination with chronic opisthorchiasis. The statistical analysis of the results of application of the modern non-pharmacological therapeutic modalities and the chronobiological approach for the purpose of the combined treatment of patients presenting with chronic cholecystitis in combination with opisthorchiasis with the use of contingency table and logit regression, allowed not only to estimate the interdependence and interrelation between the characteristics of interest but also to reveal predictors of therapeutic effectiveness. These findings are of great practical importance since they can be used for the choice of therapeutic strategies for the management of this category of patients.

[CHRONOLOGICAL APPROACH TO COMPLEX TREATMENT OF PATIENTS WITH CHRONIC CHOLECYSTITIS IN COMBINATION WITH THE OPISTHORCHIASIS].

The development of new technologies of medical rehabilitation of patients with chronic cholecystitis in combination with a chronic opisthorchiasis, remains an actual problem of clinical gastroenterology. The use of a group chronobiological approach to the complex treatment of these patients including EHF-therapy allows to increase efficiency of the conducted measures. The analysis of results testified to beneficial effect of such approach on indicators of a functional condition of hepatobiliarity system and an organism in general. The positive dynamics of all studied indicators provided high thera- peutic effect (to 84.8%), and the revealed contingency of these results to features of carrying out treatment, allowed to establish their interrelation (χ² = 104.13; p = 0.0001; Kramer's V-coefficient = 0.35). It guarantees (is a predictor) receiving of high therapeutic effect (Percent Concordant of = 86.4%; the standardized coefficient = 2.54; r = 0.001) of the complex treatment including EHF-therapy with use of chronobiological approach to treatment of patients with chronic cholecystitis in combination with a chronic opisthorchiasis. The established dependences have a great practical importance and can be used in a choice of tactics of treatment of this category of patients.

[Effects of acupuncture of Jianjing (GB 21) on gallbladder volume and symptoms of cholecystitis patients].

OBJECTIVE: To observe the effect of acupuncture of Jianjing (GB 21) and non-acupoint on gallbladder volume and clinical symptoms of chronic cholecystitis patients. METHODS: Sixty cases of chronic cholecystitis patients were equally randomized into Jianjing (GB 21) group and non-acupoint group. A filiform needle was inserted into Jianjing (GB 21) or non-acupoint (2 cun lateral to the mid-point between the spinous processes of the 6th and 7th cervical vertebrae) on the right side, manipulated for a while till "Deqi", and retained for 30 min. A color Doppler ultrasound scanner was used to detect the volume of the gallbladder before and 15 min after acupuncture stimulation and 30 min after withdrawal of the acupuncture needle. Changes of the patients symptoms of shoulder-back pain, stomachache, distension and nausea were evaluated according to the patients' complaints. RESULTS: After acupuncture intervention, the remission rates of shoulder-back pain and stomachache in non-acupoint and GB 21 groups were 56.67% and 90.00% respectively, while the effective rates of the patients' gastric distention and nausea in non-acupoint and GB 21 groups were 16.67% and 23.33%, respectively. The therapeutic effect of Jianjing (GB 21) was apparently superior to that of non-acupoint in pain relief (P < 0.05). Fifteen min following acupuncture stimulation and 30 min after withdrawal of the acupuncture needle, the gallbladder volume in cholecystitis patients with deflated gallbladder was increased apparently in GB 21 group (P < 0.01), and that in patients with expanded gallbladder was decreased significantly (P < 0.01). No significant differences were found among pre-, during and post-treatment in the non-acupoint group in the effects of acupuncture on regulation of the deflated and expanded gallbladder volume (P > 0.05). CONCLUSION: Acupuncture stimulation of Jianjing (GB 21) can effectively relieve shoulder-back pain and stomachache, and regulate the volume of the deflated and expanded gallbladder in cholecystitis patients. The effect of acupuncture of non-acupoint is relatively poorer in relieving the cholecystitis patients' symptoms and regulating the gallbladder volume.

[Rational diagnostics of acute abdomen]. / Rationelle Diagnostik des "akuten Abdomens"

BACKGROUND: In view of the threat that comes with an acute abdomen, it is of major importance that diagnostics are executed quickly and efficiently. In the course of this two tendencies can be differentiated: 1) general use of complex examination (e.g. CT, MRT) of all potential patients and 2) step-by-step-diagnostics with advanced diagnostics as and when required. MATERIAL AND METHODS: A total of 444 patients with an acute abdomen as admission diagnosis were investigated. All data were evaluated prospectively and analyzed retrospectively. All patients had the same basic diagnostics consisting of aclinical history, clinical examination, laboratory examination, abdominal sonography and x-ray overview images. These examinations were supplemented when required by advanced measures, such as CT, colon enema with contrast fluid, endoscopic examination and diagnostic laparotomy. RESULTS: Three different disease groups of unequal diagnostic need could be identified. The first group, presented in the form of an appendicitis showed that in 80% of all patients a basic diagnosis was sufficient. Advanced examination such as CT affected 14%. The negative appendectomy rate amounted to 8%. Other diseases belonging to the first group were ileus, acute biliary diseases, perforation etc. In the second group presented in the form of a diverticulitis, an advanced radiological examination was required in 84% of all cases. Similar results are also expected in cases of pancreatitis. In the third group presented in the form of coprostasis, inflammatory etiology was found in 39% of all secondary diseases. However the symptoms became clinically apparent after treatment of the coprostasis. In this group a basic diagnosis was satisfactory in 84% of cases, however, a diagnostic laparotomy was inevitable for 3% of these patients. CONCLUSION: Generally step-by-step diagnostic approach has proven itself to be efficient. For 80% of all patients it makes advanced diagnostic measures unnecessary. The exceptions are diseases in which it is necessary to know not only the diagnosis but also the disease stage. In these cases (e.g. pancreatitis, diverticulitis etc.) advanced diagnostics should be pursued from the onset. The necessity of a diagnostic laparotomy has lost importance for 1% of all patients.

An unusual complication following transarterial chemoembolization: acute myocardial infarction.

Transarterial chemoembolization has been widely used to treat unresectable hepatocellular carcinoma. Various complications have been reported, but they have not included acute myocardial infarction. Acute myocardial infarction results mainly from coronary artery occlusion by plaques that are vulnerable to rupture or from coronary spasm, embolization, or dissection of the coronary artery. It is associated with significant morbidity and mortality. We present a case report that describes a patient with hepatocellular carcinoma who underwent transarterial chemoembolization and died subsequently of acute myocardial infarction. To our knowledge, there has been no previous report of this complication induced by transarterial chemoembolization for hepatocellular carcinoma. This case illustrates the need to be aware of acute myocardial infarction when transarterial chemoembolization is planned for the treatment of hepatocellular carcinoma, especially in patients with underlying coronary artery disease.

[Use of essentiale and cholagogum in prevention of cholelithiasis in fat hepatosis with concomitant cholecystitis].

AIM: To assess efficacy of essentiale in combination with cholagogum in prevention of cholelithogenesis in patients with fat hepatosis (FH) and concomitant cholecystitis (CC). MATERIAL AND METHODS: 100 patients aged 31-60 years with FH and CC were examined using clinical, device and biochemical tests. The diagnosis was verified by the results of ultrasonography, computed and MR tomography. Fractionated duodenal tubing followed by biochemical examination of bile was conducted in all the patients. RESULTS: Changes in physico-chemical properties of hepatic and vesical bile corresponding to stage I of cholelithiasis occurred in most of the examinees. Treatment with essentiale +cholagogum is clinically effective, improves functional condition of bile ducts and the liver, diminishes bile lithogenicity. CONCLUSION: In fat hepatosis and concomitant cholecystitis, essentiale and cholagogum improve biochemical composition of bile, resulting finally in decreased risk of cholelithogenesis.

Obstetric triage revisited: update on non-obstetric surgical conditions in pregnancy.

New findings and diagnostic advances warrant revisiting key features of acute non-obstetric abdominal pain in pregnancy. Four of the most frequently seen conditions warranting surgical intervention are: appendicitis, cholecystitis, pancreatitis, and bowel obstruction. Because pregnancy often masks abdominal complaints, effectively assessing and triaging abdominal pain in pregnant women can be difficult. Working in obstetric triage settings and triaging obstetric phone calls demand continual updating of abdominal assessment knowledge and clinical skills.

[The drug "Selena" in the complex treatment of patients with chronic inflammatory diseases of the biliary system]. / Preparat "Selena" v kompleksnomu likuvanni khvorykh na khronichni zapal'ni zakhvoriuvannia biliarnoï systemy.

The drug selena of the Novamed firm has been shown to be of high clinical, biochemical, and immunological effectiveness in a combined treatment of patients with chronic inflammatory diseases of the biliary system presenting with immunological disorders, that was evidenced by a sooner than in controls disappearance or alleviation of clinical manifestations of the disease, normalization of clinical indices for blood, ultrastructure of the immunocompetent cells, and by less time for the functional state of the liver to return to normal. It is suggested that the drug effect on the immune system might be mediated through normalization of lipid peroxidation and of the system for antioxidant defence.

Risk of pancreatic cancer in relation to alcohol drinking, coffee consumption and medical history: findings from the Japan collaborative cohort study for evaluation of cancer risk.

We evaluated the associations of such lifestyle factors as alcohol drinking, coffee consumption and medical history with risk of death from pancreatic cancer in a large-scale prospective cohort study [the Japan Collaborative Cohort Study for Evaluation of Cancer Risk (JACC study)] in Japan. Subjects were 110,792 (46,465 men and 64,327 women) inhabitants who were enrolled from 45 areas throughout Japan. At baseline, a self-administered questionnaire was used to obtain information on lifestyle factors and medical history. Cox proportional hazard models were used to calculate relative risks. During the follow-up period (mean +/- SD 8.1 +/- 1.8 years), 225 deaths due to pancreatic cancer were identified. Overall, neither alcohol nor coffee intake was associated with risk of death from pancreatic cancer. Heavy coffee consumption (> or =4 cups/day), however, may increase the risk. Men who reported a history of diabetes mellitus and women who reported a history of gallstone/cholecystitis were at significantly (2-fold) increased risk of death from pancreatic cancer.

Recurrent septic episodes following gallstone spillage at laparoscopic cholecystectomy.

A 51-year-old woman underwent emergency laparoscopic cholecystectomy. Stone loss occurred during gallbladder dissection. Histology showed empyema of the gallbladder. Postoperatively, she developed a subhepatic abscess that required percutaneous drainage. Two years after surgery, she re-presented with a right paracolic abscess. Transsciatic CT-guided drainage of the abscess was performed. Barium enema excluded colonic pathology. Two weeks later, she developed a right gluteal abscess deep to the recent drain site. Ultrasound-guided drainage was performed followed by a sonogram. The sonogram ruled out communication with the peritoneum. Two further subhepatic abscesses occurred during the next 5 years; the first abscess was drained percutaneously, but the second required open drainage: At laparotomy, gallstone fragments were found within the abscess cavity. The site of the previous gluteal drain continued to discharge intermittently. An MRI scan showed an uncomplicated sinus track. Subsequent sinography of the right gluteal track demonstrated an opacity at the apex of the sinus. The sinus was laid open and a gallstone retrieved. The patient has remained well for 3 years. Complications due to gallstone spillage generally manifest themselves shortly after surgery. This case demonstrates that lost stones may cause chronic abdominal and abdominal wall sepsis. In cases of chronic abdominal sepsis after laparoscopic cholecystectomy, the possibility of lost stones should be considered even if stones are not positively shown on imaging.

[Galvanization of the liver in the prevention of cholelithiasis in patients with chronic cholecystitis]. / Gal'vanizatsiia pecheni v profilaktike kholelitiaza u bol'nykh khronicheskim kholetsistitom.

It is shown in 22 patients with chronic noncalculous cholecystitis that hepatic exposure of such patients to constant current changes chemical composition of bile components in such a way that bile lithogenic characteristics make formation of choleliths less probable.

[A trial of the use of sandostatin in patients with chronic pancreatitis]. / Opyt primeneniia sandostatina u bol'nykh khronicheskim pankreatition.

Out of 15 patients with chronic pancreatitis (CP) treated with sandostatin, 8 patients demonstrated a complete and 6 partial response. One patient did not respond. Pain relief occurred in all of them. Side effects were registered in 3 patients (doughy stools 4 times a day throughout treatment). Normal blood levels of pancreatic enzymes, insulin secretion, parameters of blood inhibitory system did not change much because of sandostatin administration, whereas hypercoagulation got diminished. Rat experiments have revealed a trend to trypsin lowering in tissues of unaffected pancreas and more intensive inhibition of active trypsin by tissue inhibitors.

[A comparison of different methods for quantum hemotherapy in treating complicated forms of acute cholecystitis in middle-aged and elderly patients]. / Sravnenie razlichnykh metodov kvantovoi gemoterapii pri lechenii oslozhnennykh form ostrogo kholetsistita u bol'nykh pozhilogo i starcheskogo vozrasta.

Quantum hemotherapy (QH) was used in complex treatment of elderly and senile patients operated upon for complicated forms of acute cholecystitis. Under examination there were 75 patients. Transfusion of UV irradiated donor plasma was found to be most effective of the QH methods used by us in the complex treatment of acute cholecystitis in elderly and senile patients.