Perioperative management of obstructive jaundice.
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Blood Coagulation Disorders↗
Biomedical subjects
T Diamond
Publications and source records attributed to T Diamond.
Cutaneous metastasis as a complication of hepatic intra-arterial chemotherapy.
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Adenocarcinoma↗
Intestinal barrier dysfunction in clinical and experimental obstructive jaundice and its reversal by internal biliary drainage.
Intestinal mucosal barrier function in obstructive jaundice was assessed in an animal model and in patients. The effect of internal biliary drainage in patients was also examined. Bile duct ligation for 1 week in the rat resulted in significant bacterial translocation (in seven of 12 animals following ligation versus none of the shamoperated controls, P < 0.01). Intestinal permeability, measured by the urinary recovery of orally administered polyethylene glycol, was also significantly increased (+66.2 per cent for ligation versus -11.6 per cent for sham, P < 0.01). A prospective study was performed on 33 patients with obstructive jaundice undergoing internal biliary drainage, and results were compared with those in six non-jaundiced patients undergoing laparotomy or endoscopic retrograde cholangiopancreatography and in 11 health volunteers. The lactulose: mannitol ratio was used as an intestinal permeability index. Mean(s.e.m.) intestinal permeability assessed before operation was significantly increased in jaundiced patients compared with control patients (0.050(0.010) versus 0.016(0.003), P < 0.005). The mean(s.e.m.) lactulose: mannitol ratio in the healthy volunteers was 0.020(0.003), which was similar to that in control patients. In the jaundiced group of patients the intestinal permeability index fell to within normal levels after 28 days of internal biliary drainage (0.050 before operation versus 0.021 at 28 days, P < 0.02). These data indicate that intestinal barrier function is impaired in obstructive jaundice and that this impairment is reversed by return of bile to the gastrointestinal tract.
Animals↗
Estrogen replacement may be an alternative to parathyroid surgery for the treatment of osteoporosis in elderly postmenopausal women presenting with primary hyperparathyroidism: a preliminary report.
Parathyroid surgery is indicated in patients presenting with primary hyperparathyroidism (PHPT) and osteoporosis (defined as bone mineral density more than 2 standard deviations below normal). Many are elderly women with complex medical problems, either unwilling or considered unfit for surgery. Estrogen replacement therapy (ERT) may potentially be an alternative form of therapy in this group. We studied 15 consecutive postmenopausal women presenting with PHPT and osteoporosis. Group 1 comprised 5 women who elected to be treated with ERT (conjugated equine estrogen, 0.3-0.625 mg/day). The other 10 women underwent successful parathyroidectomy. These 10 patients were randomly subdivided into group 2 (5 patients who received calcitriol 0.25 micrograms b.i.d. for 12 months following surgery) and group 3 (5 patients who received elemental calcium 1 g/day for 12 months following surgery). Lumbar spine and femoral neck bone mineral density (BMD) were measured prior to and after 12 months of therapy, using a dual-energy X-ray absorptiometer (Lunar DPX-L). The three groups did not differ with respect to their ages (group mean 71.8 years), or baseline serum calcium (group mean 2.77 mmol/l), serum parathyroid hormone (group mean 11.0 pmol/l), lumbar spine BMD (group mean 0.93 g/cm2) and femoral neck BMD (group mean 0.73 g/cm2). Serum calcium normalized in all patients who underwent surgery and none developed hypoparathyroidism. A non-significant decrease in serum calcium was seen in patients treated with ERT only. Lumbar spine (+5.3% per year; 95% CI, 1.1% to 9.6%) and femoral neck BMD (+5.5% per year; 95% CI, -2.1% to 13.2%) increased significantly after 12 months of ERT (p < 0.001 compared with pre-therapy values). These increases in BMD did not differ significantly from those in patients who underwent successful parathyroidectomy followed by either calcitriol therapy or calcium replacement (lumbar spine BMD increase of +6.2% per year, 95% CI 3.1% to 9.4%; and femoral neck BMD increase of +3% per year, 95% CI 0 to 6%). In summary, increases in lumbar spine and femoral neck BMD occur following treatment of PHPT. ERT appeared as effective as parathyroidectomy (combined with either calcitriol or calcium supplements) for the treatment of osteoporosis in elderly postmenopausal women presenting with PHPT.
Aged↗
Acquired osteosclerosis associated with intravenous drug use and hepatitis C infection.
Hepatitis C has recently been recognized as a secondary cause of osteosclerosis; a further example, the first outside of North America, is described. A 37-year-old man with a history of intravenous drug use and known to be hepatitis C antibody positive presented with bone pain. Radiographs and magnetic resonance imaging demonstrated an increase in cortical and trabecular bone that on biopsy was of a normal lamellar pattern but markedly sclerotic. Biochemical markers of bone formation (serum osteocalcin) and resorption (urinary hydroxyproline excretion rate) were both markedly elevated. Pain lessened following administration of pamidronate. Biochemical markers of bone turnover fell towards their reference ranges 12 months after initiating pamidronate therapy but without significant change in bone mineral density. Osteosclerosis is a rare complication of hepatitis C infection, the symptoms of which are controllable with diphosphonate therapy.
Adult↗
The identification of false positive responses to the pentagastrin stimulation test in RET mutation negative members of MEN 2A families.
OBJECTIVE: The pentagastrin stimulation test is the traditional test used for the identification of asymptomatic individuals in multiple endocrine neoplasia type 2A (MEN 2A) and familial medullary thyroid carcinoma (FMTC). The identification of mutations in the RET proto-oncogene segregating with the disease phenotype in MEN 2A and FMTC families has made it possible to re-examine the validity of using this test for the identification of affected family members. DESIGN: Sequential and single pentagastrin stimulation test data were collected following the identification of RET mutation positive and RET mutation negative members of families with MEN 2A or FMTC. PATIENTS: RET mutations were identified in 16 Australian and New Zealand MEN 2A or FMTC families. An analysis of 39 individuals from these families was included in this study. Thirty-two individuals (14 males, 18 females) had previously been determined as RET mutation negative. Seven individuals (6 males, 1 female) had previously been determined as RET mutation positive. Two RET mutation negative males had thyroidectomy based on prior pentagastrin test results. MEASUREMENTS: Serum calcitonin levels in response to stimulation with pentagastrin were measured at 0, 1, 2, 5 and 10 minutes post injection. Mutation analysis of the RET proto-oncogene was performed in all individuals. In two RET mutation negative individuals from two MEN 2A families, thyroidectomy was performed and C-cells were quantitated in order to determine the diagnosis of C-cell hyperplasia. RESULTS: There was a statistically significant difference (P < 0.013) between RET mutation negative male and female mean peak calcitonin responses of 282 +/- 236 and 96 +/- 62 (mean +/- SD) ng/l respectively. False positive responses to pentagastrin stimulation were identified in seven individuals who were RET mutation negative in two of the 16 families. Histologic examination of the thyroid glands in the two RET mutation negative individuals who had thyroidectomy demonstrated C-cell hyperplasia in one but not in the other. CONCLUSIONS: There is considerable overlap between pentagastrin test results in individuals who are RET mutation positive and those who are RET mutation negative. These results indicate a need for routine performance of RET proto-oncogene analysis on all individuals at risk of developing MEN 2A or FMTC and a coupling of pentagastrin test results and RET proto-oncogene analysis in the decision to proceed with thyroidectomy.
Adolescent↗
Fine adjustments in thyroxine replacement and its effect on bone metabolism.
We studied 10 postmenopausal women with Hashimoto's hypothyroidism treated with varying doses of L-thyroxine replacement. Each patient received incremental doses of L-thyroxine sufficient to achieve subclinical hypothyroidism, euthyroidism, and subclinical hyperthyroidism as determined by normal total serum thyroxine levels (80-160 micrograms/L) and serum TSH concentrations greater than 3.5, 0.3-3.5, and less than 0.3 mU/L, respectively. Metabolic parameters of bone turnover (including serum bone Gla-protein, serum alkaline phosphatase, serum procollagen 1, and serum carboxytelopeptide) were assessed once steady state was achieved, and measurements were compared to 10 healthy controls matched for age and years since the menopause. Our findings suggest that overzealous thyroxine replacement producing subclinical hyperthyroidism may result in an increase in bone turnover as reflected by elevated serum carboxytelopeptide concentrations.
Adult↗
Ultrasound-guided parathyroid aspiration to diagnose parathyroid adenomas.
AIM: To ascertain the accuracy of ultrasound-guided fine needle aspiration and parathyroid hormone assay in the identification of parathyroid adenomas. DESIGN: Case study. SETTING: Tertiary referral clinic. PATIENTS: 12 subjects, consisting of 10 female and two male patients, with documented primary hyperaparathyroidism. INTERVENTION: Ultrasonography of the parathyroid glands was performed using an Acuson XP 128 machine with a linear array 7.5 MHz multihertz probe. Following accurate localization of the parathyroid lesion, fine needle aspiration was performed using a 23 gauge needle, and parathyroid hormone assay was performed on the aspirate. Preoperative localization was compared with intra-operative findings. RESULTS: Ultrasound examination detected 10 out of a possible 12 parathyroid adenomas (83% sensitivity), while ultrasound-guided fine needle aspiration only confirmed nine out of the 12 adenomas (75% sensitivity). CONCLUSIONS: While ultrasound-guided fine needle aspiration may be simple and with minimal morbidity, it does not appear to provide any advantage over ultrasound examination alone for the localization of parathyroid adenomas. It has a potential role in defining the nature of ultrasonically localized nodules.
Adenoma↗
Endoscopic drainage aborts endotoxaemia in acute cholangitis.
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Acute Disease↗
Bacterial translocation and gut microflora in obstructive jaundice.
Bacterial translocation from the gut is implicated in the pathophysiology of complications associated with obstructive jaundice. Absence of intraluminal bile salts and their antiendotoxic effects may result in overgrowth of bacteria, promoting bacterial translocation. The large bowel is the largest source of gram negative bacteria but the small bowel is more permeable. This study investigated the effect of obstructive jaundice on bacterial translocation and on the indigenous luminal microflora at 3 sites in the gastrointestinal tract. Significant bacterial translocation was demonstrated following 7 d of bile duct ligation compared with control or sham operated groups. A qualitative disturbance of the caecal indigenous microflora was demonstrated in jaundiced rats. There was no 'site-to-site' variation in the indigenous microflora at the 3 intestinal sites studied. We conclude that experimental obstructive jaundice for 1 wk promotes bacterial translocation without significant quantitative disturbance of the intestinal microflora in the small intestinal or caecum.
Animals↗
Renal dysfunction in obstructive jaundice.
The association between renal dysfunction and obstructive jaundice is well established. Despite a substantial number of clinical reviews and prospective studies, the exact incidence and extent of the problem has not been determined accurately. Various pathogenic mechanisms and therapeutic strategies have been proposed but renal dysfunction remains a persistent problem in hepatobiliary practice. The intention of this review is to determine the current extent of the problem, outline the proposed pathophysiological mechanisms and assess the current therapeutic options.
Acute Kidney Injury↗
Non-surgical trauma to the extrahepatic biliary tract.
Non-surgical trauma to the extrahepatic biliary tract is uncommon and encountered only rarely by surgeons outside specialist hepatobiliary centres. Such injury often results in significant morbidity and mortality. This review outlines the incidence, classification, mechanisms of injury, presentation, diagnostic techniques and management options. Depending on the type of biliary injury identified, an optimal method of repair is suggested. Recommendations are made for surgeons who encounter this type of injury and do not have the appropriate expertise for definitive management.
Adolescent↗
Mortality, endotoxaemia and cytokine expression after intermittent and continuous hepatic ischaemia.
This study compared mortality rates, endotoxaemia, systemic tumour necrosis factor (TNF) and interleukin (IL)-6 concentrations after continuous and intermittent hepatic ischaemia. Two groups of rats were subjected to continuous or intermittent left hepatic inflow occlusion for a total period of 120 min in each group. Intermittent ischaemia was associated with significantly lower mortality rates than continuous ischaemia (four of 20 versus 15 of 20; P = 0.0015). In a separate study, again following 120 min continuous or intermittent ischaemia, systemic blood was sampled at 0 min, 1 h, 3 h and 5 h after final clamp release for measurement of endotoxin, TNF and IL-6 concentrations. Endotoxin concentrations were significantly lower at 1 h, as were TNF and IL-6 concentrations at 3 and 5 h, after final clamp release in the group having intermittent ischaemia (P < 0.05). Intermittent ischaemia is associated therefore with significantly reduced mortality rates and lower systemic endotoxin, TNF and IL-6 concentrations when compared with continuous ischaemia.
Animals↗
Cystic duct laceration by metallic clips: a cautionary note.
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Adult↗
Cyclical etidronate plus ergocalciferol prevents glucocorticoid-induced bone loss in postmenopausal women.
OBJECTIVE: To assess the benefit of cyclical etidronate plus ergocalciferol for the prevention of glucocorticoid-induced bone loss in a 2-year, prospective, open study based in an osteoporosis clinic. PATIENTS AND METHODS: Group 1 consisted of 15 postmenopausal women (mean age 62.6 +/- 3.3 years) who commenced glucocorticoid therapy and were treated with cyclical etidronate (400 mg/d for the first month; thereafter, 400 mg/d for 2 weeks of every 3-month period), elemental calcium (1 g/d), and ergocalciferol (0.5 mg/wk). Group 2 consisted of 11 postmenopausal women (mean age 60.2 +/- 4.7 years) with glucocorticoid-induced osteoporosis, who were attending the clinic at the same time and were treated with calcium supplements only (1 g/d). MEASUREMENTS: Lumbar spine and femoral neck bone mineral densities (BMD) were measured at baseline and after 12 and 24 months of glucocorticoid therapy using a dual energy x-ray absorptiometer. RESULTS: The two groups did not differ with respect to age, years since the menopause, mean daily glucocorticoid dose, and baseline BMD values. During the first year of therapy, mean lumbar spine BMD increased from an initial value of 0.88 g/cm2 to 0.94 g/cm2, an increase of 7% per year (95% confidence interval [CI] 3.7% to 10.2%; P < 0.001 compared with controls). Significant increases in BMD of 2.5% per year were also observed in the femoral neck (95% CI -1% to 6%; P < 0.01 compared with controls). After the second year of cyclical etidronate therapy, femoral neck BMD continued to increase (P < 0.05 compared with value at 12 months), while lumbar spine BMD remained stable. CONCLUSION: Chronic glucocorticoid therapy may result in bone loss at most skeletal sites. Therapy with cyclical etidronate plus ergocalciferol not only prevented glucocorticoid-induced bone loss, but even increased lumbar spine and femoral neck BMD in postmenopausal women commencing glucocorticoid therapy.
Absorptiometry, Photon↗
Osteoporosis as a complication of orchiectomy in 2 elderly men with prostatic cancer.
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Aged↗
Hypercalcaemia in a patient with fatal adenosquamous carcinoma of the colon.
OBJECTIVE: To report a rare manifestation of metastatic adenosquamous carcinoma of the colon in a patient presenting with humoral hypercalcaemia of malignancy mediated by parathyroid hormone related peptide (PTHrP). CLINICAL FEATURES: A 58-year-old man with metastatic adenosquamous carcinoma of the colon presented with hypercalcaemia. A technetium bone scan excluded osteolytic bone secondaries. A negative parathyroid subtraction scan and a low serum immunoreactive parathyroid hormone level (1-34 [amino acid fragment]) made the diagnosis of primary hyperparathyroidism unlikely. The diagnosis of humoral hypercalcaemia of malignancy was considered on the basis of an elevated serum PTHrP level and positive tumour immunoreactivity to PTHrP antiserum. INTERVENTION AND OUTCOME: The hypercalcaemia was effectively treated on two occasions with intravenous administration of aminohydroxy propilidene diphosphonate. Despite interventional chemotherapy, the patient died of progressive carcinomatosis. CONCLUSION: Hypercalcaemia is an extremely rare occurrence in carcinoma of the colon. This is the first documented case of humoral hypercalcaemia of malignancy associated with adenosquamous carcinoma of the colon mediated by PTHrP.
Carcinoma, Adenosquamous↗