ISSN 2148 - 4902
NORTHERN CLINICS OF ISTANBUL • İSTANBUL KUZEY KLİNİKLERİ
Vol. 3 • No. 2 • Year 2016
The prophylactic effect of Viscum album in streptozotocin-induced diabetic rats • The effect of serum and follicular fluid anti-Mullerian hormone level on the number of oocytes
retrieved and rate of fertilization and clinical pregnancy • Anesthetic approaches in carotid body tumor surgery • A retrospective analysis of endoscopic treatment outcomes in patients with postoperative bile
leakage • The prevalence of nonalcoholic fatty liver disease in healthy young persons • Determining depression level of caregivers providing home healthcare services • Evaluation of
nutritional status using anthropometric measurements and MQSGA in geriatric hemodialysis patients • Inflammatory arthritis mimicking Complex Regional Pain Syndrome (CRPS) in a child • Apert
syndrome • Pertussis-like syndrome associated with adenovirus presenting with hyperleukocytosis • Perforated duodenal diverticulum • Laparoscopic cholecystectomy in an adult with agenesis of
INDEXED IN TUBITAK TR INDEX, PUBMED CENTRAL, EBSCO, CINAHL AND TURKIYE CITATION INDEX.
right hemidiaphragm and limb reduction defects • Diagnostic challenges in cervical tuberculous lymphadenitis • Separation techniques: Chromatography
NORTHERN CLINICS OF ISTANBUL İSTANBUL KUZEY KLİNİKLERİ Editor-in-Chief
Vıce Editors
Bekir Durmus, M.D.
Berna Terzioglu Bebitoglu, M.D. Levent Doganay, M.D. Tunc Eren, M.D. Yavuz Bastug, M.D. Arzu Tatlipinar, M.D. Derya Buyukkayhan, M.D.
Scientıfıc Commıttee Abdullah Aydin, M.D.
Eren Ozek, M.D.
Kemal Memisoglu, M.D.
Recep Alp, M.D.
Adem Ozkan, M.D.
Eyup Gumus, M.D.
Kemal Nas, M.D.
Remzi Cevik, M.D.
Afitap Icagasioglu, M.D.
Fahri Ovali, M.D.
Kemalettin Koltka, M.D.
S. Tahir Eren, M.D.
Ahmet Gocmen, M.D.
Fatih Goktay, M.D.
Leyla Karadeniz Bilgin, M.D.
Sabahat Aksaray, M.D.
Alaattin Ozturk, M.D.
Fatih Saygili, M.D.
Lutfullah Orhan, M.D.
Sait Naderi, M.D.
Ali Ihsan Dokucu, M.D.
Fatma Eti Aslan, M.D.
Mahmut Durmuş, M.D.
Salih Boluk, M.D.
Ali Ozdemir, M.D.
Ferruh Isman, M.D.
Mehmet Ali Ozcan, M.D.
Salih Cetinkursun, M.D.
Ali Riza Cenk Celebi, M.D.
Filiz Akyuz, M.D.
Mehmet Doganay, M.D.
Sarenur Gokben, M.D.
Ali Riza Odabas, M.D.
Filiz Topaloglu Demir, M.D.
Mehmet Eren, M.D.
Sahin Senay, M.D.
Asiye Kanbay, M.D.
Fugen Aker, M.D.
Mehmet Kanbay, M.D.
Selcuk Mistik, M.D.
Atakan Yesil, M.D.
Fusun Mayda Domac, M.D.
Mehmet Selcuki, M.D.
Serhat Citak, M.D.
Ateş Kadioglu, M.D.
Gizem Dinler Doganay, M.D.
Mehmet Tayyar, M.D.
Seyhan Hidiroglu, M.D.
Atilla Polat, M.D.
Gozde Kir Cinar, M.D.
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Selami Sozubir, M.D.
Ayse Cikim Sertkaya, M.D.
Gulnur Tokuc, M.D.
Melih Atahan Guven, M.D.
Sema Yilmaz, M.D.
Ayse Serap Karadag, M.D.
H. Muammer Karakas, M.D.
Metin Akbulut, M.D.
Sevki Erdem, M.D.
Aysegul Gunduz, M.D.
Hakan Erdogan, M.D.
Metin Kapan, M.D.
Soner Sanioglu, M.D.
Aytekin Guven, M.D.
Hale Akbaylar, M.D.
Mine Hekimgil, M.D.
Sukran Kose, M.D.
Aytekin Oguz, M.D.
Haluk Vahaboglu, M.D.
Muhammed Fatih Onsuz, M.D. Tamer Okay, M.D.
Ayten Kadanali, M.D.
Hamit Okur, M.D.
Muhammet Tekin, M.D.
Tarik Sapci, M.D.
Baris Onder Pamuk, M.D.
H. Isin Ozisik Karaman, M.D.
Murat Acar, M.D.
Tayfun Kirazli, M.D.
Bekir Atik, M.D.
Hasan Bombaci, M.D.
Murat Muhcu, M.D.
Tongabay Cumurcu, M.D.
Beyhan Cengiz Ozyurt, M.D.
Hasan Borekci, M.D.
Mustafa Aldemir, M.D.
Tolga Baglan, M.D.
Birsen Yurugen, M.D.
Haydar Sur, M.D.
Mustafa Caliskan, M.D.
Tolga Canbak, M.D.
Canan Agalar, M.D.
Hilmi Ciftci, M.D.
Mustafa Girgin, M.D.
Tuba Tulay Koca, M.D.
Cevdet Ugur Kocogullari, M.D. Hulya Apaydin, M.D.
Nelgin Gerenli, M.D.
Tuba Yavuzsen, M.D.
Derya Buyukkayhan, M.D.
Huseyin Bayramlar, M.D.
Nezih Ozkan, M.D.
Turhan Caskurlu, M.D.
Destina Yalcin, M.D.
Ibrahim Akalin, M.D.
Nihat Aksakal, M.D.
Turkan Kudsioglu, M.D.
Didem Akcali, M.D.
Ibrahim Ali Ozemir, M.D.
Nilay Sahin, M.D.
Umut Kefeli, M.D.
Didem Korular Tez, M.D.
Ibrahim Ikizceli, M.D.
Nuri Aydin, M.D.
Veli Citisli, M.D.
Dilaver Tas, M.D.
Ihsan Karaman, M.D.
Nusret Acikgoz, M.D.
Volkan Ince, M.D.
Duygu Geler Kulcu, M.D.
Ihsan Metin Leblebici, M.D.
Onur S. Goksel, M.D.
Yasar Bukte, M.D.
Ebru Zemheri, M.D.
Ilknur Aktas, M.D.
Orhan Alimoglu, M.D.
Yesim Tuncok, M.D.
Emek Kocaturk Goncu, M.D.
Ismail Islek, M.D.
O. Emek Kocaturk Goncu, M.D. Yurdanur Kilinc, M.D.
Emin Evren Ozcan, M.D.
Kadriye Avci, M.D.
Ozge Ecmel Onur, M.D.
Yuksel Altintas, M.D.
Emine Samdanci, M.D.
Kamil Ozdil, M.D.
Ozlem Baysal, M.D.
Yuksel Ersoy, M.D.
Ercan Madenci, M.D.
Kaya Saribeyoglu, M.D.
Ozlem Guneysel, M.D.
Eren Gozke, M.D.
Kazim Capaci, M.D.
Ozlem Tanriover, M.D.
NORTHERN CLINICS OF ISTANBUL İSTANBUL KUZEY KLİNİKLERİ YEAR 2016 VOLUME 3 NUMBER 2
p-ISSN 2148 - 4902 e-ISSN 2536 - 4553
Ownership and Accountability for Contents on behalf of the Istanbul Northern Anatolian Association of Public Hospitals
Kemal Memisoglu, M.D.
Publicatıon Manager
Bekir Durmus, M.D.
Publicatıon Coordinators
Neslihan Buyukmurat, M.D.
Umut Elmas
Executive Office Istanbul Anadolu Kuzey Kamu Hastaneler Birligi Genel Sekreterligi E5 Karayolu Uzeri, 34752 Atasehir, Istanbul, Turkey Phone: +90 216 578 78 00 Fax: +90 216 577 40 48 http://www.kuzeyklinikleri.com e-mail: bilgi@kuzeyklinikleri.com Issued by the Istanbul Northern Anatolian Association of Public Hospitals Indexed in TUBITAK TR Index, PubMed Central, EBSCO, CINAHL, Turkiye Citation Index.
Publisher
Press
KARE PUBLISHING Altayceşme Mah., Samanyolu Sok., Mecit Varli Apt., No: 19/6, 34843 Maltepe, Istanbul, Turkey Tel: +90 216 550 61 11 Fax: +90 216 550 61 12 http://www.kareyayincilik.com e-mail: kare@kareyayincilik.com
DESIGN
Ali Cangul alicangul@kareyayincilik.com
Info
YILDIRIM PRINTING HOUSE Yuzyil Mah., Massit Matbaacılar Sitesi, 1. Cad. No: 101, Bagcilar, Istanbul, Turkey Tel: +90 212 629 80 37 Fax: +90 212 629 80 39
Press date: October 2016 Circulation: 1000 Type of publication: Periodical
English Editing by
Gurkan Kazanci, M.D. PhD. Kazanci English Editing, and Medical Translation Office kazanci.g@gmail.com
Northern Clinics of Istanbul (NCI) is a peer-reviewed journal published triannually by the Istanbul Northern Anatolian Association of Public Hospitals. Materials published in the Journal is covered by copyright ©2016 NCI. All rights reserved. This publication is printed on paper that meets the international standard ISO 9706:1994. National Library of Medicine recommends the use of permanent, acid-free paper in the production of biomedical literature.
KARE PUBLISHIN G
CONTENTS Vol. 3 • No. 2 • Year 2016
VI
INSTRUCTIONS FOR THE AUTHORS
IX EDITORIAL
EXPERIMENTAL ORIGINAL ARTICLES
83–89
The prophylactic effect of Viscum album in streptozotocin-induced diabetic rats A. Turkkan, H. B. Savas, B. Yavuz, A. Yigit, E. Uz, N. A. Bayram, B. Kale
90–96
The effect of serum and follicular fluid anti-Mullerian hormone level on the number of oocytes retrieved and rate of fertilization and clinical pregnancy S. E. Bolat, S. Ozdemirci, T. Kasapoglu, B. Duran, L. Goktas, E. Karahanoglu
97–103
Anesthetic approaches in carotid body tumor surgery A. S. Kavakli, N. K. Ozturk
104–110 A retrospective analysis of endoscopic treatment outcomes in patients with postoperative bile leakage S. Sayar, S. Olmez, U. Avcioglu, I. Tenlik, B. Saritas, K. Ozdil, E. Altiparmak, E. Ozaslan 111–117 The prevalence of non-alcoholic fatty liver disease in healthy young persons G. Okur, Z. Karacaer 118–123 Determining depression level of caregivers providing home healthcare services B. Arican, M. Guney, N. Akbal, B. H. Demiral, A. Nadir, I. Kavci Kokar, M. R. Dabak, M. Sargin 124–130 Evaluation of nutritional status using anthropometric measurements and MQSGA in geriatric hemodialysis patients I. P. Yigit, R. Ulu, H. Celiker, A. Dogukan
C A S E REPORTS
131–134 Inflammatory arthritis mimicking Complex Regional Pain Syndrome (CRPS) in a child: A case report Z. Egilmez, S. T. Turgut, A. Icagasioglu, I. Bicakci 135–139 Apert syndrome: A case report and review of the literature T. T. Koca 140–142 Pertussis-like syndrome associated with adenovirus presenting with hyperleukocytosis: Case report H. Sarbay, A. Polat, E. Mete, Y. I. Balci, M.Akin 143–145 Perforated duodenal diverticulum: A case report M. Gulmez, M. K. Yildiz, H. M. Odabasi, H. H. Abuoglu, O. Ilhan, K. Kaytaz 146–149 Laparoscopic cholecystectomy in an adult with agenesis of right hemidiaphragm and limb reduction defects: First report in literature J. Sagiroglu, E. Tombalak, S. Basaran Yilmaz, F. Balyemez, T. Eren, O. Alimoglu
INVITED REVIEWS
150–155 Diagnostic challenges in cervical tuberculous lymphadenitis: A review H. S. Deveci, M. Kule, Z. Altin Kule, T. Erden Habesoglu 156–161 Separation techniques: Chromatography O. Coskun
INSTRUCTIONS FOR THE AUTHORS Northern Clinics of Istanbul
- NCI is a peer-reviewed, open-access, international journal published by the Istanbul Northern Anatolian Association of Public Hospitals (INAAPH). The NCI is printed 3 times a year. Free full-text articles in English are available at www. kuzeyklinikleri.com. The NCI is indexed in the Turkey Citation Index (Türkiye Atıf Dizini). The journal publishes research, interesting case reports, letters to the editor, review articles, editorial comments, medical news, and guidelines. The NCI accepts manuscripts written in Turkish and English. Opinions presented in published articles do not represent official endorsement of the INAAPH. Manuscripts should be prepared in accordance with the Uniform Requirements for Manuscripts Submitted to Biomedical Journals, which is regularly updated by the International Committee of Medical Journal Editors (ICMJE), and available at http://www.icmje.org. ARTICLE TYPES The NCI publishes the kinds of articles briefly described below.
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or
institution
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EDITORIAL
Dear Northern Clinics of Istanbul Readers, Please welcome our journal's second issue for 2016. I would like to thank our authors, referees and you, our readers, for the interest you have shown in our journal. In this issue, we are publishing seven original research articles, five case reports and two reviews. The original research articles are entitled: "The prophylactic effect of Viscum album in streptozotocininduced diabetic rats," "The effect of serum and follicular fluid anti-Mullerian hormone level on the number of oocytes retrieved and rate of fertilization and clinical pregnancy," "Anesthetic approaches in carotid body tumor surgery�, “A retrospective analysis of endoscopic treatment outcomes in patients with postoperative bile leakage," "The prevalence of non-alcoholic fatty liver disease in healthy young persons," "Determining depression level of caregivers providing home healthcare services," "Evaluation of nutritional status using anthropometric measurements and MQSGA in geriatric hemodialysis patients." The case report section includes: "Inflammatory arthritis mimicking Complex Regional Pain Syndrome (CRPS) in a child," "Apert syndrome: A case report and review of the literature," "Pertussis-like syndrome associated with adenovirus presenting with hyperleukocytosis, “Perforated duodenal diverticulum," "Laparoscopic cholecystectomy in an adult with agenesis of right hemidiaphragm and limb reduction defects: First report in literature" which we think are interesting. This issue's reviews, "Diagnostic challenges in cervical tuberculous lymphadenitis," "Separation techniques: Chromatography" are also presented to your attention. As the editorial team of this journal, we would like to celebrate the authors who contributed to the content of this issue and the referees who spent their valuable time assessing its articles. I hope to see you again with the next issue. Bekir Durmus, Assoc. Prof. M.D.
Editor-in-Chief
Experimental
BASIC MEDICAL SCIENCES
North Clin Istanbul 2016;3(2):83–9 doi: 10.14744/nci.2016.22932
The prophylactic effect of Viscum album in streptozotocin-induced diabetic rats Asuman Turkkan,1 Hasan Basri Savas,2 Berire Yavuz,1 Ayse Yigit,3 Efkan Uz,3 Nezire Asli Bayram,4 Banu Kale5 Suleyman Demirel University Faculty of Medicine, Isparta, Turkey
1
Department of Medical Biochemistry, Suleyman Demirel University Faculty of Medicine, Isparta, Turkey
2
Department of Medical Genetic, Suleyman Demirel University Faculty of Medicine, Isparta, Turkey
3
Department of Medical Biology and Genetic, Suleyman Demirel University Faculty of Medicine, Isparta, Turkey
4
Department of Internal Medicine, Suleyman Demirel University Faculty of Medicine, Isparta, Turkey
5
ABSTRACT OBJECTIVE: Viscum album (VA) is a species of mistletoe in the family Santalaceae that is thought to have therapeutic properties for several diseases, including diabetes. In the present study, conventional experimental rat model was used with diabetes induced with streptozotocin (STZ) to evaluate effect of VA on lipid peroxidation and antioxidant system. METHODS: Total of 32 adult, male Sprague-Dawley rats were divided into 4 groups of 8 rats: Control group, STZ group, VA group, and group administered VA+STZ. VA extract was 100 mg/kg preparation delivered once a day by oral gavage for 10 days. Single dose of 55 mg/kg STZ citrate buffer (0.1 M, pH 4.5) was administered intraperitoneally to induce diabetes. Fasting blood glucose level was measured and recorded. Animals were sacrificed, and catalase (CAT), malondialdehyde (MDA), and protein present in liver and kidney tissue samples were measured. Activity of CAT, an antioxidant enzyme, was studied according to the Aebi method. MDA, a product of lipid peroxidation, was analyzed using Draper and Hadley spectrophotometric procedure. Protein level was determined using supernatant and extract of tissue homogenates according to Lowry method. Data were assessed using one-way analysis of variance and pairwise comparisons between groups. Post-hoc analysis included Dunnet test, Duncan test, and least significant difference test. P<0.05 was considered significant probability value. RESULTS: Oxidative stress is associated with diabetic complications. VA administered to diabetic rats reduced oxidative stress and improved their general condition. CONCLUSION: Further studies are needed to enhance understanding of potential antidiabetic and antioxidant effects of VA. Keywords: Antioxidant; CAT; diabetes; MDA; Viscum album.
Received: December 01, 2015 Accepted: June 27, 2016 Online: November 22, 2016 Correspondence: Dr. Hasan Basri SAVAS. Suleyman Demirel Universitesi Tip Fakultesi, Tibbi Biyokimya Anabilim Dalı 32200 Isparta, Turkey. Tel: +90 246 - 211 94 06 e-mail: drhbs63@gmail.com © Copyright 2016 by Istanbul Northern Anatolian Association of Public Hospitals - Available online at www.kuzeyklinikleri.com
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V
iscum album (mistletoe) is a plant growing in tropical and temperate climatic zones that contains alkaloids (substances which prevents parasitic infection in plants); lectins (proteins which can reversibly bind to carbohydrate residues on proteins); viscotoxins (substances with cytotoxic effects); polyholosides (substances which are effective against cancer and prevents the development of tumors); flavonoids (substances which are antioxidants, have protecting effects against cancer, and boost the immune system) [1, 2, 3]. While Viscum album causes economic damage by means of the increment and quality losses in trees on one hand, it produces benefits for human beings as a medicinal plant and for animal farming as a fodder plant on the other hand [4]. Diabetes is a condition developing because of the deterioration of the carbohydrate, fat and protein metabolisms resulting from the lack of the insulin secretion or decreased sensitivity of tissues to insulin. The deterioration in the antioxidant system also have a part in the decline in the clinic state of the patient. In diabetics, the fasting blood glucose, the plasma LDL (Low-Density Lipoprotein) and the free fatty acid levels increase remarkably [5]. In many studies conducted on Viscum album, antioxidant parameters have been examined and it has been found out that the plant might have an effect of decreasing the oxidative stress. A number of plant extracts, including that of Viscum album, have been applied on the groups comprising the stomach and colon tissues of cancer patients and healthy individuals, and it has been shown that Viscum album has an inhibiting effect on xanthine oxidase and adenosine deaminase, which shows an antioxidant activity [6]. There are also studies which have shown that Viscum album might increase the insulin secretion and improve the glycemic control. One of these studies is the study in which rats in which diabetes had been induced by means of STZ were given Viscum album for short and long periods (for 4 hours and 3 weeks respectively), the antidiabetic and antilipidemic effects of it were examined. The results of this study showed that Viscum album had caused hypoglycemia in these rats [7]. In another study carried out on 20
North Clin Istanbul â&#x20AC;&#x201C; NCI
Wistar rats, the rats were divided into groups and, following a 12-hour period of hunger, they were loaded, depending on their groups, with glycose and Viscum album extract under phenobarbital anesthesia. Then blood samples were taken from the rats with fifteen-minute intervals for a period of 3 hours in order to examine their glycose, insulin and glucagon levels. While the extract resulted in no changes in the glucose levels in healthy rats, it lowered the level of blood sugar in diabetic rats (35.3%). It was found out that the insulin secretion had increased both in diabetic and healthy rats and it was shown that Viscum album could have antiglycemic and insulinotropic effects [8]. In another study carried out on rats in which diabetes had been induced by means of STZ and which had been divided into groups based on the amount of Viscum album given to them, it was shown that Viscum album could have antihyperlipidemic and antioxidant properties (by releasing MDA and GSH) [9]. In another study carried out at the cellular level, it was shown that the Viscum album extract applied to pancreatic B cells could induce the secretion of insulin and thus could be used as an antidiabetic substance [10]. In a study in which the effectiveness of the herbal treatments used for diabetes was investigated, the rats in which diabetes had been induced by means of STZ were given Viscum album for a period of 9 days and it was found out that the extract resulted in a decrease in polyphagia and polydipsia. However, no effect was observed on the plasma glycose and insulin values. This suggests that Viscum album can be used in decreasing the symptoms without having any effect on glycemic control [11]. In recent years, studies on alternative medicine and treatment for protection against and curing diabetes have gained remarkable intensity. Although Viscum album is commonly used in folk medicine for diabetes treatment both in elderly and young people, there is no study which has been conducted about its use for protection against this disease. By means of the present study, it is aimed to investigate of the prophylactic effects of Viscum album, which is believed in Turkey to have a curing effect on a number of diseases including diabetes and thus is
Turkkan et al., The prophylactic effects of Viscum album in streptozotocin-induced diabetic rats
used commonly, on the antioxidant system and the plasma glycose levels in rats. MATERIALS AND THE METHODS Animals 32 adult male Sprague-Dawley rats weighing 200250 g were used for experimental procedures. The ambient temperature and relative humidity of the animal room were 21±1ºC and 60±7%, respectively. The room was illuminated with artificial light for 12/12 hours dark/light. The animals were allowed free access to standard pelleted food and tap water. The study, which was conducted after the required permit is obtained from the Local Council of Ethics for Animal Experiments in Süleyman Demirel University, was conducted in the Experiment Animals and Medical Investigation Implementation and Research Center in Süleyman Demirel University. Experimental design 32 adult male Sprague-Dawley rats were divided into the following four groups, each containing eight rats: Control (C) group, streptozotocin (STZ) group, Viscum album (VA) group and Viscum album + streptozotocin (VA+STZ) group. After the STZ had been prepared in citrated buffer (0.1 M, pH 4.5) with a rate of 55 mg/kg, it was applied to rats in a single dose and in an intraperitoneal way [12]. Depending on their groups, the prepared extract was given to the rats daily by means of gavage for a period of 10 days (100 mg/kg). On the 11th day, diabetes was induced by means of streptozotocin (55 mg/kg) in specified groups. The values were measured by means of the blood taken from their tails to glucometer strips. Preparation of Viscum album First, the leaves of the Viscum album collected from the Pınargözü region of the Elmalıyurt Village in the district of Gölhisar in the province of Burdur on January and February were separated and were dried in 45ºC temperature for a period of 5-6 hours by the researcers. Then they were processed into small pieces in a blender to prepare the extract. The
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dry and ground leaves were mixed with the 95 % ethanol at a rate of 1:5. Then the mixture was kept at 4ºC for a period of 24 hours before sieving it using a 0.45 µm membrane filter. After ethanol is removed from the solution, it was kept at -20ºC until it is used. The Viscum album extract was given to the rats in the relevant groups (to the groups ‘VA’ and ‘VA+STZ’) by means of oral gavage at a dose of 100 mg/kg for a period of 10 days. Inducing diabetes by using STZ After the STZ had been prepared in citrated buffer (0.1 M, pH 4.5) with a rate of 55 mg/kg, it was applied to rats in a single dose and in an intraperitoneal way [12]. The plasma glucose levels were determined by measuring them by glucometer using a drop of blood taken from the tip of the tails of the rats. Accutrend Plus GCT Glucometer was used for measuring of the plasma glucose levels of rats. The monitor of the glucometer device uses a reflectance photometer for measuring the intensity of the color formed at the end of the reaction. These measuring uses the software translates the intensity to the corresponding glucose values. Glucose is converted to gluconolactone with pyrolinquinol quinone-dependent GDH enzyme. This in turn reduced the enzyme forms. bis- next mediator in oxidized form enzyme returning to step (2-hydroxyethyl) - (4-hidroksiiminohekzo from 2,5-dienyl) ammonium chloride selectively reduces. The reduced mediators oxide and convert the yellow indicator to blue [13]. It was assumed that the disease had developed if the blood glycose level exceeds 250 mg/dl. After the STZ had been applied, the blood glycose levels were monitored on a daily basis. At the end of the two weeks, the rats were sacrificed, their liver and kidney tissues were removed and their antioxidant parameters were examined. Biochemical measurements 0.05 M Tris-HCl buffer with a pH value of 7.4 was used in the homogenization of the tissues. The tissue samples were weighed out by using a sensitive balance and their wet weights were recorded. Then they were placed in Eppendorf tubes and kept at
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North Clin Istanbul – NCI
Table 1. MDA-CAT and serum glucose levels in groups (mean±SEM)
Liver MDA
Liver CAT
Kidney MDA
C 0.16±0.020 2.29±0.08 0.23 + 0.01 STZ 0.18±0.018 1.60±0.14 0.28±0.01 VA 0.22±0.05 2.36±0.22 0.28±0.02 VA+STZ 0.26±0.02 2.02±0.11 0.28±0.01
Kidney CAT 0.75±0.04 0.55±0.04 0.70±0.04 0.79±0.06
Glucose after STZ 165.50±15.09 442.25±17.47 255.50±12.93 392.00±14.24
C: Control group; STZ: Streptozotocin group; VA: Viscum album group and Viscum album+streptozotocin (VA+STZ) group; SEM: standard error mean.
-80ºC until the biochemical examinations are conducted on them. At the beginning of the homogenization process, the wet weights of the tissues were determined. They were put into glass tubes by maintaining their low temperature and then 2 ml of cold Tris-HCl buffer was added over them. Then plastic bowls were filled with ice and the tissues in glass tubes were placed in these plastic bowls and they were homogenized at 16.000 rev/min for a period of 3 minutes. Buffer was added in a way that the last volume was 10 times the weight of the weight of the tissue. By maintaining them in low temperature, the homogenates were placed into the Eppendorf tubes. The amount of MDA protein was determined by using the homogenates obtained. By means of the centrifugation of the homogenates at +4ºC at 5.000 rev (min for a period of 30 minutes, supernatants were obtained. Then, from the selected supernatants, the amount of proteins was determined by means of CAT enzyme activities. The tissue homogenates, supernatants and extracts were backed up and kept at -80ºC [14]. Determining the proteins Determination of the proteins in the homogenates, supernatants and extracts of the homogenized samples was carried out by using the Lowry method. According to this method, the cupper-protein complex is formed in the alkali solution, which, in turn, reduces the Folin-Ciocalteu-Phenol reagent, resulting in a dark blue color. The degree of the darkness of the blue color is directly proportional with the concentration of the protein.
Determining the MDA MDA is a product of lipid peroxidation. The amount of malondialdehyde was determined by the spectrophotometric method based on the Draper and Hadley’s method. In this method, the color produced by the reaction of MDA and thiobarbituric acid (TBA) is considered by means of a spectrophotometric measurement [15]. Determining the CAT activity Catalase activity was examined using the Aebi’s method. Hydrogen peroxide (H2O2) gives maximum absorbance at 240 nm. The H2O2 added into the experimental environment is broken down by the catalase enzyme into water and oxygen, which manifests itself on the ultraviolet spectrum as a decrease in the absorbance. This decrease in the absorbance is directly proportional to the activity of the CAT enzyme [16]. Statistical analysis SPSS 20.00 package program was used for statistical analysis. ANOVA which is a parametric test, was performed for comparing of groups MDA and CAT levels. 0.05 was considered significant. In the significant parameters, post hoc Dunnet, Duncan, LSD tests were performed. Numerical data obtained were expressed as mean±standard error (SEM). RESULTS When the liver MDA values are compared between STZ and VA groups and between STZ and C
Turkkan et al., The prophylactic effects of viscum album in streptozotocin-induced diabetic rats
groups, it was seen that the MDA values are lower in the STZ group (p=0.006 and 0.015, respectively). The differences between the liver MDA values of the other groups were found to be insignificant. The comparison of the kidney MDA values between the STZ and C groups, STZ and VA groups, and STZ and VA+STZ groups showed that the MDA level was significantly higher in the STZ group (p=0.029, p=0.014 and p=0.011, respectively). When the kidney CAT activity is compared between the STZ and C groups and the STZ and STZ+VA groups, it was found to be lower in the STZ group (p=0.028 and p=0.006). When the liver CAT values are compared between the STZ and C groups and the STZ and VA groups, a significant decrease was observed in the STZ group (p=0.012 and p=0.006). When the glucose values following the application of STZ were examined, it was seen that the glucose value for the VA group was higher than that for the C group (p=0.001); the glucose value for the STZ group was significantly higher than that for the C group (p=0.000); and the glucose value for the STZ+VA group was higher than that for the C group (p=0.000). When the glucose values for the VA and STZ groups were compared, it was seen that the glucose value for the STZ group was higher (p=0.000); and, when the values for the VA and STZ+VA groups were compared, the glucose value for STZ+VA was found to be higher (p=0.000). No significant difference was found out between the STZ+VA and STZ groups in terms of their glucose levels. DISCUSSION When the balance between the free radicals produced during the physiological processes occurring in the body or during pathological processes and the antioxidant system is disturbed in favor of the free radicals, the oxidative damage occurs. The organism tries to protect itself against this oxidative damage by enzymatic and non-enzymatic ways. Catalase and MDA are among the important enzymes used in this enzymatic process of protection.
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Diabetes is a disease that affects the millions of people every sex and race effective and globally every year [17, 18]. Diabetes is a disease which disturbs the glycemic control and the antioxidant metabolism disorder plays a role in the development of the clinic state. In a study investigating the possible effects of Viscum album, in decreasing oxidative stress, which have been applied on the stomach and colon tissues of cancer patients and healthy individuals, it has been shown that Viscum album has an inhibiting effect on xanthine oxidase and adenosine deaminase [6]. There is also a study which have shown that Viscum album might increase the insulin secretion and improve the glycemic control. In this study, rats in which diabetes had been induced by means of STZ were given Viscum album for short and long periods (for 4 hours and 3 weeks respectively) and the antidiabetic and antilipidemic effects of it were examined. The results of this study showed that Viscum album had caused hypoglycemia in these rats [7]. In another study carried out on Wistar rats, the rats were divided into groups and, following a 12-hour period of hunger, they were loaded, depending on their groups, with glucose and Viscum album extract. Then blood samples were taken from the rats in order to examine their glycose, insulin and glucagon levels. While the extract resulted in no changes in the glucose levels in healthy rats, it lowered the level of blood sugar in diabetic rats. It was found out that the insulin secretion had increased both in diabetic and healthy rats and it was shown that Viscum album could have antiglycemic and insulinotropic effects [8]. In a study carried out on rats in which diabetes had been induced by means of STZ and which had been divided into groups based on the amount of Viscum album given to them, it was shown that Viscum album could have antihyperlipidemic and antioxidant properties (by releasing MDA and GSH) [9]. In another study carried out at the cellular level, it was shown that the Viscum album extract applied to pancreatic B cells could induce the secretion of insulin and thus could be used as an antidiabetic substance [10]. In a study in which the effectiveness of the herbal treatments used for diabetes was investigated, the rats in which diabetes had been induced by means of
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STZ were given Viscum album and it was found out that the extract resulted in a decrease in polyphagia and polydipsia. However, no effect was observed on the plasma glycose and insulin values. This suggests that Viscum album can be used in decreasing the symptoms without having any effect on glycemic control [11]. In the present study, which has been conducted at the biochemical level, the antioxidant activity in the liver and kidney tissues of rats has been investigated. This activity has been tried to be calculated based on the levels of MDA, which plays an important role in lipid peroxidation and has a function of decreasing the oxidative stress, and catalase, which is an antioxidant enzyme. When the MDA values are compared among the groups formed within the scope of the experiment, significant differences were found out between the STZ and VA groups (p=0.014) and STZ and VA+STZ groups (p=0.011), the values being higher for the STZ group. In the rats in which diabetes had been induced, the Viscum album given beforehand resulted in significant changes in the kidney MDA values, which has an effect of decreasing the oxidative stress. When the blood sugar values were analyzed after the application of the STZ, no significant difference was found out between the STZ+VA and STZ groups. This indicates that the Viscum album given beforehand has no effect on the glycemic control. Consequently, an increase in the enzymatic activity of catalase, which is an antioxidant enzyme functioning in the kidney tissue, and a decrease in the level of MDA, which is an indication of lipid peroxidation, were observed among the rats given Viscum album. Considering the fact that a decrease in the oxidative stress provides positive contributions for the improvement of the clinical state and the overall situation in diabetes, it can be said that Viscum album can produce benefits in the improvement of the clinical state in diabetics. However, there is a need for further studies, especially the studies investigating the active ingredient, in order to find out the degree of the antioxidant and antidiabetic effects of Viscum album.
North Clin Istanbul – NCI Conflict of Interest: None declared. Financial Disclosure: The authors declared that this study has received no financial support.
REFERENCES 1. Baytop T. Türkiye’de bitkiler ile tedavi (Geçmişte ve Bugün). İ.Ü. Yay. No: 3560, Ecz. Fak. Yay. No: 54, İstanbul (1984). 2. Miller AG. Viscum album L. (Flora of Turkey and the East Aegean Islands) vol. 7, Davis, P.H. University Press, Edinburgh (1982). 3. Zeybek N. Farmasötik Botanik, Kapalı Tohumlu Bitkiler (Angiospermae) Sistematiği ve Önemli Maddeleri, Ege Üniv. Ecz. Fak., No:l, Ege Üniv. Basımevi, İzmir (1985). 4. Yüksel B, Akbulut S, Keten A. Çam Ökseotu (Viscum album ssp. austriacum (wiesb.) vollman)’nun Zararı, Biyolojisi ve Mücadelesi. Süleyman Demirel Üniversitesi Orman Fakültesi Dergisi 2005;2:111–24. 5. Thomas E. Andreoli. Cecil Essential of Medicine. 4th ed. 1997. (Claude BJ, Charles CJ, Fred P, Russell CL. Cecil Essentials of Medicine. 4th ed. 1997). 6. Namuslu M, Kocaoglu H, Celik HT, Avci A, Devrim E, Genc Y, et al. Effects of aqueous soybean, mistletoe and red clover extracts on activities of adenosine deaminase and xanthine oxidase enzyme. Bratisl Lek Listy 2014;115:367–71. 7. Adaramoye O, Amanlou M, Habibi-Rezaei M, Pasalar P, Ali MM. Methanolic extract of African mistletoe (Viscum album) improves carbohydrate metabolism and hyperlipidemia in streptozotocin-induced diabetic rats. Asian Pac J Trop Med 2012;5:427–33. 8. Eno AE, Ofem OE, Nku CO, Ani EJ, Itam EH. Stimulation of insulin secretion by Viscum album (mistletoe) leaf extract in streptozotocin-induced diabetic rats. Afr J Med Med Sci 2008;37:141–7. 9. Orhan DD, Aslan M, Sendogdu N, Ergun F, Yesilada E. Evaluation of the hypoglycemic effect and antioxidant activity of three Viscum album subspecies (European mistletoe) in streptozotocin-diabetic rats. J Ethnopharmacol 2005;98:95–102. 10. Gray AM, Flatt PR. Insulin-secreting activity of the traditional antidiabetic plant Viscum album (mistletoe). J Endocrinol 1999;160:409–14. 11. Swanston-Flatt SK, Day C, Bailey CJ, Flatt PR. Evaluation of traditional plant treatments for diabetes: studies in streptozotocin diabetic mice. Acta Diabetol Lat 1989;26:51–5. 12. Ergun F, Deliorman D. Viscum album L. (Ökse Otu) Bitkisinin Kimyasal Bileşimi. Ankara Ecz Fak Der 1995;24:95–107. 13. Ekiz E, Duran ŞA, Ulaş M. Hastabaşı Sistemlerle Yapılan Glukoz Monitörizasyonunda Hangi Yöntem Daha Doğru? Türk Klinik Biyokimya Derg 2014;12:1–7. 14. Inui M, Kadoma M, Tada M. Purification and characterization
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of phospholamban from canine cardiac sarcoplasmic reticulum. J Biol Chem 1985;260:3708–15. 15. Draper HH, Hadley M. Malondialdehyde determination as index of lipid peroxidation. Methods Enzymol 1990;86:421–32. 16. Aebi H. Catalase In: Bergmeyer HU(ed) Methods of enzymatic analysis. New York and London Academic Press 1974;673–
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7. 17. Lavin N. Lippincott Williams & Wilkins, Endokrinoloji ve Metabolizma El Kitabı, 3. Baskı. İstanbul: Güneş Kitabevi 2006. s. 12–82. 18. Özenoğlu A, Hatemi HH. Diabette Beslenme. İstanbul: İstanbul Medikal Yayıncılık 2004. s. 12–8.
Orıgınal Article
OBSTETRICS & GYNECOLOGY
North Clin Istanbul 2016;3(2):90–6 doi: 10.14744/nci.2016.02418
The effect of serum and follicular fluid anti-Mullerian hormone level on the number of oocytes retrieved and rate of fertilization and clinical pregnancy Seda Eymen Bolat,1 Safak Ozdemirci,2 Taner Kasapoglu,3 Bulent Duran,4 Levent Goktas,5 Ertugrul Karahanoglu3 Department of Obstetrics and Gynecology, Yalvac State Hospital, Yalvac, Isparta, Turkey
1
Department of Gynecology, Etlik Zubeyde Hanim Women’s Health Training and Research Hospital, Ankara, Turkey
2
Department of Gynecology Risky Pregnancy, Etlik Zubeyde Hanim Women’s Health Training and Research Hospital, Ankara, Turkey
3
Department of Obstetrics and Gynecology, Abant Izzet Baysal University Faculty of Medicine, Bolu, Turkey
4
Vocational School of Health Services, Igdir University, Igdir, Turkey
5
ABSTRACT OBJECTIVE: The objective of this study was to evaluate the relationship between oocyte yield, fertilization, and clinical pregnancy (CP), and anti-Mullerian hormone (AMH) level in serum and follicular fluid during in vitro fertilization treatment. METHODS: Forty-four infertile women who underwent IVF treatment using multiagonist protocol were included in this study. Baseline level of AMH in serum and follicular fluid was measured on third day of menstrual cycle. AMH level in serum and follicular fluid was then measured again on day of oocyte pick-up. Pearson correlation and binary regression tests were used for statistical analysis. For Type 1 error, p=5% was selected as cut-off value for statistical significance. RESULTS: Serum AMH level was positively correlated with total number of oocytes retrieved and rate of fertilization and CP (r=0.397, p=0.008; r=0.401, p=0.007; and r=0.382, p=0.011, respectively). There was significantly negative correlation between serum level of follicle-stimulating hormone (FSH) and fertilization rate (r=-0.320; p=0.034), as well as serum FSH level and CP rate (r=-0.308; p=0.042). There were no significant correlations between AMH level in follicular fluid and IVF treatment outcomes. CONCLUSION: Serum AMH levels may be more reliable for prediction of total number of oocytes retrieved and rate of fertilization and CP than AMH levels in follicular fluid. Keywords: Anti-Mullerian hormone (AMH); clinical pregnancy; fertilization; follicle-stimulating hormone (FSH); follicular fluid; infertility; in vitro fertilization.
Received: March 29, 2016 Accepted: August 5, 2016 Online: November 25, 2016 Correspondence: Dr. Safak OZDEMIRCI. Etlik Zubeyde Hanim Kadin Sagligi Egitim ve Arastirma Hastanesi, Jinekoloji Klinigi, Etlik, Ankara, Turkey. Tel: +90 312 - 567 40 00 e-mail: safakozdemirci@gmail.com © Copyright 2016 by Istanbul Northern Anatolian Association of Public Hospitals - Available online at www.kuzeyklinikleri.com
Bolat et al., Anti-Mullerian hormone
A
nti-mullerian hormon (AMH) is a member of the super family of “transforming growth factor-β” and it is synthesized by granulosa cells which develop from primary follicle up to the stage of a large antral folllicle [1]. AMH inhibits selection, and maturation of follicle- stimulating hormone – dependent follicle [2] with resultant prevention of rapid depletion of primordial follicle pool [3]. Up to now, despite the presence of publications indicating the presence of a positive association between serum AMH levels, and clinical pregnancy (CP) rates [4, 5], some research findings have noted lack of any significant correlation between them [6, 7]. In the literature a study asserted favourable contribution of higher AMH levels in follicular fluid on CP rates [7], however a separate publication reported negative effects of these levels on CP rates [8]. Nevertheless, follicular fluid (FF) AMH level is generally thought to be a reliable marker for successful CP in patients who underwent embryo transfer [9]. In some studies a positive correlation was found between serum baseline AMH level, and fertilization rates [5, 10], nevertheless, in another study such a correlation could not be demonstrated. [11]. As deduced from the results of the publications, direct, and indirect effects of serum, and follicular fluid AMH levels on in vitro fertilization (IVF) have not been clarified yet. In our study, we planned to investigate the effectiveness of serum, and FF AMH levels on the number of oocytes retrieved, fertlization, and rates of CP. According to our research hypothesis, serum, and FF AMH levels may be useful in the prediction of CPs realized after IVF treatment. MATERIALS AND METHODS Our study was planned as a prospective cohort research, and consisted of 44 women with the diagnosis of infertilitywho were included in the IVF treatment program between January 2014, and June 2014. The study was approved by the Ethics Committee of A.I.B.U. Faculty of Medicine with the decision #2014–03. The study was perfromed in Infertilty Unit of A.I.B.U. Faculty of Medicine, and Ankelife Test Tube Baby Center. Written, and
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undersigned informed consent of all study participants were obtained. Patients with only female-factor infertility were included in the study, while those with male-factor infertility were ruled out. Despite induction of ovulation using high dose FSH, women whose follicles did not mature or oocytes could not be retrieved were excluded from the study During pre-interview with the patients, their medical histories, and previous treatments for infertility were recorded. Following general physical, and gynecologic examinations, for baseline hormonal evaluation immunoenzymatic method was employed on the third day of the menstrual cycle to measure serum FSH, E2, and LH levels. On the same day number of antral follicles, dimensions of the ovaries, and uterus were evaluated ultrasongraphically using 5 mHz with vaginal ultrasound probe (General Electric Alfa Logic 200, USA). Hysterosalpingographic examinations (between 6, and 11. days of the menstrual period) serologic tests (HBsAg, anti-HBs, anti-HIV, antiHCV), servicovaginal smear, antibiogram of the servical smear, blood typing, whole blood count, and spermiogram (following 3 days of sexual abstinence) were requested. On the 2. day of the menstrual cycle, follitropin –alpha (Gonal-F) treatment was initiated, and multiple-dose antagonist protocol was administered taking baseline FSH value, body mass index, number of antral follicles into consideration. From the initiation of the treatment up to the day of HCG administration, the patients underwent transvaginal control US examinations daily or on alternate days, and beginning from the 7. day of the menstrual cycle up to the initiation of HCG , the treatment was maintained with the addition of daily doses of 0.25 mg of a GnRH antagonist (Cetrorelix). After formation of two follicles greater than 18mm in diameter was achieved, 500 mcg chorionic gonadotropin–alpha (Ovitrelle) was injected subcutaneously. Nearly 36 hours following administration of chorionic gonadotropin –alpha, follicular aspiration was performed through vaginal route with the patient in the lithotomy position using oocyte aspiration needle mounted in the transvaginal 17 mmcaliber, and 30 cm- long, single -or dual -lumen US
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probe under sterile conditions, and general anesthesia. Follicular aspiration was performed under 125 mmHg negative pressure. Mature oocytes retrieved from the follicular fluid were transferred on IVFGI, and G2 culture media. On oocyte aspiration day, following 12 hours of overnight fasting, venous blood samples (8 ml) were drawn while the patients were sitting erect. Serum portions of the blood samples were obtained using dry serum separator tubes containing clot activator, and serum separator gel (Vacuette, Greiner Bio-one GmbH, Kremsmünster, Austria). Blood samples were left under room temperature for 30 minutes. Samples of follicular fluid were transferred into absolutely empty tubes. Both follicular fluid, and blood samples were centrifufed under +4oC, and at 1250 g for 15 minutes to separate their serum portions. Samples of serum, and follicular fluid were kept under -80oC till analysis of the supernatant portion of the follicular fluid. Immediately before the analysis, frozen samples were thawed in a stepwise fashion. Recurrent freezing, and thawing procedures were not performed. In pregnant women who may develop severe ovarian hyperstimulation syndrome “agonist triggering” protocol was used to invoke HCG production. Lucrin Daily was injected subcutaneously at a dose of 0.2 mg using a PPD syringe. Thirty-six hours later oocytes were retrieved. The patients who received “agonist triggering” were also subjected to “total freezing”. Serum AMH levels were measured in blood samples drawn just before OPU, and on the day of OPU. AMH levels were measured using, AMH Gen II ELISA commercial kit (A79765, Beckman Coulter, Inc, California, USA). Principle of the test was evaluated based on enzymatically induced twoway immunoassay method. Calibration curve was drawn using a calibrator at 0.16–0,4–1.2–4–10– 22.5 ng/ ml concentrations. Detection limit was determined as the lowest value, ie. 0.08 ng/ml. İntra-, and inter-experimental CV (coefficient variation) were 5.4, and 5.6% at a concentration of 4.42 ng/ ml, while the corresponding CVs at a concentration of 14.03 ng/ml were reported as 3.6 and 4.5%, respectively. The measurements were performed at 450 nm using Biokit (ELX800, Barselona, Spain) device, and the results were expressed in ng/ml.
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Observation of two pronuclei or two bipolar bodies under microscope 18–20 hours after intracytoplasmic sperm injection was accepted as the presence of fertilization. Embryo transfer was performed between 3–5 days after OPU. Embryos at 16-cell blastocyst stage were transferred. The advancement of embryo transfer catheter within the uterine cavity was monitored using an abdominal ultrasound probe so as to place the embryos in the uterine cavity. Following the procedure, catheters were flushed with physiologic saline to determine if any embryos were retained within the catheter, and the presence of embryos was checked under microscope. Ultrasonographic detection of fetal cardiac activity at sixth gestational week was considered as an evidence of clinical pregnancy. Descriptive statistics were used to define demographic data. Intergroup statistical analysis of CP, and fertilization rates was realized using a parametric test, namely Student t-test. Variable predictive values of data which revealed statistically significant differences between groups, and related clinical outcomes were analyzed with binary logistic regression models. Correlation coefficients were graded as weak (0–0.30), moderate (0.31–0.50), strong (0.51– 0.70), and complete (0.71–1.0). P=0.05 was accepted as the cut-off value for statistical significance. RESULTS A total of 48 patients were included in the study. One patient with FSH value of 13 IU/ml,and three patients refractory to stimulation of ovulation were excluded rom the study. Embryos were retrieved from 44 infertile patients aged between 24–40 years who were eligible for the study. Embryos were harveste from. 37 (84.9%) patients.In 36.4% (16/44) patients clinical pregnancy could be achieved. A statistically significant difference was detected between mean (±SD) ages of the patients in whom CP was achieved or failed. (30.8±4.8 vs 34.4±4.2 years, p=0.014). Period of infertility among patients who became pregnant was statistically significantly different from that of those who couldn’t achieve pregnancy. (7.64±3.0 vs 10.4±2.9 years, p=0.004) (Table 1). Serum AMH levels
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Table 1. Demographic characteristics of the pregnant, and non-pregnant patients after application of IVF
CP (+) CP (-) n=16 n=28
p
Age (year)a 30.8±4.8 34.4±4.2 0.014* 2 a Body mass index (kg/m ) 29.2±5.4 29.9±3.5 0.844 Duration of infertility (year)a 7.6±3.0 10.4±2.9 0.004* a: Student t-test was used; *: Statistically significant; IVF: In vitro fertilization; CP: Clinical pregnancy.
Table 2. Laboratory values, and number of oocytes retrieved of the pregnant, and non-pregnant patients after application of IVF
CP (+) n=16
CP (-) n=28
p
Serum AMH (ng/ml)a 1.52±1.04 0.86±0.58 0.011* Follicular AMH (ng/ml)a 2.1±0.73 1.66±0.82 0.057 Serum FSH (mIU/ml)a 7.66±2.81 6.20±1.38 0.042* Number of oocytes retrieved 11.5±5.3 4.29±2.24 0.001* a: Student t-test was used; *: Statistically significant; IVF: In vitro fertilization; CP: Clinical pregnancy.
were statistically significantly higher in the group who achieved CP. (mean±SD: 1.52±1.04 ng/ml vs 0.86±0.58 ng/ml; p=0.011). Serum FSH levels in women who became pregnant were statistically significantly higher (ortalama±mean±SD: 7.66±2.81 mIU/ml vs 6.20±1.38 mIU/ml p=0.042). The number of embryos retrieved was statistically significantly different between groups with successful, and failed IVF (mean±SD: 11.45±5.31 vs 4.29±2.24; p<0.001) (Table 2). Moderately positive correlations were found between serum AMH levels, and both number of oocytes retrieved (r=0.387, p=0.008),and also fertilization rates (r=0.401, p=0.007). However a moderately positive but statistically insignificant correlation was detected between serum AHM levels, and CP rates (r=0.382, p=0.11). A statistically but moderately significant negative correlation was found between serum FSH level, fertilization and CP. A statistically significant but negative correla-
tion was detected between serum FSH level, and fertilization, while serum FSH level was statistically significantly but moderately correlated with CP rates (r=-0.320 p=0.034 vs r=-0.308, p=0.042, respectively) (Table 3). Binary logistic regression analysis revealed that the number of oocytes retrieved was the only parametre which increased CP rates (Table 4). DISCUSSION Since reduced ovarian reserve is the only significant cause of infertility, serum AMF level, and the number of antral follicles are the most important parametres during the evaluation process of the ovarian reserve before treatment of patients scheduled for IVF [6, 9]. Because of the presence of a relationship between serum AMH concentration,
Table 3. Correlations between serum, and follicular fluid hormone levels, and the number of oocytes retrieved, fertilization, and CP rates Serum AMH (ng/ml) Follicular AMH (ng/ml) Serum FSH (mIU/ml)
Number of oocytes retrieved
Fertilization rates
CP rates
r p r p r p 0.397 0.144 -0.280
0.008* 0.351 0.065
0.401 0.250 -0.320
0.007* 0.102 0.034*
0.382 0.128 -0.308
0.011* 0.408 0.042*
r: Pearson correlation coefficient; *: Statistically significant; CP: Clinical pregnancy; AMH: Anti-mullerian hormone; FSH: Follicle-stimulating hormone.
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Table 4. Binary logistic regression analysis of factors effecting clinical pregnancy rates Age (year) Serum AMH Serum FSH NOOR Constant
Odds ratio 0.984 1.358 0.432 9.993 0.000
Odds ratio incl. 95% Confidence Interval Min.
Max.
p
0.786 1.232 0.886 0.190 9.729 0.761 0.092 2.024 0.287 1.295 77.088 0.027* – – 0.146
NOOR: Number of oocytes retrieved; *: Statistically significant (p<0.05); FSH: Follicle-stimulating hormone; AMH: Anti-müllerian hormone.
and the number of of antral follicles [12], measurements of AMH levels are being used in clinical practice to determine the number of antral, and pre-antral follicles [13]. FSH eliminates, inhibitory effects of AMH on follicular development during IVF treatment [14]. In our study, we made a correlation analysis serum AMH levels, the number of oocytes retrieved, fertilization, and CP rates in patients who received IVF treatment, and found a moderately positive correlation among these parametres. However since according to correlation analysis more than one parametre positively induced increases in CP rates, we applied binary logistic regression analysis, and disclosed that only the number of oocytes retrieved was effective on increased CP rates. Gnoth et al. have demonstrated that AMH is an important parametre to be used as a screening test for the determination of reduced ovarian reserve [15]. The same team found that AMH levels below 1.26 ng/ml had identified women with lower ovarian reserve (number of oocytes ≤4) with 97% sensitivity. While; AMH levels below 0.5 ng/ml could detect women with very low ovarian reserve (number of oocytes, ≤2) with 88% sensitivity [15]. With aging, AMH levels in circulation, number, and quality of oocytes decrease [16, 17]. Number of oocytes retrieved was found to be higher in wom-
en with higher AMH levels when compared with age-matched women with relatively lower AMH levels [18]. As an outcome of our study, we found a positive correlation between serum AMH levels, and the number of of oocytes retrieved. Although publications supporting the outcome of our study which reportedly indicated benefit of using serum AMH values in the prediction of the number of oocytes retrived during IVF cycles [2, 4, 5, 9, 19, 20, 21] in a study by Takahashi et al. could find absence of a correlation between AMH, and the number of antral follicles [11]. The reason of inability to detect a correlation between serum AMH levels, and the number of oocytes retrieved might be related to failure to collect oocytes from follicles smaller than 17 mm in diameter. Besides measurement of serum AMH levels during oocyte retrieval process might be the reason for these totally different outcomes. [11]. Hypothetically, elimination of inhibitory effect of AMH on follicular development by the action of FSH [14] might play a role in the reduction of AMH levels after treatment with FSH. Some publications have demonstrated the presence of a positive correlation between serum AMH concentration, and CP rates [4, 5, 9] while others have reported lack of any correlation between CP rates, and serum AMH levels [6, 7, 8]. Wunder DM et al. (2008) detected significantly higher AMH concentrations both in serum, and follicular fluid of the patients who achieved clinical pregnancy [9]. A positive correlation was reported between AMH levels in follicular fluid, implantation, and CP. Besides determination of follicular fluid AMH levels has been reported to be of use in the identification of potentially implantable embryos. However in a study by Metha et al. the authors detected higher CP rates in patients with lower follicular fluid AMH levels [8]. Any difference between post-IVF CP levels could not be found between women aged 40 years with serum AMH levels lower, and higher than 1 ng/ml [18]. Detection of live births among women with very low (<0.4 ng/ml) serum AMH levels [19] has suggested potentially effective roles of factors other than serum AMH levels (especially quality of oocytes, and embryos) on CP rates. In two literature publications, it has been reported
Bolat et al., Anti-Mullerian hormone
that serum AMH levels did not contribute to the determination of quality of oocytes [22], and also they were not effective in the prediction of quality of embryos [11, 22]. In another study, the authors claimed that serum, and follicular fluid AMH levels were correlated with the quality of oocytes, and embryos [7]. Follicular fluid AMH levels can increase quality of oocytes, and embryos due to their roles in the metabolism of granulosa cells. Also in our study, although a statistically significantly positive correlation existed between serum AMH levels, and CP rates, we could not detect any relationship between follicular fluid AMH levels, and clinical pregnancy. However in another study a correlation was found between follicular fluid AMH levels, and CP rates. [7]. In various studies, diverse effects of AMH levels on CP may be related to quality, and number of oocytes, and embryos, endometrial or uterine factors, and problems arising during embryo transfer. We think that serum AMH levels are not singly, and directly effective on increased CP rates. In our study, we found a positive correlation between serum AMH level, and fertilization rates. In some studies a positive [5, 7, 10] and a strong [23] correlation has been detected between fertilization, and baseline AMH levels. Lower fertilization rates were detected in patients with lower serum AMH levels relative to those with higher serum AMH levels [6]. However, Takahashi et al. could not find a significant difference between serum AMH levels in women with and without fertilization potential [11]. In our study any correlation could not be found between follicular fluid AMH levels, and fertilization. Also in a study by Capkin any correlation between follicular fluid AMH levels, and fertilization was not reported [4]. In another study, 3.42 fold higher AMH levels in follicular fluid samples of the fertilized group were reported [11]. However in a study by Mehta [8], higher fertilization rates, and improved embryo quality were indicated in the infertile group with lower follicular fluid AMH levels In a study by Majumder (2010) baseline serum AMH levels were reported to be more important in the determination of the number of embryos when compared with other parametres [20].
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Decreased ovarian reserve may be associated with lower CP rates, decreased number of oocytes, and embryos retrieved, and consequently reduced number of embryos of higher quality. Relationship between ovarian reserve, and lower CP rates constituted a significant problem in the context of our study design, however herein the most important issue of the debate, should be the ways of predicting the presence of an embryo of higher quality In conclusion, despite existence of a strong correlation between CG, and serum AMH levels, among parametres we investigated, only number of oocytes retrieved increased CP rates. Positive correlation between serum AMH levels, and number of oocytes retrieved suggested a possibly indirect role of serum AMH levels in the prediction of CP rates. At the same time for the clarification of the controversial literature information on serum, and follicular fluid AMH levels concerning stages of IVF treatment (oocyte retrieval, fertilization, and embryo) due to diverse outcomes of the studies performed, we suggest that further multicentered randomized controlled studies involving greater number of participants should be performed. Conflict of Interest: None declared. Financial Disclosure: The authors declared that this study has received no financial support. Authorship contributions: Concept – S.E.B., S.O., B.D.; Design – S.E.B., S.O., B.D.; Supervision – S.E.B., S.O., B.D.; Data collection &/or processing – S.E.B., L.G.; Analysis and/or interpretation – S.E.B., T.K.; Writing – S.O.; Critical review – T.K., B.D., L.G., E.K.
REFERENCES 1. Su HI, Maas K, Sluss PM, Chang RJ, Hall JE, Joffe H. The impact of depot GnRH agonist on AMH levels in healthy reproductive-aged women. J Clin Endocrinol Metab 2013;98:1961–6. 2. Durlinger AL, Gruijters MJ, Kramer P, Karels B, Kumar TR, Matzuk MM, et al. Anti-Müllerian hormone attenuates the effects of FSH on follicle development in the mouse ovary. Endocrinology 2001;142:4891–9. 3. Seifer DB, Maclaughlin DT. Mullerian Inhibiting Substance is an ovarian growth factor of emerging clinical significance. Fertil Steril 2007;88:539–46. 4. Capkın Sİ, Ozyer S, Karayalçın R, Moraloğlu O, Ozcan S, Uğur M. Serum and follicular fluid Anti-Mullerian hormone concen-
96 trations at the time of follicle puncture and reproductive outcome. J Turk Ger Gynecol Assoc 2012;13:21–6. 5. Hazout A, Bouchard P, Seifer DB, Aussage P, Junca AM, CohenBacrie P. Serum antimüllerian hormone/müllerian-inhibiting substance appears to be a more discriminatory marker of assisted reproductive technology outcome than follicle-stimulating hormone, inhibin B, or estradiol. Fertil Steril 2004;82:1323–9. 6. Lekamge DN, Barry M, Kolo M, Lane M, Gilchrist RB, Tremellen KP. Anti-Müllerian hormone as a predictor of IVF outcome. Reprod Biomed Online 2007;14:602–10. 7. Lin WQ, Yao LN, Zhang DX, Zhang W, Yang XJ, Yu R. The predictive value of anti-Mullerian hormone on embryo quality, blastocyst development, and pregnancy rate following in vitro fertilization-embryo transfer (IVF-ET). J Assist Reprod Genet 2013;30:649–55. 8. Mehta BN, Chimote MN, Chimote NN, Nath NM, Chimote NM. Follicular-fluid anti-Mullerian hormone (FF AMH) is a plausible biochemical indicator of functional viability of oocyte in conventional in vitro fertilization (IVF) cycles. J Hum Reprod Sci 2013;6:99–105. 9. Wunder DM, Guibourdenche J, Birkhäuser MH, Bersinger NA. Anti-Müllerian hormone and inhibin B as predictors of pregnancy after treatment by in vitro fertilization/intracytoplasmic sperm injection. Fertil Steril 2008;90:2203–10. 10. Tsakos E, Tolikas A, Daniilidis A, Asimakopoulos B. Predictive value of anti-müllerian hormone, follicle-stimulating hormone and antral follicle count on the outcome of ovarian stimulation in women following GnRH-antagonist protocol for IVF/ET. Arch Gynecol Obstet 2014;290:1249–53. 11. Takahashi C, Fujito A, Kazuka M, Sugiyama R, Ito H, Isaka K. Anti-Müllerian hormone substance from follicular fluid is positively associated with success in oocyte fertilization during in vitro fertilization. Fertil Steril 2008;89:586–91. 12. de Vet A, Laven JS, de Jong FH, Themmen AP, Fauser BC. Antimüllerian hormone serum levels: a putative marker for ovarian aging. Fertil Steril 2002;77:357–62. 13. Dewailly D, Andersen CY, Balen A, Broekmans F, Dilaver N, et al. The physiology and clinical utility of anti-Mullerian hormone in women. Hum Reprod Update 2014;20:370–85. 14. Ebner T, Sommergruber M, Moser M, Shebl O, Schreier-Lech-
North Clin Istanbul – NCI ner E, Tews G. Basal level of anti-Müllerian hormone is associated with oocyte quality in stimulated cycles. Hum Reprod 2006;21:2022–6. 15. Gnoth C, Schuring AN, Friol K, Tigges J, Mallmann P, Godehardt E. Relevance of anti-Mullerian hormone measurement in a routine IVF program. Hum Reprod 2008;23:1359–65. 16. Chen SL, Xia R, Chen X, Luo YQ, Wang LL, Wu YQ, et al. Prediction of ovarian reserve, poor response and pregnancy outcome based on basal antral follicle count and age in patients undergoing in vitro fertilization-embryo transfer. [Article in Chinese] Nan Fang Yi Ke Da Xue Xue Bao 2011;31:572–7. [Abstract] 17. Nardo LG, Christodoulou D, Gould D, Roberts SA, Fitzgerald CT, Laing I. Anti-Müllerian hormone levels and antral follicle count in women enrolled in in vitro fertilization cycles: relationship to lifestyle factors, chronological age and reproductive history. Gynecol Endocrinol 2007;23:486–93. 18. Tokura Y, Yoshino O, Ogura-Nose S, Motoyama H, Harada M, Osuga Y, et al. The significance of serum anti-Müllerian hormone (AMH) levels in patients over age 40 in first IVF treatment. J Assist Reprod Genet 2013;30:821–5. 19. Lukaszuk K, Kunicki M, Liss J, Bednarowska A, Jakiel G. Probability of live birth in women with extremely low anti-Müllerian hormone concentrations. Reprod Biomed Online 2014;28:64– 9. 20. Majumder K, Gelbaya TA, Laing I, Nardo LG. The use of antiMüllerian hormone and antral follicle count to predict the potential of oocytes and embryos. Eur J Obstet Gynecol Reprod Biol 2010;150:166–70. 21. Reichman DE, Goldschlag D, Rosenwaks Z. Value of antimüllerian hormone as a prognostic indicator of in vitro fertilization outcome. Fertil Steril 2014;101:1012–8. 22. Melo MA, Garrido N, Alvarez C, Bellver J, Meseguer M, Pellicer A, et al. Antral follicle count (AFC) can be used in the prediction of ovarian response but cannot predict the oocyte/embryo quality or the in vitro fertilization outcome in an egg donation program. Fertil Steril 2009;91:148–56. 23. Muttukrishna S, McGarrigle H, Wakim R, Khadum I, Ranieri DM, Serhal P. Antral follicle count, anti-mullerian hormone and inhibin B: predictors of ovarian response in assisted reproductive technology? BJOG 2005;112:1384–90.
Orıgınal Article
ANESTHESIOLOGY & REANIMATION
North Clin Istanbul 2016;3(2):97–103 doi: 10.14744/nci.2016.32154
Anesthetic approaches in carotid body tumor surgery Ali Sait Kavakli, Nilgun Kavrut Ozturk Department of Anesthesiology and Reanimation, Antalya Training and Research Hospital, Antalya, Turkey
ABSTRACT OBJECTIVE: Carotid body tumors (CBT) are benign tumors that originate from neural non-chromaffin cells that are typically localized near carotid bifurcation. Surgical removal of the tumor is the most appropriate treatment. General anesthesia is preferred anesthetic technique for CBT surgery. Basic elements of anesthetic management are protection of hemodynamic stability and maintaining cerebral perfusion pressure (CPP). The aim of this study was to evaluate anesthetic management of CBT surgery and present the literature knowledge. METHODS: The study included 10 consecutive patients with diagnosis of CBT who underwent surgery at Antalya Training and Research Hospital, in Antalya, Turkey, between 2013 and 2016. Preoperative demographic details; comorbidities; side of surgical site; duration of operation; length of intensive care unit (ICU) and hospital stay; change of intraoperative blood pressure; use of inotropic drugs, blood products, and analgesics; postoperative visual analogue scale (VAS) pain score; and complications were recorded. RESULTS: According to Shamblin classification, 3 tumors were type I and the remaining 7 were type II. Tumors were located on right side in 6 patients, and on left in 4. Blood loss sufficient to require transfusion was observed in 1 patient. Average intraoperative blood loss was 287±68 mL. Tachycardia and hypertension were observed in 1 patient; bradycardia and hypotension were seen in 4 patients. Infusion for inotropic support was administered to 1 patient. Mean duration of operation was 109±20 minutes. Mean VAS score was 4±1, mean ICU tramadol consumption was 80±25 mg. Duration of stay in ICU and hospital were 2.4±1.1 hours and 3.8±0.7 days, respectively. Mortality and neurological complications were not seen in postoperative period. CONCLUSION: CBT surgery requires close and complex anesthesia management. Protection of hemodynamic stability against sudden hemodynamic changes, monitoring, and maintaining CPP are the most important aspects of anesthetic management. Keywords: Anesthetic considerations; carotid body tumors; glomus tumors.
C
arotid body tumors (CBT) are primary tumors of the chemoreceptor tissue, and they originate from paraganglionic corpuscles. Generally they are localized near carotid bifurcation [1]. They are gen-
erally benign, and they can have a malignant structure. Benign tumors are generally seen between 40, and 70 years of age, while malignant CBTs emerge at younger ages [2]. The mass lesions grow slowly,
Received: September 27, 2016 Accepted: October 12, 2016 Online: November 21, 2016 Correspondence: Dr. Ali Sait KAVAKLI. Antalya Egitim ve Arastirma Hastanesi Anesteziyoloji ve Reanimasyon Klinigi 07100 Antalya, Turkey. Tel: +90 242 - 249 44 00 e-mail: alisaitkavakli@hotmail.com © Copyright 2016 by Istanbul Northern Anatolian Association of Public Hospitals - Available online at www.kuzeyklinikleri.com
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however if they are not treated at an early stage, they may cause symptoms of compression, and cranial nerve dysfunction [3]. Carotid body tumors are generally benign tumors, however rarely malignant tumors can be seen. Most of them are nonfunctional, nevertheless occasionally they can be observed as tumors secreting histamine, serotonin, epinephrine, and norepinephrine. Surgical resection of the tumor is the most appropriate treatment approach [4]. Surgical resection requires experience because of the closeness of the tumor to cranial nerves, extracranial arterial structures, and complex anatomy of head and neck region. For CBT surgery, general anesthesia is preferred. Fluctuations in blood pressure especially manipulation, and excision of the tumor require very careful monitorization by the anesthetist. Although CBTs are nonfunctional tumors, 1–3% of them possess hormonal activity [5]. This condition should be assessed during pre-anesthetic evaluation, and necessary precautions should be taken during operation. In tumors with vascular invasion, one should be prepared for the possibility of bleeding. If crossclamping is required cerebral monitorization, and protection of cerebral perfusion are the most fundamental components of the anesthetic method. The purpose of this study is to evaluate anesthetic approach, and reveal literature information. MATERIALS AND METHODS The data of 10 consecutive patients among 176 patients who underwent surgery for the management of carotid body tumor at Antalya Training and Research Hospital, Antalya, Turkey between 2013 and 2016 were retrospectively examined, and included in the analysis. The patients who underwent throat surgery or carotid artery surgery for indications other than CBT, and those with missing file data were excluded from the study. Patient data were retrieved by investigating patient files, and digital records. Demographic data of the patients, their comorbidities, side, and duration of operation, hospital,
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and intensive care unit stays, intraoperative blood pressure, variations in heart rates, inotropic drug use, amounts of blood, and blood products used, and complications were recorded. Anesthetic management All patients were operated under general anesthesia. For premedication 0.05 mg/kg midazolam was administered. The patients were brought into operating room, and underwent 3-channel electrocardiography, monitorization using pulse oximetry, and arterial monitorization via radial artery cannulation. Then anesthetic induction was applied. Following routine anesthetic induction, the subclavian vein on the opposite side of the operation side was canulated to monitor central venous pressure. Then appropriate colloid, and crystalloid infusions were performed so as to maintain central venous pressure, and mean arterial blood pressure at 8–10 mmHg, and 55–60 mmHg, respectively. Sudden drops in blood pressure were managed with 5 mg bolus doses of ephedrine. In patients whose adequate blood pressure levels could not be achieved despite adequate fluid infusion,and admisistration of ephedrine, inotropic support infusions were initiated. Intraoperative cerebral monitorization was achieved using cerebral oxymetre (Masimo RDS7A, Masimo Corp., Irvine, California, USA), and at the termination of the operation, the patients were extubated in the operating room. For the purpose of postoperative observation, the patients were brought into intensive care unit of cardiovascular surgery. Consciousness, maintaince of hemodynamic stability without the need for inotropic support, absence of respiratory distress, persistence of blood gas analysis results within normal limits (pO2>70 mmHg, and pCO2<50 mmHg), and VAS scores of ≤5 were used as criteria for discharge from intensive care unit. Surgical technique Through a parallel skin incision made on the sternocleidomastoid muscle, cervical region was explored. Following exploration of common carotid artery,
Kavakli et al., Anesthetic approaches in carotid body tumor surgery
mean±standard deviation, and numbers (percentages) Age (yrs) Mean±SD Gender Male Female ASA score ASA 1 ASA 2 ASA 3 Side of operation Right Left EF (%) Mean±SD Comorbidities Hypertension Diabetes mellitus COPD CAD PAD
n
% 53±14.1
4 6
40 60
2 4 4
20 40 40
7 3
70 30 51±9.9
5 4 1 1 1
Mean arterial blood pressure (mmHg)
Table 1. Demographic data are indicated as
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90 80 70 60 50 40 30 Preinduction, postinduction, during excision, postoperative 1. hour 1
2
3
4
5
6
7
8
9
10
Figure 1. Mean arterial blood pressure measurement at different time intervals.
50 40 10 10 10
ASA: American Society of Anaesthesiologists; EF: Ejection fraction; COPD: Chronic obstructive pulmonary disease; CAD: Coronary artery disease; PAD: Peripheral artery disease; SD: Standard deviation.
and its branches, n. vagus, and n. hypoglossus were accessed, and protected. Dissection was started from the bifurcation of carotid artery, and advanced up to the upper edge of the tumor. In all patients, tumor was totally dissected from common carotid artery and its branches. Major vascular injury or disruption of vascular integrity was not observed. Statistical Analysis SPSS version 21 Statistical Software (SPSS Inc., Chicago, IL, USA) program was used for the analysis of statistical data of the patients. All data were expressed as numbers, and percentages. The results were indicated as mean±standard deviation. RESULTS A total of 10 patients (male, n=4; 40%, and female, n=6; 60%) were operated at Antalya Training and
Research Hospital with the diagnosis of CBT between the years 2013, and 2016. Seven of these patients applied with the complaints of painless neck mass, while the remaining 3 patients were discovered incidentally during cervical ultrasonograms obtained for various indications Demographic data of the patients are shown in Table 1. Right (n=6, 60%), and left (n=4; 40%) sided tumors were detected. Based on Shamblin classification, the patients were evaluated as type 1 (n=3; 30%), and type 2 (n=7, 70%). In one patient, bleeding was observed on carotid bifurcation, and controlled with primary suturing during tumor resection. Mean tumor diameters were detected as 3.9±1.6 cm. Cross-clamping was used in one patient, and intraluminal shunt was not employed in any patient. Hypertension, and tachycardia developed in one patient during tumoral excision. In four patients hypotension, and bradycardia were observed during tumoral excision (Figure 1). Three patients of these 4 cases were treated with bolus doses of ephedrine. Since the remaining patient did not respond adequately to bolus doses of ephedrine, infusion of inotropic support was started. A significant difference was not detected between preoperative, intraoperative, and postoperative peak heart rates. Cerebral oximetry values estimated at five differ-
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Table 2. Intra-, and post-operative data as expressed
as mean±standard deviation or number (percentage) Number (%) of patients who received bolus doses of ephedrine Number (%) of patients who were started on inotropic infusion support Mean amount of intraoperative blood loss, ml Duration of surgery, min Duration of anesthesia, min Postoperative mean VAS score Postoperative tramadol utilization, mg Intensive care unit stay, hr Hospital stay, day
4 (40%) 1 (10%) 287±68 109±20 124±18 4±1 80±25 2.4±1.1 3.8±0.7
VAS: Visual analogue scale
ent timepoints (pre-induction baseline, postinduction, before,and after tumor excision, and at the termination of the operation) were compared. In none of the patients a drop of more than 25% did not occur relative to baseline values. Mean intraoperative blood loss was 287±68 ml. One patient required blood transfusion because of abundant amounts of blood loss. Mean total duration of surgery was 109±20 minutes. All patients were monitored in the intensive care unit during postoperative period. Mean postoperative tramadol consumption was 80±25 mg. Mean VAS score at postoperative 0 (entrance into intensive care unit), and 1. hour was 4±1 points (Table 2). During postoperative period permanent neurological damage, and mortality were not seen in none of the cases. DISCUSSION CBT is localized on superolateral regions of the throat, posteroinferior part of the corner of the lower jaw, and it can yield symptoms as solid, painless swelling increasingly growing within years Occasionally, these tumors can be discovered incidentallly. Their incidence rates have been reported between 0.06, and 3.3:100000, and they are seen
more frequently in women when compared with men [6]. They can be seen at any age, however they are observed most frequently between 4. and 5. decades [7]. Cervical ultrasound is the first diagnostic tool to be applied. Computed tomography (CT), magnetic resonance (MR) imaging, and MR angiography yield information about the composition of the tumor, and the relationship between the tumor, and soft tissue, bone, and surrounding vasculature. Diagnostic accuracy, and sensitivity of computed tomographic angiography in the detection of carotid body tumors have been reported as 100 percent [8]. According to Shamblin classification, carotid body tumors are classified into 3 types based on the severity of internal carotid artery involvement [9]. In Type 1 carotid artery is minimally involved, and it is seen in 26% of the cases with CBT. This type of tumors can be easily removed. In Type 2, internal carotid artery is partially surrounded by the tumor. Its dissection is sometimes challenging, but generally it is easily extirpated. It is seen in 40% of the cases with CBT. However Type 3 is seen in 27% of the cases with CBT. It completely invades arterial structures, and so its dissection is not possible. In the treatment of these types, internal and/or external carotid arteries should be also removed. In our series, all patients were classified as Type 1, and Type 2. We didn’t encounter any Type 3 patient. Carotid body tumors has a tendency to accompany head and neck paragangliomas, malignant tumors of lungs, breast, and larynx, and they are bilateral or multiple. Therefore during preoperative evaluation the existence of other tumors should be carefully investigated. When literature is reviewed, mostly preference for general anesthesia for CBT surgery is noted. However in some cases cited in the literature local, and regional anesthesia were applied. In a series consisting of 4 cases reported by Toktas et al. local anesthesia had been used, and any surgical complication was not seen [10]. In the literature a case with CBT operated under cervical plexus block has been reported [11]. A patient who had been considered to have a higher risk for general anesthesia
Kavakli et al., Anesthetic approaches in carotid body tumor surgery
because of Eisenmenger syndrome had been operated under continuous cervical plexus block, and any complication had not been encountered. Cervical plexus block is a preferred anesthetic method for carotid artery surgery [12, 13]. However use of these methods for CBT surgery may harbor some contraindications. CBT is frequently localized on carotid bifurcation, and during regional applications, because of the hypervascularity of the tumor, unwanted punctures of the tumoral mass may be encountered. Because of risk of bleeding, needle or open biopsy is containdicated in these tumors [14]. In addition, hemodynamic deterioration is possible because of the possibility of catecholamine release from the tumor. During application of nerve block, in order to refrain from perforation of the tumor with the needle, regional applications under ultrasound guidance may have higher procedural safety. In patients with CBT carrying higher risk for general anesthesia, preference for regional anesthesia will be more appropriate. Since we hadn’t any patient with higher risk for general anesthesia, so as to refrain from complications of regional anesthesia, we preferred general anesthesia in all of our patients. Knowing functional status of the tumor is important during preoperative evaluation for anesthetic technique. Presence of excessive cathecolamine release should be investigated during preoperative period using urinary metanephrine, and vanillylmandelic acid measurements. During surgery for functional tumors, alpha-adrenergic blocker drugs should be at hand so as to prevent hypertensive episodes due to excessive cathecolamine discharge [15]. Preoperative cathecolamine levels of all of our patients were within normal limits. Planning fluid therapy plays an important role in the maintenance of hemodynamic status. Therefore, central venous pressure should be monitored, and required resuscitation with fluid replacement should be readily available. Invasive arterial monitorization, close follow-up of hemodynamic state is absolutely necessary for maintenance of blood pressure during specific intervals, and blood gas analyses. Because of the presence of potential ischemic ar-
101
eas, and already dilated vessels, normocapnic state should be preferred during anesthesia. Hypercapnia may result in dilation of vessels outside ischemic areas, and blood flows through these dilated vessels leading to “steal phenomenon”, and worsened ischemic state. However hypocapnia further causes increases severity of vasoconstruction at ischemic areas [16]. Bleeding is one of the most important intraoperative complications. Especially during excision of the tumors which invaded carotid artery, substantial amount of blood loss can occur, and sudden hemodynamic changes can be observed. Based on Shamblin classification tumor types, CBTs of type II, and III have been found to be associated with greater amounts of blood loss, longer operation times, higher incidence of nöronal damage, more severe vascular injury, and frequent need for repair [17, 18]. Excessive blood loss during excision of the tumor, and potential complications can be predicted based on preoperative classification, and preparation of preoperative blood supply should be made accordingly. Blood loss requiring blood transfusion occurred in only one of our cases This case was Type 2 CBT according to Stamblin classification This bleeding occurring on the carotid bifurcation was stopped with primary suturing. Especially in Stamblin Type 3 group where tumor invaded carotid artery, cross-clamping should be applied to preclude excessive bleeding during excision of the tumor. Especially in cases with stenosis of the contralateral carotid artery detected during clamping neurologic monitorization conveys importance. For the monitorization of neurologic status, electroencephalography [19], measurement of somatosensory evoked potentials [20], transcranial Doppler US [21], measurement of carotid stump pressure [22] and cerebral oxymetre [23] can be used. The superiority of one method over another has not been demonstrated exactly [24]. During clamping of the carotid artery, if stenosis of the contralateral carotid artery was detected, use of a shunt can be a proper alternative. During shunting, risk of embolism or carotid artery dissection has been reported in 1–3% operated cases [25]. It has been revealed in many studies that during cross-clamping,
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maintenance of mean blood pressure values at nearly 20% higher levels higher than the baseline values has a protective effect on the preservation of cerebral perfusion [26]. Thus focal ischemia is avoided by ensuring optimal cerebral perfusion. It has been already known that barbiturates used during this period contribute to redistribution, and protect the tissues against focal ischemia [27]. Brain edema is associated with cytotoxic, and vasogenic edema, and it usually follows an ischemic process. Use of mannitol is useful in the reduction of this type of edema [28]. In our series we performed cerebral monitorization using cerebral oximeter in our patients. We applied cross-clamping in one of these patients because of intractable bleeding. We didn’t use a shunt in this patient, while cross-clamping procedure lasted for 8 minutes, and bleeding was stopped using primary suturing. During postoperative period any neurological complication was not encountered in this patient. Lack of any control group was the main limitation of this study which prevented comparison of data. Scarce number of patients was another limitation of the study. Studies performed with higher number of patients may further elaborate outcomes of this study Conclusion Surgery of carotid body tumors requires close monitorization, and complex anesthetic management. Cerebral monitorization, and preservation of cerebral perfusion are important issues especially during tumoral resection, and cross-clamping. During preoperative period, performing necessary preparations, being prepared for excess amounts of blood loss, and maintenance of optimal blood pressure levels against sudden hemodynamic changes are among the basic components of anesthetic management. Conflict of Interest: None declared. Financial Disclosure: The authors declared that this study has received no financial support. Authorship contributions: Concept – A.S.K.; Design – A.S.K.; Supervision – A.S.K., N.K.O.; Data collection &/or processing – A.S.K., N.K.O.; Analysis and/or interpretation –
North Clin Istanbul – NCI A.S.K., N.K.O.; Literature search – A.S.K., N.K.O.; Writing – A.S.K., N.K.O.; Critical review – A.S.K., N.K.O.
REFERENCES 1. Del Guercio L, Narese D, Ferrara D, Butrico L, Padricelli A, Porcellini M. Carotid and vagal body paragangliomas. Transl Med UniSa 2013;6:11–5. 2. Obholzer RJ, Hornigold R, Connor S, Gleeson MJ. Classification and management of cervical paragangliomas. Ann R Coll Surg Engl 2011;93:596–602. 3. İlhan G, Bozok Ş, Özpak B, Güneş T, Gökalp O, Bayrak S, et al. Diagnosis and management of carotid body tumor: a report of seven cases. Turk Gogus Kalp Damar Cer Derg 2013;21:194– 200. 4. Mataracı İ, Rabuş MB, Kırali K, Kıran B, Yanartaş M, Sunar H, et al. Diagnosis and surgical treatment of carotid body tumors. Turk Gogus Kalp Damar Cer Derg 2008;16:86–90. 5. Offergeld C, Brase C, Yaremchuk S, Mader I, Rischke HC, Gläsker S, et al. Head and neck paragangliomas: clinical and molecular genetic classification. Clinics (Sao Paulo) 2012;67 Suppl 1:19–28. 6. Sajid MS, Hamilton G, Baker DM; Joint Vascular Research Group. A multicenter review of carotid body tumour management. Eur J Vasc Endovasc Surg 2007;34:127–30. 7. Georgiadis GS, Lazarides MK, Tsalkidis A, Argyropoulou P, Giatromanolaki A. Carotid body tumor in a 13-year-old child: Case report and review of the literature. J Vasc Surg 2008;47:874-880. 8. Jin ZQ, He W, Wu DF, Lin MY, Jiang HT. Color Doppler Ultrasound in Diagnosis and Assessment of Carotid Body Tumors: Comparison with Computed Tomography Angiography. Ultrasound Med Biol 2016;42:2106–13. 9. Shamblin WR, ReMine WH, Sheps SG, Harrison EG Jr. Carotid body tumor (chemodectoma). Clinicopathologic analysis of ninety cases. Am J Surg 1971;122:732–9. 10. Toktaş F, Yümün G, Gücü A, Göncü T, Eriş C, Çayır Ç, et al. Protective Surgical Procedures for Carotid Body Tumors: A Case Series. Erciyes Med J 2014;36:133–5. 11. Jones HG, Stoneham MD. Continuous cervical plexus block for carotid body tumour excision in a patient with Eisenmenger’s syndrome. Anaesthesia 2006;61:1214–8. 12. Sait Kavaklı A, Kavrut Öztürk N, Umut Ayoğlu R, Sağdıç K, Çakmak G, İnanoğlu K, et al. Comparison of Combined (Deep and Superficial) and Intermediate Cervical Plexus Block by Use of Ultrasound Guidance for Carotid Endarterectomy. J Cardiothorac Vasc Anesth 2016;30:317–22. 13. Çoruh T, Yapıcı N, Yılmaz C, Çınar B, Maçika H, Abay G, et al. Karotis endarterektomisinde genel anestezi, servikal pleksus blokajı ve servikal epidural anestezi yöntemlerinin karşılaştırılması. GKD Anest Yoğ Bak Dern Derg 2000;6:30–4. 14. Köhler HF, Carvalho AL, Mattos Granja NV, Nishinari K, Kowalski LP. Surgical treatment of paragangliomas of
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the carotid bifurcation: results of 36 patients. Head Neck 2004;26:1058–63. 15. Hu K, Persky MS. Treatment of head and neck paragangliomas. Cancer Control 2016;23:228–41. 16. Stoelting RK, Dierdorf SF. Diseases of the nervous system. In: Stoelting RK, Dierdorf SF, editors. Anesthesia and Co-existing Disease. 4th ed. Philadelphia: Churchill Livingstone; 2002. p. 233–2. 17. Burnichon N, Brière JJ, Libé R, Vescovo L, Rivière J, Tissier F, et al. SDHA is a tumor suppressor gene causing paraganglioma. Hum Mol Genet 2010;19:3011–20. 18. Luna-Ortiz K, Rascon-Ortiz M, Villavicencio-Valencia V, Herrera-Gomez A. Does Shamblin’s classification predict postoperative morbidity in carotid body tumors? A proposal to modify Shamblin’s classification. Eur Arch Otorhinolaryngol 2006;263:171–5. 19. Guay J, Kopp S. Cerebral monitors versus regional anesthesia to detect cerebral ischemia in patients undergoing carotid endarterectomy: a meta-analysis. Can J Anaesth 2013;60:266–79. 20. Malcharek MJ, Kulpok A, Deletis V, Ulkatan S, Sablotzki A, Hennig G, et al. Intraoperative multimodal evoked potential monitoring during carotid endarterectomy: a retrospective study
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of 264 patients. Anesth Analg 2015;120:1352–60. 21. van der Schaaf IC, Horn J, Moll FL, Ackerstaff RG. Transcranial Doppler monitoring after carotid endarterectomy. Ann Vasc Surg 2005;19:19–24. 22. Calligaro KD, Dougherty MJ. Correlation of carotid artery stump pressure and neurologic changes during 474 carotid endarterectomies performed in awake patients. J Vasc Surg 2005;42:684–9. 23. Pedrini L, Magnoni F, Sensi L, Pisano E, Ballestrazzi MS, Cirelli MR, at al. Is Near-Infrared Spectroscopy a Reliable Method to Evaluate Clamping Ischemia during Carotid Surgery? Stroke Res Treat 2012;2012:156975. 24. Li J, Shalabi A, Ji F, Meng L. Monitoring cerebral ischemia during carotid endarterectomy and stenting. J Biomed Res 2016;3:31. 25. Whiten C, Gunning P. Carotid endarterectomy: intraoperative monitoring of cerebral perfusion. Curr Anaesth Crit Care 2009;20:42–5. 26. Allian R, Marone LK, Meltzer J, Jeyabalam G. Carotid endarterectomy. IntAnesthesiology Clin 2005;43:15–38. 27. McConkey, Kien ND. Cerebral protection with thiopentone during combined carotid endarterectomy and clipping of intraluminal aneurysm. Anesthesia Intensive Care 2007;30:219–22.
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Orıgınal Article
GASTROENTEROLOGY
North Clin Istanbul 2016;3(2):104–10 doi: 10.14744/nci.2016.65265
A retrospective analysis of endoscopic treatment outcomes in patients with postoperative bile leakage Suleyman Sayar,1 Sehmus Olmez,2 Ufuk Avcioglu,3 Ilyas Tenlik,4 Bunyamin Saritas,5 Kamil Ozdil,1 Emin Altiparmak,6 Ersan Ozaslan6 Department of Gastroenterology, Umraniye Trianing and Research Hospital, Istanbul, Turkey
1
Department of Gastroenterology, Adana Numune Training and Research Hospital, Adana, Turkey
2
Department of Gastroenterology, Koru Hospital, Ankara, Turkey
3
Department of Gastroenterology, Turkish Advanced Specialty Training and Research Hospital, Ankara, Turkey
4
Department of Gastroenterology, Medicalpark Hospital, Elazig, Turkey
5
Department of Gastroenterology, Ankara Numune Training and Research Hospital, Ankara, Turkey
6
ABSTRACT OBJECTIVE: Bile leakage, while rare, can be a complication seen after cholecystectomy. It may also occur after hepatic or biliary surgical procedures. Etiology may be underlying pathology or surgical complication. Endoscopic retrograde cholangiopancreatography (ERCP) can play major role in diagnosis and treatment of bile leakage. Present study was a retrospective analysis of outcomes of ERCP procedure in patients with bile leakage. METHODS: Patients who underwent ERCP for bile leakage after surgery between 2008 and 2012 were included in the study. Etiology, clinical and radiological characteristics, and endoscopic treatment outcomes were recorded and analyzed. RESULTS: Total of 31 patients (10 male, 21 female) were included in the study. ERCP was performed for bile leakage after cholecystectomy in 20 patients, after hydatid cyst operation in 10 patients, and after hepatic resection in 1 patient. Clinical signs and symptoms of bile leakage included abdominal pain, bile drainage from percutaneous drain, peritonitis, jaundice, and bilioma. Twelve (60%) patients were treated with endoscopic sphincterotomy (ES) and nasobiliary drainage (NBD) catheter, 7 patients (35%) were treated with ES and biliary stent (BS), and 1 patient (5%) was treated with ES alone. Treatment efficiency was 100% in bile leakage cases after cholecystectomy. Ten (32%) cases of hydatid cyst surgery had subsequent cystobiliary fistula. Of these patients, 7 were treated with ES and NBD, 2 were treated with ES and BS, and 1 patient (8%) with ES alone. Treatment was successful in 90% of these cases. CONCLUSION: ERCP is an effective method to diagnose and treat bile leakage. Endoscopic treatment of postoperative bile leakage should be individualized based on etiological and other factors, such as accompanying fistula. Keywords: Biliary fistula; ERCP; postoperative bile leakage.
Received: October 11, 2016 Accepted: October 17, 2016 Online: November 24, 2016 Correspondence: Dr. Suleyman SAYAR. Umraniye Egitim ve Arastirma Hastanesi, Gastroenteroloji Klinigi, Elmalikent Mahallesi, Adem Yavuz Cad. No: 1, Umraniye, Istanbul, Turkey. Tel: +90 216 - 632 18 18 e-mail: drssayar@gmail.com © Copyright 2016 by Istanbul Northern Anatolian Association of Public Hospitals - Available online at www.kuzeyklinikleri.com
Sayar et al., Endoscopic treatment outcomes in patients with postoperative bile leakage
M
ost complications after surgical interventions on biliary system are related to iatrogenic injuries. Biliary injury may result in bile leakage (biliary fistula), bile duct obstruction or bile duct stricture. Bile leakage most commonly occurs after cholecystectomy. Laparoscopic cholecystectomy is more commonly associated with bile injuries than its open counterpart [1, 2]. The incidence of biliary injuries after laparoscopic cholecystectomy varies between 0.5–0.9 percent in different series [3]. Other causes of biliary leakage include orthotropic liver transplantation, hydatid cyst surgery involving the biliary system, liver biopsy, Trans jugular intrahepatic portosystemic shunt (TIPS), hepatic tumor ablation, penetrating sharp object injuries, and blunt object injuries. Irrespective of the nature of injury, the majority of bile injuries cannot be detected during surgery [4]. Surgical therapy of bile leakages at the postoperative period increases patient morbidity and mortality [5, 6]. Endoscopic retrograde cholangiopancreatography (ERCP) plays a major role for treating postoperative bile leakages. The aim of this study to analyze the clinical, laboratory, radiological, and endoscopic characteristics of, and the efficiency of endobiliary prosthesis in patients with bile leakage after abdominal surgery who were treated with ERCP in Ankara Numune Training and Research Hospital retrospectively. MATERIALS AND METHODS This study included a total of 31 patients diagnosed as bile leakage and treated with ERCP after biliary surgery or liver surgery performed for various etiologies in Ankara Numune Training and Research Hospital between January 2008 and May 2012. Patients’ age, sex, etiology for surgical intervention, symptoms, physical examination findings, complete blood counts and blood chemistry results, and daily amount of discharge (ml) from abdominal drain before the endoscopic therapy were recorded. The radiological, endoscopic, and other diagnostic methods used for the detection of bile leakage were evaluated. ERCP was performed by a single experienced endoscopist using side-viewing duodenoscope at a single center. The site and grade of
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leakage, endoscopic treatment method, the type of injury, and the size of endobiliary prosthesis if used for endoscopic therapy were also recorded. The severity of bile leak was classified by endoscopic retrograde cholangiography into low grade (leak identified only after intrahepatic opacification) or high grade (leak observed before intrahepatic opacification). Injury type was categorized according to Strasberg’s classification. The findings of control cholangiography, and the complications detected during and after endoscopic therapy were recorded. In patients with postoperative bile leakage after hydatid cyst surgery the preoperative anatomic localization, diameter, and type (Gharbi) of the cyst were recorded. The endoscopic therapy was considered successful when no signs of bile leakage was observed in the control cholangiography after endoscopy, or when a patient’s radiological, clinical, and laboratory findings improved after endoscopic treatment but no control cholangiogram was taken at discharge. Statistical analysis The study data were analyzed by SPSS for Windows 18 software package. The categorical variables were expressed as number and percentage, and the continuous variables as mean±Standard error. RESULTS The study included a total of 31 subjects (10 males and 21 females). The mean age of the patients were 53.4±13.2 and 50.8±19.5 years for male and female subjects, respectively. The clinical signs or symptoms of bile leakage included abdominal pain in 26 patients (83%), bile drainage from percutaneous drain in 23 (74%) patients, peritonitis in eight (25%) patients, bilioma in three (9%) patients, and jaundice in six (19%) patients. Demographic features, indication for operation, type of operation and signs and symptoms of patients with bile leakage were summarized on Table 1. The leak was from a cystic stump in 11 (55%) of cases, from right peripheric bile ducts in two (10%),
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North Clin Istanbul – NCI
Table 1. Demographic features, indication for opera-
Table 3. Clinical characteristics, applied treatment,
tion, type of operation and signs and symptoms of patients with bile leakage Parameters
and treatment efficiency in cases with cystobiliary fistula after hydatid cyst surgery
Total (n=31)
n
Age (years) Sex Male Female Type of operation Laparoscopic cholecystectomy Hydatid cyst surgery Open cholecystectomy Hepatic resection Signs and symptoms associated with bile leakage Abdominal pain Postoperative biliary drainage Peritonitis Jaundice or hyperbilirubinemia Bilioma
%
51±17.4 10 21
32 68
14 10 6 1
45 32 19 3
26 23 8 6 3
83 74 25 19 9
Table 2. Patients having bile leakage after cholecys-
tectomy
Injury type Strasberg type A Strasberg type D Leakage severity Low-grade High-grade Applied treatment ES+NBD ES+BS ES Complication Minor bleeding Treatment efficiency
Total (n=20) n
%
18 2
90 10
16 4
80 20
12 7 1
60 35 5
4 20
20 100
BS: Biliary stent; ES: Endoscopic sphincterotomy; NBD: Nasobiliary drainage.
Preoperative Overt Occult Postoperative (Bile drainage from drain) Gharbi type Type 2 Type 3 Type 4 Applied Treatment ES ES+NBD ES+BS Treatment efficiency ES+NBD ES+BS ES
n=10
1 9 10 1 8 1 1 7 2 6/7 1/2 1/1
BS: Biliary stent; ES: Endoscopic sphincterotomy; NBD: Nasobiliary drainage.
gall bladder bed in 5 (25%), common hepatic duct in one (5%), and common bile duct in one (5%) after cholecystectomy. Among these patients, 18 (90%) had a Strasberg type A injury and two (10%) had a type D injury. A low-grade leakage was observed in 16 (80%) of the cases and a high-grade leakage in 4 cases (20%) after cholecystectomy. Twelve (60%) patients with bile leakage were treated by endoscopic sphincterotomy (ES) and nasobiliary drainage (NBD) catheter; seven (35%) by ES and biliary stent (BS); one (5%) by ES alone. Common bile duct stones were detected by ERCP in five (25%) of these patients. All cases with bile leakage after cholecystectomy (n=20) were treated in a single session. The mean duration of follow-up with NBD was 12.4 days (minimum 6, maximum 12 days) in the cases treated by NBD and ES. Bile drainage from bile drain ceased after a mean of 4 days (2–7 days) in 9 cases treated by NBD and ES. There was a lowgrade leakage in 9 cases and a high-grade leakage in 3 cases treated by NBD and ES. Eight cases treated by
Sayar et al., Endoscopic treatment outcomes in patients with postoperative bile leakage
NBD and ES underwent a control cholangiography and were free of any persistent leakage. All of these cases were successfully treated in a single session. Patients having bile leakage after cholecystectomy are summarized in Table 2. Two of the cases treated by BS and ES were treated using a 10 Fr plastic stent and 5 patients were treated using a 7 Fr plastic stent. Bile drainage from surgical drain ceased in 2 days (1–3 days) in four of these patients. Cases treated by BS, 6 had lowgrade leakage and 1 had high-grade leakage. These cases were successfully treated in a single session. No severe, ERCP-related complications were observed. One case presenting with postoperative bile drainage from surgical drain following left lobectomy for rectum Ca metastasis was treated by a 10 Fr BS in a second ERCP session upon persistent bile drainage from surgical drain at 11th day after NBD and ES and in the absence of effective bile drainage from NBD. Ten (32%) of the patients were occurred after hydatid cyst surgery and had cystobiliary fistula. All of these cases presented with bile drainage from surgical drain in the postoperative period, with one having overt cystobiliary communication with signs of preoperative cholangitis and cholestasis. Hydatid cysts were located in right hepatic lobe in 4 cases, hilus or central section in 5 (50%), and left hepatic lobe in 1. According to the Gharbi classification, 8 had type 3, 1 had type 2, and 1 had type 4 hydatid cyst. Only one case had signs suggestive of overt cystobiliary communication on preoperative ultrasonography. Seven patients were treated by ES and NBD, 2 by ES and BS, and 1 (8%) by ES alone. Three cases had papillary stenosis on ERCP. Six out of 7 patients treated by ES and NBD had favorable outcomes. One case had failed treatment by NBD and ES and underwent surgery. The mean NBD follow-up was 9 days (3–14 days). One case with postoperative low-output cystobiliary communication was successfully treated by ES alone. One out of two patients treated by BS (7 Fr) and ES was successfully treated while one case was successfully treated by NBD at a second session after failed BS therapy. An overall analysis of cases undergoing
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endoscopic therapy for cystobiliary fistula after hydatid cyst surgery revealed that 9 (90%) cases were successfully treated by ERCP. No serious, ERCPrelated complication was encountered. DISCUSSION Bile leakage is a rare complication that most commonly occurs after cholecystectomy. Biliary injuries are more common after laparoscopic cholecystectomy than open cholecystectomy [7]. Biliary injury is categorized into major and minor forms, the former involving common bile duct or common hepatic duct while the latter involving peripheric ducts. The mechanisms of bile injuries during laparoscopic cholecystectomy have been well defined [8, 9]. The most common scenario involves inadvertently injuring common bile duct by confusing it with cystic canal. Surgical skill and experience, misevaluation of anatomical structures during surgery, local operative risk factors (local inflammation, bleeding, obesity, hepatic cirrhosis, scleroatrophic gall bladder, hepatic neoplasms, Mirizzi’s syndrome, obesity, and penetrating duodenal ulcer), and aberrant anatomy are the major risk factors for injury [10, 11, 12]. Bile injuries during cholecystectomy may result in bile leakage, bile strictures, or both. The most common types of leakage after cholecystectomy are the cystic stump leakages and lowgrade, spontaneously closing leaks seen in Luschka canals. Major bile duct injuries involving the common hepatic duct and common bile duct usually result in high-grade leakages [13, 14, 15]. The most common signs and symptoms include abdominal pain, jaundice, fever, ascites, and biliomas. Most cases with bile leakage present within 1 week after surgery although this period may well extend to 3 months [9, 16, 17]. Bile leakage can be diagnosed by ultrasonography, computed tomography, magnetic resonance cholangiopancreotography (MRCP), scintigraphy, endoscopic retrograde cholangiopancreatography (ERCP), fistulography, percutaneous transhepatic cholangiopancreatography (PTC) and laparotomy. ERCP has recently been the most widely employed method for both diagnosis and treatment. The basic
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principles of the endoscopic method include relieving pressure excess within the biliary system (via ES and/or biliary prosthesis [stent or NBD]), and removing bile from the leakage site by biliary prostheses. The most common factor for the success of endoscopic therapy is whether bile tree has lost its continuity. Strasberg type A, D injuries, type E injuries with incomplete incision, and aberrant canal injuries demonstrable via cholangiogram (Strasberg B,C,E5) can be treated by ERCP. Therapy to be applied during ERCP (ES and/or endobiliary prosthesis) is determined by the injury type determined by findings of cholangiography, leakage grade (lowgrade vs high-grade), and other factors accompanying injury (common bile duct stones or strictures). The most common cause of bile leakage in this study was cholecystectomy operation performed for bile stone disease, most of which were laparoscopic surgeries (64%, in 20 patients). The second most common cause was cystobiliary fistulas detected after hydatid cyst surgery (n=10, 32%). In our study bile leakage after cholecystectomy most commonly occurred from cystic stump and gall bladder bed. Eighty percent (n=16) of cases had low-grade leakage and 90% (n=18) had Strasberg Type A injury. Almost all cases (95%, n=19) were treated with NBD or BS in addition to ES. Endoscopic therapy was successful in all cases. 10F plastic stent was used in two of the cases and 7F plastic stents were used in five cases treated by ES+BS. Stents were retrieved 4–6 weeks later in all cases. All cases treated for bile leakage after cholecystectomy were successfully treated in a single session. Successful endoscopic therapy in all of our cases may be explained by the majority of injuries being Strasberg Type A, low-grade injuries that were mostly treated by ES application. Animal studies evaluating the pressure gradient between the common bile duct and duodenum after sphincterotomy or stent placement have shown that intrabiliary pressure was reduced more effectively in the stent placement group than the group that undergone ES alone [18, 19]. Other clinical and experimental studies have also revealed that biliary stent therapy in conjunction with ES was more effective than ES alone in eliminating oddi sphincter
North Clin Istanbul – NCI
pressure [20, 21, 22]. Although different studies have provided conflicting data regarding the endoscopic therapy efficiencies of NBD and BS, general opinion suggests that they are equally effective. NBD may be preferred to BS in highly morbid cases in which a repeat control cholangiogram is contemplated [23]. There are no exact data about the correlation of the size and diameter of the prosthesis and the efficiency of endoscopic therapy. The therapy is individualized according to other factors (e.g common bile duct stone, stricture, and risk of post-ERCP pancreatitis). Bile fistula is the most common complication in liver hydatid cyst [24, 25]. Its postoperative incidence varies from 5% to 63% [24, 25, 26, 27]. High-output fistulas lasting more than 10 days in the postoperative period are defined as persistent biliary fistulas. Low-output fistulas may be closed spontaneously, without the need for an endoscopic intervention. ERCP is recommended in the case of obstructive signs in bile ducts caused by residual cystic materials, cholangitis, and development of postoperative persistent external biliary fistula. It can also be performed in a later stage when secondary sclerosing cholangitis or oddi fibrosis takes place. Using ES and/or endobiliary prostheses (ES or NBD) in ERCP reduces the pressure gradient between the biliary system and duodenum, diverting bile flow to duodenum. In our study patients successfully treated with ES and NBD. The efficiency of ERCP approaches 90% in cases with biliary fistula as in our study [28]. Some researchers have advocated that ES alone and removing cystic material in the common bile duct whenever present would suffice for treatment of hydatid cyst disease involving biliary system. However, many other researchers have recommended using biliary prostheses in addition to ES for a couple of days to weeks [28, 29, 30]. Adas et al. and Akçakaya et al. demonstrated that using biliary stent or NBD in conjunction with ES improved treatment success when biliary strictures or choledocolithiasis accompanied high-output fistulas [28, 30]. Çiçek et al. recommended NBD use owing to its properties of reducing intrabiliary pressure more
Sayar et al., Endoscopic treatment outcomes in patients with postoperative bile leakage
efficiently and enabling intraoperative detection of the localization of cystobiliary communication when applied at the preoperative period [31]. In the present study 10 patients with biliary fistula after hydatid cyst surgery were treated by ERCP. Three of the cases were detected to have an accompanying papillary stenosis. One case treated by ES and NBD was applied surgical therapy for concurrent persistent chronic fistula. One case presenting with low-output persistent fistula was treated by ES alone. In conclusion, our study showed that ERCP is an effective method for the diagnosis and treatment of post-surgical bile fistula. Endoscopic therapy should be individualized on the basis of the etiology, fistula output, grade, and presence of other pathologies accompanying fistula. Conflict of Interest: None declared. Financial Disclosure: The authors declared that this study has received no financial support. Authorship contributions: Concept – S.S., E.O.; Design – S.S., Supervision – S.S.; Data collection &/or processing – S.S., S.O., U.A., I.T., E.O.; Analysis and/or interpretation – S.S., K.O.; Literature search – S.S.; Writing – S.S., B.S., E.A.; Critical review – S.S., B.S., K.O., E.A.
REFERENCES 1. Roslyn JJ, Binns GS, Hughes EF, Saunders-Kirkwood K, Zinner MJ, Cates JA. Open cholecystectomy. A contemporary analysis of 42,474 patients. Ann Surg 1993;218:129–37. 2. Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 1995;180:101–25. 3. Adamsen S, Hansen OH, Funch-Jensen P, Schulze S, Stage JG, Wara P. Bile duct injury during laparoscopic cholecystectomy: a prospective nationwide series. J Am Coll Surg 1997;184:571–8. 4. Bergman JJ, van den Brink GR, Rauws EA, de Wit L, Obertop H, Huibregtse K, et al. Treatment of bile duct lesions after laparoscopic cholecystectomy. Gut 1996;38:141–7. 5. Martin RF, Rossi RL. Bile duct injuries. Spectrum, mechanisms of injury, and their prevention. Surg Clin North Am 1994;74:781–807. 6. Sandha GS, Bourke MJ, Haber GB, Kortan PP. Endoscopic therapy for bile leak based on a new classification: results in 207 patients. Gastrointest Endosc 2004;60:567–74. 7. Roy PG, Soonawalla ZF, Grant HW. Medicolegal costs of bile duct injuries incurred during laparoscopic cholecystectomy.
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HPB (Oxford) 2009;11:130–4. 8. Larson GM, Vitale GC, Casey J, Evans JS, Gilliam G, Heuser L, et al. Multipractice analysis of laparoscopic cholecystectomy in 1,983 patients. Am J Surg 1992;163:221–6. 9. Scott TR, Zucker KA, Bailey RW. Laparoscopic cholecystectomy: a review of 12,397 patients. Surg Laparosc Endosc 1992;2:191–8. 10. Krähenbühl L, Sclabas G, Wente MN, Schäfer M, Schlumpf R, Büchler MW. Incidence, risk factors, and prevention of biliary tract injuries during laparoscopic cholecystectomy in Switzerland. World J Surg 2001;25:1325–30. 11. Moossa AR, Mayer AD, Stabile B. Iatrogenic injury to the bile duct. Who, how, where? Arch Surg 1990;125:1028–31. 12. Barkun AN, Rezieg M, Mehta SN, Pavone E, Landry S, Barkun JS, et al. Postcholecystectomy biliary leaks in the laparoscopic era: risk factors, presentation, and management. McGill Gallstone Treatment Group. Gastrointest Endosc 1997;45:277–82. 13. Kitami M, Murakami G, Suzuki D, Takase K, Tsuboi M, Saito H, Takahashi S. Heterogeneity of subvesical ducts or the ducts of Luschka: a study using drip-infusion cholangiography-computed tomography in patients and cadaver specimens. World J Surg 2005;29:217–23. 14. Ko K, Kamiya J, Nagino M, Oda K, Yuasa N, Arai T, et al. A study of the subvesical bile duct (duct of Luschka) in resected liver specimens. World J Surg 2006;30:1316–20. 15. Rerknimitr R, Sherman S, Fogel EL, Kalayci C, Lumeng L, Chalasani N, et al. Biliary tract complications after orthotopic liver transplantation with choledochocholedochostomy anastomosis: endoscopic findings and results of therapy. Gastrointest Endosc 2002;55:224–31. 16. Davidoff AM, Branum GD, Meyers WC. Clinical features and mechanisms of major laparoscopic biliary injury. Semin Ultrasound CT MR 1993;14:338–45. 17. Davidoff AM, Pappas TN, Murray EA, Hilleren DJ, Johnson RD, Baker ME, et al. Mechanisms of major biliary injury during laparoscopic cholecystectomy. Ann Surg 1992;215:196–202. 18. Tantia O, Jain M, Khanna S, Sen B. Iatrogenic biliary injury: 13,305 cholecystectomies experienced by a single surgical team over more than 13 years. Surg Endosc 2008;22:1077–86. 19. Katsinelos P, Kountouras J, Paroutoglou G, Chatzimavroudis G, Germanidis G, Zavos C, et al. A comparative study of 10-Fr vs. 7-Fr straight plastic stents in the treatment of postcholecystectomy bile leak. Surg Endosc 2008;22:101–6. 20. Youngelman DF, Marks JM, Ponsky T, Ponsky JL. Comparison of bile duct pressures following sphincterotomy and endobiliary stenting in a canine model. Surg Endosc 1997;11:126–8. 21. Kim KH, Kim TN. Endoscopic management of bile leakage after cholecystectomy: a single-center experience for 12 years. Clin Endosc 2014;47:248–53. 22. Manouras A, Genetzakis M, Antonakis PT, Lagoudianakis E, Pattas M, Papadima A, et al. Endoscopic management of a relapsing hepatic hydatid cyst with intrabiliary rupture: a case report and review of the literature. Can J Gastroenterol 2007;21:249–
110 53. 23. Galati G, Sterpetti AV, Caputo M, Adduci M, Lucandri G, Brozzetti S, et al. Endoscopic retrograde cholangiography for intrabiliary rupture of hydatid cyst. Am J Surg 2006;191:206–10. 24. Somani SK SA. Resolution of Hepatic Hydatid Cyst with Biliary Communication with ERCP. J Gastroint Dig Syst 2012;2:114. 25. Kayaalp C, Bzeizi K, Demirbag AE, Akoglu M. Biliary complications after hydatid liver surgery: incidence and risk factors. J Gastrointest Surg 2002;6:706–12. 26. El Malki HO, El Mejdoubi Y, Souadka A, Mohsine R, Ifrine L, Abouqal R, et al. Predictive model of biliocystic communication in liver hydatid cysts using classification and regression tree analysis. BMC Surg 2010;10:16. 27. de Aretxabala X, Perez OL. The use of endoprostheses in biliary fistula of hydatid cyst. Gastrointest Endosc 1999;49:797–9.
North Clin Istanbul – NCI 28. Adas G, Arikan S, Gurbuz E, Karahan S, Eryasar B, Karatepe O, et al. Comparison of endoscopic therapeutic modalities for postoperative biliary fistula of liver hydatid cyst: a retrospective multicentric study. Surg Laparosc Endosc Percutan Tech 2010;20:223–7. 29. Sharma BC, Reddy RS, Garg V. Endoscopic management of hepatic hydatid cyst with biliary communication. Dig Endosc 2012;24:267–70. 30. Akcakaya A, Sahin M, Karakelleoglu A, Okan I. Endoscopic stenting for selected cases of biliary fistula after hepatic hydatid surgery. Surg Endosc 2006;20:1415–8. 31. Cicek B, Parlak E, Disibeyaz S, Oguz D, Cengiz C, Sahin B. Endoscopic therapy of hepatic hydatid cyst disease in preoperative and postoperative settings. Dig Dis Sci 2007;52:931–5.
Orıgınal Article
GASTROENTEROLOGY
North Clin Istanbul 2016;3(2):111–7 doi: 10.14744/nci.2016.28199
The prevalence of non-alcoholic fatty liver disease in healthy young persons Gokcan Okur,1 Zehra Karacaer2 Department of Radiology, Etimesgut Military Hospital, Ankara, Turkey
1
Department of Infectious Diseases and Clinical Microbiology, Etimesgut Military Hospital, Ankara, Turkey
2
ABSTRACT OBJECTIVE: This aim of the present study was to determine prevalence of non-alcoholic fatty liver disease (NAFLD) in healthy young persons admitted for annual medical check-ups. METHODS: A retrospective study was conducted in a military hospital. Total of 254 healthy males were included and participants were divided into 2 groups according to presence and grade of NAFLD. Demographic data, biochemical test results, and ultrasonography findings were collected from all patients. Statistical analyses were performed using SPSS software, version 22.0 (SPSS, Inc., Chicago, IL, USA). RESULTS: Prevalence of NAFLD was 10.6%. Significant differences were found with regard to age; levels aspartate transaminase, alanine transaminase, gamma-glutamyl transferase, and alkaline phosphatase; body mass index (BMI); and presence of NAFLD (p=0.014, p=0.022, p=0.003, p≤0.001, p=0.004, and p≤0.001, respectively). When compared to those with grade 1 NAFLD, levels of alanine transaminase, fasting blood glucose, gammaglutamyl transferase, triglycerides, total cholesterol and age variables were higher in those with grade 2 NAFLD. However, no statistically significant difference was noted when comparing grades of NAFLD. CONCLUSION: Though this study included patients with normal BMI and normal laboratory test results, presence of NAFLD was not rare in these otherwise healthy young men. Liver enzyme levels were within normal limits; however, there was slight tendency to be high consistent with presence and grade of NAFLD. Keywords: Healthy; non-alcoholic fatty liver disease; prevalence; ultrasonography.
N
onalcoholic fatty liver disease (NAFLD) is a clinicopathological entity leading to major health issues, like metabolic syndrome (MS), in both adults and children. It is described as a lipid accumulation in excess of 5% of the liver wet weight, without alcohol consumption [1, 2, 3]. A group of
pathologies ranging from simple hepatic steatosis to non-alcoholic steatohepatitis (NASH) and cirrhosis are defined as NAFLD. The word “hepatic steatosis” in this context specifies simple benign fatty infiltration of the liver. However, NASH refers to inflammation and necrosis of the hepatocytes, ac-
Received: October 11, 2016 Accepted: October 22, 2016 Online: November 16, 2016 Correspondence: Dr. Zehra KARACAER. Gulhane Egitim ve Arastirma Hastanesi, Enfeksiyon Hastaliklari ve Klinik Mikrobiyoloji, 06010 Ankara, Turkey. Tel: +90 312 - 249 10 11 e-mail: zehrakaracaer@yahoo.com © Copyright 2016 by Istanbul Northern Anatolian Association of Public Hospitals - Available online at www.kuzeyklinikleri.com
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companied by steatosis, and is diagnosed with a tissue biopsy [3]. The frequency of NAFLD varies throughout the different regions of the world, and is markedly predominant in certain places. In the United States (US), its frequency is estimated to be from 16% to 23%, and in Europe and the Middle East it ranges from 20% to 30% [3, 4]. In Turkey, the prevalence of NAFLD varies from 19.8% to 42% in adults, and from 6% to 11.8% among children [1, 2, 5, 6]. However, in those patients with MS, its prevalence is markedly higher, increasing to 69.94% [7]. To the best of our knowledge, there have been few studies published on the prevalence of NAFLD in healthy subjects in Turkey [8]. Moreover, the prevalence values from the US and Europe could be associated with a spectrum of different diseases, and cannot be applied directly to a healthy population. Therefore, this study was aimed at establishing the prevalence of NAFLD in individuals with no apparent risk factors for this disease in Turkey. MATERIALS AND METHODS For this research, a retrospective study was conducted in the radiology department in a military hospital in Turkey between 01 January 2012 and 31 October 2014. In total, 254 patients were included in this study population, which was taken from individuals admitted to the hospital for annual medical check-ups. These subject had normal parameters for their fasting blood glucose (FBG), aspartate transaminase (AST), alanine transaminase (ALT), γ-glutamyl transferase (GGT), alkaline phosphatase (ALP), triglycerides (TG), total cholesterol (TC), body mass index (BMI) and arterial blood pressure. NAFLD was determined and graded according to the ultrasonography (USG) findings. Due to the absence of grade 3 NAFLD, all of the subjects were divided into two groups according to the presence and grade of NAFLD. Our study group was similar in terms of age (20–45 years old), and all of them were males. The exclusion criteria were positive serology for hepa-
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Table 1. Demographic data and biochemical results of subjects
Variables Age (year) BMI (kg/m2) Weight (kg) Height (cm) ALT (0–45 U/L)* AST (0–35 U/L)* FBG (74–106 mg/dl)* GGT (0–55 U/L)* ALP (38–155 U/L)* TG (50–200 mg/dl)* TC (110–200 mg/dl)*
Median
Min.–Max.
27 24 74 178 19 21 92.0 17 64 84.5 167
21–41 19–25 56–90 166–193 7–45 10–34 73–105 6–51 15–116 50–200 103–200
ALP: Alkaline phosphatases; ALT: Alanine aminotransferase; AST: Aspartate aminotransferase; BMI: Body mass index; FBG: Fasting blood glucose; GGT: γ–glutamyltransferase; Min: Minimum; Max: maximum; TC: Total cholesterol; TG: Triglycerides; *: Normal value.
titis B virus and hepatitis C virus, the presence of other causes of liver disease, regular or excessive alcohol consumption (>40 gr/day), medical history which is significant for hepatic steatosis, established MS and obesity. The medical record data for all of the subjects was collected through a retrospective review of their charts, including: age, BMI, AST, ALT, FBG, TC, TG, ALT, AST, GGT, ALP and USG results. A hepatic USG examination was performed by two experienced radiologists with a GE Logiq 5 PRO ultrasound system (GE Medical Systems, Milwaukee, WI, USA) using a convex broadband (4–10 Mhz) transducer. In the assessment, NAFLD was defined as diffusely increased liver echogenicity when compared to the right kidney cortex, and graded according to the following criteria [9]. Grade 1: Increased diffuse echogenicity, but normal vascular walls and diaphragm echogenicity. Grade 2: The intrahepatic vein/artery walls and diaphragm echogenicity were partly obscured by the increased parenchyma echogenicity in a diffuse manner. Grade 3: The diaphragm wall echogenicity was
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Table 2. Results of the presence and the grade of NAFLD in patients
The presence of NAFLD p valueb (Median/Min.–Max.)
Present (n=27)
Absent (n=227)
The grade of NAFLD (Median/Min.–Max.) Grade 1 (n=20)
Grade 2 (n=7)
30.5 (22–41) 31 (23–40) Age (year) 31 (22–41) 27 (20–40) 0.014c 2 BMI (kg/m ) 25 (21–25) 23 (19–25) <0.001c 25 (21–25) 25 (22–25) Weight (kg) 79 (65–90) 74 (56–90) 0.012c 79.5 (69–90) 78 (65–88) Height (cm) 178 (167–188) 178 (166–193) 0.814 179.5 (167–188) 176 (172–186) a ALT (0–45 U/L) 23 (15–41) 21 (10–34) 0.003c 22.5 (15–41) 25 (15–35) a AST (0–35 U/L) 23 (16–34) 19 (7–45) 0.022c 23 (16–34) 21 (17–34) FBG (74–106 mg/dl)a 93 (80–103) 91 (73–105) 0.201 92 (80–101) 97 (86–103) GGT (0–55 U/L)a 25 (11–49) 17 (6–51) <0.001c 24.5 (11–49) 26 (19–33) a c ALP (38–155 U/L) 79 (18–99) 63 (15–116) 0.004 79 (18–99) 73 (59–93) TG (50–200 mg/dl)a 87 (56–199) 84 (50–200) 0.385 80.5 (58–183) 128 (56–199) TC (110–200 mg/dl)a 169 (133–199) 167 (103–200) 0.323 168 (133–199) 170 (147–193)
p valueb
Grade 3 (n=0) – – – – – – – – – – –
0.978 0.974 0.781 0.657 0.579 0.435 0.33 0.58 0.719 0.15 472
ALP: Alkaline phosphatases; ALT: Alanine aminotransferase; AST: Aspartate aminotransferase; BMI: Body mass index; FBG: Fasting blood glucose; GGT: γ–glutamyltransferase; Min: Minimum; Max: maximum; TC: Total cholesterol; TG: Triglycerides; NAFLD: Non-alcoholic fatty liver disease; a: Normal values; b: Mann-Whitney U; c: a p-value of <0.05 was considered statistically significant.
not visualized, and the posterior segments of the liver were poorly assessed. The Declaration of Helsinki and Good Clinical Practice Guidelines were respected during the entire process of enrolling patients and collecting, analysing and reporting the data. Verbal consent was obtained from patients. Approval from the local ethics committee was obtained before conducting this study (8000–1–15/ 16 February 2015). The statistical analysis was performed using the IBM SPSS 22.0 software. As described above, all of the subjects were divided into two groups, and descriptive statistics were applied to each group. The normal distribution of the variables was evaluated using the Kolmogorov-Smirnov test, and non-parametric methods were used for the non-normally distributed values (Mann-Whitney U and Kruskal Wallis). Because of the non-normal distribution, the continuous variables were obtained as the median (minimum-maximum). The categorical variables were presented as the frequency and percentage, and a p-value of <0.05 was considered to be statistically significant.
RESULTS A total of 254 male participants were included in this study. The demographic data and biochemical test results are shown in Table 1, and all of the patients had normal arterial blood pressure. The USG examination revealed NAFLD in a total of 27 of the subjects; of these, 20 had grade 1 and seven had grade 2. There were no instances of grade 3 NAFLD found in our subjects. According to our results, the prevalence of NAFLD was 10.6%. Although the levels of the liver enzymes were within the normal limits, there was a slight increasing tendency, according to the grade of NAFLD, in some of the applied tests. For example, the ALT, FBG, GGT, TG and TC values and the age were found to be higher in those subjects with grade 2 NAFLD than in those with grade 1 NAFLD. However, no difference was noted between the grade and the variables (Table 2). Significant differences were found between the age, weight, AST, ALT, GGT, ALP and BMI and the presence of NAFLD (p=0.014, p=0.012, p=0.022,
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p=0.003, p≤0.001, p=0.004 and p≤0.001, respectively) (Table 2). DISCUSSION The detailed biological behaviour of NAFLD is unclear, but it seems to be determined by the severity of the histological damage. Cross-sectional studies for NAFLD have shown that most subjects exhibit fatty liver only, and it is widely believed that the progression to steatohepatitis or fibrosis over time is a rare condition. Some publications have reported the frequency of advanced hepatic fibrosis to be 30%–40% at the time of diagnosis, whereas wellestablished cirrhosis was found in 10%–15% of the patients. A progression to hepatocellular carcinoma has also been emphasized in literature [10]. Although no significant increase has been reported in the mortality rates specifically related to NAFLD, those patients with NASH usually reveal higher mortality rates (35%–85%) when compared to the overall population [4]. There are various clinical conditions that may accompany NAFLD; for example, MS is a very important etiological factor in the development of NAFLD. It is defined by the following conditions: high waist circumference, hyperlipidaemia, hypertension and a high FPG level. Those patients having MS features are at a high risk for NAFLD. Other conditions presumed to be associated with NAFLD include ethnicity, certain medications (e.g. tamoxifen, corticosteroids and oestrogens), excess carbohydrates, rapid weight loss, altered small bowel anatomy, certain metabolic diseases (e.g. hypobetalipoproteinaemia, abetalipoproteinaemia, Wilson’s disease, etc.), infections (e.g. chronic hepatitis C virus, human immunodeficiency virus and acquired immune deficiency syndrome) and some evolving pathologies (e.g. polycystic ovary syndrome, hypothyroidism, etc.) [11]. Similar to other clinical conditions, with the increase in the prevalence of obesity, NAFLD has increased over time. Because it is the most common aetiology of cryptogenic cirrhosis (cirrhosis that cannot be explained by other causes), NAFLD has become a serious medical problem in the US [3].
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The prevalence of obesity is 32% for adults and 17% for adolescents in the US population [12], and the prevalence of NAFLD has been reported to be 75% in morbidly obese patients, with cirrhosis detected in 3–11% of them [4]. In pertinent publications, the prevalence of NAFLD in Turkey are 11.8% among obese children [2] and 32% among obese adults [5]. In our research, we found the prevalence of NAFLD to be 10.6%; however, we cannot establish a comparison due to the absence of related publications on healthy young subjects. We thought that the annual check-up provides the awareness of NAFLD. Therefore, our patients might take precautions against occurrence or progression of NAFLD. It is known that the frequency of NAFLD frequency increases with age [5, 13]. Our results showed lower prevalence rates when compared with the US and European statistics for adults [4], but similar rates to those children with NAFLD in Turkey [1, 2, 5, 6]. Unfortunately, our results cannot be compared with similar age groups in Turkey. The prevalence of NAFLD was found to be 23.2% in a transient elastography study on the basis of a controlled attenuation parameter (CAP) [8]. It is known that CAP obtained by transient elastography is a more sensitive method compared to US due to its capability to detect less severe grades of hepatic steatosis [14, 15]. Kaya et al. [8]. may observed higher prevalence because of using more sensitive method. The more well-known risk factors for NAFLD are a high BMI, advanced age and the presence of MS [5, 10, 16]. Our study group was composed of subjects that tested negative for hepatitis, with no identified risk factors for NAFLD, but there was a significant difference with regard to the age, weight, BMI, ALT, AST, GGT and ALP in terms of the development of NAFLD, which was observed in one of ten subjects. In spite of the participants’ normal hepatic enzyme levels, there was a slight tendency toward increasing, compatible with the grading of the NAFLD, in some of the applied tests. Although there could be one possible mechanism for the development of NAFLD in our subjects, due to the retrospective study design composed of
Okur et al., Non-alcoholic fatty liver disease
healthy young subjects, we cannot establish a hypothesis for this. However, we can estimate that an increase in the grade of NAFLD may cause a slight tendency toward an increase in the hepatic enzymes. Therefore, we suggest some preventive changes be considered at this stage, such as lifestyle modifications, dietary changes and/or sporting activities, before progression to grade 3 NAFLD. Our results showed that an apparent clinico-laboratory deterioration cannot be determined by routine physical or laboratory tests. We suggest that a liver USG is a very cost-effective and easily available imaging method which can help in the detection of these subjects before the development of severe fatty infiltration in the future. Furthermore, a strong correlation between NAFLD and coronary artery disease may be crucial to determining those subjects who have relevant risk factors for cardiovascular disease [16, 17, 18]. Therefore, USG can be applied as a screening tool along with routine check-ups. Many studies have revealed that liver enzymes can be helpful in the determination or prediction of NAFLD and its grading, but due to the high variability of liver enzymes (including AST and ALT), we cannot conclude that these enzymes play a definite role in the accurate diagnosis of NAFLD [17]. In their study, Abangah et al. [19] found that the BMI and TG are the most effective factors in determining the severity of fatty liver disease and USG grading of patients with NAFLD. However, AST was not found to be a reliable marker, according to that study, because it may show alterations in many conditions [19]. Some authors have suggested that the parameters related to MS (such as the BMI, ALT, AST, GGT and FBG) are significantly different in NAFLD, when compared to non-NAFLD cases. In addition, the BMI and AST were found to be statistically different [7]. Bellentani et al. [20] showed that 79% and 55% of patients with NAFLD had normal ALT levels. Therefore, ALT has no impact on the entire histological spectrum of NAFLD, and normal levels may accompany underlying NASH. This suggests an independent variable, and that the histological spectrum cannot be significantly different between elevated and normal ALT values [21]. Obika et al.
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[22] also showed that liver enzyme changes might not have any associations with NAFLD Moreover, approximately half of the NAFLD patients having persistently normal ALT values revealed potentially progressive liver disease [23]; therefore, the ALT level is not a reliable indicator in determining liver damage severity [24]. The prevalence of NAFLD has been rated and graded according to the USG results in many publications [9, 11, 13, 25, 26]. Overall, hepatic USG is a simple, noninvasive technique that is widely used in clinical practice to detect the fatty infiltration of the liver [27]. The sensitivity and specificity of USG for detecting NAFLD have been reported to range from 64% to 94% and from 84% to 97.3%, respectively [9, 28, 29, 30]. This study did have some limitations. For instance, our study group was composed of males only, because the participant recruitment was restricted to patients in a military hospital. Consequently, we could not evaluate our results with regard to gender differentiation. Another limitation was that liver biopsies were not performed in our subjects because there were no definite risk factors for advanced NAFLD in this population. Therefore, we were not able to predict any subjects with NASH among these participants. In most cases, NAFLD has a benign course, and due to the hazards associated with biopsies and the lack of established effective therapies, the role and effectiveness of liver biopsies remains a controversial issue. However, a liver biopsy is an accurate method for the diagnosis of NASH, and can detect the severity of liver damage in a long-term survey. The risk factors for advanced disease include an age >45 years old, the presence of type 2 diabetes mellitus or morbid obesity (BMI >39 kg/m2) and an AST/ALT ratio >1 [3, 10]. It seems more reasonable to avoid unnecessary biopsy interventions, limiting those to patients who are likely to have more advanced liver disease. Clinical and laboratory tests may not be a sensitive methods for diagnosing NAFLD at an early stage, and a complete history and physical examination should be used simultaneously with laboratory
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test results and USG findings [19]. We suggest that an annual check-up should be done with USG in NAFLD screening since, as in our study, mild or moderate NAFLD can often be detected in subjects with no risk factors. Those individuals at a mild or moderate stage should be informed and followed to prevent the progression of the disease. In conclusion, despite the fact that our study group was composed of healthy subjects with normal BMIs and normal laboratory test results, the prevalence of NAFLD was not a rare occurrence. Therefore, the metabolic determinants that show lipid accumulation in the liver may not play major predictive roles in patients with NAFLD. We thought that our results can be adapted for every male subject of similar age who have annual checkup and no regular or excessive alcohol consumption in our country. Further studies are required for a detailed evaluation of these individuals. Conflict of Interest: None declared. Financial Disclosure: The authors declared that this study has received no financial support. Authorship contributions: Concept – G.O., Z.K.; Design – G.O., Z.K.; Supervision – G.O., Z.K.; Data collection &/or processing – G.O., Z.K.; Analysis and/or interpretation – Z.K.; Literature search – Z.K.; Writing – G.O., Z.K.; Critical review – G.O., Z.K.
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North Clin Istanbul – NCI 7. Demir ME, Aydogan T, Pamukcu M, Ulas T, Eren MA. Ultrasound evaluation of metabolic syndrome patients with hepatosteatosis. Journal of clinical and Experimental Investigations 2013;4:153–8. 8. Kaya E, Demir D, Alahdab YO, Yilmaz Y. Prevalence of hepatic steatosis in apparently healthy medical students: a transient elastography study on the basis of a controlled attenuation parameter. Eur J Gastroenterol Hepatol 2016;28:1264–7. 9. Incedayı M, Pekkafali MZ, Sildiroglu HO, Basekim CC, Kizilkaya E. Sonographic and histopathological correlation in diffused fatty liver. Anatol J Clin Investig 2012;6:1–5. 10. Sass DA, Chang P, Chopra KB. Nonalcoholic fatty liver disease: a clinical review. Digestive Diseases and Sciences January 2005. 11. Puri P, Sanyal AJ. Nonalcoholic fatty liver disease: definitions, risk factors, and workup, (review). Clinical Liver Disease 2012;1:4. 12. Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obesity in the United States, 1999-2004. JAMA 2006;295:1549–55. 13. Wang CC, Hsu CS, Liu CJ, Kao JH, Chen DS. Association of chronic hepatitis B virus infection with insulin resistance and hepatic steatosis. J Gastroenterol Hepatol 2008;23:779–82. 14. Sasso M, Beaugrand M, de Ledinghen V, Douvin C, Marcellin P, Poupon R, et al. Controlled attenuation parameter (CAP): a novel VCTE™ guided ultrasonic attenuation measurement for the evaluation of hepatic steatosis: preliminary study and validation in a cohort of patients with chronic liver disease from various causes. Ultrasound Med Biol 2010;36:1825–35. 15. Schwenzer NF, Springer F, Schraml C, Stefan N, Machann J, Schick F. Non-invasive assessment and quantification of liver steatosis by ultrasound, computed tomography and magnetic resonance. J Hepatol 2009;51:433–45. 16. Sarikaya S, Vurdem UE, Erdem FH, Inci F, Erdem A. Relationship between the extent of coronary artery disease and fatty liver severity in nonalcoholic fatty liver disease patient. AIBU Izzet Baysal Tıp Fakultesi Dergisi 2012:7:1–3. 17. Agarwal AK, Jain V, Singla S, Baruah BP, Arya V, Yadav R, Singh VP. Prevalence of non-alcoholic fatty liver disease and its correlation with coronary risk factors in patients with type 2 diabetes. J Assoc Physicians India 2011;59:351–4. 18. Mohammadi A, Bazazi A, Maleki-Miyandoab T, GhasemiRad M. Evaluation of relationship between grading of fatty liver and severity of atherosclerotic finding. Int J Clin Exp Med 2012;5:251–6. 19. Abangah G, Yousefi A, Asadollahi R, Veisani Y, Rahimifar P, Alizadeh S. Correlation of Body Mass Index and Serum Parameters With Ultrasonographic Grade of Fatty Change in Non-alcoholic Fatty Liver Disease. Iran Red Crescent Med J 2014;16:12669. 20. Bellentani S, Scaglioni F, Marino M, Bedogni G. Epidemiology of non-alcoholic fatty liver disease. Dig Dis 2010;28:155–61. 21. Mofrad P, Contos MJ, Haque M, Sargeant C, Fisher RA, Luketic VA, et al. Clinical and histologic spectrum of nonalcoholic fatty
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117 26. Inci A, Meral CE. Ultrasonographic assessment of the prevalence of hepatic steatosis in inactive hepatitis B carriers. Viral Hepatitis Journal 2013;19:46–8. 27. Foster KJ, Dewbury KC, Griffith AH, Wright R. The accuracy of ultrasound in the detection of fatty infiltration of the liver. Br J Radiol 1980;53:440–2. 28. Joseph AE, Saverymuttu SH, al-Sam S, Cook MG, Maxwell JD. Comparison of liver histology with ultrasonography in assessing diffuse parenchymal liver disease. Clin Radiol 1991;43:26–31. 29. Saverymuttu SH, Joseph AE, Maxwell JD. Ultrasound scanning in the detection of hepatic fibrosis and steatosis. Br Med J (Clin Res Ed) 1986;292:13–5. 30. Palmentieri B, de Sio I, La Mura V, Masarone M, Vecchione R, Bruno S, et al. The role of bright liver echo pattern on ultrasound B-mode examination in the diagnosis of liver steatosis. Dig Liver Dis 2006;38:485–9.
Orıgınal Article
FAMILY MEDICINE
North Clin Istanbul 2016;3(2):118–23 doi: 10.14744/nci.2016.65487
Determining depression level of caregivers providing home healthcare services Bilal Arican,1 Murat Guney,2 Nuseybe Akbal,2 Bahadir Han Demiral,2 Ahmet Nadir,2 Ilknur Kavci Kokar,2 Mustafa Resat Dabak,2 Mehmet Sargin3 Department of Family Medicine, Mengen District State Hospital, Bolu, Turkey
1
Department of Family Medicine, Kartal Dr. Lutfi Kirdar Training and Research Hospital, Istanbul, Turkey
2
Department of Family Medicine, Istanbul Medeniyet University Goztepe Training and Research Hospital, Istanbul, Turkey
3
ABSTRACT OBJECTIVE: Due to increase in elderly population as result of longer life expectancy and the incidence of chronic disease, greater importance should be given to elderly care and the needs of primary caregivers. The purpose of this study was to determine depression status of caregivers who were providing in-home healthcare services. METHODS: This study was conducted with caregivers for 63 home-dependent patients who benefited from the services provided by Kartal Dr. Lutfi Kirdar Training and Research Hospital Family Practice Clinic between May 15, 2013 and July 1, 2013 using a socio-demographic variables questionnaire and the Beck Depression Inventory. Data were analyzed using Kolmogorov-Smirnov test, Mann-Whitney U test, Student’s-t test and chisquare test. RESULTS: Of the total, 87.3% of survey participants were women . Average age was 52.47 years; 73% were married, 17.5% were single, and 9.5% were widows. Monthly income of 50.8% of participants was between TL 1000 and 3000. Of all the patients, 77.8% were totally, and 22.2% were semi-dependent. Depression was detected in 61.1% of patient relatives who were responsible for patient healthcare and in 22.2% of paid professional caregivers (p=0.052). Depression was detected at rate of 37% in caregivers who had been providing nursing care for less than 1 year, 63% for those who had been caregivers for 1 to 5 years, and for those providing care for more than 5 years, rate was 63 %. Rate of depression in study participants overall was 55.6%. CONCLUSION: Duration of providing care, dependency level of patient, and level of intimacy affect caregivers. They need psychological support. Keywords: Beck; caregiver; depression; home care.
Received: November 24, 2015 Accepted: October 23, 2016 Online: November 12, 2016 Correspondence: Dr. Bilal ARICAN. Mengen Ilce Devlet Hastanesi, Bolu, Turkey. Tel: +90 374 - 356 10 20 e-mail: arican.bl@gmail.com © Copyright 2016 by Istanbul Northern Anatolian Association of Public Hospitals - Available online at www.kuzeyklinikleri.com
Arican et al., Determining depression level of caregivers providing home healthcare services
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ncreases in average life span, disability rates, and incidence of chronic diseases have brought about an increase in the number of applications to medical institutes with resultant crowding in hospitals. Prevention of the crowding in hospitals, reduction of health care expenses, and providing more comfort to home- care patients have revealed the crucial need for home health care services in the whole world [1, 2, 3]. Home health care services had been firstly brought to agenda in the United States of America in the 18th century, and in 1960s Medicare (goverment health insurance for elderly), and Medicaid (health insurance for the poor) had been legalized. Owing to dramatic cut they ensured in hospital heslth care expenditures, since then these health insurance systems have been widely used [4]. In our country, home health care services were legalized in the year 2005 and they were firstly applied by private health care organizations. With application of family medicine health care services, and establishment of Home Health Care Services, Ministry of Health, and Social Welfare started to offer home health care services free of charge [5]. Ministry of Health, and Social Welfare defined home health care services as “services provided by trained personnel with the intention to facilitate adaptaton of the bedridden patients caused by an ailment or senility to their present condition, to decrease their burden, and shorten their recovery process” [6]. In association with bed-, and home-dependent state due to senility, chronic disease and/or disability, physical, and mental state of the patients are impaired, and subsequently caregivers experience various problems. Each individual is in need of basic prerequisites as being loved, appreciated, and selfrealized, and social environments Individuals providing hrealth care services most of the time make sacrifices from their lives. However their services are not appreciated as they expect, and they are forced to estrange themselselves from social life [7, 8, 9]. According to TÜİK (Turkish Statistical Institute) data, in the year 2000, the population aged ≥65 years constituted 5.7% of the general population [10], while in the year 2013, this ratio raised
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to 7.7 in 2013 [11]. Increases in elderly population, and incidence of chronic diseases will also increase the number of home-dependent patients, and their caregivers, and accordingly the problems of their health care providers will come to light [12]. In the light of all this information, our study was planned, and realized based on a justification that investigations aiming at determination of depression levels of the caregivers providing home health care services for home-dependent patients is needed desperately. MATERIALS AND METHODS A face-to-face survey study was performed with caregivers who provided home health care services for 63 patients who applied to the outpatient clinics of family Medicine of Dr. Lütfi Kirdar Kartal Training and Research Hospital between 05.05.2013, and 07.01.2013. In this survey we aimed to encompass all of target group who received home health care services during the aforementioned time interval, rather than selecting a special sampling. As data collection tool interview forms prepared by the investigators, and Beck Depression Scale (BDS) so as to determine their levels of depression were used. The participants were interrogated regarding various sociodemographic variables as age, gender, educational state, income level, marital status, number of years spent for the care of the patient, their intimacy to the patient (professional personnel or a relative caring for the health of the elderly people), and dependency state (totally or partially dependent) of the patient. Based on the responses given to the questions contained in the BDS forms, severity of depression was categorized as minimal (0–9 pts), mild (10–16 pts), moderate (17–33 pts), and severe (≥34 pts) [13]. The data obtained were analyzed using SPSS (Statistical Package for the Social Sciences) package program. For normal distribution of continuous variables Kolmogorov- Smirnov test was employed. The groups with continuous variables were compared based on their distribution patterns with MannWhitney U or Student-t-test. For the comparison of categoric variables chi-square test was used. P<0.05 was accepted as the level of statistical significance.
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1, 2%
Table 1. Distribution of participants based on their sociodemographic characteristics Gender Female Male Educational status Illiterate Primary school Secondary school Lycée University (assocaite degree, licence, postgraduate) Marital status Married Single Divorced
n % 17, 27%
55 87.3 8 12.7 5 7.9 18 28.6 15 23.8 16 25.4 9 14.3
46 73 11 17.5 6 9.5
Minimal Mild Moderate Severe
28, 44%
17, 27%
Figure 1. Distribution of frequency of depression among all participants.
30
RESULTS Study population (total n, 63) consisted of 55 (87.3%) female, 46 (73%) married, 18 (28.6%) primary school- graduate participants with an overall median age of 52.4 (27–81) years (Table 1). Monthly income of the caregivers were 1000– 3000 (n=32; 50.8%), ≤1000 (n=29, 46%), and ≥3000 (n=2; 3.2%) Turkish Liras. Fifty-seven (85.7%) participants were relatives or intimates of the patients, while 9 (14.3%) participants were professionals caring for the elderly people. The caregivers enrolled in the study were providing healthcare services for fully- (n=49; 77.8%) or semi-dependent (n=14; 22.2%) patients Mild, moderate, and severe degrees of depression were detected in 17 (27%), 17 (27%), and 1 (1.6%) participant caregiver, respectively (Figure 1). Depression of various degrees of severity was seen in 61.2% (n=30) of caregivers of the totally dependent patients (mild, n=12; moderate, n=17, and severe, n=1), while mild depressive state was noted in 35.7% (n=5) of the health care personnel caring for semi-dependent patients (p<0.05). Depression
26
25
22
20 15
15
5 0
11
9
10 2 2
1
0
1 year or less Mild
6
4
1–5 years
Moderate
5 years and longer Severe
Total
Mild: Number of patients with mild depression Moderate: Number of patients with moderate depression Severe: Number of patients with severe depression Total: Total number of patients grouped based longevity of health care service
Figure 2. Distribution of severity of depression according to the duration of health care service.
was observed in 61.1% (n=33) of patients’ relatives, and in 22.2% (n=2) of paid caregivers (p=0.052). Depression was also detected in caregivers who were offering health care services for home- dependent patients for ≤1 (37%; n=4), 1–5 (63%; n=14), and ≥5 (65%; n=17) years in indicated percentages, respectively. (p=0.051) (Figure 2).
Arican et al., Determining depression level of caregivers providing home healthcare services
DISCUSSION In this study which was performed to draw attention to integrated approach in the presentation of home health care services, and detect rates of depression among caregivers, and most effective depressionstimulating factors, we revealed that 87.3% of the nursing personnel was of female gender. Altun et al. (1998), and Akca et al. (2005) also indicated that majority of these health care providers consisted of female caregivers [14, 15]. Based on the results of Household Labor Force Survey implemented by Turkish Statistical Institute, employment rate of Turkish population aged ≥15 years relative to the general population was 45.9% in the year 2013. Employment rates among male, and female population were estimated as 65.2, and 27.1%, respectively [11]. When these outcomes, and responsibilities, and social position imposed on female population by traditional population structure are taken into consideration, detection of higher number of female caregivers should not be a surprising outcome. Most of (85.7%) the caregivers who participated in our study were relatives of the patients. In many studies performed in Turkey on caregivers providing health care services for patients in need, it was observed that caregivers were mostly relatives of the patients (their sons, mothers, siblings) [13]. TAYA (Research on Turkish Family Structure) survey study conducted in 1992 revealed that 63% of the elderly was living at their home, with one of their children (36%) or nursing homes (1%) [16]. In TAYA survey study performed in 2011, the study participants aged between 18–60 years responded to the question related to their thoughts about their living place when they will become old, and unable to take good care of themselves as nursing home (nearly 17%), and 32% of them wanted to receive home health care services. In the same study, higher number of younster wanted to stay at nursing homes or requested home health care services. Considering changing sociocultural environment, and inadequate number of available nursing homes [17], the critical importance of home health care services in the future becomes apparent.
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Diagnosis of depression, their triggering factors, and classification have been the subject of researches, and debates for years. In a study performed among middle-aged people, lifetime prevalence of depression was found as 19 percent [18]. However researchers have detected varying incidence rates in special populations, and different segments of the society when compared with the population in general. Sahin et al. detected incidence rates of depression among individuals aged over 65 years staying in nursing homes, and living at their homes as 48.1, and 34.2%, respectively [19]. In a USA study on caregivers providing nursing care for chronic needy patients, the incidence of depression has been reported as 40 percent. In the same study, correlation between depressive symptoms, age, educational level, and the degree of nursing neediness of the patients was reported [20]. In a study by Aksayan, and Cimete, the authors reported that 66% of the caregivers experienced fatigueness, anxiety, and altered social life, and requested health professional at home to solve these problems [21]. In our study depression was detected in 55.6% of all caregivers. When workload, and emotional intimacy of the caregivers towards their patients were taken into consideration, higher incidence rates of depression are anticipated among nursing staff. Depression was observed in 61.2% (n=30), and 35.7% (n=5) of study participants who were providing health care services for their fully-, and semi-dependent patients, respectively (p<0.05). These findings may be attributed to challenging nursing care of fully dependent patients, impaired psychological mood of caregivers, their isolation from their social environment, and their sparing less time for themselves in comparison with those caring for semi-dependent patients. In studies performed, a significant correlation was detected between duration of health care services and incidence of depression. In cases where long-term patient care is required, depressive symptoms have been detected in 40–70% of caregivers, while diagnosis of depression has been made in 50% of them [22]. In our study, depression was detected in caregivers who were providing health care services for ≤1 (37%) year, 1–5 (63%), and >5 (65%) years in indi-
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cated incidence rates (Figure 2). Significant increase in depressive symptoms in line with the longevity of health care services might be related to isolation of the caregivers from their social environment, and friend circle, feeling themselves lonely, and increase in emotional intimacy with the patient. Therefore, the caregivers should be informed about burden of this process, and possible inconveniences, and necessary precautions should be taken. To this end, studies should be performed so as to protect mental, and physical health of caregivers, and required investigations, and follow-up should be conducted within the context of home health care services. In our study depression was significantly more frequently detected among relatives attending their patients when compared with professional caregivers. Depressive state was detected in 61.1% of these relatives, and in 22.2% of professional caregivers. Similar comparative study has not been encountered in the literature. Significant difference between both groups as for rates of depression may be attributed to much stronger emotional ties of the relative caregivers with their patients, and establishment of more closer empathy between these two groups. Professional caregivers who were paid for health care services they provide, may not develop emotional intimacy, and emphatize less frequently with the patient. In conclusion, lower rates of symptoms of depression in this group are anticipated. However it should not be forgotten that depression is a clinical diagnosis, and making a definitive diagnosis of depression without clinical evaluation based on BDS scoring system is not an appropriate approach. As established in various studies concerning the effects of sociodemographic variables on depression, low income level, illiteracy, unemployment, female gender, widowhood, and other social problems are among risk factors for depresion [23]. Contrary to expectations, in generalizations performed as a result of these studies similar prevalence rates of depression have been detected in populations with high,and low income levels [24, 25, 26]. Similarities were detected between rates of depression, and gender, income level, age, schooling, and marital status of our study participants without any significant correlation among these parametres.
North Clin Istanbul – NCI
Conclusion The importance of home health care service which is a new application for our country is obvious, and concensus is forming about its increasing impetus in near future. However outcomes of our study we performed during implementation of health care services have revealed that providing services for patients is not a satisfactory approach. Besides, caregiver’s need for psychologic, and physical support has been also revived in our study. Health care services should be improved, and provided with a multidisciplinary approach, and requirements for caregivers should be considered within this context. Conflict of Interest: None declared. Financial Disclosure: The authors declared that this study has received no financial support. Authorship contributions: Concept – B.A, M.R.D.; Design – B.A; Supervision – B.A.; Data collection &/or processing – B.A., M.G., N.A., A.N.; Analysis and/or interpretation – B.A, M.G., N.A., B.H.D., M.R.D.; Literature search – B.A., M.G.; Writing – B.A., M.G., I.K.K.; Critical review – B.A., M.S., M.R.D.
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Orıgınal Article
NEPHROLOGY
North Clin Istanbul 2016;3(2):124–30 doi: 10.14744/nci.2016.73383
Evaluation of nutritional status using anthropometric measurements and MQSGA in geriatric hemodialysis patients Irem Pembegul Yigit,1 Ramazan Ulu,2 Huseyin Celiker,2 Ayhan Dogukan2 Department of Nephrology, Malatya State Hospital, Malatya, Turkey
1
Department of Nephrology, Firat University Faculty of Medicine, Elazig, Turkey
2
ABSTRACT OBJECTIVE: Malnutrition is common among hemodialysis patients and is associated with higher rates of morbidity and mortality. The aim of this study was to evaluate nutritional status of geriatric hemodialysis patients. METHODS: Total of 163 hemodialysis patients were initially screened, and 55 patients (28 males, 27 females; mean age: 72.9±8.4 years) met the criteria for inclusion. Patients were divided into 3 groups according to modified quantitative subjective global assessment (MQSGA) scores: Group I (n=22) normal nutrition, Group II (n=20) mild-to-moderate malnutrition, and Group III (n=13) severe malnutrition. RESULTS: When we assessed the correlation between MQSGA nutrition score and data of malnourished patients (n=33), positive significant correlation was found between age, C-reactive protein level, and malnutrition-inflammation score. Negative significant correlation was found between body mass index, bicep skinfold, tricep skinfold, mid-arm circumference, mid-arm muscle circumference, and phosphate and albumin levels. CONCLUSION: Malnutrition is very common and increasing with aging in geriatric hemodialysis patients. MQSGA score and anthropometric measurements can be used to assess nutritional status in geriatric hemodialysis patients. Keywords: Anthropometric measurements; geriatric; hemodialysis; malnutrition; MQSGA.
I
n recent years, increasing numbers of geriatric patients started dialysis because of higher prevalence of diabetes mellitus (DM), hypertension, and cardiovascular diseases. According to the 2014 registry report [1], 48% of patients starting dialysis in Turkey were ≥65 years old. Due to the bio-
logical, psychological and social outcomes of aging, the prevalence of malnutrition is increasing in these patients. Protein-energy wasting (PEW), a state of loss of body protein mass and energy stores, is a common syndrome among patients on maintenance hemodialysis (MHD), and a large amount of argu-
Received: August 31, 2016 Accepted: October 18, 2016 Online: November 26, 2016 Correspondence: Dr. Irem Pembegul YIGIT. Malatya Devlet Hastanesi, Nefroloji Klinigi, Malatya, Turkey. Tel: +90 422 - 211 20 48 e-mail: pembegulmd@yahoo.com © Copyright 2016 by Istanbul Northern Anatolian Association of Public Hospitals - Available online at www.kuzeyklinikleri.com
Yigit et al., MQSGA in geriatric hemodialysis patients
ment shows that PEW is associated with increased morbidity and mortality in these patients [2]. The pathogenesis of PEW in MHD patients is multifactorial, including uremic milieu, metabolic acidosis, inadequate dialysis, secondary hyperparathyroidism, gastroparesis, loss of appetite, inadequate dietary calorie and protein intake, polypharmacy, hypercatabolism and comorbidities [3, 4]. The incidence of malnutrition among elderly MHD patients may be higher than younger patients [5]. Also, depression, cognitive dysfunction, poverty, loneliness and sedentarism are additional factors take part in the pathogenesis of PEW in geriatric MHD patients. According to various nutritional assessment methods, the prevalence of PEW in the elderly MHD patients is reported in a range of 26–77% [6]. PEW and inflammation often co-exist and are associated with accelerated atherosclerosis and is called malnutrition-inflammation-atherosclerosis (MIA) syndrome. The life expectancy and quality of life decrease with the increasing incidence of the components of the MIA syndrome in MHD patients [7, 8]. Because of this situation international guidelines recommend that nutritional status should be assessed periodically in patients on MHD. The wide range of prevalence of PEW in MHD patients is probably explained by the lack of a gold standart to detect PEW in these patients and nutritional status is frequently ignored in many dialysis centers. Different methods are used to assess the nutritional status of MHD patients, such as Subjective Global assessment (SGA), modified quantitative subjective global assessment (MQSGA) and malnutrition–inflammation score (MIS). MQSGA was developed by Kalantar-Zadeh et al. [9], suggesting that a modified malnutrition scoring system may be superior to the SGA and an inexpensive, rapidly conducted tool used by physicians to assess PEW in MHD patients. In current literature, there is very little data about the nutritional status of geriatric MHD patients. Hence, in this study, we assessed the nutritional status of geriatric MHD patients in our HD units using standard techniques of assessment like anthropometric measurements and biochemical parameters and the correlation with MQSGA and MIS.
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MATERIALS AND METHODS Patients This cross sectional study was performed at Hemodialysis Units of Firat University and Malatya State Hospital, Turkey. The study was approved by the Local Ethic Committee of Firat University and all patients gave written informed consent. All subjects underwent detailed clinical examination. Demographic information and medical history of patients were obtained at baseline by interview with patients and review of the medical records. 163 MDH patients were initially screened and 55 patients included due to no presence of an exclusion criteria. Exclusion criteria of the study were as follows: Patients who had been receiving HD for less than 3 months, <65 years old, serum PTH levels >800 pg/ml, malignancy, infectious disease, insufficient dialysis (Kt/Vurea <1.2), receiving parenteral nutrition, treatment with immunosuppressor drugs, unwillingness to participate to the study and unable to answer the questions due to dementia. All patients received 3 times a week about 3.5–4 h/each session on standard bicarbonate dialysis using a standart biocompatible HD membrane. Blood flow rates were 250–300 ml/min and dialysate flow rates were 500 ml/min. Ultrafiltration varied according to the patients’ actual weight. Patients divided into three groups according to MQSGA scores, Group I (n=22) normal nutrition, Group II (n=20) mildto-moderate malnutrition, and Group III (n=13) severe malnutrition. Laboratory assessment Blood samples were taken after an overnight fast in the morning between 07.00–08.00 a.m. before the HD session. At the end of the HD session the blood pump speed was reduced to <80 ml/min and blood samples was obtained at 2 min post-dialysis from the arterial dialysis tubing for the calculation of the adequacy of dialysis by Kt/Vurea. Laboratory analyses, including creatinine, total cholesterol, triglyceride, albumin, iron, total iron binding capacity (TIBC), albumin, calcium, phosphorus, alkaline phosphates (ALP), parathyroid hormone (PTH), hemoglobin (Hb) and C-Reactive Protein (CRP)
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were measured by standard laboratory methods in central laboratories at the same day and by using standard automated methods. Kt/Vurea calculations of the patients were made on-line via the Hypertension Dialysis and Clinical Nephrology website (www.hdcn.com) by submitting patients’ dialysis technique and test results. Modified quantitative subjective global assessment MQSGA involves seven components; weight change, dietary intake, gastrointestinal symptoms, functional capacity, comorbidity, signs of subcutaneous fat and muscle wasting. Each component was given a score from 1 (normal) to 5 (very severe). The MQSGA score, sum of all components, ranged from 7 (normal) to 35 (severely malnourished). Patients were categorized into three groups: normal nutrition (score of 7–10), mild-to-moderate malnutrition (score of 11–20), and severe malnutrition (score of 21–35). Malnutrition-inflammation score MIS is regarded as one of the comprehensive and specific scoring systems spesific for evaluation of MIA in MHD patients (10). This questionnaire includes 10 parameters and evaluated by giving scores between 0 (normal) and 3 (severely malnourished). The first three sections are similar to SGA items, but the fourth section includes serum albumin and TIBC. The MIS has total score ranging from 0 (normal) to 30 (severely malnourished and inflammation status). Anthropometric measurements Height, body weight and anthropometric measurements were performed within 10–30 minutes after HD treatment by the nephrologist. Biceps skinfold (BSF) and triceps skinfold (TSF) thicknesses were measured with a conventional skinfold caliper using standard techniques. Mid-arm circumference (MAC) was measured with a plastic tape. Mid-arm muscle circumference (MAMC) was calculated from the formula: MAMC=MAC - (3.1415xTSF). All anthropometric measurements were performed
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non-access arm. Body mass index (BMI) was calculated as the ratio of post-HD body weight in kilogram and the square of the height in meters (kg/m2). Statistical analysis Statistical analyses were performed using the Statistical Package for Social Sciences for Windows ver 17.0 (SPSS Inc., Chicago, IL, USA). All categorical variables were reported as percentages and compared using chi-square test. Continuous variables were presented as mean±standard deviation (SD). Normality of variables was assessed by Kolmogorov–Smirnov test. Kruskal-Wallis test was conducted to compare parameters among groups and the Mann-Whitney U test was performed to test the significance of pairwise differences for multiple comparisons. Pearson correlation coefficient test was used to assess the strength of association between MQSGA score and antropometric parameters. For all statistical tests, p value of <0.05 was considered as statistically significant. RESULTS Our study included 55 geriatric patients 28 males and 27 females with the mean age of 72.9±8.4 (range 65–79) years. The cause of renal failure among MHD patients included diabetic nephropaty, 17 (30.9%); hypertension 22 (40.0%), chronic glomerulonephritis, 3 (5.4%), polycystic kidney disease, 3 (5.4%), other 2 (3.6%), and unknown in 8 (14.6%) patients. The mean duration of HD was 30.36±15.70 (range 3–63) months. Only three patients had central venous permanent catheters and the others (n=52) had arteriovenous fistula. Based on the MQSGA score, 22 patients (40%) were found to have adequate nutritional status, 20 patients (36.4%) had mild-to-moderate malnutrition and 13 patients (23.6%) had severe malnutrition. Demographic characteristics, baseline data, anthropometric measurements and laboratory parameters of study population are presented in Table 1 and Table 2. All anthropometric measurements of patients with normal nutrition were significantly higher than patients with both mild-to-moderate and
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Table 1. Demographic characteristics parameters in the three groups subdivided according to MQSGA scores Parameter Age (year) Gender Female Male Comorbid conditions (%) Diabetes Hypertension Coronary arter disease Periferal vascular disease Literate (%) Living with the family (%) HD duration (month) Kt/Vurea BMI (kg/m2)
Group I (n=22)
Group II (n=20)
Group III (n=13)
68.9±3.4
70.3±4.5
78.6±3.6
13 8 7 9 12 6 40.9 30.0 15.4 36.4 25.0 46.1 18.2 25.0 30.8 – 10 23 59 55 23 90.9 95 84.6 32.8±13.6 29.6±16.1 28.2±11.8 1.4±0.1 1.3±0.2 1.3±0.1 22.9±2.3 21±1.6 18.5±1.5
BMI: Body mass index; HD: Hypertension dialysis; MQSGA: Modified quantitative subjective global assessment.
severe malnutrition. Serum albumin, Hb, total iron binding capacity, creatinin, phosphate levels were significantly lower in patients both mild-tomoderate and severe malnutrition. The MQSGA score had no significant correlation with gender (p>0.05) and duration of HD (p>0.05), both men and women had equal tendency toward malnutrition. Additionally, if the sample was divided between those who had diabetes and those who did not, there was no significant correlation between diabetes and MQSGA score. When we assessed the correlation between MQSGA score and data in only malnourished patients (n=33), a positive significant correlation was found between age (r=0.645, p=0.000), CRP (r=0.239, p=0.032), MIS (r=0.612, p=0.000) and negative significant correlation was found between BMI (r=-0.663, p=0.000), BSF (r=-0.702, p=0.000), TSF (r=0.587, p=0.000), MAC (r=-0.841, p=0.000), MAMC (r=-0.830, p=0.000), phosphate (r=0.324, p=0.014), albumin (r=-0.519, p=0.011), Hb (r=-0.439, p=0.026) and total iron binding capacity (r=-0.243, p=0.039) (Table 3).
DISCUSSION PEW is always underestimated and may lead to serious consequences in geriatric MHD patients, including impaired physical functioning, poorer quality of life, frequent superimposed illness and increased mortality [10]. KDOQI suggested that MHD patients should have periodic nutrition screening, consisting of laboratory measures (eg, albumin), body weight and food intake and repeated screening for malnutrition every six months [11]. The present study analyzed the prevalence of PEW defined according to MQSGA score and anthropometric measurements in elderly MHD patients. 60% of our elderly MHD patients had malnutrition (36.4% of patients had at mild-tomoderate and 23.6% of patients had at severe level) and MQSGA score was elevated with patients’ age. Even though, previous studies showed that malnutrition was significantly more frequent in women [12, 13], our study no significant correlation between malnutrition and gender. In elderly patients social isolation, cognitive dysfunction in maintain-
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Table 2. Laboratory parameters and anthropometric measurements of study population Parameter
Group I (n=22)
Hemoglobin (g/dl) Creatinine (mg/dl) Total cholesterol (mg/dl) Triglyceride (mg/dl) Albumin (g/dl) Phosphorus (mg/dl) Calcium (mg/dl) TIBC (mg/dl) PTH (pg/ml) CRP (mg/l) MQSGA MIS TSF (mm) BSF (mm) MAC (cm) MAMC (cm)
Group II (n=20)
Group III (n=13)
11.6±0.4 10.4±0.3 9.2±0.6 9.6±2.7 9±2.5 7.8±1.7 184.6±52.3 163.2±37.4 140.1±23.9 178.4±82.9 155.1±41.9 133.4±26.4 4±0.6 3.5±0.8 2.4±0.4 4.9±1.2 4.9±1 3.2±0.9 9±1.8 9.2±1.9 8.8±1.4 189.2±43.4 160.6±65.7 141.9±32.1 346.3±72.9 301.2±119.7 215.3±62.2 2.9±1.3 3.8±1 4.9±1.2 8.1±1.6 13.2±2.4 22.8±2.8 8.4±2.1 12.2±1.4 15.3±1 11.9±2.1 10.8±1.6 8.9±1.1 15.4±2 13.4±1.8 11±1 27.3±1.6 25.6±1 22.5±1.2 24±1.5 22.2±1 19.4±1
p value
a,b,c b,c a,b,c a,b,c a,b,c b,c NS a,b,c b,c b,c a,b,c a,b,c a,b,c a,b,c a,b,c a,b,c
BSF: Biceps skinfold; CRP: C-reactive protein; MAC: Mid-arm circumference; MAMC: Mid-arm muscle circumference; MIS: Malnutrition–inflammation score; MQSGA: Modified quantitative subjective global assessment; PTH: Parathyroid hormon; TIBC: Total iron binding capacity; TSF: Triceps skinfold; a: Comparison between group I and group II is p<0.05; b: Comparison between group II and group III is p<0.05; c: Comparison between group I and group III is p<0.05.
Table 3. The correlation analysis of anthropometric as-
sessment and MQSGA in MHD patients with malnutrition Parameters r p BMI (kg/m2) BSF (mm) TSF (mm) MAC (cm) MAMC (cm)
-0.663 -0.702 -0.587 -0.841 -0.830
0.000 0.000 0.000 0.000 0.000
BMI: Body mass index; BSF: Biceps skinfold; MAC: Mid-arm circumference; MAMC: Mid-arm muscle circumference; TSF: Triceps skinfold.
ing basic nutritional requirements and depression may result in malnutrition. Furtermore, literacy state and living with family did not affect nutrition status in our patient groups. Patients with DM have a higher incidence of PEW in comparison with non-DM in MHD pa-
tients. Both insulin deprivation and degree of insulin resistance appear to play important role in this process [14, 15]. In our study, there was no significant correlation with MQSGA score and DM in elderly MHD patients. We concluded that this is related with small number of diabetic malnurished elderly patients. A serum cholesterol of <100 mg/dL suggests the presence of protein-energy wasting among hemodialysis patients [16]. Although lower total cholesterol levels were observed in malnurished geriatric MHD patients, this study found no statically significant correlation between MQSGA scores and cholesterol levels [17, 18]. Serum phosphorus levels were found low in elderly patients and this was considered as related with poor nutritional intake. When giving phosphorus binding threapy in elderly patients, it must be taken into account that this may lead lead to wasting, with loss of muscle mass and strength and ultimately worse physical functioning. A previous
Yigit et al., MQSGA in geriatric hemodialysis patients
study showed that dose of dialysis was associated with improvement of nutritional status in MHD patients [19]. In our study, patient groups had a range of Kt/Vure between 1.3 and 1.6 and there was no marker for inadequate dialysis for malnutrition. BMI and serum albumin levels have been traditionally known as nutritional markers. Many studies emphasize the protective effect of a higher BMI is in improved survival in MHD patients [20, 21]. Additionally, a BMI lower than 20 kg/m2 is considered an index of malnutrition [22] and was found in the 48.5% of the malnourished patients. In this study, we measured serum albumin levels to indirectly assess malnutrition and we found elderly malnourished MHD patients have significantly low albumin levels than well nourished patients. This may be due to lower protein intake, a lower rate of albumin synthesis or underlying inflammation among this population. Also, hypoalbuminemia has been the strongest predictor of cardiovascular disease and mortality in MHD patients [23, 24]. Additionally, phycisians must keep in mind the specificity of serum albumin as a nutritional marker is limited in the presence of inflammation and fluid overload. Inflammation is also an important factor affecting malnutrition and often co-exists in MHD patients. Meuwese et al. have reported that inflammation induced to increased lipolysis, muscle protein impairment, leading to sarcopenia, anorexia and increased mortality in these patients [25]. According to Kalantar-Zadeh et al study, CRP had significant correlation with MQSGA, similar to our finding [26]. Additionally, we showed that both serum CRP levels and MIS were significantly higher in malnourished elderly patients. The MIS was found significantly associated with hospitalization and mortality as well as indices of nutrition, inflammation and anemia [27, 28]. Malnutrition is a preventable and treatable condition, if it is identified earlier. The MAC reflects the thickness of subcutaneous fat and muscle and MAMC measures the protein status in the body. This study showed that anthropoemetric measurements (TSF, BSF, MAC and MAMC) had a significant negative correlation both MQSGA
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score and MIS in malnourished MHD patients. And these findings were similar to previous studies [10, 29] suggesting that decrease in anthropometric measurements is associated with increased malnutrition. Also, we found that anthropometric measurements had a significant positive correlation with BMI. According to our data, malnourished patients significantly have lower BMI than nonmalnourished patients. A meta-analysis reported the association of lower mortality rates in HD patients with higher BMI [30]. Combination of these anthropometric assessments may be as effective as MQSGA for evaluation of malnutrition of geriatric MHD patients and more frequent nutritional status evaluation in these patients may be more useful. There are several limitations in this study. The small sample size may limit the power of the study. We did not analyze inflammatory markers (except CRP) to quantify the degree of systemic inflammation. Additionally, we did not use more elaborate methods, such as dual energy X-ray absorptiometry (DEXA) and bioelectrical impedance in this study. A large prospective study is needed to assesment of nutritional status and recommendations for prevention and treatment of malnutrition in elderly MHD patients. In conclusion, malnutrition is very common and increasing with aging in geriatric MHD patients and physicians must be careful at early stage of malnutrition so as to increase the quality of life of these patients. MQSGA and antrophometric measurements may use to assess nutritional status in geriatric MHD patients. Conflict of Interest: None declared. Financial Disclosure: The authors declared that this study has received no financial support. Authorship contributions: Concept – I.P.Y., R.U.; Design – I.P.Y., R.U; Supervision – I.P.Y., R.U., H.C., A.D.; Materials – I.P.Y., R.U.; Data collection &/or processing – I.P.Y., R.U; Analysis and/or interpretation – I.P.Y., R.U.; Literature search – I.P.Y., R.U.; Writing – I.P.Y., R.U.; Critical review – H.C., A.D.
REFERENCES 1. Suleymanlar G, Ates K, Seyahi N. National Nephrology, Dialysis and Transplantation Registry Report of Turkey 2014. Ministry of Health and Turkish Society of Nephrology Joint Report,
130 Ankara 2015. 2. Riella MC. Nutritional evaluation of patients receiving dialysis for the management of protein-energy wasting: what is old and what is new? J Ren Nutr 2013;23:195–8. 3. Dukkipati R, Kopple JD. Causes and prevention of proteinenergy wasting in chronic kidney failure. Semin Nephrol 2009;29:39–49. 4. Kim JC, Kalantar-Zadeh K, Kopple JD. Frailty and proteinenergy wasting in elderly patients with end stage kidney disease. J Am Soc Nephrol 2013;24:337–51. 5. Canaud B, Tong L, Tentori F, Akiba T, Karaboyas A, Gillespie B, et al. Clinical practices and outcomes in elderly hemodialysis patients: results from the Dialysis Outcomes and Practice Patterns Study (DOPPS). Clin J Am Soc Nephrol 2011;6:1651–62. 6. Santin FG, Bigogno FG, Dias Rodrigues JC, Cuppari L, Avesani CM. Concurrent and Predictive Validity of Composite Methods to Assess Nutritional Status in Older Adults on Hemodialysis. J Ren Nutr 2016;26:18-25. 7. Kalantar-Zadeh K, Ikizler TA, Block G, Avram MM, Kopple JD. Malnutrition-inflammation complex syndrome in dialysis patients: causes and consequences. Am J Kidney Dis 2003;42:864–81. 8. Mazairac AH, de Wit GA, Grooteman MP, Penne EL, van der Weerd NC, van den Dorpel MA, et al. A composite score of protein-energy nutritional status predicts mortality in haemodialysis patients no better than its individual components. Nephrol Dial Transplant 2011;26:1962–7. 9. Kalantar-Zadeh K, Kleiner M, Dunne E, Lee GH, Luft FC. A modified quantitative subjective global assessment of nutrition for dialysis patients. Nephrol Dial Transplant 1999;14:1732–8. 10. Chen J, Peng H, Yuan Z, Zhang K, Xiao L, Huang J, et al. Combination with anthropometric measurements and MQSGA to assess nutritional status in Chinese hemodialysis population. Int J Med Sci 2013;10:974–80. 11. K/DOQI, National Kidney Foundation. Clinical practice guidelines for nutrition in chronic renal failure. Am J Kidney Dis 2000;35:1–140. 12. Espahbodi F, Khoddad T, Esmaeili L. Evaluation of malnutrition and its association with biochemical parameters in patients with end stage renal disease undergoing hemodialysis using subjective global assessment. Nephrourol Mon 2014;6:16385. 13. Farrokhi R, Majdzadeh N, Dehghani M. Assessing Protein Intake through Urea Production Rate in Chronic Hemodialysis Patients of Kerman in 2001. J Kerman Univ Med Sci 2004;11:188–96. 14. Cano NJ, Roth H, Aparicio M, Azar R, Canaud B, Chauveau P, et al. Malnutrition in hemodialysis diabetic patients: evaluation and prognostic influence. Kidney Int 2002;62:593–601. 15. Pupim LB, Flakoll PJ, Majchrzak KM, Aftab Guy DL, Stenvinkel P, Ikizler TA. Increased muscle protein breakdown in chronic hemodialysis patients with type 2 diabetes mellitus. Kidney Int
North Clin Istanbul – NCI 2005;68:1857–65. 16. Fouque D, Pelletier S, Mafra D, Chauveau P. Nutrition and chronic kidney disease. Kidney Int 2011;80:348–57. 17. Basaleem HO, Alwan SM, Ahmed AA, Al-Sakkaf KA. Assessment of the nutritional status of end-stage renal disease patients on maintenance hemodialysis. Saudi J Kidney Dis Transpl 2004;15:455–62. 18. Zhang K, Cheng G, Cai X, Chen J, Jiang Y, Wang T, et al. Malnutrition, a new inducer for arterial calcification in hemodialysis patients? J Transl Med 2013;11:66. 19. Azar AT, Wahba K, Mohamed AS, Massoud WA. Association between dialysis dose improvement and nutritional status among hemodialysis patients. Am J Nephrol 2007;27:113–9. 20. Piccoli A, Nigrelli S, Caberlotto A, Bottazzo S, Rossi B, Pillon L, et al. Bivariate normal values of the bioelectrical impedance vector in adult and elderly populations. Am J Clin Nutr 1995;61:269–70. 21. Kopple JD, Zhu X, Lew NL, Lowrie EG. Body weight-forheight relationships predict mortality in maintenance hemodialysis patients. Kidney Int 1999;56:1136–48. 22. Fouque D, Vennegoor M, ter Wee P, Wanner C, Basci A, Canaud B, et al. EBPG guideline on nutrition. Nephrol Dial Transplant 2007;22 Suppl 2:45–87. 23. Goodkin DA, Bragg-Gresham JL, Koenig KG, Wolfe RA, Akiba T, Andreucci VE, et al. Association of comorbid conditions and mortality in hemodialysis patients in Europe, Japan, and the United States: the Dialysis Outcomes and Practice Patterns Study (DOPPS). J Am Soc Nephrol 2003;14:3270–7. 24. Foley RN, Parfrey PS, Harnett JD, Kent GM, Murray DC, Barre PE. Hypoalbuminemia, cardiac morbidity, and mortality in end-stage renal disease. J Am Soc Nephrol 1996;7:728–36. 25. Meuwese CL, Carrero JJ, Stenvinkel P. Recent insights in inflammation-associated wasting in patients with chronic kidney disease. Contrib Nephrol 2011;171:120–6. 26. Kalantar-Zadeh K, Kopple JD, Block G, Humphreys MH. A malnutrition-inflammation score is correlated with morbidity and mortality in maintenance hemodialysis patients. Am J Kidney Dis 2001;38:1251–63. 27. Afşar B, Sezer S, Ozdemir FN, Celik H, Elsurer R, Haberal M. Malnutrition-inflammation score is a useful tool in peritoneal dialysis patients. Perit Dial Int 2006;26:705–11. 28. Kalantar-Zadeh K, Block G, McAllister CJ, Humphreys MH, Kopple JD. Appetite and inflammation, nutrition, anemia, and clinical outcome in hemodialysis patients. Am J Clin Nutr 2004;80:299–307. 29. Jones CH, Wolfenden RC, Wells LM. Is subjective global assessment a reliable measure of nutritional status in hemodialysis? J Ren Nutr 2004;14:26–30. 30. Jialin W, Yi Z, Weijie Y. Relationship between body mass index and mortality in hemodialysis patients: a meta-analysis. Nephron Clin Pract 2012;121:102–11.
CASE REPORT
PM&R
North Clin Istanbul 2016;3(2):131â&#x20AC;&#x201C;4 doi: 10.14744/nci.2015.33043
Inflammatory arthritis mimicking Complex Regional Pain Syndrome (CRPS) in a child: A case report Zeliha Egilmez,1 Selin Turan Turgut,2 Afitap Icagasioglu,1 Irem Bicakci1 Department of Physical Medicine and Rehabilitation, Istanbul Medeniyet University, Goztepe Training and Research Hospital,
1
Istanbul, Turkey Physical Medicine and Rehabilitation Clinics, Red Crescent Society Private Commodity Exchange Hospital, Konya, Turkey
2
ABSTRACT Joint complaints in childhood are seen frequently and differential diagnosis can be difficult. Juvenile idiopathic arthritis (JIA) is the most common rheumatological disease of childhood. It involves peripheral joint arthritis, chronic synovitis, and extra-articular manifestations. Accurate diagnosis can take a long time and sometimes multiple diagnoses are used while following the patient until a final diagnosis can be reached. Arthritis may be triggered by trauma and confused with other diseases like complex regional pain syndrome (CRPS), in which trauma plays a role in the etiology. In the present case, ankle pain in an 8-year-old girl was misdiagnosed as CRPS. Keywords: Arthritis; child; complex regional pain syndrome.
J
oint complaints in childhood are common and differential diagnosis can be difficult. Juvenile idiopathic arthritis ( JIA) is the most frequently seen rheumatic disease in childhood [1]. JIA is a disease primarily involving the peripheral joints and is accompanied by chronic synovitis and extraarticular findings. Although the etiology and risk factors of the disease are not precisely known, immunogenetic susceptibility and environmental factors are suspected. Infections, physical trauma and stress to joints, and immune hyperactivity against self-antigens may be other causes [2, 3]. Post-
traumatic oligoarthritis may be attributed to new autoantibodies produced as a result of damage. The most common type of juvenile rheumatoid arthritis ( JRA) is oligoarthritis accompanied by antinuclear antibody (ANA) positivity and uveitis, which is more commonly observed in girls [4]. JIA is diagnosed clinically. The precise diagnosis may take a long time. Therefore, patients may be monitored using multiple diagnoses at the outset. CRPS is a syndrome characterized by pain in distal extremities, edema, restricted mobility, skin changes and vasomotor disorders. It is classified
Received: May 10, 2015 Accepted: October 28, 2015 Online: April 04, 2016 Correspondence: Dr. Zeliha EGILMEZ. Istanbul Medeniyet Universitesi Goztepe Egitim ve Arastirma Hastanesi, Fiziksel Tip ve Rehabilitasyon Klinigi, 34722 Kadikoy, Istanbul, Turkey Tel: +90 216 566 40 00 e-mail: zelihagencoglu@hotmail.com Š Copyright 2016 by Istanbul Northern Anatolian Association of Public Hospitals - Available online at www.kuzeyklinikleri.com
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as CRPS Type 1 (reflex sympathetic dystrophy [RSD]), which develops without a known nerve lesion, and CRPS Type 2 (causalgia), which develops due to a nerve lesion [5]. Various symptoms and findings, such as allodynia, hyperalgesia, swelling, sweating and changes in skin blood flow, motor weakness, increased or decreased hair growth, thin and glowing skin, and osteoporosis may indicate CRPS [6]. The most common cause is trauma, resulting in bone fracture and soft tissue damage. However, there is no underlying cause in 2â&#x20AC;&#x201C;17% of cases. This article presents a JIA case that was mistaken for CRPS Type 1. CASE REPORT An 8-year old girl presented at the clinic with complaints of pain, swelling and restricted mobility persisting for 3 months in her right ankle (Figure 1). She stated that she had initially sought emergency medical attention for pain in her ankle after unintentionally stepping on her foot. Two-sided ankle radiography appeared normal, and naproxen sodium of 20 mg/kg/day, ice therapy, and resting splint were recommended with diagnosis of soft tissue injury. Ankle radiography was repeated after patient presented at orthopedic clinic after 1 month of continued pain, and spotted osteoporosis (OP) was detected in calcaneus and navicular bones (Figure 2). Multiple hyperintense signal increases were observed in spotted form on T2weighted MRI (magnetic resonance imaging) series in millimetric sizes in all tarsal bones, as well
Figure 1. Swollen right ankle.
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Figure 2. Spotted osteoporosis in calcaneus and navicular bones.
as the presence of tibiotalar-diffused intra-articular effusion, fluid in most of the intertarsal joints and surrounding peroneal tendons and tibialis posterior tendon consistent with tendinitis (Figures 3, 4). Diagnosed with CRPS Type 1 secondary to trauma, analgesic treatment and contrast bath were recommended. Patient next presented at outpatient clinic with non-regressed complaints. There was morning stiffness for about 5 to 10 minutes and she limped throughout the day. There were no symptoms of fever, rash, abdominal
Figure 3. Spotted form and millimetric sizes in all tarsal bones, fluid collection surrounding the peroneal tendons and tibialis posterior tendon.
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normal. Pediatric rheumatology department was consulted with assumed diagnosis of oligoarticular JIA. Pre-diagnosis was confirmed by pediatric rheumatology department, and treatment with sulfasalazine 500 mg 2×1 was initiated, as an insufficient response had been obtained with longterm, full-dose nonsteroidal anti-inflammatory drug (NSAID) therapy. Decreases in pain and swelling were observed in a follow-up examination conducted 1 month later, and decreases in inflammatory markers were also observed in laboratory tests (erythrocyte sedimentation rate [ESR]: 11 mm/h, WBC: 8700). Figure 4. Tibiotalar-diffused intra-articular effusion, fluid collection in intertarsal joints.
pain, chest pain, weight loss or muscle weakness. There were no systemic diseases, recent upper respiratory tract infection or chronic drug use in her medical history. There were no specific diseases in family history or systemic examination. Pain that increased with movement, swelling, temperature increase and edema were observed in the right ankle. There was no redness, coldness, hyperhidrosis, hypohidrosis, atrophy, change to hair, allodynia or hyperalgesia. Right ankle mobility ranges were 5° for dorsiflexion and 45° for plantar flexion. Examination results for other extremities were normal. Laboratory results for erythrocyte sedimentation rate (ESR), white blood cell (WBC), hemoglobin and platelet count were found to be 40 mm/h, 13400, 12.4 g/dL and 334000, respectively; and renal and hepatic functions, electrolytes and uric acid results were normal. Urine analysis revealed no pathology. Anti-streptolysin-O (ASO), C-reactive protein (CRP), rheumatoid factor (RF) and anti-double-stranded DNA antibody (antidsDNA) results were negative. While immunoglobulin (Ig) A, Ig G, and Ig M levels were normal, Ig E was 671.00(↑). Anti-nuclear antibody ANA (+) indirect immunofluorescence (IIF) 1/100 Ig G (+) showed a speckled, finely granular pattern. Sacroiliac joint radiography and MRI were
DISCUSSION JIA defines a group of diseases characterized by arthritis of unknown origin that lasts for more than 6 weeks in 1 or more joints with onset before 16 years of age. It is classified as oligoarticular, polyarticular, or systemic-onset JIA based on clinical findings and laboratory characteristics within first 6 months. The most common type of JIA is oligoarticular JIA (50–60%). Some 50% of patients present monoarthritis with asymmetric involvement of joints of the lower extremities [7]. In this case, history of trauma, pain, swelling, edema and spotted OP image (spotted OP is not specific to CRPS; it is observed in 30–80% of cases) suggested CRPS; however, absence of vasomotor/trophic changes, allodynia, hyperalgesia, presence of nonpitting edema and limitation to one joint led the authors to consider laboratory findings in differential diagnosis. Absence of fever, absence of severe pain, sensitivity and erythema in joint, and moderate level of leukocytosis excluded septic arthritis. Radiological findings of early JIA include OP around the joint, increased intra-articular fluid, joint space widening and periarticular soft tissue edema [8]. Observed osteoporosis must not be considered only for CRPS. Patient complaints that persisted for 3 months (criterion is minimum 6 weeks), increased sedimentation, mild leukocytosis, increased Ig, and positive ANA led to consideration of inflammatory pathologies. Involve-
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ment of single joint, gender and ANA positivity suggested oligoarticular JRA. NSAIDs are used as first-line therapy for JIA, and NSAID may be administered alone if disease activity is low. In a case with active arthritis, the use of NSAIDs alone for more than 2 months is not recommended [9, 10] and a second-line therapy, such as adding sulfasalazine 50 mg/kg/day is suggested. The present patient responded to treatment with sulfasalazine in addition to NSAID, and the response supported the diagnosis. In the pediatric population, patients presenting with joint complaints must be evaluated in terms of rheumatologic diseases. Arthritis may be triggered by trauma and confused with other diseases, such as CRPS, where trauma plays a role in etiology. Although there have been CRPS cases that were confused with inflammatory arthritis in literature, we found no JIA case that was confused with CRPS [11]. In conclusion, all pathologies involving locomotor system must be considered in children presenting with joint complaints. Conflict of Interest: None declared. Financial Disclosure: The authors declared that this study has received no financial support. Authorship contributions: Concept – S.T.T.; Design – S.T.T.; Supervision – A.I; Data collection &/or processing – Z.E.; Analysis and/or interpretation – I.B.; Literature search – Z.E.; Writing – Z.E., S.T.T., I.B.; Critical review – A.I.
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REFERENCES 1. Ravelli A, Martini A. Juvenile idiopathic arthritis. Lancet 2007;369:767–78. 2. Aslan M, Kasapcopur O, Yasar H, Polat E, Saribas S, Cakan H, et al. Do infections trigger juvenile idiopathic arthritis? Rheumatol Int 2011;31:215–20. 3. Huang JL. New advances in juvenile idiopathic arthritis. Chang Gung Med J 2012;35:1–14. 4. Gori S, Broglia AM, Ravelli A, Aramini L, Di Fuccia G, Nicola CA, et al. Frequency and complications of chronic iridocyclitis in ANA-positive pauciarticular juvenile chronic arthritis. Int Ophthalmol 1994-1995;18:225–8. 5. Harris EJ, Schimka KE, Carlson RM. Complex regional pain syndrome of the pediatric lower extremity: a retrospective review. J Am Podiatr Med Assoc 2012;102:99–104. 6. Naleschinski D, Baron R. Complex regional pain syndrome type I: neuropathic or not? Curr Pain Headache Rep 2010;14:196– 202. 7. Kahn P. Juvenile idiopathic arthritis: an update for the clinician. Bull NYU Hosp Jt Dis 2012;70:152–66. 8. Cassidy TJ, Patty RE. Juvenile Rheumatoid Arthritis. Textbook of Pediatric Rheumatology. Third Ed. WB. Saunders 1995:133– 223. 9. Beukelman T, Patkar NM, Saag KG, Tolleson-Rinehart S, Cron RQ, DeWitt EM, et al. 2011 American College of Rheumatology recommendations for the treatment of juvenile idiopathic arthritis: initiation and safety monitoring of therapeutic agents for the treatment of arthritis and systemic features. Arthritis Care Res (Hoboken) 2011;63:465–82. 10. Weiss PF. Diagnosis and treatment of enthesitis-related arthritis. Adolesc Health Med Ther 2012;2012:67–74. 11. Baysal Ö, Altay ZE, Durmuş B, Baysal T. Is it Complex Regional Pain Syndrome Type 1 or Inflammatory Arthritis? Turk J Phys Med Rehab 2011;57:45–50.
Case Report
PM&R
North Clin Istanbul 2016;3(2):135â&#x20AC;&#x201C;9 doi: 10.14744/nci.2015.30602
Apert syndrome: A case report and review of the literature Tuba Tulay Koca Department of Physical Medicine and Rehabilitation, Malatya State Hospital, Malatya, Turkey
ABSTRACT Apert syndrome is the rare acrocephalosyndactyly syndrome type 1, characterized by craniosynostosis, severe syndactyly of hands and feet, and dysmorphic facial features. It demonstrates autosomal dominant inheritance assigned to mutations in the fibroblast growth factor receptor gene. Presently described is case of a 19-year-old female patient diagnosed on physical examination with Apert syndrome based on acrocephaly, prominent forehead, ocular hypertelorism, proptosis, short and broad nose, pseudoprognathism, dental crowding and ectopia, maxillar hypoplasia, low hairline, webbed neck, pectus excavatum, and severe, bilateral syndactyly of hands and feet. The multiple phenotypic signs of Apert syndrome make multidisciplinary team, including dentist, neurosurgeon, plastic surgeon, physiatrist, ophthalmologist, perinatalogist and geneticist, essential for successful management. Keywords: Acrocephalosyndactyly; Apert syndrome; craniosynostosis.
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pert syndrome was firstly described by a French physician, Eugene Apert [1]. This syndrome is a form of acrocephalodactyly (Type 1). It is a rarely seen congenital disorder characterized by a autosomal dominant inheritance which manifests itselt with craniosynostosis, midface hypoplasia, and symmetric syndactyly of hands, and feet [2]. Craniofacial deformities specific to Apert syndrome (AS) include craniofacial deformities, acrocephaly (cone-shaped calvarium), prominent forehead, proptosis, hyperteleorism, and flattened nose with a low bridge. Oral signs may be enumerated as pseudocleft, high-arched palate, transverse, and sagittal maxillary hypoplasia, dental crowding, delay in
dentition, ectopic teeth, disarrayed teeth, and teeth crowding can be enumerated. Mandibula is generally normal in size, and pseudoprognatism can be seen. Rarely symptoms related to central nervous system, cardiac, gastrointestinal, and urogenital system, and vertebral anomalies have been reported [3]. Herein, we have aimed to present a 91-year-old female patient diagnosed as AS based on dysmorphic facial manifestations (prominent forehead, ocular hypertelorism, proptosis, lateral gaze, flattened nose with low bridge, hypoplasic maxilla), disarrayed teeth, webbed neck, short hairline, pectus excavatus, severe syndactyly of hands, and feet, in the light of the literature information.
Received: October 13, 2014 Accepted: March 24, 2015 Online: May 14, 2016 Correspondence: Dr. Tuba Tulay KOCA. Malatya Devlet Hastanesi, Fiziksel Tip ve Rehabilitasyon Klinigi, Malatya, Turkey. Tel: +90 416 - 228 28 00 e-mail: tuba_baglan@yahoo.com Š Copyright 2016 by Istanbul Northern Anatolian Association of Public Hospitals - Available online at www.kuzeyklinikleri.com
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CASE REPORT A 19 year-old female patient applied to the medical board. At first examination, dysmorphic face, hand, and foot deformities, webbed neck were observed. The patient had normal height, and weight for her age. Family history of the patient was inquired. Her elder sister had also the same dysmorphic facial features. Her mental examination was unremarkable. She hadn’t had any symptoms related to cardiac, and respiratory system up to now. On physical examination acrocephaly, prominent forehead, hypertelorism, proptosis, lateral gaze of the left eye, broad nasal root, webbed neck, short hairline, pectus excavatum, cutaneous syndactyly of both hands, enlarged thumbs, subluxations of distal phalanges of hands, total syndactyly of toes of both feet, polydactyly (6 fingers), and brachydactyly were detected (Figure 1). Radiological evaluation revealed acroephaly, flattened occiput, increase in anterior opening of maxilla, A
B
and hypoplasia, teeth crowding, ectopic teeth, tapered inferior tip of the mandibula, and pseudoprognatism (Figure 2 A). Cutaneous syndactyly of both hands, flexion deformity of all fingers, widening of distal phalanx of the thumb, and occasional subluxation of distal phalanges were detected (Figure 2 B). Cervical, and lumbar vertebras were not abnormal. Anteroposterior radiograms of both feet demonstrated total syndactyly, polydactyly (6 toes), brachydactyly of 4. digits of both feet, clinodactyly of both big toes, and occasional subluxations (Figure 2 C). DISCUSSION AS is known as acrocephalosyndactyly type I which is a form of craniosynostosis. AS is characterized mainly by premature craniosynostosis, hypertelorism, syndactyly of hands, and feet, and many phenotypical symptoms. It has an autosomal dominant inheritance, and develops as a mutation of fiC
Figure 1.
(A) Frontal view of the patient’s face, and neck. (B) Anterior view of patient’s both hands reveal widened thumbs, cutaneous syndactyly, and flexion deformities of all fingers. (C) Anteroposterior view of both feet, complete syndactyly.
A
B
C
Figure 2. (A) Lateral radiogram of patient’s head, and neck. (B) Anteroposterior (AP) radiogram of patient’s both hands. (C) Anteroposterior (AP) radiogram of both feet of the patient.
Koca, Apert syndrome: A case report and review of the literature
broblast growth factor receptor -2 gene (FGFR2) on 10q26 gene locus. FGFR2 gene enables coding of a protein called fibroblast growth factor receptor -2 gene. This protein is one of the four FGFRs responsible for the formation of blood vessels, wound healing, embryonic evolution, and regulation of cellular division, growth, and maturation. FGFR binds to fibroblast growth factors with higher affinity, and plays an important role in signal pathways which function in the fusion process of skull bones. Molecular basis of Apert syndrome is very specific. Two different types of mutation have been demonstrated in the binding site between immunoglobulin like loop- 2, and immunoglobulin like loop -3 on fibroblast growth factor receptor -2 (FGFR2). Besides, intracellular signals oriented by FGFR play an important role in the embryogenesis, and in its deficiency, premature gastrulation, implantation anomalies, impairment of epithelial-mesencyhmal interaction, and defects in membranous, and endochondrial bone formation are seen. Most of the patients have a normal karyotype [4]. Although in our country specific gene mutation analysis is performed in private medical centers, in our province we havenâ&#x20AC;&#x2122;t this opportunity. AS is especially seen in children of the parents (frequently advanced paternal age) of advanced age. It was learnt that her father was 42 years of age when she was born. Although generally paternal mutations are seen, most of the cases are sporadic, and develop because of new mutations. Its incidence is 9.9â&#x20AC;&#x201C;15.5 per one million live births which do not differ between genders [5, 6]. Phenotypic manifestations of the disease are explained by premature fusion of cranial sutures Premature closure of coronal sutures before 3 months of age causes shorter anteroposterior diameter, high, and prominent forehead associated with acrocephalic (cone-shaped) head. The most prominent symptoms of this syndrome are syndactyly of hands, and feet [5, 6]. Our patient also had the most marked symptoms namely acrocephaly, syndactyly of fingers, and toes. In these patients midface is hypoplasic. Eye manifestations include hypertelorism, proptosis, and downslanting palpebral fissures. Nose, and nasal root is short, and widened. Our patient carries all specific facial characteristics.
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Rarely internal organ (renal, cardiac, gastrointestinal, genitourinary) involvement, elbow, shoulder, vertebral column (vertebral malsegmentation, fusion, hemivertebra) deformities, and frequently central nervous system defects (cerebellar, gyral, cortical defects, lysencephaly, hypogenesis or agenesis of corpus callosum, ventriculomegaly) which cause mental disorders have been reported. In patients with Apert syndrome, upper respiratory tract infections, sleep apnea, and malnutrition can be seen Respiratory distress can be severe requiring endotracheal intubation or tracheostomy. In our case apart from mild degrees of dyspnea, and snoring, any other symptom suggesting internal organ pathology was not found. In patients with AS, true megalencephaly is seen, however generally mental disorders are rarely encountered [2, 3, 4, 5, 6]. During physical examination of our patient webbed neck, and short hairline which are rarely seen in patients with AS were observed. These features are discriminating characteristics between Turner and Noonan syndrome. Normal height of our patient who had not mental disorder ruled out other diagnoses. Vertebral anomalies and most frequently cervical fusion which can be seen in 68% of the patients was not detected in our patient [7]. Anteroposterior diameter of anterior cranial fossa is relatively shorter, because of forward displacement of greater wings of sphenoid bone, forehead is steep, wide, and flat, temporal regions are protruded, and occiput is flattened. In our patient a prominent forehead, and a flat occipitus were observed. Because of forward displacement of the sphenoid bone, and blockade of the frontal bone, maxillary bone can not develop on all three planes. Consequently, maxillary height, width of the nasal cavity, and nasopharyngeal height decrease, This anatomic configuration severely prevents development of oropharyngeal, and nasopharyngeal cavity. In these patients, usually oral respiration is seen with resultant impairment of respiratory functions. The patient said that she hadnâ&#x20AC;&#x2122;t shortness of breath, however she stated that she had snored some nights Ophthalmic symptoms have been explained by enlargement of middle cranial fossa towards anteroinferior direction because of the position of the greater wings of sphenoid bone, and decrease in the anteroposterior diameter of the orbita secondary
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to impingement of the orbita on lateral walls of the orbita [8]. Down syndrome characterized by hypertelorism, flattened nose, short stature, and mental retardation may be considered in the differential diagnosis. Oral symptoms are explained by decrease in especially anteroposterior diameter of the maxilla with resultant crowding of teeth, and increase in anteror opening of the oral cavity [9]. In patients with AS, hand, and foot deformities which effect daily life can be seen [10]. Pedal deformities which can be named in the literature as ‘Apert’s foot’ were divided in 3 types by Baluth and von Torne [11]. Our patient was consistent with type 3 where syndactyly was seen in all toes. In AS patients with hand, and foot deformities, syndactyly should be corrected in order to increase quality of life of these patients. For this purpose surgical correction including partial amputation can be applied. Feet of the AS patients are not frequently suitable for wearing normal shoes because of pressure pain, and often surgery is required [12]. In the differential diagnosis other genetic disorders which can be seen apart from craniosynostosis include Crouzon, Carpenter (acrocephalosyndactyly type 2), Chotzen, and Pfeiffer syndromes. Specific association of craniosynostosis has been correlated with mutation in the FGFR gene [13]. In the Crouzon syndrome characterized by craniosynostosis, and dysmorphic face, acrocephaly, brachycephaly, exophthalmos, proptosis, hypertelorism, hooked nose, hypoplasic maxilla, ear, and palatine deformities occur. AS especially demonstrates similar characteristics with Crouzon syndrome. In the Crouzon syndrome, contrary to AS, extremities are not involved, and craniofacial deformities lead a milder course. However in AS, multiple sutures fuse prematurely. The face is asymmetric, forehead is more prominent,and exophthalmos is not so severe. Hand, and foot deformations, and especially extreme cases of syndactyly is its discriminative feature. We did not think of Crouzon syndrome in our patient with prominent extremity involvement. Some authors consider Apert-Crouzon syndrome as a separate entity. Pfeiffer syndrome is characterized by craniosynostosis, enlarged thumb, and toes. Interestingly, in our patient thumbs of both hands were enlarged just like Pfeiffer syndrome. However in Carpenter
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syndrome cloverleaf skull is a typical manifestation with with facial paralysis, and characteristic facial features [14, 15, 16]. The concomitancy between AS and toes with preaxial polydactyly in Carpenter syndrome has been reported in many cases. Our patient with polydactylic toes resembles a case with Carpenter syndrome. In the literature, it has been indicated that polydactylic form of AS may always accompany Carpenter syndrome [17]. In summary, although our patient had signs, and symptoms characteristic of AS, as seen in Pfeiffer syndrome, she also manifested a different mutation per se characterized by an enlarged thumb, and polydactylic form of AS associated with Carpenter syndrome Syndromes characterized by craniosynostosis can not be definitely discriminated from each other, and as was seen in our case, their concomitancy in rare cases has been reported. Besides, our case demonstrated differences from other cases with having webbed neck, and short hairline. If family history of AS is detected, then fetal DNA analysis can detect specific mutations. Prenatal diagnosis can be made by demonstration of craniosynostosis, and syndactyly on prenatal ultrasound, and detection of FNGR gene mutation at 16. gestational week. AS is a rarely seen disorder without a complete cure which imposes material, and moral burden on the patient, his/her family, and health organizations. Therefore essential approach should be to establish the diagnosis by prenatal US, and termination of the pregnancy [18]. Since symptoms of AS demonstrate large variability, the diagnosis, and treatment of the disease require treatment by a multidisciplinary team in collaboration with neurosurgeon, plastic, and reconstructive surgeon, physiatrist, ophthalmologist, psychiatrist, neurologist, perinatologist, and genetician. Diagnosis is based on clinical, radiological, and genetic evaluation. Though its definitive treatment is not available, for anatomical deformities corrective surgery can provide cure. Cranial corrective operations, and fronto-orbital surgery are advised for infants aged 6–9 months, and generally reconstruction of synostosis is considered for patients older than 6 years. Besides these patients can manifest emotional, and behavioural disorders and because of severe craniofacial anomalies, they require psychiatric consultation [19].
Koca, Apert syndrome: A case report and review of the literature
Conflict of Interest: No conflict of interest was declared by the authors. Financial Disclosure: The authors declared that this study has received no financial support.
REFERENCES 1. DeGiovanni CV, Jong C, Woollons A. What syndrome is this? Apert syndrome. Pediatr Dermatol 2007;24:186–8. 2. Bhatia PV, Patel PS, Jani YV, Soni NC. Apert’s syndrome: Report of a rare case. J Oral Maxillofac Pathol 2013;17:294–7. 3. Kumar GR, Jyothsna M, Ahmed SB, Sree Lakshmi KR. Apert’s Syndrome. Int J Clin Pediatr Dent 2014;7:69–72. 4. Varoli FP, Santos KCP, Costa C, Oliveira JX. Apert syndrome: clinical and radiographic features and case report. Rev Odonto Cienc 2011;26:96–9. 5. Cohen MM Jr, Kreiborg S. Agenesis of the corpus callosum. Its associated anomalies and syndromes with special reference to the Apert syndrome. Neurosurg Clin N Am 1991;2:565–8. 6. Cohen MM Jr. Craniosynostosis and syndromes with craniosynostosis: incidence, genetics, penetrance, variability, and new syndrome updating. Birth Defects Orig Artic Ser 1979;15:13–63. 7. Kreiborg S, Barr M Jr, Cohen MM Jr. Cervical spine in the Apert syndrome. Am J Med Genet 1992;43:704–8. 8. Katzen JT, McCarthy JG. Syndromes involving craniosynostosis and midface hypoplasia. Otolaryngol Clin North Am 2000;33:1257–84.
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9. Açıkgöz Y, Nurşen B, Yalın T, İncesu L, Küçüködük Ş. Apert Syndrome: A Case Report and Review of the Literature. O.M.Ü. Tıp Derg 2006;23:59–64. 10. Mason WH, Wymore M, Berger E. Foot deformities in Apert’s syndrome. Review of the literature and case reports. J Am Podiatr Med Assoc 1990;80:540–4. 11. Blauth W, von Törne O. “Apert’s foot” (in acrocephalo-syndactyly) (author’s transl). [Article in German] Z Orthop Ihre Grenzgeb 1978;116:1–6. [Abstract] 12. Meyer JL. Apert’s syndrome: (acrocephalosyndactylism). J Foot Surg 1981;20:210–3. 13. Cohen MM Jr. Craniosynostoses: phenotypic/molecular correlations. Am J Med Genet 1995;56:334–9. 14. Jabs EW. Toward understanding the pathogenesis of craniosynostosis through clinical and molecular correlates. Clin Genet 1998;53:79–86. 15. Benmiloud S, Chaouki S, Atmani S, Hida M. Apert syndrome. [Article in French] Pan Afr Med J 2013;14:66. [Abstract] 16. Krueger JL, Ide CH. Acrocephalosyndactyly. (Apert’s syndrome). Ann Ophthalmol 1974;6:787–9. 17. Yonenobu K, Tada K, Tsuyuguchi Y. Apert’s syndrome-a report of five cases. Hand 1982;14:317–25. 18. Hansen WF, Rijhsinghani A, Grant S, Yankowitz J. Prenatal diagnosis of Apert syndrome. Fetal Diagn Ther 2004;19:127–30. 19. Gündüz S, Demirel N, Baş AY, Okumuş N, Zenciroğlu A. Apert Sendromu. Turkish J Pediatr Dis 2013;2:94–5.
Case Report
PEDIATRICS
North Clin Istanbul 2016;3(2):140â&#x20AC;&#x201C;2 doi: 10.14744/nci.2015.15807
Pertussis-like syndrome associated with adenovirus presenting with hyperleukocytosis: Case report Hakan Sarbay,1 Aziz Polat,1 Emin Mete,2 Yasemin Isik Balci,1 Mehmet Akin1 Department of Pediatric Hematology and Oncology, Pamukkale University Faculty of Medicine, Denizli, Turkey
1
Department of Pediatric Allergy, Pamukkale University Faculty of Medicine, Denizli, Turkey
2
ABSTRACT Adenovirus is an infectious viral agent that causes variety of clinical presentations such as respiratory disease, conjunctivitis, and gastroenteritis. Hepatitis, pancreatitis, myocarditis, encephalitis, and disseminated infection are primarily seen in immunocompromised patients. Rarely, adenovirus infection can present with pertussis-like syndrome. Described here is case of pertussis-like syndrome associated with adenovirus presenting with hyperleukocytosis. Keywords: Adenovirus; hyperleucocytosis; pertussis-like syndrome.
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denovirus, is a non-enveloped, double- strand DNA virus consisting of seven sub-species (A, B, C, D, E, F, G), and 52 different serotypes [1]. Adenovirus which is resistant against conditions of external environment is transmitted through respiratory tract, direct contact, and collectively used objects [2]. In clinical practice adenovirus most frequently causes respiratory tract infections, and gastroenteritis. Besides it can present with various clinical manifestations as pharyngoconjunctival fever, hemorrhagic cystitis, epidemic keratoconjunctivitis, myocarditis, hepatitis, encephalomyelitis, and invagination. In infants, and immunocompromised patients adenovirus infections can be seen [3]. Rarely adenovirus may present with pertussis-like syndrome characterized by paroxysmal fits of coughing
[4, 5]. In the pediatric age group the most frequent cause of hyperleucocytosis is acute leukemia [6]. Among infectious diseases, in pertussis infection hyperleucocytosis invariably accompanied by lymphocytosis can be seen [7]. In this article, a patient with pertussis-like syndrome caused by adenovirus who presented with hyperleuocytosis has been reported. CASE REPORT A 9-month-old female patient was brought to a health institute with complaints of coughing persisting for 2 weeks. Her hematologic tests revealed the presence of hyperleucocytosis (107.000/mm3), and consequently she was referred to us with the
Received: May 13, 2015 Accepted: August 11, 2015 Online: October 16, 2016 Correspondence: Dr. Hakan SARBAY. Pamukkale Universitesi Tip Fakultesi, Cocuk Hematoloji ve Onkoloji Bolumu Denizli, Turkey. Tel: +90 850 - 222 07 24 e-mail: drhakansarbay@hotmail.com Š Copyright 2016 by Istanbul Northern Anatolian Association of Public Hospitals - Available online at www.kuzeyklinikleri.com
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Table 1. Whole blood cell count, and peripheral smear results of the patient x Day
WBC (/mm3)
Hemoglobin (gr/dl)
Platelet (/mm3)
Neutrophil (%)
Lymphocyte (%)
Monocyte (%)
Eosinophil (%)
1. day 3. day 7. day
102.900 66.680 42.290
10.6 10.9 10.9
797.000 761.000 678.000
26 22 18
72 72 78
2 4 2
– 2 2
WBC: Whole blood cell.
initial diagnosis of leukemia. Her history revealed the presence of vomiting, and diarrhea in addition to her complaints of coughing within the first week. She hadn’t been vaccinated. Her personal, and family history were unremarkable. Her general health state was evaluated as moderately well. Her oropharynx was hyperemic, and crepitant rales were heard bilaterally over basal lobes of her lungs. The liver was palpable 2 cm below the costal margin. Some of her laboratory values were as follows: hemoglobin: 10.6 gr/dl, WBC: 102.900/mm3, platelets: 797.000/ mm3, normal hepatic, and renal function test results; uric acid: 2.5 mg/dl, and LDH: 386 U/L. Results of peripheral smear analysis were as follows : neutrophils: 26%, lymphocyte: 72%, monocyte: 2%, absence of atypical cells, and blast cells. Hypochromic, and microcytic erythrocytes and anisocytosis were detected. Abundant clusters of platelets were seen. On chest X-ray, dimensions of mediastinum were within normal limits, and infiltration in the right paracardiac region was seen. The patient was started on intravenous fluid therapy, and nebulized salbutamol was administered. PPD test –negativity was noted. Levels of immunoglobulins, C3, and C4 were within normal limits. Polymerase chain reaction (PCR) performed with throat swab, and respiratory tract panel realized for adenovirus infection yielded positive results. On pertussis culture media any bacterial growth was not observed. PCR test could not detect any evidence of pertussis infection. Respiratory tract infection caused by an adenovirus, and hyperleucocytosis were contemplated. On 3. day of her hospitalization WBC was 66.680/mm3. During follow-up of the patient, her respiratory symptoms, and complaints of coughing regressed at the end of the first week of her hospitalization. On
7. day of her hospital stay WBC was 42.290/mm3. Whole blood cell counts,and results of her peripheral smear are shown in Table 1. Complaints of the patient regressed, and her clinical problems resolved during her follow-up, and consequently she was discharged with prescription of a vacination plan. DISCUSSION Classical whooping cough infection courses with paroxysmal fits of coughing, vomiting after coughing, deep inspirium, and intermittent symptoms of coughing lasting longer than 28 days up to 3 months [7]. Adenovirus infections most frequently present with manifestations of respiratory tract infections, and gastroenteritis [3]. In our patient coughing episodes lasted for 3 weeks, and in the first week diarrhea, and vomiting accompanied complaints of coughing. In the pediatric age group acute leukemias are the most frequent causes of hyperleukocytosis [6]. Apart from leukemias, infections, drugs, bleeding, hypersensitivity reactions, splenectomy, and solid tumors induce leukemoid reaction leading to development of hyperleukocytosis. However hyperleukocytosis secondary to absolute lymphocytosis is seen in pertussis, tuberculosis, and viral infections. Among viral infections, EBV infection is the most frequent cause of hyperleukocytosis [8]. Whole blood cell count of our patient demonstrated hyperleukocytos, anemia, and reactive thrombocytosis. Lymphocytes were seen in 72% of peripheral smears. Morphologic examination of leukocytes did not reveal presence of atypical cells, and blastocytes. Detection of hypochromia, microcytosis,and anocytosis suggested the presence iron deficiency anemia. Tests to be made to clarify the etiology of postinfectious anemia were
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planned. Development of thrombocytosis was presumably attributed to anemia, and infection. Apart from Bordetella pertussis infection the manifestations of pertussis-like coughing can be encountered during the course of infections caused by Chlamydophila pneumoniae, Chlamydiae trochomatis, Mycoplasma pneumoniae, adenoviruses, and Bordetella bronchiseptica. In a study on 149 patients who presented with clinical manifestations of pertussis, the most frequently detected infectious agents, apart from Bordetella pertussis were adenoviruses, Parainfluenza, Mycoplasma pneumoniae, and RSV. In this study, adenoviruses, and Mycoplasma pneumoniae were detected in 3, and 1.3% of the cases, respectively [4]. In patients presenting with clinical manifestations of pertussis where Bordetella pertussis can not be isolated or can not be confirmed serologically, investigation for infectious agents as Mycoplasmae, Chlamydiae, and adenoviruses has been recommended [9]. Gold standard for the diagnosis of pertussis is detection of bacterial growth on culture which has a 100% specificity. Its sensitivity changes depending on many factors as stage of the disease, initiation of antimicrobial treatment, sampling method, quality of the material used for sampling, conditions of delivery of the sample to the laboratory, and experience of the laboratory, and ranges between 12, and 60 percent. PCR is another method used for the diagnosis of pertussis. The World Health Organization recommends combined use of antibiograms, and PCR technique for the diagnosis of pertussis. Sensitivity, and specificity of PCR method have been indicated as 70–99%, and 86–100%, respectively [10]. In our patient bacterial growth was not detected on pertussis culture media. PCR test yielded negative results. PCR respiratory tract panel revealed presence of adenovirus, and absence of Mycoplasma pneumoniae, and RSV. Although the patient presented to our clinic with pertussis-like coughing, complaints of vomiting, and diarrhea at the beginning of the disease, shorter duration of the coughing when compared with whoopig cough, and in consideration of laboratory test results, presumptive diagnosis of pertussis-like syndrome secondary to adenovirus infection, and hyperleucocytosis were made. Since all her necessary vaccinations were not performed, and diagnostic laboratory methods were not 100%
sensitive, Bordatella infection could not be ruled out conclusively. In conclusion, in patients presenting with clinical manifestations of pertussis, and hyperleucocytosis, if especially etiologic agent can not be cultivated, then adenovirus infections should be considered in the differential diagnosis, and relevant investigations should be carried out. Conflict of Interest: None declared. Financial Disclosure: The authors declared that this study has received no financial support. Authorship contributions: Concept – H.S., A.P., Y.I.B., M.A.; Design – H.S., A.P. Y.I.B., M.A.; Supervision – H.S.; Data collection &/or processing – H.S.; Analysis and/or interpretation – H.S.; Writing – H.S.; Critical review – A.P., E.M. Y.I.B., M.A.
REFERENCES 1. American Academy of Pediatrics. [Adenovirüs enfeksiyonları. İçinde: Pickering LK, Baker CJ, Long SS, McMillan J, editörler. Redbook: 2006 enfeksiyon hastalıkları komite raporu. 27. baskı.] Elk Grove Village: IL American Academy of Pediatrics 2006:211–2. 2. Henquell C, Boeuf B, Mirand A, Bacher C, Traore O, Déchelotte P, et al. Fatal adenovirus infection in a neonate and transmission to health-care workers. J Clin Virol 2009;45:345–8. 3. Behrman RE, Kliegman RM, Jenson HB. Nelson textbook of pediatrics. 18 th ed. Pennsylvania: Saunders; 2007. p. 1393–4. 4. Wirsing von König CH, Rott H, Bogaerts H, Schmitt HJ. A serologic study of organisms possibly associated with pertussis-like coughing. Pediatr Infect Dis J 1998;17:645–9. 5. Ferrer A, Calicó I, Manresa JM, Andreu A, Moraga F, Valle I. Microorganisms isolated in cases of pertussis-like syndrome. [Article in Spanish] Enferm Infecc Microbiol Clin 2000;18:433–8. [Abstract] 6. Porcu P, Cripe LD, Ng EW, Bhatia S, Danielson CM, Orazi A, et al. Hyperleukocytic leukemias and leukostasis: a review of pathophysiology, clinical presentation and management. Leuk Lymphoma 2000;39:1–18. 7. Munoz FM. Pertussis in infants, children, and adolescents: diagnosis, treatment, and prevention. Semin Pediatr Infect Dis 2006;17:14–9. 8. George TI. Malignant or benign leukocytosis. Hematology Am Soc Hematol Educ Program 2012:475–84. 9. American Academy of Pediatrics, Red Book. Pertussis 2003. 10. ID_2010May_Pertussis-Diagnostics-Brochure.http:// www.aphl.org/AboutAPHL/publications/Documents/ ID_2010May_Pertussis-Diagnostics-Brochure.pdf (Available at: 06.01.2014).
Case Report
GENERAL SURGERY
North Clin Istanbul 2016;3(2):143â&#x20AC;&#x201C;5 doi: 10.14744/nci.2016.50469
Perforated duodenal diverticulum: A case report Mehmet Gulmez, Mehmet Kamil Yildiz, Haci Mehmet Odabasi, Haci Hasan Abuoglu, Onur Ilhan, Kubra Kaytaz Department of General Surgery, Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey
ABSTRACT Duodenum is the second most frequent location for diverticulum in the digestive tract, surpassed only by the colon. Perforation is rare, but it is the most serious complication of duodenum diverticula. Presently described is case of 22-year-old male patient who presented at emergency department with abdominal pain and vomiting. Surgery was performed with prediagnosis of perforated duodenum diverticula based on results of computed tomography. Keywords: Duodenal diverticulum; duodenum; perforation.
D
uodenum is the second most frequent location for a diverticulum in the digestive tract after the colon. From duodenal diverticula complications as diverticulitis, pancreatitis, bleeding, choleductal occlusion and perforation can develop. Perforation is the most rarely seen, but the most serious complication. In this paper, we aimed to present a 22-year-oldpatient operated with the diagnosis of perforated duodenal diverticulum who presented with clinical manifestations of acute abdomen. CASE REPORT
A 22-year-old male patient consulted to our emergency service with complaints of abdominal pain
and vomiting persisting for two days. His anamnesis did not reveal any disease or previous operation. His vital signs were as follows: ABP: 120/70 mmHg, pulse rate: 78/min, body temperature: 36.7oC. On physical examination marked tenderness and abdominal guarding were detected on the upper right abdominal quadrant. Rebound sign was not found. Digital rectal examination and examination of other bodily systems did not reveal any abnormality. Some laboratory test results were as follows: Htc: 42.2 WBC: 13800/mm3, FBG: 142 mg/dL, BUN: 19 mg/dL, creatinine: 0.8 mg/dL, C-reactive protein 7.65 mg/dL. Hepatic enzymes and amylase values were within normal limits. Upright abdominal radiograms did not demonstrate any evidence suggesting subdiaphragmatic free air. Gallbladder and biliary tracts were normal on whole
Received: December 07, 2014 Accepted: April 05, 2015 Online: June 12, 2015 Correspondence: Dr. Mehmet GULMEZ. Haydarpasa Numune Egitim ve Arastirma Hastanesi, Genel Cerrahi Klinigi, Istanbul, Turkey. Tel: +90 216 - 542 32 32 e-mail: mehmetgulmez86@hotmail.com Š Copyright 2016 by Istanbul Northern Anatolian Association of Public Hospitals - Available online at www.kuzeyklinikleri.com
North Clin Istanbul – NCI
144 A
Figure 1. Duodenal diverticulum and free air in its vicinity.
abdominal ultrasound without intraabdominal free fluid. The patient underwent oral/intravenous contrast -enhanced computed tomography (CT) and at the junction of 2., and 3. parts of the duodenum, a 3.5 cm –long diverticulum filled with oral contrast material and free air in its vicinity were detected (Figure 1). The patient was urgently operated with the diagnosis of perforated duodenal diverticulum. Surgical exploration revealed the presence of periduodenal phlegmon. Following liberation of the duodenum using Kocher manoeuvre, perforated duodenal diverticulum was detected at the junction of the second and third part of the duodenum (Figure 2 A). Diverticulum was nearly 4 cm in length and diverticulectomy was performed using GIA linear cutting stapler (GIATM Stapler, Covidien, Mansfield, MA, USA) (Figure 2 B). The patient was discharged without any postoperative problem and complaint. DISCUSSION Duodenal diverticulum was firstly described by Chomel in the year 1710 [1]. The incidence rates of duodenal diverticulum are 0.8–1% in contrast-enhanced radiograms, 20–32% in autopsy series and 7–23% in ERCP series [2, 3]. Duodenum is the second most frequent location for a diverticulum in the digestive tract after the colon. Duodenal diverticula have been classified as congenital and acquired. Acquired duodenal diverticula are more frequently seen and they occur as a result of mucosal and sub-
B
Figure 2.
(A) Perforated duodenal diverticulum. (B) Diverticulectomy performed using GIA linear cutter stapler.
mucosal herniation through the area where blood vessels penetrate and weaken muscular layer. Since they are not covered by any muscular layer they are called “psedodiverticula”. Acquired diverticula are extraluminal. They can be multiple and generally they are localized on the mesenteric aspect of the second part of the duodenum. Though congenital diverticula frequently localized on the second part of the duodenum, they can extend up to the fourth part of the duodenum. Complications of duodenal diverticula can develop including diverticulitis, pancreatitis, bleeding, choleductal obstruction and perforation. Perforation is a rarely seen, but the most serious complication [4]. In the literature, only 162 cases have been reported [5]. Perforation can be iatrogenic [6], and occur during ERCP procedure or develop as a result of erosion due to enterolith [7], and diverticulitis [8].
Gulmez et al., Perforated duodenal diverticulum
Usually nonspecific symptoms are seen. Most frequently, sudden onset of right upper abdominal quadrant pain, nausea and vomiting are observed. Rarely signs of peritoneal irritation are observed. [9]. Since perforation of the duodenal diverticulum occurs mostly in the retroperitoneal space, upright plain abdominal radiogram generally does not demonstrate presence of free air. Because of difficulties in establishing preoperative diagnosis, only in 13% of the cases accurate preoperative diagnosis could be made [10]. Computed tomography (CT) is the most useful diagnostic method in cases with perforated duodenal diverticulum. Computed tomography can demonstrate retroperitoneal abscess, fluid and air [8]. It has been reported that in selected advanced patients with serious comorbidities and those with milder symptoms and physical examination findings without any evidence of sepsis have been treated with conservative methods as nasogastric drainage, hydration with intravenous fluids, intravenous antibiotherapy and total parenteral nutrition [5]. The optimal treatment option for the perforated duodenal diverticulum is surgery. We also considered surgical alternative as a priority because of the signs of peritoneal irritation detected on physical examination. The most frequently preferred method is diverticulectomy combined with single or twolayered closure [11]. Dependent on the location of duodenal diverticula, the presence of biliary tract obstruction, severity of retroperitoneal inflammation, duodenal diversion, tube duodenostomy, segmental duodenum resection or more complex surgical methods as pylorus-sparing Whipple operation can be performed [11, 12]. The complications of the surgical interventions applied include duodenal fistula, intraabdominal abscess, sepsis, and pancreatitis [10]. Laparoscopic interventions also reportedly yielded successful outcomes [13]. Conclusion Duodenal diverticulum is a rarely seen serious complication which can be fatal. Computed tomography is the most important diagnostic imaging modality and surgery is the most effective treatment method. The patient gave his “ Informed Volunteer Consent Form” concerning use of his medical information for scientific publication.
145 Conflict of Interest: No conflict of interest was declared by the authors. Financial Disclosure: The authors declared that this study has received no financial support. Authorship contributions: Concept – M.G., M.K.Y., H.M.O., H.H.A., O.I., K.K.; Design – M.G., M.K.Y., H.M.O., H.H.A., O.I., K.K.; Data collection &/or processing – M.G., M.K.Y., H.M.O., H.H.A., O.I., K.K.; Literature search – M.G., M.K.Y., H.M.O., H.H.A., O.I., K.K.; Writing – M.G., M.K.Y., H.M.O., H.H.A., O.I., K.K.; Critical review – M.G., M.K.Y., H.M.O., H.H.A., O.I., K.K.
REFERENCES 1. Chomel JB. Report of a case of duodenal diverticulum containing gallstones. Acad R Sci Paris 1710;48–50. 2. Ersan Y, Yavuz N, Çiçek Y, Ergüney S, Kuşaslan R, Belli A, et al. Clinical analysis and review of related literature in cases of duodenal diverticulosis. Cerrahpaşa J Med 2005;36:120–7. 3. Yin WY, Chen HT, Huang SM, Lin HH, Chang TM. Clinical analysis and literature review of massive duodenal diverticular bleeding. World J Surg 2001;25:848–55. 4. Ming TY, Feng HK, Cherng YJ, Chuan CD, Pai LT, Chi LY. Clinical challenge: diverticulitis of third and fourth portion of the duodenum with perforation. Rev Esp Enferm Dig 2012;104:156–7. 5. Thorson CM, Ruiz PS, Roeder RA, Sleeman D, Casillas VJ. The perforated duodenal diverticulum. Arch Surg 2012;147:81–8. 6. Cavanagh JE Jr. Iatrogenic perforation of perivaterian duodenal diverticulum: report of a case. Can J Surg 1996;39:336–8. 7. Franzen D, Gürtler T, Metzger U. Solitary duodenal diverticulum with enterolith as a rare cause of acute abdomen. [Article in German] Swiss Surg 2002;8:277–9. [Abstract] 8. Sakurai Y, Miura H, Matsubara T, Imazu H, Hasegawa S, Ochiai M. Perforated duodenal diverticulum successfully diagnosed preoperatively with abdominal CT scan associated with upper gastrointestinal series. J Gastroenterol 2004;39:379–83. 9. Favre-Rizzo J, López-Tomassetti-Fernández E, Ceballos-Esparragón J, Hernández-Hernández JR. Duodenal diverticulum perforated by foreign body. Rev Esp Enferm Dig 2013;105:368–9. 10. Duarte B, Nagy KK, Cintron J. Perforated duodenal diverticulum. Br J Surg 1992;79:877–81. 11. Martinez-Cecilia D, Arjona-Sanchez A, Gomez-Alvarez M, Torres-Tordera E, Luque-Molina A, Valenti-Azcarate V. Conservative management of perforated duodenal diverticulum: a case report and review of the literature. World J Gastroenterol 2008;14:1949–51. 12. Schnueriger B, Vorburger SA, Banz VM, Schoepfer AM, Candinas D. Diagnosis and management of the symptomatic duodenal diverticulum: a case series and a short review of the literature. J Gastrointest Surg 2008;12:1571–6. 13. Tagaya N, Shimoda M, Hamada K, Ishikawa K, Kogure H. Laparoscopic duodenal diverticulectomy. Surg Endosc 2000;14:592.
CASE REPORT
GENERAL SURGERY
North Clin Istanbul 2016;3(2):146â&#x20AC;&#x201C;9 doi: 10.14744/nci.2015.68926
Laparoscopic cholecystectomy in an adult with agenesis of right hemidiaphragm and limb reduction defects: First report in literature Julide Sagiroglu,1 Ercument Tombalak,1 Sarenur Basaran Yilmaz,2 Fikret Balyemez,3 Tunc Eren,1 Orhan Alimoglu1 Department of General Surgery, Istanbul Medeniyet University Faculty of Medicine, Istanbul, Turkey
1
Department of Medical Genetics, Istanbul Medeniyet University Faculty of Medicine, Istanbul, Turkey
2
Department of Radiology, Istanbul Medeniyet University Faculty of Medicine, Istanbul, Turkey
3
ABSTRACT The importance of the complete absence of a hemidiaphragm or unilateral diaphragmatic agenesis in adulthood in relation to performing laparoscopic procedures has not been well documented. This article reports for the first time in literature a case of successful laparoscopic cholecystectomy in an adult with previously undiagnosed unilateral diaphragmatic agenesis. A 36-year-old female complaining of stubborn right upper abdominal pain radiating to her upper back was diagnosed as having cholelithiasis and was scheduled for laparoscopic cholecystectomy. There were also bilateral upper extremity malformations to a certain level. Routine diagnostic tests demonstrated that her entire liver and some bowel loops were in the right hemithorax, suggesting right-sided diaphragmatic hernia. Laparoscopic procedure was performed with the insertion of four trocars. Exploration of abdomen revealed total absence of the right hemidiaphragm. Cholecystectomy was completed laparoscopically in about 45 minutes without need for additional trocars. Patient had an uneventful recovery and was discharged on the second postoperative day without any complaint. Laparoscopic cholecystectomy in adults with diaphragmatic agenesis and intrathoracic abdominal viscera can be performed successfully. Nevertheless, any bile duct aberrations must be documented prior to surgery, and the surgeon should be able to convert to open procedure if necessary. Keywords: Agenesis; cholecystectomy; diaphragm; laparoscopic; unilateral.
C
ongenital diaphragmatic agenesis (DA) may be isolated or accompanied by additional major malformations, such as pulmonary defects, limb defects, cardiac defects, genitourinary anomalies, and central nervous system abnormalities [1]. Dia-
phragmatic agenesis is an exceedingly rare condition and information regarding laparoscopic procedures on patients with DA has not been documented. In literature, only 1 other case of asymptomatic unilateral DA presenting with cholelithiasis in adulthood
Received: July 05, 2015 Accepted: July 19, 2015 Online: November 04, 2015 Correspondence: Dr. Julide SAGIROGLU. Istanbul Medeniyet Universitesi Tip Fakultesi, Genel Cerrahi Anabilim Dali, Istanbul, Turkey Tel: +90 216 566 40 62 e-mail: sagirj@gmail.com Š Copyright 2016 by Istanbul Northern Anatolian Association of Public Hospitals - Available online at www.kuzeyklinikleri.com
Sagiroglu et al., Agenesis of right hemidiaphragm and limb reduction defects
147
precluding cholecystectomy has been reported [2]. The present case is that of an adult patient with previously unknown unilateral DA who underwent laparoscopic cholecystectomy. CASE REPORT A 36-year-old female presented with a 1-year history of progressive dyspepsia and right upper quadrant (RUQ) pain radiating to right upper back. Since early childhood she had never had a good nightâ&#x20AC;&#x2122;s sleep without a pile of four pillows. The patient also had remarkable congenital upper extremity malformations, such as limited elbow joint mobility, fifth finger clinodactyly, a short fifth metacarpal bone on the right, and a short left forearm with only 3 fingers. The patient was the fifth child of non-consanguineous, healthy parents and she had given birth to 2 healthy children through normal delivery. Her perinatal history was unremarkable. Radiographs showed mild lumbar scoliosis, nonvisualized first and second metacarpal bones and fingers on the left hand; very small, triangular-shaped third interphalangeal bone; short and bowed left radius and ulna; and radio-humeral synostosis on the left. Physical examination also revealed diminished breath sounds and dullness upon percussion to the right pulmonary base. All laboratory parameters and liver function tests were normal. Chest x-ray suggested a right diaphragmatic hernia (Figure 1). Abdominal ultrasound and computed tomography (CT) confirmed right diaphragmatic herniation of abdominal viscera and elevated gallbladder with a bile stone of 9 mm (Figures 2, 3). Left medial segment and right lobe of the liver were athrophic, lateral segment of the left lobe and caudate lobe were hyperthrophic. Magnetic resonance choledochopancreatography (MRCP) confirmed normal intrahepatic and extrahepatic bile ducts (Figure 4). After CO2 insufflation of the abdomen to 12 mmHg, trocars were inserted through the umbilicus for the camera, subxyphoid and two paraumbilical working ports. Laparoscopy revealed right hemidiaphragm agenesis with an intra-thoracic liver. Bowel loops and omentum were partially in the
Figure 1. Postanterior (PA) chest x-ray right hemithorax. Central tendon of the diaphragm was absent. Gallbladder was elevated and the tip of the fundus had a slight posterolateral rotation. Cholecystectomy was completed laparoscopically in about 45 minutes without the need for additional trocars. Patient was discharged on the second postoperative day without any complaint.
Figure 2. Computed tomography (CT), axial view
North Clin Istanbul â&#x20AC;&#x201C; NCI
148
On the eighth follow-up week, she was referred to the medical genetics clinic for mutational analysis. Chromosome analysis revealed a 46, XX, normal karyotype and a C677T heterozygous mutation of MTHFR gene. Echocardiogram was normal. DISCUSSION
Figure 3. Computed tomography (CT), coronal view
Figure 4. Magnetic raphy (MRCP)
resonance choledocho-pancreatog-
Agenesis of hemidiaphragm is exceedingly rare in adults. In literature, 9 previous case reports of this condition in adults have been published [3, 4]. Bingham first described DA in 1959 as a distinct entity from the more common Bochdalek-type of posterolateral congenital diaphragmatic defect [5]. The incidence of DA is reportedly 27â&#x20AC;&#x201C;31% of cases of congenital diaphragmatic hernia. Additional information on the management of neonatal DA has enabled better survival. The incidence of adults with DA is likely to increase in the future due to the higher survival rates of neonates. Diagnosis of DA in adults is based on a high index of clinical suspicion as well as imaging studies. Dullness upon percussion, and absent or diminished breath sounds in a lung field may indicate congenital diaphragmatic hernia. Imaging studies (chest radiography and abdominal ultrasound) are confirmatory. In adults with DA presenting with cardiorespiratory or gastrointestinal symptoms, the main principle of diagnosis should be systematic investigation of the gastrointestinal tract to rule out pathology in the herniated intrathoracic viscera. Incidence of bile stones has not been clearly defined in adults with DA. There is 1 former case report in literature presenting an adult with bile stones who had previously unknown right-sided DA [1]. Wakai et al. preferred non-surgical management of cholecystocholedocholithiasis for this patient. Abdominal ultrasound revealed dilatation of intra and extra-hepatic bile ducts suggestive of choledocholithiasis. Gallbladder was not visualized during laparoscopy, which precluded laparoscopic cholecystectomy. Endoscopic retrograde cholangiopancreatography (ERCP) confirmed common bile duct dilatation with choledocholithiasis. The patient had no other co-morbid medical condition, so they decided on conservative management.
Sagiroglu et al., Agenesis of right hemidiaphragm and limb reduction defects
ERCP with endoscopic sphincterotomy, stone extraction, and stenting of the common bile duct were performed. Following ERCP, gallstone dissolution therapy was initiated. In the present case, gallbladder and extrahepatic bile ducts were very well visualized both preoperatively and intraoperatively, which enabled completion of the operation laparoscopically. Liver and gallbladder were elevated, and the tip of the gallbladder fundus showed slight posterolateral rotation. Cholecystectomy was completed laparoscopically within 45 minutes and additional trocars were not needed. Limb reduction defects are one of the most common concomitant conditions with 10% ratio in non-syndromic congenital diaphragmatic hernia [6]. Co-existence of limb reduction defects and congenital diaphragmatic hernia is thought to be the result of an abnormality in developmental genes that are especially active in the early embryonic stage when limb formation and diaphragm development overlap [6, 7]. In addition to genetic factors, some teratogen exposure is considered to be responsible for this state, such as Vitamin A deficiency or any disruption of the retinoic acid pathway [8]. Though there are reports about a genetic basis for congenital diaphragmatic hernia, it is still uncertain. In the presented case, clinical findings did not fit into any known single gene disorder with congenital diaphragmatic hernia, including Fryns syndrome, Smith-Lemli-Opitz syndrome, Brachman de Lange syndrome, CHARGE syndrome, Goldenhar syndrome, Beckwith-Wiedeman syndrome, Marfan syndrome, Noonan syndrome, Spondylocostal Dysostosis syndrome, Simpson-Golabi–Behmel syndrome, and Fraser syndrome. Presence of both congenital diaphragmatic hernia and limb reduction defects was accepted as a co-existence with an unidentified genetic basis or a novel syndrome in this case. In adults with DA, laparoscopic cholecystectomy can be performed successfully. Nevertheless,
149
bile duct aberrations must be documented prior to surgery, and the surgeon should be able to convert to open procedure if necessary. Emphasis can be placed on conservative management, followed by gallstone dissolution therapy when laparoscopy fails to provide adequate visualization of the gallbladder and the ductal system. Acknowledgements: Authors are thankful to all medical and surgical staff of the faculty. Conflict of Interest: None declared. Financial Disclosure: The authors declared that this study has received no financial support. Authorship contributions: Concept – J.S.; Design – J.S.; Supervision – J.S., T.E., O.A.; Funding – All authors; Materials – J.S., E.T., F.B.; Data collection &/or processing – J.S., E.T., S.B.Y., F.B.; Analysis and/or interpretation – J.S., S.B.Y.; Literature search – J.S., E.T., S.B.Y.; Writing – J.S., S.B.Y.; Critical review – O.A., T.E.
REFERENCES 1. Slavotinek AM, Warmerdam B, Lin AE, Shaw GM. Populationbased analysis of left- and right-sided diaphragmatic hernias demonstrates different frequencies of selected additional anomalies. Am J Med Genet A 2007;143A:3127–36. 2. Wakai A, Winter DC, O’Sullivan GC. Unilateral diaphragmatic agenesis precluding laparoscopic cholecystectomy. JSLS 2000;4:259–61. 3. Passarge E, Halsey H, German J. Unilateral agenesis of the diaphragm. Humangenetik 1968;5:226–30. 4. Gibbs DL, Rice HE, Farrell JA, Adzick NS, Harrison MR. Familial diaphragmatic agenesis: an autosomal-recessive syndrome with a poor prognosis. J Pediatr Surg 1997;32:366–8. 5. Bingham JAW. Herniation through congenital diaphragmatic hernia defects. Br J Surg 1959;47:1–15. 6. van Dooren MF, Brooks AS, Tibboel D, Torfs CP. Association of congenital diaphragmatic hernia with limb-reduction defects. Birth Defects Res A Clin Mol Teratol 2003;67:578–84. 7. Bhan V, Rajagopal P, Kumar K, Raghavendra KH. Agenesis of the hemidiaphragm: a rare presentation in an adult. Indian J Chest Dis Allied Sci 2013;55:109–11. 8. Macayran JF, Doroshow RW, Phillips J, Sinow RM, Furst BA, Smith LM, et al. PAGOD syndrome: eighth case and comparison to animal models of congenital vitamin A deficiency. Am J Med Genet 2002;108:229–34.
Invited Review
EN&T
North Clin Istanbul 2016;3(2):150â&#x20AC;&#x201C;55 doi: 10.14744/nci.2016.20982
Diagnostic challenges in cervical tuberculous lymphadenitis: A review Hande Senem Deveci,1 Mustafa Kule,2 Zeynep Altin Kule,2 Tulay Erden Habesoglu1 Departmen of Ear, Nose and Throat, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
1
Departmen of Ear, Nose and Throat, Mugla State Hospital, Mugla, Turkey
2
ABSTRACT Tuberculosis is a very serious disease and incidence is once again on the rise. Lymph node tuberculosis is one of the most common extrapulmonary manifestations of tuberculosis. In differential diagnosis of chronic, painless cervical lymphadenopathy, cervical tuberculous lymphadenitis should be kept in mind. A high index of suspicion is needed for diagnosis of tuberculous lymphadenitis, which is known to mimic a number of pathological conditions. This article reviews epidemiology, clinical manifestations, and diagnostic techniques for cervical tuberculous lymphadenitis. Keywords: Cervical tuberculous lymphadenitis; extrapulmonary tuberculosis; tuberculosis.
T
uberculosis (TB) is a common, and in many cases lethal, infectious disease caused by various strains of mycobacteria, usually Mycobacterium tuberculosis [1]. Today in developing countries tuberculosis is still a major health problem. As a consequence of increased human immunodeficiency virus (HIV) prevalence and increasing immigration rate, tuberculosis (TB) is also re-emerging as a health care problem in developed countries [2]. Tuberculosis which mainly involves the lungs can also cause infection in almost all other organs and tissues in the body. TB bacilli enter the lymphatic system and blood stream to reach the extrapulmonary organs. Notable extrapulmonary infection sites include the pleura, the central nervous system, the lymphatic system, the genitourinary system, and the bones and joints [3]. Lymph node tuberculosis (LNT) is
a common cause of lymphadenopathy in areas in which TB is endemic. In countries with a low prevalence of TB, LNT is the most common extrapulmonary form [4]. In contrast, in high prevalence areas, the LNT incidence is second to that of TB pleuritis [2]. The most common LNT form is mycobacterial cervical lymphadenitis (MCL) [5, 6]. Although new diagnostic methods have been developed, especially in patients without a history of tuberculosis, the cervical tuberculous lymphadenitis (CTL) diagnosis is still elusive. In differential diagnosis of CTL, other granulomatous lymphadenitis should be considered such as non-tuberculous mycobacteria (including M. scrofulaceum, M. avium, and M. haemophilum), sarcoidosis, toxoplasmosis, tularemia, fungal disease, cat-scratch disease and neoplasms [7, 8]. The diagnosis is necessitating a high index of suspicion.
Received: January 25, 2016 Accepted: June 23, 2016 Online: September 28, 2016 Correspondence: Dr. Hande Senem DEVECI. Fatih Sultan Mehmet Egitim ve Arastirma Hastanesi, Kulak Burun Bogaz Klinigi, Istanbul, Turkey. Tel: +90 216 - 578 30 00 e-mail: senemesen@yahoo.com Š Copyright 2016 by Istanbul Northern Anatolian Association of Public Hospitals - Available online at www.kuzeyklinikleri.com
Deveci et al., Diagnostic challenges in cervical tuberculous lymphadenitis
Kent and et al. alleged that CTL is the result of lympho-hematogenous spread of pulmonary tuberculosis [9]. According to Powell, this entity is a hyperreaction of lymph nodes against previous pulmonary tuberculosis [10]. And also Yew et al. suggested that the predominant pathway of spread of the tubercle bacilli to the cervical lymph nodes is from lung parenchyma as the lymphatics of the right lung and the lower lobe of the left lung normally drain to the right supraclavicular lymph nodes and then upwards to the right lower cervical chain [11]. However, the pathogenesis of CTL without pulmonary tuberculosis cannot be explained by this theory, and also alternate routes of spread to lymph nodes, such as the tonsils and adenoids, have been proposed [12]. Lymph node tuberculosis could be also occurring by direct exposure to infection [3]. In this review, we aimed to discuss the diagnostic methods of CTL and to evaluate the usefulness of these diagnostic methods. Dermographic findings Age and gender distribution of CTL is different from the pulmonary tuberculosis. CTL is more frequent in females and in the younger age groups, whereas pulmonary tuberculosis is more common in males and in the older age groups [2, 13, 14]. Dandapat et al. have suggested that this phenomenon occurs as a consequence of male-dominated communities, where women experience poorer living conditions, and because young females generally notice differences in their appearance earlier than males [15]. Clinical presentation In the differential diagnosis of a cervical mass, CTL should be kept in mind especially in endemic areas. CTL may present as a unilateral single or multiple painless lump, mostly located in the posterior cervical or supraclavicular region [6, 16]. The duration of lymphadenopathy at time of presentation is typically 1–2 months, varying from 3 weeks to 8 months [8, 17]. Fistula formation can be seen in almost 10% of the mycobacterial cervical lymphadenitis [6, 18], though it is rare in atypical cases [19]. There is a significant variability in the literature on the occurrence of clinical signs and symptoms of LNT other than the cervical mass. However night sweats,
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weakness, cough and fever could be also seen in these patients in different ratios [2, 15]. These systemic symptoms are more commonly seen in HIV positive patients [20]. Also in HIV-positive patients the lymphadenopathies are more commonly seen as symmetrical and multiple contrasted with presentation with focal and asymmetrical lymphadenopathies of HIVnegative patients [21]. Accompanying pulmonary tuberculosis is reported in 18%–42% of patients. The higher rate of pulmonary tuberculosis is seen in HIV-positive patients rather than HIV-negative patients [22]. Diagnostic tools In order to make a diagnosis of CTL suspicion is mandatory. A detailed history and physical examination which is supported with hematological tests, tuberculin test, imaging techniques, fine-needle aspiration (FNA), and molecular tests will help arrive at an early diagnosis of tuberculous lymphadenitis and allow early initiation of treatment before the final diagnosis can be made by incisional biopsy and culture [8, 23, 24]. Hematological tests Although there is no specific blood test, leukocytosis, thrombocytosis, anemia, hyponatremia and increased ALP results are associated with chronic disease condition and these results create a doubt about an infective condition. Also elevated ESR show up a non-specific inflammatory response [25, 26]. Extrapulmonary involvement can be seen in more than 50% of patients with concurrent AIDS and pulmonary tuberculosis [3]. Because of the coinfection risk of extrapulmonary forms of tuberculosis in HIV-positive patients, all patients with CTL suspects have to be tested for HIV [14, 26, 27]. Tuberculin skin test Tuberculin skin test (TST) is used to show delayed-type hypersensitivity reactions against mycobacterial antigen, in which the reagent is mostly protein purified derivative (PPD). The test becomes positive 2–10 weeks after the mycobacterial infection. Positive reactions (>10-mm induration) can occur in M. tuberculosis infections. Suspicious reac-
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tions (5- to 9-mm induration) can occur after BCG vaccination, M. tuberculosis infection or nontuberculous mycobacterial infections. Negative reactions (<4-mm induration) represent a lack of tuberculin sensitization. False-negative reactions can occur in at least 20% of all people with active tuberculosis. The test may also be false positive in different conditions, like other infections, metabolic disease, malnutrition, live virus vaccination, malignancy, immunosuppressive drugs, newborns, elderly people, stress, sarcoidosis and inadequate test application [28]. Mandatory Bacille Calmette–Guerin (BCG) vaccination is in some countries may increase the false-positivity [2]. Although the value of the test is controversial [29], the positivity of TST is up to 98% in USA [17] and 100% in Turkey [30] in HIV-negative tuberculosis patients. Thus TST is a valuable, but nonspecific test for assessment of TB in Turkey [2, 30]. Imaging techniques Chest X-ray, neck ultrasound (USG), computerized tomography (CT) and magnetic resonance imaging (MRI) of neck can be performed in cervical lymphadenopathies. Chest X-ray findings may be positive in 10–40% of patients [31]. However, the normal chest X-ray should not exclude the CTL diagnosis. The changes in size, shape (L/T ratio), echogenicity and morphology of the nodal hilum or cortex have been suggested as sonographic criteria for differentiation of benign pathologies from malignant. However, USG findings do not show diseasespecific features for CTL. It can also be used as an imaging tool for the guided aspirations. Therefore, when combined with fine-needle aspiration, it has a very high sensitivity and specificity [32]. CT and MRI are valuable complementary techniques in evaluation of CTL. However, they are not sufficient to make a certain diagnosis. They accurately demonstrate the sites, pattern and extend of the disease. Imaging features are varied and nonspecific, although rim enhancement or calcification, if present, can be a strong indicator of the disease [33]. There are three patterns of nodal involvement in tuberculosis lymphadenitis on CT or MR images [34, 35]. In the early course of disease, the nodes are homogenous in attenuation and after adminis-
North Clin Istanbul – NCI
tration of intravenous contrast they enhance homogeneously. As the disease progress, the second and the most common pattern, a node with central area of necrosis, is seen. At CT, the affected nodes have center of low attenuation with an enhancing rim. At MRI, the enhancing areas are of intermediate signal intensity with T1-weighted sequences and are hypointense with T2-weighted sequences, whereas non-enhancing areas are relatively hypointense with T1-weighted sequences and markedly hyperintense with T2-weighted sequences. The non-enhancing areas indicate caseation or liquefaction necrosis, and the enhancing areas indicate granulation tissue with an inflammatory hypervascularity and increased vascular permeability. The third pattern is a fibrocalcified node that is usually seen in patients who have been treated. At CT, the node is homogenous and the calcification could be noticed. At MRI, it is homogenously hypointense both in T1- and T2weighted sequences and does not enhance after injection of contrast material [33, 34]. Fine-needle aspiration In fine-needle aspiration (FNA), a thin needle is inserted into an infected, swollen, superficial lymph node. Then, the taken aspirate material could be allocated for cytological examination, acid-fast bacilli (AFB) staining, culturing and/or molecular testing. Fine-needle aspiration cytology shows up a wellformed epithelioid granuloma and the presence of caseous necrosis [36]. These finding are highly suggestive of tubercular etiology, especially in developing countries where the incidence of tuberculosis is high [36]. The sensitivity and specificity of FNA cytology in the diagnosis of tuberculous lymphadenitis are 88% and 96%, respectively [37]. However, typical granulomas and caseation are less likely to be found in HIV-positive tuberculosis lymphadenitis because of the impaired T-cell function [20]. Therefore bacteriological confirmation is essential. Combination of FNA cytology with the culture or a TST further increases the diagnostic yield in CTL [29, 38]. FNA material also subjected to Ziehl-Neelsen (ZN) staining for AFB, mycobacterial culture and molecular test [20]. ZN staining and microscopic evaluation is rapid, cheap and easy. Sensitivity ranges from 46–78%
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and the specificity is actually 100% [36]. But the sensitivity ratio varies according to the source of the sample. Tandesse et al. revealed that concentrated aspirate material increase the yield of AFB staining procedure [39]. Culture A definitive diagnosis of tuberculosis lymphadenitis can be made by demonstration of M. tuberculosis in an affected lymph node by culture. However, a negative culture result should not exclude the diagnosis of CTL [28]. Isolation of mycobacterium by culture is possible in 10–69% of the cases [6, 24, 40]. And also the long duration of culture (6–8 weeks) cause delay in initiation of treatment and is assessed as time-consuming. Molecular testing Polymerase chain reaction (PCR) which is a nucleic acid amplification test, provide a rapid, specific and sensitive diagnosis of M. tuberculosis. [24]. After FNAs, PCR should be performed for the samples. When we scan the literature, the positivity of PCR from FNA materials were found 71.4%, 76.4% and 92.1% in three different studies [41, 42]. In one of these studies, Suzuki K. et al. compared the sensitivity of cytological examination, smears, cultures and PCR technique using an aspiration procedure for cervical tuberculous lymphadenitis. And the ratios of these techniques were 13.3%, 50%, 60% and 71.4%, respectively [43]. Histopathologic examination and PCR of an excisional biopsy should be recommended only for patients in whom FNA-PCR is negative or when there is discrepancy with the clinical impression [24]. Histopathology Histopathologic examination is one of the most important diagnostic method of CTL [6, 44, 45, 46]. Langerhans giant cells, caseating necrosis, granulomatous inflammation and calcification can be seen in histopathological examination [47]. Though histopathology is most reliable method for diagnosis of cervical lymphadenitis, its feasibility is limited due to its non-acceptability, as it is an invasive procedure [20]. Although it’s an invasive technique, early surgical excision of the tubeculous
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lymphadenitis is considered as an adjunct to antibiotic therapy. So surgical excision has been recommended for treatment failure cases of tuberculosis lymphadenitis and for patients who have discomfort from tense, fluctuant lymph nodes [17, 31]. Preferred surgical method is excision of an infected lymph node. Because incisional biopsy is associated with sinus tract and fistula formation and therefor is contraindicated [48]. Conclusion Tuberculosis (TB) is a major health concern in developing countries. This disease is a systemic disease which may give rise to cervical lymphadenitis as an extrapulmonary manifestation of the disease. The most usual signs and symptoms are the appearance of a chronic, painless mass in the neck, which is persistent and usually grows with time. Because of no other remarkable symptom their diagnosis and distinction need a high index of suspicion, and application of a variety of diagnostic modalities. However, it is not possible or practical to apply all of the diagnostic procedures in all patients. This would be time consuming and expensive. Increased ESR, leukocytosis thrombocytosis, anemia, hyponatremia and increased ALP results put forward a non-specific inflammation or a chronic disease status. Chest radiographs do not have any diagnostic value. And tuberculin skin test is also not valuable in areas where BCG vaccination is mandatory. CT and MRI scans may show characteristic signs and the localization of the CTL which may help if the surgical excision would be planned in future. After a FNA, a combination of conventional techniques (such as cytology, staining, culture) with PCR must be applied for the rapid and early diagnosis of CTL. Therefore, the value of FNA is indisputable. The definitive diagnosis of tuberculous lymphadenitis is done by excisional biopsy and histopathologic examination if all other techniques fail. Conflict of Interest: None declared. Financial Disclosure: The authors declared that this study has received no financial support. Authorship contributions: Concept – H.S.D.; Design – H.S.D.; Supervision – H.S.D.; Data collection &/or processing – M.K., Z.A.K.; Analysis and/or interpretation – H.S.D.; Writing – H.S.D.; Critical review – T.E.H.
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North Clin Istanbul – NCI lymphadenitis in Central Africa: clinical presentation of 157 cases. Int J Tuberc Lung Dis 1997;1:215–9. 22. Shriner KA, Mathisen GE, Goetz MB. Comparison of mycobacterial lymphadenitis among persons infected with human immunodeficiency virus and seronegative controls. Clin Infect Dis 1992;15:601– 5. 23. Ibekwe AO, Shareef Z, Kindy S. Diagnostic problems of tuberculous cervical adenitis (scrofula). Am J Otolaryngol 1997;18:202–5. 24. Singh KK, Muralidhar M, Kumar A, Chattopadhyaya TK, Kapila K, Singh MK, et al. Comparison of in house polymerase chain reaction with conventional techniques for the detection of Mycobacterium tuberculosis DNA in granulomatous lymphadenopathy. J Clin Pathol 2000;53:355–61. 25. Fitzpatrick EL, LeJeune FE Jr. Mycobacterial cervical lymphadenitis: a review. J La State Med Soc 1996;148:451–4. 26. Yoon HJ, Song YG, Park WI, Choi JP, Chang KH, Kim JM. Clinical manifestations and diagnosis of extrapulmonary tuberculosis. Yonsei Med J 2004;45:453–61. 27. Barnes PF, Lakey DL, Burman WJ. Tuberculosis in patients with HIV infection. Infect Dis Clin North Am 2002;16:107–26. 28. Bayazit YA, Bayazit N, Namiduru M. Mycobacterial cervical lymphadenitis. ORL J Otorhinolaryngol Relat Spec 2004;66:275–80. 29. Lau SK, Wei WI, Kwan S, Yew WW. Combined use of fine-needle aspiration cytologic examination and tuberculin skin test in the diagnosis of cervical tuberculous lymphadenitis. A prospective study. Arch Otolaryngol Head Neck Surg 1991;117:87–90. 30. Cinar F, Cinar S, Yilmaz B, Gürsel O. Purified protein derivative: the vital part of the cervical tuberculous adenitis diagnosis. Otolaryngol Head Neck Surg 2003;129:245–7. 31. Fontanilla JM, Barnes A, von Reyn CF. Current diagnosis and management of peripheral tuberculous lymphadenitis. Clin Infect Dis 2011;53:555–62. 32. Gupta A, Rahman K, Shahid M, Kumar A, Qaseem SM, Hassan SA, et al. Sonographic assessment of cervical lymphadenopathy: role of high-resolution and color Doppler imaging. Head Neck 2011;33:297–302. 33. Moon WK, Han MH, Chang KH, Im JG, Kim HJ, Sung KJ, et al. CT and MR imaging of head and neck tuberculosis. Radiographics 1997;17:391–402. 34. Moon WK, Im JG, Yu IK, Lee SK, Yeon KM, Han MC. Mediastinal tuberculous lymphadenitis: MR imaging appearance with clinicopathologic correlation. AJR Am J Roentgenol 1996;166:21–5. 35. Lee Y, Park KS, Chung SY. Cervical tuberculous lymphadenitis: CT findings. J Comput Assist Tomogr 1994;18:370–5. 36. Mittal P, Handa U, Mohan H, Gupta V. Comparative evaluation of fine needle aspiration cytology, culture, and PCR in diagnosis of tuberculous lymphadenitis. Diagn Cytopathol 2011;39:822–6. 37. Gupta SK, Chugh TD, Sheikh ZA, al-Rubah NA. Cytodiagnosis of tuberculous lymphadenitis. A correlative study with microbiologic examination. Acta Cytol 1993;37:329–32. 38. Ellison E, Lapuerta P, Martin SE. Fine needle aspiration diagnosis of mycobacterial lymphadenitis. Sensitivity and predictive value in the United States. Acta Cytol 1999;43:153–7. 39. Tadesse M, Abebe G, Abdissa K, Bekele A, Bezabih M, Apers L, et al. Concentration of lymph node aspirate improves the sensitivity of
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acid fast smear microscopy for the diagnosis of tuberculous lymphadenitis in Jimma, southwest Ethiopia. PLoS One 2014;9:106726. 40. Kanlikama M, Ozsahinoglu C, Akan E, Ozcan K. Mycobacterial species causing cervicofacial infection in Turkey. Eur Arch Otorhinolaryngol 1993;250:237–9. 41. Baek CH, Kim SI, Ko YH, Chu KC. Polymerase chain reaction detection of Mycobacterium tuberculosis from fine-needle aspirate for the diagnosis of cervical tuberculous lymphadenitis. Laryngoscope 2000;110:30–4. 42. Chiesa Estomba CM, Betances Reinoso FA, Rivera Schmitz T, Ossa Echeverri CC, González Cortés MJ, Santidrian Hidalgo C. Head and neck tuberculosis: 6-year retrospective study. Acta Otorrinolaringol Esp. 2016;67:9–14. 43. Suzuki K, Yagi M, Sakagami T, Fujisawa T, Miyamoto M, Kobayashi Y, et al. A Clinical Study on Cervical Tuberculous Lymph-
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Invited Review
BIOCHEMISTRY
North Clin Istanbul 2016;3(2):156–60 doi: 10.14744/nci.2016.32757
Separation techniques: Chromatography Ozlem Coskun Department of Biophysics, Canakkale Onsekiz Mart University, Canakkale, Turkey
ABSTRACT Chromatography is an important biophysical technique that enables the separation, identification, and purification of the components of a mixture for qualitative and quantitative analysis. Proteins can be purified based on characteristics such as size and shape, total charge, hydrophobic groups present on the surface, and binding capacity with the stationary phase. Four separation techniques based on molecular characteristics and interaction type use mechanisms of ion exchange, surface adsorption, partition, and size exclusion. Other chromatography techniques are based on the stationary bed, including column, thin layer, and paper chromatography. Column chromatography is one of the most common methods of protein purification. Keywords: Chromatography; column chromatography; protein purification.
C
hromatography is based on the principle where molecules in mixture applied onto the surface or into the solid, and fluid stationary phase (stable phase) is separating from each other while moving with the aid of a mobile phase. The factors effective on this separation process include molecular characteristics related to adsorption (liquid-solid), partition (liquid-solid), and affinity or differences among their molecular weights [1, 2]. Because of these differences, some components of the mixture stay longer in the stationary phase, and they move slowly in the chromatography system, while others pass rapidly into mobile phase, and leave the system faster [3]. Based on this approach three components form the basis of the chromatography technique. • Stationary phase: This phase is always composed of a “solid” phase or “a layer of a liquid adsorbed on the surface a solid support”.
• Mobile phase: This phase is always composed of “liquid” or a “gaseous component.” • Separated molecules The type of interaction between stationary phase, mobile phase, and substances contained in the mixture is the basic component effective on separation of molecules from each other. Chromatography methods based on partition are very effective on separation, and identification of small molecules as amino acids, carbohydrates, and fatty acids. However, affinity chromatographies (ie. ion-exchange chromatography) are more effective in the separation of macromolecules as nucleic acids, and proteins. Paper chromatography is used in the separation of proteins, and in studies related to protein synthesis; gasliquid chromatography is utilized in the separation of alcohol, esther, lipid, and amino groups, and observation of enzymatic interactions, while molecu-
Received: February 17, 2016 Accepted: October 01, 2016 Online: November 11, 2016 Correspondence: Dr. Ozlem COSKUN. Canakkale Onsekiz Mart Universitesi Tip Fakultesi, Terzioglu Yerleskesi, Dekanlik Binasi, Biyofizik Anabilim Dali, Canakkale, Turkey. Tel: +90 286 - 218 00 18-2300 e-mail: ozlemcd38@hotmail.com © Copyright 2016 by Istanbul Northern Anatolian Association of Public Hospitals - Available online at www.kuzeyklinikleri.com
Coskun, Chromatography
lar-sieve chromatography is employed especially for the determination of molecular weights of proteins. Agarose-gel chromatography is used for the purification of RNA, DNA particles, and viruses [4]. Stationary phase in chromatography, is a solid phase or a liquid phase coated on the surface of a solid phase. Mobile phase flowing over the stationary phase is a gaseous or liquid phase. If mobile phase is liquid it is termed as liquid chromatography (LC), and if it is gas then it is called gas chromatography (GC). Gas chromatography is applied for gases, and mixtures of volatile liquids, and solid material. Liquid chromatography is used especially for thermal unstable, and non-volatile samples [5]. The purpose of applying chromatography which is used as a method of quantitative analysis apart from its separation, is to achive a satisfactory separation within a suitable timeinterval. Various chromatography methods have been developed to that end. Some of them include column chromatography, thin-layer chromatography (TLC), paper chromatography, gas chromatography, ion exchange chromatography, gel permeation chromatography, high-pressure liquid chromatography, and affinity chromatography [6]. Types of chromatography • Column chromatography • Ion-exchange chromatography • Gel-permeation (molecular sieve) chromatography • Affinity chromatography • Paper chromatography • Thin-layer chromatography • Gas chromatography • Dye-ligand chromatography • Hydrophobic interaction chromatography • Pseudoaffinity chromatography • High-pressure liquid chromatography (HPLC) Column chromatography Since proteins have difference characteristic features as size, shape, net charge, stationary phase used,and binding capacity, each one of these characteristic components can be purified using chromatographic methods. Among these methods,most frequently column chromatography is applied. This technique
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Figure 1. Column chromatography. is used for the purification of biomolecules. On a column (stationary phase) firstly the sample to be separated, then wash buffer (mobile phase) are applied (Figure 1). Their flow through inside column material placed on a fiberglass support is ensured. The samples are accumulated at the bottom of the device in a tme-, and volume-dependent manner [7]. Ion- exchange chromatography Ion- exchange chromatography is based on electrostatic interactions between charged protein groups, and solid support material (matrix). Matrix has an ion load opposite to that of the protein to be separated, and the affinity of the protein to the column is achieved with ionic ties. Proteins are separated from the column either by changing pH, concentration of ion salts or ionic strength of the buffer solution [8]. Positively charged ion- exchange matrices are called anion-exchange matrices, and adsorb negatively charged proteins. While matrices bound with negatively charged groups are known as cation-exchange matrices, and adsorb positively charged proteins (Figure 2) [9]. Gel- permeation (molecular sieve) chromatography The basic principle of this method is to use dextran containing materials to separate macromolecules based on their differences in molecular sizes. This procedure is basically used to determine molecular weights of proteins, and to decrease salt concentra-
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Protein content Cations bind to stationary phase
Gel beads Column bed
Column Anion-exchange resin
Figure 2. Ion- exchange chromatography. tions of protein solutions [10]. In a gel- permeation column stationary phase consists of inert molecules with small pores. The solution containing molecules of different dimensions are passed continuously with a constant flow rate through the column. Molecules larger than pores can not permeate into gel particles, and they are retained between particles within a restricted area. Larger molecules pass through spaces between porous particles, and move rapidly through inside the column. Molecules smaller than the pores are diffused into pores, and as molecules get smaller, they leave the column with proportionally longer retention times (Figure 3) [11]. Sephadeks G type is the most frequently used column material. Besides, dextran, agorose, polyacrylamide are also used as column materials [12]. Affinity chromatography This chromatography technique is used for the purification of enzymes, hormones, antibodies, nucleic acids, and specific proteins [13]. A ligand which can make a complex with specific protein (dextran, polyacrylamide, cellulose etc) binds the filling material of the column. The specific protein which makes a complex with the ligand is attached to the solid support (matrix), and retained in the column,while free proteins leave the column. Then the bound protein leaves the column by means of changing its ionic strength through alteration of pH or addition of a salt solution (Figure 4) [14].
Figure 3.
Gel-permeation (molecular sieve) chroma-
tography.
Figure 4. Affinity chromatography. Paper chromatography In paper chromatography support material consists of a layer of cellulose highly saturated with water. In this method a thick filter paper comprised the support, and water drops settled in its pores made up the stationary “liquid phase.” Mobile phase consists of an appropriate fluid placed in a developing tank. Paper chromatography is a “liquid-liquid” chromatography [15]. Thin-layer chromatography Thin-layer chromatography is a “solid-liquid adsorption” chromatography. In this method station-
Coskun, Chromatography
ary phase is a solid adsorbent substance coated on glass plates. As adsorbent material all solid substances used. in column chromatography (alumina, silica gel, cellulose) can be utilized. In this method, the mobile phase travels upward through the stationary phase The solvent travels up the thin plate soaked with the solvent by means of capillary action. During this procedure, it also drives the mixture priorly dropped on the lower parts of the plate with a pipette upwards with different flow rates. Thus the separation of analytes is achieved. This upward travelling rate depends on the polarity of the material, solid phase, and of the solvent [16]. In cases where molecules of the sample are colorless, florescence, radioactivity or a specific chemical substance can be used to produce a visible coloured reactive product so as to identify their positions on the chromatogram. Formation of a visible colour can be observed under room light or UV light. The position of each molecule in the mixture can be measured by calculating the ratio between the the distances travelled by the molecule and the solvent. This measurement value is called relative mobility, and expressed with a symbol Rf. Rf. value is used for qualitative description of the molecules [17]. Gas chromatography In this method stationary phase is a column which is placed in the device, and contains a liquid stationary phase which is adsorbed onto the surface of an inert solid. Gas chromatography is a “gas-liquid” chromatography. Its carrier phase consists of gases as He or N2. Mobile phase which is an inert gas is passed through a column under high pressure. The sample to be analyzed is vaporized, and enters into a gaseous mobile phase phase. The components contained in the sample are dispersed between mobile phase, and stationary phase on the solid support. Gas chromatography is a simple, multifaceted, highly sensitive, and rapidly applied technique for the extremely excellent separation of very minute molecules. It is used in the separation of very little amounts of analytes [18]. Dye- ligand chromatography Development of this technique was based on the
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demonstration of the ability of many enzymes to bind purine nucleotides for Cibacron Blue F3GA dye [19]. The planar ring structure with negatively charged groups is analogous to the structure of NAD. This analogy has been evidenced by demonstration of the binding of Cibacron Blue F3GA dye to adenine, ribose binding sites of NAD. The dye behaves as an analogue of ADP-ribose. The binding capacity of this type adsorbents is 10–20-fold stronger rhat that of the affinity of other adsorbents. Under appropriate pH conditions, elution with high-ionic strength solutions, and using ionexchange property of adsorbent, the adsorbed proteins are separated from the column [20, 21]. Hydrophobic interaction chromatography (HIC) In this method the adsorbents prepared as column material for the ligand binding in affinity chromatography are used. HIC technique is based on hydrophobic interactions between side chains bound to chromatography matrix [22, 23]. Pseudoaffinity chromatography Some compounds as anthraquinone dyes, and azodyes can be used as ligands because of their affinity especially for dehydrogenases, kinases, transferases, and reductases The mostly known type of this kind of chromatography is immobilized metal affinity chromatography (IMAC) [24]. High-prssure liquid chromatography (HPLC) Using this chromatography technique it is possible to perform structural, and functional analysis, and purification of many molecules within a short time, This technique yields perfect results in the separation, and identification of amino acids, carbohydrates, lipids, nucleic acids, proteins, steroids, and other biologically active molecules, In HPLC, mobile phase passes throuıgh columns under 10–400 atmospheric pressure, and with a high (0.1–5 cm//sec) flow rate. In this technique, use of small particles,and application of high presure on the rate of solvent flow increases separation power, of HPLC and the analysis is completed within a short time. Essential components of a HPLC device are solvent depot, high- pressure pump, commercially
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prepared column, detector, and recorder. Duration of separation is controlled with the aid of a computerized system, and material is accrued [25]. Application areas of chromatography in medicine Chromatography technique is a valuable tool for biochemists, besides it can be applied easily during studies performed in clinical laboratories For instance, paper chromatography is used to determine some types of sugar, and amino acids in bodily fluids which are associated with hereditary metabolic disorders. Gas chromatography is used in laboratories to measure steroids, barbiturates, and lipids. Chromatographic technique is also used in the separation of vitamins, and proteins. Conclusion Initially chromatographic techniques were used to separate substances based on their color as was the case with herbal pigments. With time its application area was extended considerably. Nowadays, chromatography is accepted as an extremely sensitive, and effective separation method. Column chromatography is one of the useful separation, and determination methods. Column chromatography is a protein purification method realized especially based on one of the characteristic features of proteins. Besides, these methods are used to control purity of a protein. HPLC technique which has many superior features including especially its higher sensitivity, rapid turnover rate, its use as a quantitative method, can purify amino acids, proteins, nucleic acids, hydrocarbons, carbohydrates, drugs, antibiotics, and steroids. Conflict of Interest: None declared. Financial Disclosure: The authors declared that this study has received no financial support.
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