Arshikov, I.

Petkov, P.

Zozikov, V.

English

Varna Medical University Press: Journals

CONCERNING EXTRAHEPATIC CHOLESTASIA IN VIRAL HEPATITISV. Zozikov, P. Petkov, I. ArshikovDisorders in the metabolism of biliary pigments in viral hepatitis are usually of the hepato-parenchymal jaundice type. A number of mechanisms constitute the genesis of the latter, namely: tissue destruction (direct rela­tionship between biliary and blood capillary systems), functional cellulary derangements (disturbances in bipolarity, permeability and glucoronoid capacity) etc. Recently, intrahepatic mechanical stoppage of bile flow has been frequently mentioned on account of the same disease (the so-called cho­lestatic or cholangiolitic form). However, the problem of the eventual pre­sence of extrahepatic mechanical factors in the genesis is insufficiently cla­rified, or more correctly, their role in the intensification and prolongation of the icterus in viral hepatitis. The question is concerned about the lymph nodes ad portam hepatis. Being substantially enlarged in instances of hepa­titis in their capacity of regional lymphatic barriers, couldn’t they contri­bute for the biliary congestion by way of external compression of the major biliary ducts?Some authors (Holler, Beiglbock quoted by Siede (9)) draw a particular attention to the generalized hyperplasia of the lymph nodes in this condition, considering it furthermore, as its most characteristic feature. Holler more­over, coins the disease with the term “infectious reticuloendotheliosis“ — quoted by Stanchev (3). The latter opinion is not condivided by all the aut­hors (9). And yet, single reports are found in the literature related to consi­derable increase of the portal lymph nodes during acute and chronic hepa­titis, proved obductionally (Wallgren, Selander — quoted by Siede (9)) or operatively (Gerota and assoc. (5)). The relationship of these lymph nodes however, has not been elucidated irsofar genesis and character of the icteral syndrome observed is concerned. According to Popper and Schaffner (7), extrahepatic (compressive) jaundice is noted merely in malignant outgrowths (primary or metastatic) of the portal lymph apparatus infiltrating the bile ducts and thus securing fixation. Similar forms of jaundice, by rule, are very seldom (8). Enlarged lymph nodes ad portam hepatis were the cause for cholestasia merely in nine cases of the series observed by Watson (10) including 128 patients with extrahepatic compressive icterus. Among the remainder tumorous-like enlargements in the same region (leukosis, lympho­granulomatosis, tuberculosis, infectious mononucleosis), manifested chole­stasia is recognised still more rarely — merely in exceptional cases (2, 4, 8).Recently, we had the possibility of observing a rare clinical case, deserv­ing a special consideration on account of the statements herein made as well120 V. Zozikov, P. Petkov, I. Arshikov 2as on account of substantial diagnostical and therapeutical difficulties related to it:Case report — Lefter M ., aged 23; history of illness №2539. He fell ill of epidemic hepatitis in August 1963 and underwent treatment at the infectious department of the hospital in the town T. He had a grave course and was unconscious for nearly two days. By the way, he was also treated with cortisone. He was dismissed on his insistence, not completely cured, on the 23rd day of hospitalization. One month later he sustained a re­currence and was readmitted for hospital treatment. In ten days he was discharged with a slight icterus.At the infectious diseases clinic of the Higher Medical Institute in Varna the patient was referred on 20 December, 1963 with phenomena of adynamia, anorexia, moderately pronounced jaundice and hepatomegaly (3 cm beneath the costal arch, dense elastic con­sistency).Laboratory findings: (investigations carried out repeatedly).Urine: persistent bilirubinuria and hyperurobilinogenuria; erythrocyte sedimentation reaction, leuko- and hemogram: normal; MacLagan: 80—95 U; Weltmann: VIII test- tubes; serai bilirubin: 3.0—7.9 mg ?o (mainly direct); Proteinogram: total protein normal, albumins — 40—45%, gamma-globulins — 28—31 %; Transaminase (SGPT): 340— 250 U; serum iron: 256 gamma %; total cholesterol: 256 mg°o; Weinberg — negative; fluoroscopy of the stomach, duodenum and bile ducts — within normal limits.Dietary and therapeutical regimens (vitamins, dehydrocortisone, biomycin, plasma transfusions and glucosis, Karlsbad salt etc.) resorted to did not bring about the results anticipated. The icterus, hepatomegaly, subjective complaints and abnormal paraclinica! findings persisted over the three-month hospitalization period of the patiet in our clinic. It was assumed that very likely a chronified viral hepatitis case was concerned with pro­tracted cholestasia, without evident tendency for improvement under the effect of the conservative therapy applied. However, we could not discard with certainty the possi­bility for some other cause accounting for the continuous biliary retention — for instance, mechanical subhepatic obstruction. By virtue of the circumstances existing, accordingly described, it was decided to resort to surgical intervention — periarterial neurectomy after Marret-Guy. The operation was performed at the Propedeutical surgery clinic of the Higher Medical Institute in Varna on March 7th, 1964. At the operation the liver was found with raised consistency. The portal lymph nodes exhibited tumorous-like enlarge­ment (measuring 2—3 cm in diameter) and enveloped the hepatic artery and the bile duct. During partial neurectomy and extirpation of lymph nodes in the vicinity of the common bile duct, the nodes were abundantly bleeding. On sectioning they exhibited cystic changes and from the cyst lymph was discharged. The biopsy of a hepatic section revealed mesen­chyme inflammatory process with overloading of biliary pigment cells, whereas the biopsy of a piece from the lymph node — the characteristic picture of reaction in chronic nonspe­cific process with pronounced reticular hyperplasia (investigator: ass. prof. K. Popov, M. D., Chair of Pathoanatomy — Higher Medical Institute, Varna).The postoperative period was uneventful. The jaundice abruptly subsided and comple­tely disappeared rather quickly. On the 5th postoperative day no more bilirubin was contained in the urine. On the 10th day the serum bilirubin was 0.5 mg %. On the 14th day the patient was dismissed in a very good general condition.In the course of subsequently carried out systematic follow-up studies for more than one and a half years, the patient was invariably with high spirits and anicteric. The liver was palpated over the costal arch and was not painful. The serum bilirubin was persistently beneath 1 mg°6. The MacLagan test continued to be positive (80—85 U) whereas that of Weltmann — protracted. Moderately pronounced hypoalbuminemia and hypergammaglobulinemia.Discussion and conclusionsThe changes in the regional lymph pool ad portam hepatis in the case herein described consist in: lymph stasis, hyperemia and hyperplasia of the lymph nodes. The latter finding is distinguished both macro- and microscopi­cally from the finding observed in pericholedochal lymphadenitis, frequently marked during operative interventions on account of calculous cholecystitis.3 Concerning Extrahepatic Cliolestasia in Viral Hepatitis 12Vtuberculosis and other inflammatory processes in the same locality (6). Strongly manifested periadenitis, fibrcsclerosis of the hepato-duodenal junct­ion and local inflammatory reaction on behalf of the peritoneum are usually present in similar cases; the enlargement of the lymph nodes proper is rather slightly pronounced and thus, it is assumed that causal relationship with incidentally observed jaundice is non-existant.In the patient herein reported, the tumorous-like outgrowth of the portal lymph nodes, developed in the course of severe and protracted viral hepatitis, led to a lasting, though partial extrahepatic biliary stasis. The latter caused not merely the prolonged duration of the jaundice (more than seven months), but very likely the chronification of the morbid process in the liver. The macroscopic findings in the area involved were likewise in favour of' this statement, as well as the prompt and good therapeutical effect of the operative intervention undertaken. The latter successfully restored the patency of the extrahepatic biliary system and thus, greatly contributed to the attenuation or full, disappearing of a number of symptoms in the patient discussed.We feel that in a determined number of “cholestatic” (“cholangiolitic)” forms of viral hepatitis, with suspected intrahepatic biliary stasis, virtually pathogenetic mechanisms of extrahepatic nature are very probably concerned, analogous to those of the patient herein described. Therefore, the presence of compressive extrahepatic cholestasia, caused by excessively enlarged portal lymph nodes, should always be suspected when indications are discussed for operative management of protracted icteric forms of viral hepatitis.R E  F E R E N C E S1. А л т ъ н к o в, П.  н П . П е т к о в .  Хирургия, 4, 1965.2. P а ч е в, Л., Д. М а р и н о в, Ш. Н и н ь о, Д. П а в л о в .  Вирусен хепатитв детската възраст. Мед. и физк., София, 1961, 213.3. С т а н ч е в ,  Ал. Епидемичен хепатит. Мед. и физк., София, 1958, 221.4. B o w e r ,  J . ,  А. С о с a, R.  М i г. — J AMA,  146, 1951, 987.5. С е г о t a. D., Р. B u r l u i a ,  М. S t a n c e s k o ,  S . G i r n a r u .  Lyon chi-rurg., 61, 2, 1965, 304.6. G o i n a r d ,  P., G. P е 1 i s s i e r. Therapeutique chirurgicale des icteres par retention. Paris, Masson et Cie, 1959.7. P o p p e r ,  H., F. S c h a f f n e r. Die Leber. G. Thierne Verlag, Stuttgart, 1961,837.8. S h e r l o c k ,  S h e i l a .  Dis. of the liver and bil. system. Blackwell, Oxford,1955, 720.9. S i e d e, W. Virushepatitis und Folgezustande: 2 Auflage, Л. А.  Barth, Leipzig,1958, 326.10. W a t s o п, C. J. — J AMA,  114, 1940, 2427.122 V. Zozikov, P. Petkov, I. Arshikov 40 ВНЕПЕЧОНОЧНОМ ХОЛОСТАЗЕ ПРИ ВИРУСНОМ ГЕПАТИТЕВ. Зозиков, П. Петков, Й. АришкопРЕЗ ЮМЕОбсуждается отношение регионарного лимфаденита acl portam hepatis к степени и длительности желтушного синдрома и патологического про- цесса в печени при вирусном гепатите. Описнвается случай тяжелого н протрагированного вирусного гепатита у 23-летнего мужчинн, у которого чрезвнчайное увеличение портальннх лимфатпческих узлов является при- чиной значительного (семимесячного!) продления желтухи. Оперативное удаленне опухолевидно увеличени нх лимфатпческих узлов вокруг желч- ного протока привело к бнстрому п полному исчезновению желтухи и остальннх симптомов у больного. Автори допускают, что и у известной части холостазннх (холангнолитннх) форм вирусного гепатита, при ко- торих обично предполагается наличие Енутрипечоночного холостаза, может бнть, существует подобннй внепеченочннй патогенетический фак­тор. Вот почему, в показаниях к оперативному вмешательству при про- трагированних желтушннх с]ормах вирусного гепатита должно фигу- рировать и сомнение в компрессионном внепеченочном холостазе, в ре- зультате сильного хвеличения портальннх лимфатпческих узлов.

CONCERNING EXTRAHEPATIC CHOLESTASIA IN VIRAL HEPATITIS

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CONCERNING EXTRAHEPATIC CHOLESTASIA IN VIRAL HEPATITIS

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