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3 The follow-up biochemical parameters cholestasis and oxidative stress intensity in patients with obstructive icterus induced by choledocholithiasis Saša Zajić Surgical Department Health Center Kruševac SERBIA

4 Health Center Kruševac General Hospital

5 Introduction CHOLESTASIS is a malfunction the function the liver made by impossibility bile to flow through bile ways in intestine, which as a consequence has retention bile constituents in liver and regurgitation in blood. There are damages liver cells by toxic bile acids - by powder action causing oxidative stress by induction apoptosis Kullak-Ublick i Maier, 2000

6 Extrahepatic cholestasis consequence mechanical obstacle in bile flow through ductus hepaticus, choledochus or papila Vateri. Causes: atresia and hypoplasia bile ways primary sclerosing cholangitis cancer the pancreas head obstruction by stones - choledocholithiasishiasis

7 Characteristics extrahepatic cholestasis jaundice yellow color the skin and white the eye Pain the colic type (upper-rightright stomach and epigastrium) Feeling pressure and discomfort Nausea and vomiting pain associated with jaundice suggests to calculus disease bile ways lack pain with the increase transaminasissis (AST) and bilirubins suggests against obstructive jaundice Whitehead MW. Gut 1999;45:

8 Clinical characteristics extrahepatic cholestasis Itching (pruritus) because the layer bile salts in skin does not disappear by scratching Insomnia Suicidal sensations Tiredness, depression and phobic anxiety Decreased re-absorption vitamin A,D,E,K and osteoporosissis Aholic bowel movement, steatorea Loss appetite and body weight Dark color urine Huet PM. Am J Gastro 2000;95: Glasova H. J Gastroenterol Hepatol 2002; 17:

9 Biochemical characteristics extrahepatic cholestasis Increase concentration total and conjugal bilirubins Increase activity membrane enzymes in plasma (γ- glutamyltransferase, alkal phosphatases, 5 - nukleotidases) Decrease in synthesis albumin hypoglycemia Increase free cholesterol Decrease factors coagulation protrombine and factors VII, IX i X

10 Oxidative stress in cholestasis syndrome Many experimental and clinical studies have proved the occurrence oxidative stress and increased intensity lipid peroxidation in blood plasma, liver and brain in cases cholestasis. (Parola i sar, 1996; Sokol i sar, 1998; Shivaram i sar, 1998; Tsai i sar, 1998; Rodrigues i Steer, 2000; Yerushalmi i sar, 2001; Sokol i sar, 2001; Purucker i sar, 2001; Sokolović i sar, 2004).

11 Aim Monitoring AST, ALT, GGT and ALP activities, bilirubin and cholesterol concentrations, as well as oxidative stress intensity in plasma patients with extrahepatic cholestasis induced by choledocholithiasis were imposed for aims this work.

12 Material and methods The investigation encompassed 70 patients divided into two groups. The first one is control group (30 healthy individuals), while the second was formed from 40 patients with intraluminal extrahepatic obstruction caused by choledocholithiasis.

13 Diagnosis obstructive icterus was set according to anamnesis, clinical picture and imidzing methods diagnosis (ultrasound examination bile ways, CT scen, MRCP). Testing was done with all patients when they were admitted and time when first symptoms appeared is not shorter than 3 days nor longer than 14 days. All patients from the control group are voluntary giving blood, and they are paired with the tested group patients with cholestasis by age and gender.

14 Biochemical methods All biochemical methods were determined by already existing test Ellitech firm, on biochemical analyser BTS-370 (BioSystems): activity alanin aminotransferasese (ALT), activity aspartat aminotransferasese (AST), activity -glutamyltransferasese ( -GT) GT), activity alkali phosphase (AF), concentration bilirubin amount cholesterol in serum. bilirubins (total, direct and indirect), Determination intensity oxidative stress: determination the level lipid peroxidation by measurements conc. malondialdehide (MDA) reaction with TBA (Stroeva i Makarova, 1989). determination the level oxidative modification protein by measurement conc. carbonyl groups by 2,4 dinitrophenilhidrazine (DPNH) - traditional carbonyl agent (Levine i sar, 1994).

15 Results were processed by the usage Student s T-test, and all measurement values were given as average value (X) standard deviation (SD). Results are shown in table and graph.

16 Results Tab 1. Gender distribution in tested groups number (%) men women age EHH 40 57% ,4 14, 14,1 control 30 43% ,5 18,0 total % 37 (53%) 33 (47%) 58,8 15,9 EHH-extrahepatic cholestasis During this research, in tested sample patients with extrachepatic obstruction caused by choledocholithiasis, there was not important difference in gender distribution.

17 U/l GOT (AST) kontrola holestaza Fig 1. Activity enzymes GOT (AST) in plasma patients with cholestasis *** ***p<0,001 according to control U/l GPT (ALT) *** 0 kontrola holestaza Fig 2. Activity enzymes GPT (ALT) in tested groups ***p<0,001 according to control

18 In conditions cholestasissis toxic bile acid, gathered in liver, they damage membrane hepatocytes and lead to exit citosolar ALT in circulation. ALT is citosolar enzyme hepatocyte, so even with a small damages liver tissue it exits in circulation, because it is enough that cell membrane permeable changes and the enzyme goes in fluid out cell. On the other hand AST is present also in the mitochondria (60-70 %) hepatic cells so there must be larger damage them to have increase this enzyme in plasma. Briggs at al. Management obstructive jaundice. Surgery (Oxford) 2007; 25(2): Chen D et al, Ai Zheng 2008;27(1):

19 U/l kontrola AF holestaza Fig 3. Activity enzyme alkal phosphatasis (AF) in tested groups *** ***p<0,001 according to control U/l GGT *** 50 0 kontrola holestaza ***p<0,001 according to control Fig 4. Activity enzyme γ-glutamil transpherasis (GGT) in blood plasma patients

20 With obstacle in flow bile caused by choledocholithiasis, there is solibilizing activity bile salts, that cause the release AF from the outer side cell membrane, without lyses cells themselves - in cholestasis bile salts induce synthesis new molecules AF (Alvaro i sar, 2000). Bile acids have, with their toxic activity on membrane hepatocyte, led to release γ-gt in circulation (Schmucker i sar, 1990; Castro-e-Silva Junior i sar, 1990).

21 mmol/l bil-ukupan bil-direktni bil-indirektni *** *** *** 0 kontrola holestaza ***p<0,001 according to control Fig 5. Concentration bilirubins (mmol/l) in blood plasma control and cholestasis group

22 Because mechanical obstacle in bile canals, caused by choledocholithiasis, there is retention bile colors in circulation. The direction bile changes,so with all its ingredients it starts to move from biliary to sinusoid pole hepatocyte. Part conjugate bilirubin goes into blood plasma, so hyperbilirubinemia conjugated type occurs (Phillips i sar, 1986). In the beginning cholestasis during the damages smaller levels always dominates hyperbilirubinemia conjugated type, and later during the next worse stadium the process, in plasma the concentration unconjugated bilirubin increases. - Increased concentration conjugate bilirubin in hepatic cells stops the process conjugation, and as a result have the increase concentration unconjugated bilirubin in blood (Kullak-Ublick i Maier, 2000). Unlike conjugated which is non-toxic, unconjugated biliruin in free state is very toxic to cells.

23 Tab 2. Concentration total cholesterol in plasma cholestasis patients Extrahepatic cholestasis control Total cholesterol 5,8 1,2* 5,2 0,5 *p<0,05 according to control In conditions cholestasis, the synthesis cholesterol in liver increases and there is an increased level free cholesterol and total bile acids in blood plasma (Kamisako i Ogawa, 2003). Study Dueland i co. (1991) showed that at total obstruction joint bile canal, there was an increase in activity enzimes for its synthesis in liver, which lead to increase content cholesterol and liver acids in liver and their increased secretion in circulation.

24 µmol/l *** kontrola holestaza ***p<0,001 according to control Concentration MDA (µmol/l) in plasma patients with extrahepatic cholestasis µmol/g proteina *** kontrola holestaza Level carbonyl groups in plasma patients with extrahepatic cholestasis The intesity oxidative stress measured by the level MDA and quantity carbonyl groups is significant higher in patients with extrahepatic cholestasis comparing with the control group ***p<0,001 according to control

25 Hydrophobic bile acids, held in hepatocytes during cholestasis, start creating reactive oxide radicals (ROS) from mitochondria which lead to lipid peroxidation and loss vitality liver cells. Baron i co. (1999) noted peroxidation (MDA) in rat choledochus (for 7 days). increased liver with level tied lipid ductus Sreejayan i Von Ritter, 1999

26 Bile acids disturb the transport electrons in respiratory chain mitochondria, activating formation super-oxide anion radicals (O2 ) and their metabolites H 2 O 2 i OH (Shivaram, 1998). In conditions cholestasis (by activity bile acids) there is a change permeability mitochondrial membrane (MPT), and as a consequence to loss potential mitochondrial membrane (ΔΨm) and also to cut respiratory chain and inhibition synthesis ATP, and it all results in production ROS culminating by necrosis or apoptosis hepatocyte (Rodrigues i Steer, 2000).

27 It is stated that relatively law concentrations bile acids lead to oxidative stress in hepatocite, which comes before apoptosis (Yerushalmi i sar, 2001). During apoptosis hepatocite in cholestasis, cytochrome c is released from mitochondria in citosolar. - With its lack in mitochondrial membrane, there is a leak electrons who do reduction molecule oxygen so a super-oxide radical (O 2 ) can occur, and it H 2 O 2, OH too (Kurosawa i sar, 1997).

28 The patients with extrahepatis cholestasis caused by choledocholythiasis were treated first with orthodox treatment with medicine and then ERCP and surgical therapy Increase the value markers cholestasis and intensity oxidative stress the patients with choledocholythiasis caused the damage liver tissue, and because that the big mistake for patients is not to be operated.

29 In treatment the patients with extrahepatic cholestasis caused by choledocholythiasis we used in operative technique choledochotomia with stones extraction, T-tube drainage, using Roux en Y reconstruction with small bowel or primary suture common bile duct.

30 Conclusions In patients with cholestasis induced by choledocholithiasis the significant increase enzymatic markers cholestasis (AST, ALT, -GT i AP) and bilirubin has been noticed in plasma. Cholestasis leads to increase cholesterol concetration in patients plasma, too.

31 Conclusions The oxidative stress intensity is increased in plasma patients with extrahepatic cholestasis. As during the oxidative stress, provoced by extrahepatic cholestasis comes to demage hepatocites, the surgical treatment on time is the method choice.

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