Israel Medical Association Journal

Background: The mortality rate for cholecystectomy for acute cholecystitis in the elderly is 10% in low risk patients and increases threefold in high risk patients. Ultrasound-guided percutaneous transhepatic cholecystostomy may serve as a rapid and relatively safe tool to relieve symptoms of sepsis and decrease gallbladder distension.

Objective: To determine the safety and effectiveness of PTC[1] in the treatment of acute cholecystitis in elderly debilitated high risk patients.

Methods: The study sample included 10 patients aged 63–88 (mean 77.6 years) with clinical and sonographic signs of acute cholecystitis for more than 48 hours (fever, white blood cells > 12,000/mm³, positive Murphy sign and distended gallbladder) who underwent ultrasound guided PTC. All had severe underlying disease (coronary heart disease, renal failure, chronic obstructive pulmonary disease, and others) that places them at high risk for surgical intervention.

Results: Eight patients showed rapid regression of the clinical symptoms following PTC drainage. One patient, with bacterial endocarditis, was febrile for 5 days after catheter insertion, but with rapid resolution of the biliary colic and sepsis. One patient died from perforation of the gallbladder and small bowel. PTC catheters were withdrawn 3–25 days after the procedure, and the patients remained free of biliary symptoms. Two patients underwent successful elective cholecystectomy 3 weeks later.

Conclusion: PTC may be a safe and effective treatment for high risk elderly patients with acute cholecystitis. It can be followed by elective cholecystectomy if the underlying condition improves, as soon as the patient stabilizes and no sepsis is present, or by conservative management in high surgical-risk patients.

Background: Between 1970 and 1979, there was an increase in the incidence of viral hepatitis in Israel with a shift of peak incidence to an older age in the Jewish population, followed by a declining trend during the early 1980s. In July 1999 universal immunization of infants against hepatitis A was introduced.

Objective: To evaluate the chan-ges in the epidemiology of viral hepatitis A in Israel during the past decade.

Methods: Viral hepatitis is a notifiable disease in Israel and cases are reported to the regional health offices, which in turn provide summary reports to the Ministry of Health's Department of Epidemiology. The data in this study were derived from the summary reports and from results of seroprevalence studies.

Results: Following the increase in the incidence of reported viral hepatitis (mainly due to type A) between 1970 and 1979, the rates then stabilized and around 1984 began to decline until 1992. Since then there has been a slight increase. Whereas until 1987 the rates were consistently higher in the Jewish population. since then they are higher in the Arab population. The shift in the peak age-specific incidence from the 1-4 to the 5-9 year age group observed in the Jewish population around 1970 occurred 20 years later in the Arab population. The previously described seasonality is no longer evident. Recent seroprevalence studies indicate that by age 18 years only about 30-40% of the Jewish population have anti-hepatitis A antibodies.

Conclusions: The decline in the incidence of hepatitis probably reflects the changing socioeconomic condition occurring at different times in the two major population groups. Since hepatitis A accounts for almost all the acute viral hepatitis in Israel, the universal vaccination of infants introduced in 1999 should substantially lower the morbidity within the next few years.

Background: Anti-endomysial antibodies are sensitive and specific markers for celiac disease. This antibody has recently been identified as an antibody to tissue transglutaminase, an enzyme that cross-links and stabilizes extracellular matrix proteins.

Objectives: To evaluate the clinical usefulness of an enzyme-linked immunoassay for anti-transglutaminase antibodies, and to compare the results with those of AEA, the current gold standard serological test for celiac disease.

Methods: Serum samples were collected from 33 patients with biopsy-proven celiac disease and AEA tests were performed. Control samples for anti-transglutaminase were obtained from 155 patients. An ELISA test for immunoglobulin A anti-transglutaminase utilizing guinea pig liver transglutaminase was developed and performed on all sera.  Cutoff values for the test were performed using logistic regression and receiver operating curves analysis.

Results: An optical density cutoff value of 0.34 was established for the assay. The mean value was 0.18±0.19 optical density for controls, and 1.65±1.14 for patients with celiac disease (P<0.001). Sensitivity and specificity of the assay were both 90%, while AEA had a sensitivity and specificity of 100% and 94%, respectively.

Conclusions: A tissue transglutaminase-based ELISA test is both sensitive and specific for  detection of celiac disease.

__________________________________

AEA = anti-endomysial antibody