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Serum bilirubin evolution in patients with obstructive jaundice submitted to biliary drainage
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Introdução: Em doentes com icterícia obstrutiva, a evolução da bilirrubina total sérica monitoriza a resposta a uma dada intervenção terapêutica. Os últimos estudos que avaliaram esta cinética foram feitos na década de 1980. Nos últimos 40 anos, observou-se uma grande evolução das intervenções terapêuticas, que se tornaram menos invasivas, mais eficazes e que causam menos morbilidade e mortalidade.
Objetivos: Avaliar a cinética da bilirrubina total sérica, em doentes com icterícia obstrutiva e que foram submetidos a descompressão por Colangiopancreatografia Retrograda Endoscópica (CPRE) ou por Duodenopancreatectomia.
Métodos: Registámos os valores de bilirrubina de 101 doentes internados no Hospital Garcia de Orta de 01/12/2016 a 30/11/2018. Calculámos uma curva de regressão logarítmica destes valores para chegar a um modelo generalizado. A taxa de redução de bilirrubina pós-intervenção for avaliada. Curvas de Kaplan-Meier foram criadas para analisar a duração do internamento da nossa amostra de doentes.
Resultados: A bilirrubina mediana na admissão foi de 6,8 mg/dL com um mínimo de 0,9 mg/dL e um máximo de 27,4 mg/dL. Doentes com neoplasia submetidos a duodenopancreatectomia sem CPRE prévia tiveram a bilirrubina média na admissão com valor mais alto de 16,3 ± 7,9 mg/dL. A taxa de redução nas primeiras 24h pós-intervenção foi de 2,08 mg/dL para doentes com litíase; 4,63 mg/dL para doentes com neoplasia tratados com CPRE; 1,40 mg/dL para doentes com neoplasia tratados com duodenopancreatectomia com CPRE prévia e 7,81 mg/dL nos doentes com neoplasia tratados com duodenopancreatectomia sem CPRE prévia. A duração mediana do internamento foi de 14 dias, variando com o tipo de intervenção (13 dias para doenças tratadas com CPRE, 17 dias para a Duodenopancreatectomia sem CPRE prévia e 36 dias para a Duodenopancreatectomia com CPRE prévia), a etiologia (11 dias para litíase e 17,5 para neoplasia), com o valor de bilirrubina na admissão (11 dias para bilirrubina na admissão <9 mg/dL e 18,5 dias para ≥9 mg/dL) e com a duração de internamento pré-intervenção (9,5 dias se duração pré-intervenção <6 dias e 17 dias se ≥6 dias).Discussão: a Bilirrubina é um marcador sérico usado frequentemente para avaliar o sucesso da drenagem biliar e para monitorizar a recuperação pós-intervenção e o desenvolvimento de complicações.
As curvas que descrevem a evolução de bilirrubina após a drenagem biliar presentes na literatura nos anos 1980s apresentam uma redução exponencial, enquanto as nossas curvas são melhor representadas por uma função logarítmica. Apesar disso, as nossas curvas são semelhantes às curvas descritas na literatura, observando uma diminuição rápida nos primeiros dias pós-intervenção e uma taxa de redução inferior no fim do internamento. Isto sugere que as novas intervenções terapêuticas não tiveram um impacto significativo na depuração de bilirrubina.
Introduction: In patients with obstructive jaundice the evolution of serum total bilirubin reflects the response to a given therapeutic intervention. The most recent studies that evaluated these kinetics were done in the 1980s. In the last 40 years, we have witnessed a revolution of the therapeutic techniques, that have become less invasive, more effective and lead to less morbidity and mortality. Objectives: Evaluate the kinetics of serum total bilirubin, in patients with obstructive jaundice and who underwent biliary decompression either through Endoscopic Retrograde Cholangiopancreatography (ERCP) or Pancreaticoduodenectomy. Methods: We recorded the bilirubin values of 101 patients hospitalized in Hospital Garcia de Orta from 01/12/2016 to 30/11/2018. We calculated a logarithmic regression of these values to arrive at a generalized model. The reduction rate of bilirubin post-intervention was evaluated. Kaplan-Meier curves were created to analyze the duration of hospital length of stay in our sample of patients. Results: The median bilirubin on admission was 6,8 mg/dL, with a minimum of 0,9 mg/dL and a maximum of 27,4 mg/dL. Patients with neoplasia who underwent pancreatoduodenectomy without previous ERCP had the highest average bilirubin on admission: 16,3 ± 7,9 mg/dL. The rate of decrease in the first 24h post-intervention was 2,08 mg/dL for patients with lithiasis; 4,63 mg/dL for patients with neoplasia treated with ERCP; 1,40 mg/dL for patients with neoplasia treated with pancreatoduodenectomy with previous ERCP and 7,81 mg/dL for patients with neoplasia treated with pancreatoduodenectomy without previous ERCP. The median duration of hospitalization was 14 days, varying according to the type of intervention (13 days for conditions treated with ERCP, 17 days for conditions treated with pancreatoduodenectomy without previous ERCP and 36 days for conditions treated with Pancreatoduodenectomy with previous ERCP), the etiology (11 days for lithiasis and 17,5 for neoplasia), the bilirubin on admission (11 days for bilirubin on admission <9mg/dL and 18,5 days for bilirubin on admission ≥9mg/dL) and the duration of pre-intervention hospitalization (9,5 days if duration pre-intervention <6 days and 17 days if duration pre-intervention ≥6 days). Discussion: Bilirubin is a commonly used serum marker to evaluate the success of bile duct drainage and to track post-intervention recovery and the development of complications. The curves that describe the bilirubin reduction after biliary drainage present in the 1980s literature show an exponential reduction, whereas our findings suggest a logarithmic function would be a better representation. Despite that, our curves are similar to the curves described in the 1980s, both revealing a sharp decrease in the first post-intervention days and a lower rate of decrease later in the hospitalization. This suggests that the new therapeutic techniques did not have a significant impact in the serum bilirubin clearance.
Introduction: In patients with obstructive jaundice the evolution of serum total bilirubin reflects the response to a given therapeutic intervention. The most recent studies that evaluated these kinetics were done in the 1980s. In the last 40 years, we have witnessed a revolution of the therapeutic techniques, that have become less invasive, more effective and lead to less morbidity and mortality. Objectives: Evaluate the kinetics of serum total bilirubin, in patients with obstructive jaundice and who underwent biliary decompression either through Endoscopic Retrograde Cholangiopancreatography (ERCP) or Pancreaticoduodenectomy. Methods: We recorded the bilirubin values of 101 patients hospitalized in Hospital Garcia de Orta from 01/12/2016 to 30/11/2018. We calculated a logarithmic regression of these values to arrive at a generalized model. The reduction rate of bilirubin post-intervention was evaluated. Kaplan-Meier curves were created to analyze the duration of hospital length of stay in our sample of patients. Results: The median bilirubin on admission was 6,8 mg/dL, with a minimum of 0,9 mg/dL and a maximum of 27,4 mg/dL. Patients with neoplasia who underwent pancreatoduodenectomy without previous ERCP had the highest average bilirubin on admission: 16,3 ± 7,9 mg/dL. The rate of decrease in the first 24h post-intervention was 2,08 mg/dL for patients with lithiasis; 4,63 mg/dL for patients with neoplasia treated with ERCP; 1,40 mg/dL for patients with neoplasia treated with pancreatoduodenectomy with previous ERCP and 7,81 mg/dL for patients with neoplasia treated with pancreatoduodenectomy without previous ERCP. The median duration of hospitalization was 14 days, varying according to the type of intervention (13 days for conditions treated with ERCP, 17 days for conditions treated with pancreatoduodenectomy without previous ERCP and 36 days for conditions treated with Pancreatoduodenectomy with previous ERCP), the etiology (11 days for lithiasis and 17,5 for neoplasia), the bilirubin on admission (11 days for bilirubin on admission <9mg/dL and 18,5 days for bilirubin on admission ≥9mg/dL) and the duration of pre-intervention hospitalization (9,5 days if duration pre-intervention <6 days and 17 days if duration pre-intervention ≥6 days). Discussion: Bilirubin is a commonly used serum marker to evaluate the success of bile duct drainage and to track post-intervention recovery and the development of complications. The curves that describe the bilirubin reduction after biliary drainage present in the 1980s literature show an exponential reduction, whereas our findings suggest a logarithmic function would be a better representation. Despite that, our curves are similar to the curves described in the 1980s, both revealing a sharp decrease in the first post-intervention days and a lower rate of decrease later in the hospitalization. This suggests that the new therapeutic techniques did not have a significant impact in the serum bilirubin clearance.
Descrição
Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2021
Palavras-chave
Bilirrubina total Cinética da bilirrubina Duração do internamento Icterícia obstrutiva Duodenopancreatectomia Colangiopancreatografia retrograda endoscópica (CPRE)