Background. Gestational trophoblastic disease (GTD) which includes hydatidiform mole, invasive mole, placental site trophoblastic tumor, and choriocarcinoma is a rare cause of hyperthyroidism due to excess production of placental human chorionic gonadotrophin hormone (hCG) by tumor cells. Molecular mimicry between hCG and thyroid stimulating hormone (TSH) leads to continuous stimulation of TSH receptor by extremely high levels of hCG seen in these tumors. Consequently, biochemical and clinical hyperthyroidism ensues and it is potentially complicated by thyrotoxic crisis which is fatal unless urgent therapeutic steps are undertaken. Case Description. We present a 49-year-old perimenopausal woman who presented with recurrent thyroid storm and high output cardiac failure. The initial workup revealed suppressed TSH, high-free thyroxine (FT4), and free triiodothyronine (FT3) levels with increased vascularity of the normal-sized thyroid on ultrasonography. She was managed with parenteral beta blockers, steroids, and high-dose carbimazole. Her lower abdominal tenderness led to further investigations which revealed tremendously elevated beta-hCG and a snow storm appearance on transabdominal ultrasound suggestive of GTD. She underwent curative surgery and was diagnosed with complete hydatidiform mole postoperatively by histology. Conclusion. Recurrent thyroid crisis in gestational trophoblastic disease is an exceedingly rare presentation and that is highly fatal. This case highlights the importance of early detection and treatment of the etiology of thyrotoxicosis to eliminate mortality.
Nonalcoholic fatty liver disease (NAFLD) is a common complication of obesity with prevalence rates of 65 - 85% in obese individuals. It can be associated liver cell injury eventually leading to cirrhosis. Weight loss is the primary modality of treatment of NAFLD which can be difficult to achieve and maintain in a majority of patients. Bariatric surgery has been shown to reverse NAFLD but the type of bariatric surgery that is most effective, especially in South Asian patients is not clear. In this study we aimed to compare the effectiveness of laparoscopic sleeve gastrectomy (LSG) versus laparoscopic mini gastric bypass (LMGB) in reversing NAFLD in obese Sri Lankans. We did a retrospective analysis of medical records of 155 obese patients who underwent LSG and LMBG at Colombo South Teaching Hospital, Sri Lanka. Overall 114 (73.5%) and 41 (26.5%) patients underwent LSG and LMBG respectively. Among patients who underwent LSG and LMGB, there was no statistically significant difference in the baseline body weight (112.5 ± 19.5 vs 120.2 ± 29.4 kg), BMI (44.7 ± 6.1 vs 45.9 ± 8.0 kg/m 2 ), waist circumference (WC) (female: 118.9 ± 11.2 cm vs 117.9 ± 9.0 cm, male: 125.5 ±14.7 cm vs 130.7 ±15.9 cm) and body fat percentage (BFP) (female: 45.9 ± 3.1% vs 43.1 ± 9.5%, male: 40.9 ± 6.8% vs 39.4 ± 1.6%). There was no significant difference between patients who underwent LSG and LMBG, in decrease in weight (24.7 ±7.1 kg vs 32.6 ±14.7 kg, p=0.12) and decrease in BMI (10.0 ±2.9 kg/m 2 vs 12.0 ±4.2 kg/m 2 , p=0.08) at 6 months post-procedure as compared to baseline, although LMBG showed a trend towards greater benefit. There was no statistically significant difference in the decrease in WC (19.0 ±9.9 cm vs 20.8 ±5.8) and decrease in BFP (7.4% ±5.8 vs 10.8% ±5.6). Overall 88.4% of patients had NAFLD by ultrasound scan (USS) imaging criteria. Patients with LSG and LMBG did not show a significant difference in baseline AST (31.8 ±21.1 vs 26.8 ±11.6 U/L, p>0.05) and ALT (41.1 ±30.3 vs 35.8 ±25.7, p>0.05). At 6 months post procedure, AST (21.6 ±8.1 vs 25.0 ±13.9 U/L, p=0.32) and ALT (19.1 ±9.4 vs 26.9 ±11.0 U/L, p<0.05) levels were lower in patients with LSG than patients with LMBG, although only ALT values reached statistical significance. Thus LSG showed a greater degree of AST (32.1% vs 6.7%, p<0.05) and ALT (53.5% vs 24.9%, p=0.001) reduction compared to LMBG. At 6 months post-procedure, patients who underwent LSG had less patients with elevated AST (4.4% vs 11.1%) and ALT (4.4% vs 12.5%) as compared to LMBG. Overall LSG showed a higher rate of complete reversal of NAFLD (75.0% vs 44.4%) and improvement of the grade of NAFLD (91.7% vs 66.7%) on USS imaging when compared with LMBG. In conclusion, our study reveal that LSG has a more favorable effect on complete reversal and improvement of NAFLD when compared with LMBG. This effect seems to be independent of weight loss. Thus LSG should be considered ahead of LMBG when bariatric surgery is pl...
Nonalcoholic fatty liver disease (NAFLD) ranges from non-progressive simple steatosis to progressive nonalcoholic steatohepatitis and can eventually progress to cirrhosis and even be complicated with hepatocellular carcinoma. The prevalence of NAFLD is alarming and is approximately 65-85% among obese individuals. In the United States, NAFLD is the commonest cause of chronic liver cell disease and it is predicted to become the most common indication for liver transplantation within the next 5 years. Unfortunately NAFLD has limited treatment options with generally suboptimal results. Although bariatric surgery has been found to have impressive rates of reversal of NAFLD in Caucasians, there is limited data on its effects among South Asians. In this study we aimed to find the effect of bariatric surgery on reversal of NAFLD among obese Sri Lankan patients. We did a retrospective analysis of medical records of 170 obese patients who underwent bariatric surgery at the Colombo South Teaching Hospital, Sri Lanka. Out of the patients 74.1% (n = 126) were females. The mean age was 38.1 ± 10.4 years. The mean pre-operative body weight and body mass index were 115.0 ± 23.0 kg and 45.1 ± 6.8 kg/m 2 respectively. Laparoscopic sleeve gastrectomy was the commonest type of bariatric surgery (69.5%) performed, followed by laparoscopic mini gastric bypass (24.1%) and laparoscopic Roux-en-Y gastric bypass (4.9%). One patient underwent open sleeve gastrectomy. NAFLD was detected in 88.7% pre-operatively, according to ultrasound scan (USS) imaging (grade 1 fatty liver 29.8%, grade 2 fatty liver 58.9%). On USS imaging at 6 months after the procedure, the prevalence of fatty liver reduced to 29.4% (grade 1 fatty liver 19.6%, grade 2 fatty liver 9.8%). The pre-operative mean AST and ALT values showed a significant reduction at 6 months after the procedure (30.4 ±18.6 U/L vs 22.1 ±8.9 U/L, p<0.005 and 39.1 ±28.3 U/L vs 19.8 ±9.6 U/L, p< 0.001) as compared to baseline. The percentage of patients who had AST or ALT elevation, showed significant reduction at 6 months postoperatively as compared to baseline (35.2% vs 6.9%, p<0.01). In conclusion, bariatric surgery fully reversed NAFLD in 68.1% (p<0.001) and reduced the grade of NAFLD in 87.2% (p<0.001) of patients according to USS imaging. It significantly reduced baseline AST and ALT values by 27.3% and 49.3% respectively at 6 months post procedure. Thus bariatric surgery shows impressive levels of complete reversal and downgrading of NAFLD biochemically as well as ultrasonically in Sri Lankan patients with comparable efficacy to studies done in Caucasian populations. Bariatric surgery should be considered as a potential therapeutic option in obese South Asian patients with NAFLD, especially when it is of a higher grade.
Obesity and its complications have become a major public health problem. Health risk conferred by obesity can be reduced by sustained weight loss but this is difficult in a majority. Bariatric surgery (BS) has proven to provide an excellent answer to this problem but there is minimal data in South Asians and especially in Sri Lankans. In this study we aimed to find the effect of BS on improving obesity in Sri Lankans. We did a retrospective analysis of medical records of 170 obese patients who underwent BS at the Colombo South Teaching Hospital, Sri Lanka. Overall 74.1% were females. Laparoscopic sleeve gastrectomy (LSG) was the commonest BS (69.5%) performed, followed by laparoscopic mini gastric bypass (LMGB) (24.1%) and laparoscopic Roux-en-Y gastric bypass (4.9%). Mean age was 38.1 ± 10.4 years. Mean pre-operative body weight and body mass index were 115.0 ± 23.0 kg and 45.1 ± 6.8 kg/m 2 respectively. The baseline waist circumference (WC) and body fat percentage (BFP) in females and males were 119.0 ± 11.0 cm vs 129.0 ± 14.9 cm, p<0.05 and 45.4% ± 4.8% vs 40.6% ± 6.1%, p<0.005 respectively. At 1 month, 3 months, 6 months, 9 months and 12 months after BS, patients lost 11.3 ± 5.0 kg (female: 10.0 ± 3.9 kg, male: 14.8 ± 6.0 kg, p<0.001), 19.3 ± 6.4 kg (female: 17.8 ± 4.4 kg, male: 25.5 ± 9.2 kg, p<0.01), 26.0 ± 8.8 kg (female: 24.7 ± 6.8 kg, male: 30.1 ± 13.2 kg, p=0.15), 28.7 ± 7.8 kg (female: 28.5 ± 7.8 kg, male: 29.6 ± 8.2 kg, p=0.77) and 30.1 ±8.1 kg (female: 30.0 ±8.2 kg, male: 30.8 ±8.4 kg, p=0.83) of body weight respectively. At 1 month, 3 months, 6 months, 9 months and 12 months after BS the reduction in WC from baseline were 6.1 ± 7.4 cm, 13.7 ± 8.4 cm, 19.1 ± 9.0 cm, 20.4 ± 7.8 cm and 21.1 ±8.2 cm respectively. At 1 month, 3 months, 6 months, 9 months and 12 months after BS the reduction in BFP from baseline were 1.6 ± 4.6%, 4.6 ± 6.6%, 7.5 ± 5.6%, 9.3 ± 9.9% and 9.2 ± 6.5% respectively. There was no significant difference in the reduction of WC and BFP among males and females. Patients who underwent LMGB lost more weight as compared to LSG at 3 months (22.5 ± 8.9 kg vs 18.3 ± 5.2 kg, p=0.07), 6 months (32.6 ± 14.7 kg vs 24.7 ± 7.1 kg, p=0.13) and 12 months (34.6 ± 8.4 kg vs 30.0 ± 8.4 kg, p=0.31) although this difference did not reach statistical significance. Thus BS resulted in a sustained and progressive loss of weight, WC and BFP with rapid improvement in the first 6-9 months and the effect plateauing afterwards. Males lost weight more rapidly than females in the first 6 months after BS, but at 12 months there was no difference in weight loss among the two genders. In conclusion BS provides effective, sustained and progressive weight loss in obese patients with males benefiting more in the short term but with equal efficacy among genders in the long-term. Overall LMBG shows a trend towards better efficacy in weight loss as compared to LSG, especially in the first 6 months but further studies are warranted.
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