ObjectiveIncreased aspartate aminotransferase (AST), alanine aminotransferase (ALT), and bilirubin levels were noted incidentally after a laparoscopic cholecystectomy. The percentage in which such elevation occurs and its clinical significance in the absence of bile duct injury were investigated. Summary Background DataBile duct injury is the most feared complication of laparoscopic cholecystectomy. Some laboratory tests may be indicative of this complication, such as increases in liver enzyme (AST, ALT, and alkaline phosphatase [ALP]) and bilirubin. These parameters have not been investigated in patients who had laparoscopic cholecystectomy and in whom no damage to the bile duct was noted. MethodsSixty-seven patients with normal results of preoperative liver function test were entered into the study. Blood was collected 24 hours after laparoscopic cholecystectomy, and AST, ALT, ALP, and bilirubin levels were measured. ResultsA mean 1.8-fold increase in AST occurred in 73% of patients; 82% showed a 2.2-fold increase in ALT. A statistically nonsignificant increase was noted in 53% of patients (ALP remained within normal limits), and in 14% of patients bilirubin levels were increased (they were primarily of the unconjugated type). ConclusionsIn many patients a significant increase in AST and ALT levels occurred after laparoscopic cholecystectomy, but they returned to normal values within 72 hours. The cause of this is unclear, and these elevations appear to have no clinical significance. 362

[imol/l, and clotting screen normal. A renal biopsy specimen showed focal necrotising glomerulonephritis. Wegener's granulomatosis was diagnosed and she was treated with peritoneal dialysis, blood transfusion, fresh frozen plasma, prednisolone 60 mg once a day decreasing to 45 mg after seven days, cyclophosphamide 100 mg once a day, and seven four litre plasma exchanges for albumin. Her symptoms and renal failure responded. Four days later she developed melaena and became shocked. Endoscopy showed an old duodenal ulcer with no stigmata of active bleeding and she was treated with blood transfusion and H2 antagonists. She had further episodes of bleeding and angiography showed poor splanchnic vasculature on the superior mesenteric angiogram with an obvious bleeding site in the terminal ileum (Fig 1).At laparotomy the small bowel was abnormal from the duodenojejunal flexure to the caecum with serosal telangiectasia, and the lumen was full of blood. Two palpably abnormal areas in the terminal ileum were excised. Blood was seen to come from proximal and distal ends in both diseased segments and in the resected bowel the mucosa was grossly ulcerated. The impression at operation was that there was disease of the whole of the small intestine and nothing would be gained by further resection.For 24 hours the disease was quiescent and then she rebled. At laparotomy, per oral endoscopy with a colonoscope showed an actively bleeding vessel in the ileum distal to the most distal resection. This segment of ileum was removed and an end-to-end anastomosis performed. Postoperative progress was unremarkable.Histology of the excised lesion showed a small artery in the base of an ulcer (Fig 2). Further histological examination showed inclusion bodies in both cytoplasm and nucleus of endo-1419 on 9 May 2018 by guest. Protected by copyright.

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