Hepatocellular adenoma in glycogen storage disease type IV

The development of hepatocellular adenoma has been recognized in association with glycogen storage disease type I and, less often, with glycogen storage disease type III, but, to our knowledge, it has not been reported in glycogen storage disease type IV. We had the opportunity to study an 11-month-old male infant who underwent orthotopic liver transplantation for cirrhosis that developed in the setting of glycogen storage disease type IV. A clinically unsuspected hepatocellular adenoma was present in the explanted liver. Glycogen storage disease type IV should be considered as a potential precursor to the development of hepatocellular adenoma. Recognition of this association is important, both in terms of the differential diagnosis of tumors that occur in this setting and also to anticipate potential complications of this benign neoplasm.

Immunosuppression in organ transplantation

Recent advances in the development of immunosuppressive agents, including newer immunophylin drugs such as FK-506 and lymphocyte DNA synthesis inhibitors such as RS-61443, have allowed rapid progress to be achieved in the prevention and treatment of allograft rejection. Soon, these drugs will join cyclosporine and OKT3 as significant advancements in our battle against allograft loss and dysfunction caused by rejection. Newer developments in immunosuppressive therapy depend on our ability to understand how the immune system works in mediating allograft destructive events. Therefore it is critical that our basic understanding of immunologic mechanisms be incorporated into the development and use of current and future immunosuppressive agents.

Pediatric liver transplantation

The excellent survival rates that have been achieved by pediatric liver transplantation today can be attributed to a multitude of factors. Refinements in immunosuppressive regimens, new immunosuppressive agents, improvements in surgical technique, and a better understanding of the unique issues that pertain to patient care have resulted in not only excellent survival rates, but also improvements in quality of life. The future promises even more progress in the directions of tolerance induction, expansion of the donor organ pool, and genetic manipulation allowing cellular transplantation for correction of inborn errors of metabolism.

Comparison of arterial and capillary bilirubin values in neonates with arterial lines

To determine whether arterial and capillary values for bilirubin agree in neonates, we analyzed 35 simultaneously sampled capillary and arterial specimens from 13 infants. We found a high correlation between arterial and capillary bilirubin values (r = 0.993). We conclude that arterial bilirubin samples may be substituted for capillary samples in newborn infants.

Duration of intracranial pressure monitoring does not predict daily risk of infectious complications

A group of 205 patients (115 children and 90 adults) with a total of 212 intracranial pressure (ICP) monitors were retrospectively studied with attention to daily cerebrospinal fluid cultures, duration of monitoring, associated cranial injuries, and hospital site of the ICP monitor (intensive care unit or operating room). Only closed ICP monitoring systems without irrigation or compliance testing were used, and all patients received antibiotics as prophylaxis throughout the monitoring period. There were no complications associated with monitor placement. Incidence histograms and regression analysis were used to determine the daily risk of subsequent infections, in addition to evaluating the cumulative risk of infection, as has been previously described in the literature. No relation between the duration of ICP monitoring and the rate of daily infection through the period of maximal monitoring (1-2 weeks) was found in this series. The overall incidence of infection was 7.1% with a median duration of monitoring of 7.2 days. The age of the patient (adult vs. child), site of ICP monitor placement, and nature of the underlying disease (trauma vs. nontrauma) had no significant effect on the development of monitor-related infections in our study. These data indicate that the decision to continue ICP monitoring can be based solely on the clinical necessity for further monitoring rather than on concerns for monitor removal to prevent infection.

Comparison of fecal occult blood tests for detection of gastrointestinal bleeding in pediatric patients

To compare fecal occult blood tests (Hemoccult II, Hemoccult SENSA, HemeSelect) for detecting the presence of occult gastrointestinal bleeding in a pediatric population at high risk, we analyzed stool specimens from 100 children who followed a restricted diet. Forty-two children had upper and 58 lower gastrointestinal sources of bleeding. Positivity rates ranged from 10.8% to 26% dependent upon the occult blood test. Whereas Hemoccult II and Hemoccult SENSA slides detected several positive specimens in upper gastrointestinal bleeding sources, all HemeSelect slides were negative in these subjects. In lower gastrointestinal bleeding, HemeSelect slides were positive in 26.8% of samples as opposed to 15.9% and 17.5% positivity rates for Hemoccult II and Hemoccult SENSA, but this difference was not statistically significant. We conclude that fecal occult blood tests vary, depending upon the origin of bleeding. Our results favor use of Hemoccult SENSA slides for suspected upper gastrointestinal bleeding and HemeSelect slides for lower gastrointestinal bleeding in children. However, if only one all-purpose fecal occult blood test is to be utilized, then our data supports the use of Hemoccult SENSA slides for children.

Automated total and neonatal bilirubin values in newborns: is a distinction clinically relevant?

Guidelines for managing hyperbilirubinemia in newborns were developed by using diazo methods that measure total and direct-reacting bilirubins and calculate an indirect fraction. The automated Kodak Ektachem system allows for measuring serum bilirubin by either of two dry-slide methods: TBIL, involving a modified diazo method, and NBIL, involving a dual-wavelength colorimetric method that fractionates and directly measures the unconjugated (Bu) and conjugated (Bc) bilirubins (Bu+Bc = neonatal bilirubin). The manufacturer recommends that NBIL be used in newborns less than 15 days old, which is impractical in a large, busy hospital laboratory. We compared NBIL and TBIL in 500 paired serum samples from infants less than 15 days old. We noted a statistically significant difference between TBIL and NBIL values (162.9, SD 70.4, vs 164.6, SD 69.2, mumol/L; P less than 0.0001), which was small and of no clinical significance. We conclude that TBIL values may be used with caution for newborn bilirubin screening. Furthermore, NBIL measurements are an acceptable alternative to diazo measurements for neonatal care, allowing the use of previously developed guidelines with NBIL values.

Successful late Kasai portoenterostomy

This article describes an infant with extrahepatic biliary atresia who underwent a successful hepatoportoenterostomy at age 132 days in spite of a delay in diagnosis. Contributing to the delay in diagnosis of this case were the lack of appreciation of alcoholic stools, the presence of a gallbladder and distal common bile duct on ultrasound examination, and insufficient biopsy material for interpretation. This case emphasizes the variability in presentation and potential difficulties in diagnosis and the need for intraoperative cholangiogram and exploratory laparotomy in such cases. An approach to the patient with extrahepatic biliary atresia who is diagnosed late is discussed. A successful outcome can be achieved for such patients.

Serum delta bilirubin estimation by an automated method

This study compares delta bilirubin values in 40 serum samples from patients with various diagnoses, as estimated by the automated Kodak Ektachem system and measured by a manual method. Regression analysis of the results yielded a slope = 0.832, intercept = 9.9 and r = 0.724. Within-run standard deviation was 1.7 mumol/l for the automated method. In samples with predominantly unconjugated bilirubin, the Ektachem system over-estimated delta bilirubin values. In specimens with conjugated hyperbilirubinaemia, the Ektachem system and manual method were in close agreement for delta bilirubin values. We conclude that samples with predominantly unconjugated bilirubin should have the presence of delta bilirubin confirmed by the manual assay. Since the Ektachem system currently provides the only automated means of estimating delta bilirubin values, its use appears warranted.

Six enteropathogens isolated from a case of acute gastroenteritis

Isolation of six different gastrointestinal pathogens (Entamoeba histolytica, Plesiomonas shigelloides, Campylobacter jejuni and three different Salmonella species [Salmonella typhimurium, Salmonella blockley and Salmonella hadar]) in the feces of a German female tourist suffering from acute diarrhoea after a trip to Bali.

Postatelectatic ventilation-perfusion mismatch simulating a pulmonary embolus

Ventilation-perfusion imaging was performed on a patient with chronic intermittent atelectasis of the right lung and revealed a mismatch simulating a pulmonary embolus in the right lung. A pulmonary arteriogram revealed no evidence of embolic disease; however, there was reduced capillary phase opacification of the right lung and increased pulmonary artery pressure. The findings are consistent with an isolated right pulmonary artery hypertension secondary to prolonged atelectasis causing an apparent mismatch on the ventilation-perfusion scan.

Total and direct-reacting bilirubin values by automated methods compared with liquid chromatography and with manual methods for determining delta bilirubin

This study compares total and direct-reacting bilirubin values in 40 serum samples from patients with various diagnoses, as measured by automated methods (Beckman Synchron CX-5, Beckman Astra 8, Kodak Ektachem 700) and HPLC and by a manual method for delta bilirubin. For total bilirubin, within-run CVs were less than 6%. The Ektachem 700 method underestimated bilirubin with serum samples from patients with Crigler-Najjar syndrome and from newborns in whom unconjugated bilirubin concentrations were increased but conjugated bilirubins were not present or were present only in small amounts. The Astra 8 and Synchron CX-5 methods were inaccurate with cholestatic serum samples, in which conjugated bilirubin concentrations were increased and other compounds such as bile acids could be expected to interfere. We conclude that each automated method examined provides reasonable estimates for total and direct-reacting bilirubin values for routine clinical use. The need for each laboratory to select the appropriate bilirubin method for its particular situation is obvious.

Total and direct-reacting bilirubin values by automated methods compared with liquid chromatography and with manual methods for determining delta bilirubin

This study compares total and direct-reacting bilirubin values in 40 serum samples from patients with various diagnoses, as measured by automated methods (Beckman Synchron CX-5, Beckman Astra 8, Kodak Ektachem 700) and HPLC and by a manual method for delta bilirubin. For total bilirubin, within-run CVs were less than 6%. The Ektachem 700 method underestimated bilirubin with serum samples from patients with Crigler-Najjar syndrome and from newborns in whom unconjugated bilirubin concentrations were increased but conjugated bilirubins were not present or were present only in small amounts. The Astra 8 and Synchron CX-5 methods were inaccurate with cholestatic serum samples, in which conjugated bilirubin concentrations were increased and other compounds such as bile acids could be expected to interfere. We conclude that each automated method examined provides reasonable estimates for total and direct-reacting bilirubin values for routine clinical use. The need for each laboratory to select the appropriate bilirubin method for its particular situation is obvious.

A gas-permeable scleral contact lens for visual rehabilitation

We evaluated the use of a highly gas-permeable, fluid-filled scleral lens for patients with diseased corneas for whom conventional contact lens strategies failed. Fifteen patients were successfully fit with individually fabricated scleral lenses. Significant corneal hypoxia, which limited the use of previous polymethylmethacrylate scleral lenses, was not encountered. Preliminary results suggest that a gas-permeable scleral lens may offer therapeutic as well as visual benefit to some patients with severe corneal disease.

Aminotransferase as a prognostic index in infants with liver disease

To assess the utility of the serum aspartate aminotransferase/alanine aminotransferase (AST/ALT) ratio in a group of infants with liver disorders, we retrospectively analyzed the charts of 73 infants with chronic liver disorders. Patients were considered as having either a good outcome (n = 40) or a poor outcome (n = 33), based upon the clinical course. AST and ALT in serum were measured simultaneously at the time of initial presentation and at various follow-up visits during the first 13 months after birth. At presentation (mean age 1.65 months), there was no difference in the AST/ALT ratios between the good (1.61 +/- 0.62; mean +/- SD) and poor (1.65 +/- 0.78) outcome groups (P = 0.81). However, over time, the AST/ALT ratio increased in patients in the poor-outcome group and decreased in patients in the good-outcome group. Calculating the AST/ALT ratio appears to be an easy, early, and reliable prognostic indicator for infants with hepatic disease, and may be a useful measure for evaluating liver-disease patients.

Aminotransferase as a prognostic index in infants with liver disease

To assess the utility of the serum aspartate aminotransferase/alanine aminotransferase (AST/ALT) ratio in a group of infants with liver disorders, we retrospectively analyzed the charts of 73 infants with chronic liver disorders. Patients were considered as having either a good outcome (n = 40) or a poor outcome (n = 33), based upon the clinical course. AST and ALT in serum were measured simultaneously at the time of initial presentation and at various follow-up visits during the first 13 months after birth. At presentation (mean age 1.65 months), there was no difference in the AST/ALT ratios between the good (1.61 +/- 0.62; mean +/- SD) and poor (1.65 +/- 0.78) outcome groups (P = 0.81). However, over time, the AST/ALT ratio increased in patients in the poor-outcome group and decreased in patients in the good-outcome group. Calculating the AST/ALT ratio appears to be an easy, early, and reliable prognostic indicator for infants with hepatic disease, and may be a useful measure for evaluating liver-disease patients.

Vocal cord paralysis and superior laryngeal nerve dysfunction in Reye's syndrome

Bilateral vocal cord paralysis and absent laryngeal sensation are previously unrecognized sequelae for Reye's syndrome, a severe acute encephalopathy in children. Four patients were seen at varying periods ranging from 2 weeks to 5 years after their diagnosis of an episode of severe Reye's syndrome over a 20-year period at the Children's Hospital of Los Angeles (Calif). All of the patients had bilateral true vocal cord paralysis with absent laryngeal sensitivity that was documented at endoscopy. As many as 50% of survivors of severe Reye's syndrome have breathy voices or aphonia. It is suggested that some of these children may have vocal cord dysfunction that is not the result of intubation, and are at risk for aspiration and its dangerous sequelae. A vagal nuclear injury is theorized to explain the sensory motor dysfunction of the larynx in these children.

Quantitative measurements of receptive field changes during antagonism of GABAergic transmission in primary somatosensory cortex of cats

In cortical area 3b of cats, responses of 76 single neurons to punctate indentations were recorded before and during iontophoretic administration of bicuculline methiodide (BMI), a GABAergic antagonist, at levels that did not affect spontaneous activity. Constant amplitude indentations were applied to selected sites along distal-proximal and radial-ulnar axes that intersected the most sensitive area in the receptive field. Profiles of response magnitudes were used to measure receptive field dimensions before and during antagonism of GABAergic inhibition. Blockade of GABAergic transmission caused receptive field dimensions of 48 rapidly-adapting neurons to increase an average 141%, or nearly 2.5 times their original size. Analysis of the spatial distribution of inhibition indicated that in-field inhibition was larger than surround inhibition. During BMI administration, response latency was significantly longer for response elicited from the expanded territory than for responses elicited from within the original receptive field, suggesting that receptive field expansion might be mediated by multisynaptic intracortical connections. The magnitude of receptive field expansion was independent of receptive field size or peripheral location. In a substantial number of neurons, however, BMI produced asymmetric expansions that extended only in the proximal direction. For 9 slowly-adapting neurons. BMI produced measurable increases in receptive field dimensions, but these changes were significantly smaller than the changes in rapidly-adapting neurons.

Atropine therapy and paralytic ileus in an infant

Signs of intestinal obstruction developed in a 2-month-old infant with trisomy 21 during atropine therapy. Radiographic evaluation strongly suggested Hirschsprung's disease, but rectal biopsy yielded normal histologic results. Following cessation of atropine use, the symptoms resolved completely. This case report demonstrates the association between atropine therapy and intestinal ileus. Caution is advised when using topical atropine therapy in children, especially those with Down's syndrome.

Jaundice in infancy

Jaundice in infancy may be physiologic or due to a pathologic cause. Fractionation of the serum bilirubin level is the first step in the evaluation. Unconjugated hyperbilirubinemia if left untreated may reach toxic levels. Primary hepatobiliary disorders, as well as infectious, toxic, genetic, and metabolic diseases, may manifest with conjugated hyperbilirubinemia. A carefully organized diagnostic evaluation in a timely fashion allows early identification of treatable disorders. Medical management of the complications of cholestatic liver disease remains a major challenge. Early surgical intervention for biliary atresia and significant advances in hepatic transplantation offer the opportunity for long-term survival for infants with previously fatal liver disorders.

Perioperative factors affecting the outcome following repair of biliary atresia

The records of all patients with biliary atresia seen at the Childrens Hospital of Los Angeles during a 14-year period were reviewed. Of the 41 patients who could be evaluated, 32 were treated with trimethoprim and sulfamethoxazole prophylaxis, five were given other agents, and four received no prophylaxis after surgery. At least one episode of cholangitis occurred in nine patients. With one exception, all patients destined to have cholangitis did so within 9 months of surgery. Of the nine patients, five were receiving prophylaxis at the time the disease developed, but two were no longer receiving any prophylaxis. The other two patients in whom cholangitis developed never received antibiotic prophylaxis. In the 24 patients who had a Kasai type of portoenterostomy, cholangitis developed in three of the five (60%) with a Roux-en-Y limb length less than 40 cm and in two of the 19 (10.5%) with limb lengths greater than 40 cm (P less than .02). When performed earlier than 61 days after birth, surgery resulted in adequate bile flow in 64.7% (11/17) of patients who could be evaluated as compared with 31.8% (7/22) for surgery at 61 days or later (P less than .05). Of the patients with adequate biliary drainage 11 had no apparent liver disease, but only two of the patients with poor drainage were free of clinical liver disease. The conclusion from this series is that a combination of timely surgery, intestinal conduit at least 40 cm in length, and subsequent long-term antibiotic prophylaxis favors the best bile flow and reduces the occurrence of cholangitis, resulting in the best outcome.

Hepatobiliary scintigraphy and the string test in the evaluation of neonatal cholestasis

We evaluated [99mTc]diisopropylphenyl-carbamoylmethylimidodiacetic acid ([99mTc]DISIDA) cholescintigraphy with measurement of duodenal fluid radioactivity collected by the string test in patients with neonatal cholestasis. Twenty-six infants with prolonged jaundice and acholic stools were studied prospectively. Twelve patients had neonatal hepatitis, 12 biliary atresia, and one each Alagille syndrome and alpha 1-antitrypsin deficiency liver disease. All infants except the biliary atresia patients and four of the neonatal hepatitis patients revealed bowel activity on scan 6 h after tracer administration. At 24 h, three of these latter patients with neonatal hepatitis and two of the patients with biliary atresia revealed bowel activity. String radioactive counts for neonatal hepatitis ranged from 99,574 to 967,205 cpm (374,504 +/- 232,210 cpm; mean +/- SD) and for biliary atresia from 8,342 to 370,346 cpm (117,149 +/- 98,698 cpm; mean +/- SD). While neither test alone was capable of correctly differentiating among all patients, those patients with biliary atresia had either a negative hepatobiliary scan at 24 h or string radioactive count below 197,007 cpm. Disparity between the hepatobiliary scan and the string radioactive counts mandates further diagnostic investigation. These data suggest that simultaneous administration of the string test with hepatobiliary scintigraphy is advantageous in the evaluation of infants with cholestatic jaundice.

Insurability of pediatric gastrointestinal disorders

To assess the insurability of children with gastrointestinal disorders, the authors surveyed by questionnaire 106 health-insurance companies concerning their handling of an application for health insurance for a child with a diagnosed gastrointestinal disorder. They received 24 responses (23%) of which only ten companies (42% of the respondents, 9% of the companies surveyed) completed the questionnaire. Insurance companies generally were not receptive to their inquires. The consensus of the responses was that ultimate insurability is dependent upon review of the medical record. For individual gastrointestinal diseases, responses were variable and often not easily categorized. Many companies encourage applicants previously denied coverage to reapply at a later date. Most pediatric gastrointestinal disorders are not insurable or insurable only at increased rates. Since insurability is dependent upon review of the medical record, the medical record must reflect the diagnosis and prognosis accurately. Education of the insurance industry regarding pediatric gastrointestinal disorders is encouraged.

The BUN/creatinine ratio in localizing gastrointestinal bleeding in pediatric patients

Localizing the bleeding site in pediatric patients with gastrointestinal hemorrhage may require invasive and costly diagnostic procedures. A simple index to discriminate upper and lower bleeding sources would be invaluable. We evaluated the reliability of the calculated blood urea nitrogen/creatinine (BUN/Cr) ratio in segregating upper from lower gastrointestinal bleeding sites in 40 children. For upper gastrointestinal hemorrhage, the calculated BUN/Cr ratios (mg/mg) ranged from 10 to 140, with a mean value of 34. For lower gastrointestinal bleeders, the BUN/Cr ratios ranged from 3.3 to 30, with a mean value of 16. All BUN/Cr ratios greater than 30 corresponded to patients with documented upper gastrointestinal bleeding sources. Calculation of the BUN/Cr ratio in the initial evaluation of gastrointestinal bleeding may prove useful in guiding the sequence of diagnostic procedures and examinations.

Somatotopic organization of the second somatosensory cortical area after lesions of the primary somatosensory area in infant and adult cats

The somatotopic organization of the second somatosensory cortical area (SII) and receptive fields of multineuron responses to cutaneous stimulation were studied in cats 6-16 months after lesions of the forelimb representation in the primary somatosensory area (SI) at 4 days, 4 weeks of age or in adults. No change was detected in SII. The results contrast with findings of alterations in SII of macaque monkeys following similar ablations of SI.

The effect of tin-protoporphyrin on bilirubin conjugation and production in cholestatic rats

Tin-protoporphyrin (SnP) is actively being investigated for treatment of exaggerated neonatal hyperbilirubinemia. Because both bilirubin conjugation and excretion are immature in the human newborn, we investigated the effect of SnP on bilirubin-conjugating mechanisms and the efficacy of SnP in suppressing serum bilirubin levels in adult rats made cholestatic by surgical bile duct ligation. Male Sprague-Dawley rats received SnP (100 mumol/kg body weight) subcutaneously either 24 h before or 24 or 48 h after bile duct ligation. Serum and urine specimens were collected 72 h after bile duct ligation and analyzed for bilirubin and its conjugates. As compared to a control group that received bile duct ligation and a sodium phosphate buffer injection, all SnP-treated animals had a significant lowering of total serum bilirubin levels. No differences in the distribution of serum bilirubin mono- and diconjugates in serum or urine samples were observed. However, the concentrations of covalently linked bilirubinprotein conjugates were significantly higher in the control cholestatic rats when compared to the SnP-treated animals. SnP effectively lowers serum bilirubin levels in rats with an impaired biliary excretory pathway for SnP. There was no adverse effect on bilirubin conjugation and no observable toxicity.

Systemic necrotizing angiitis with asthma: causes and precipitating factors in 43 cases

Causes and precipitating factors for systemic necrotizing angiitis (NA) with asthma were sought in 43 patients, focusing on a history of vaccination and desensitization. Mean age of patients was 43.2 years. Diagnosis was based on histopathologic findings in 25 patients, arteriography in 2, and clinical criteria in 16. History of allergic manifestations (asthma, rhinitis, eczema, urticaria) was present in the family of 19 patients. Forty-two patients presented with asthma before development of NA and 23 of them were treated with steroids. Nineteen subjects gave a history of desensitization and 5 of vaccination in the 4 weeks preceding the disease. The main symptoms of NA were asthma in 43, fever in 25, weight loss in 31, peripheral neuropathy in 29, cutaneous signs in 25, digestive signs in 16 (abdominal pain, digestive bleeding, bowel perforation), noninfectious pneumopathy with pulmonary infiltrates in 33. Eosinophilia was 8,212 +/- 6,214/mm3. Antigen HBs was found in 2 of 30 patients. Prognosis of NA with asthma was good in 15 patients who recovered completely from the disease. Seven patients died and the other patients improved but remained under treatment. The survival curve showed that 75% of patients were alive after 60 months. Our findings suggest that different causes can be considered responsible for NA, and that, in cases of NA with asthma, there is reason to consider vaccination and desensitization as precipitating factors.

The laboratory method as a variable in the diagnosis of hyperbilirubinemia

Algorithms based on fractionation of bilirubin into direct-reacting and indirect-reacting fractions by diazo methods are frequently utilized for investigation of hyperbilirubinemia. Unfortunately, direct-reacting and indirect-reacting fractions do not correspond precisely with conjugated and unconjugated pigment. Advances in analytical methods allow accurate quantitation of the individual fractions of bilirubin in serum. Three cases of hyperbilirubinemia are presented in which bilirubin fractionation by diazo methods suggested an erroneous diagnosis. Analysis of the serum samples by high-performance liquid chromatography for bilirubin conjugates confirmed the correct clinical diagnosis. Diazo methods for bilirubin analysis are subject to marked discrepancies. While the new methodology utilizing high-performance liquid chromatography is not practical for routine bilirubin analysis, optimization of diazo methods utilizing rigid and meticulous protocol is suggested. Laboratories performing diazo bilirubin determinations should correlate their results with those of other laboratories and clinical data. Clinicians need to be aware of the reliability of a particular test result before embarking on a lengthy and expensive evaluation.

Distribution of serum bilirubin conjugates in pediatric hepatobiliary diseases

We used a highly specific method, alkaline methanolysis-high performance liquid chromatography, for determining the concentration and patterns of the unconjugated and esterified bilirubin fractions in the sera of pediatric patients with hepatobiliary disease. Bilirubin-protein conjugates were assayed using a new method that selectively removes bilirubin reversibly bound to protein, allowing measurement of the tightly bound bilirubin-protein conjugates by use of a diazo method. Fifty-two serum samples from children with varying bilirubin concentrations and diagnoses were studied. Whereas no conjugated pigment was detectable in the serum samples of healthy children or in individuals with Gilbert syndrome or Crigler-Najjar syndrome, bilirubin monoester and diester conjugates and bilirubin-protein conjugates were present in the sera of children with cholestatic liver disease, and accounted for 69% +/- 15% of the total bilirubin in these samples. Bilirubin fractional analysis was incapable of differentiating extrahepatic biliary obstruction from hepatocellular disease, because of overlap between the groups. The presence of bilirubin-protein conjugates in serum always coincided with detection of bilirubin monoester and diester conjugates. The distribution of bilirubin and its conjugates in sera provides a sensitive, although nonspecific, measure of hepatic disease.

Orthotopic liver transplantation for type I Crigler-Najjar syndrome

A neurologically normal 3-year-old girl with Type I Crigler-Najjar syndrome was successfully treated with orthotopic liver transplantation. Preoperative serum bilirubin concentrations as high as 31 mg per dl were not diminished with phenobarbital or phototherapy. Bilirubin fractionation of duodenal bile prior to transplantation revealed 87.1% unconjugated bilirubin and 12.9% monoconjugates as determined by alkaline methanolysis-high-performance liquid chromatography. Postoperatively, the serum bilirubin concentration quickly fell to normal. Uridine diphosphate glucuronyl transferase activity in the recipient liver was not detectable. The gallbladder bile bilirubin concentration of 23.9 mg per dl was less than 15% of previously reported normal values. Since devastating kernicteric brain injury is the invariable outcome of Type I Crigler-Najjar syndrome, liver transplantation should be performed when phototherapy cannot maintain the serum bilirubin concentration at an unequivocally safe level.

Formation of bilirubin conjugates in human newborns

Bilirubin conjugates in the serum of newborn human infants were investigated using the alkaline methanolysis-high-performance liquid chromatography method, a specific and sensitive method for measurement of unconjugated bilirubin and bilirubin mono- and diester conjugates. Serum samples were analyzed from 13 premature infants, 11 full term newborns, 22 healthy adults, seven pregnant women at term and their corresponding infants cord blood at delivery, 46 cord blood specimens obtained at unselected deliveries, three cord bloods from infants with maternal-fetal blood group incompatibility, and two cord bloods from infants with intrauterine hypoxia. Bilirubin conjugates were not detectable in the healthy adults, maternal blood, or in the cord blood specimens except from infants with blood group incompatibility or intrauterine hypoxia. The two isomeric monoconjugates of bilirubin appeared in serum during the first 24 to 48 postnatal h in both premature and full term infants, followed by the diconjugate on the 3rd day. Conjugated esters accounted for 2 to 5% of the total bilirubin, with the diconjugate constituting 21% of total conjugated pigment (day 3). In all instances, the unconjugated serum bilirubin concentration had increased to at least 2 mg/dl in the course of physiologic neonatal hyperbilirubinemia before bilirubin conjugates became detectable. Both premature and full term human infants displayed the identical pattern of bilirubin conjugation in serum.