Surgical limitation for biliary atresia: indication for liver transplantation

Of 245 patients undergoing corrective operations for biliary atresia, jaundice was cleared in 113. In January 1988, 84 of them were living and free of jaundice and the other 19 were alive with jaundice. A vast majority of long-term survivors showed normal growth and development, and were leading normal lives for their respective ages. Portal hypertension, a common late complication, improved spontaneously or after sclerotherapy in jaundice-free patients. Therefore, liver transplantation is not recommended for jaundice-free patients even with esophageal varices. Patients with persistent severe jaundice (serum bilirubin over 10 mg/dL) and those with moderate jaundice (serum bilirubin 5 to 10 mg/dL) and severe esophageal varices require liver transplantation. Patients with moderate jaundice having no or slight varices should be carefully followed. When varices become worse or serum bilirubin rises, liver transplantation is indicated. Patients with mild jaundice (serum bilirubin lower than 5 mg/dL) have a possibility of improvement in their condition before the age of 15 years, and are not recommended for liver transplantation. The high value of the lowest postoperative bilirubin level suggests the necessity of liver transplantation in early childhood. Liver transplantation as the primary treatment for biliary atresia may be indicated only for patients over 120 days of age with an enlarged and hard liver.

A village outbreak of hepatitis A: acquaintance network and inapparent pre-school transmission compared

A village outbreak of 38 cases of serologically confirmed hepatitis A is described. The epidemic curve was a propagative one and all of the cases occurred in primary school-age or pre-school children. In 1984 the incidence in this age group was 5,000 per 100,000, about 50 times the corresponding national rate. Although 21 of the cases attended the single primary school, these cases were not clustered within school years or classes and examination of onset dates showed only four cases could have resulted from case transmission within classes. A matched triplet case-control study was undertaken to measure the risk associated with prior contact with a case within the acquaintance network and the risk of household contact with either of the two pre-school nurseries where inapparent transmission may have been occurring. Whereas a similar proportion of cases and controls had direct or indirect contact with the nurseries, 48% of cases, compared with 9% of controls, reported a previous case of jaundice within 6 weeks amongst their acquaintance network (matched triplet analysis P less than .0001).

Blood-transmitted and clotting-factor-transmitted non-A, non-B hepatitis. Clinical differences and evolution

In a prospective study of post-transfusion hepatitis (PTH) in open-heart surgery patients, non-A, non-B hepatitis was diagnosed by exclusion criteria in 100 patients (14.1%). The frequency of hepatitis was significantly higher (56.9%; p less than 0.001) in patients receiving blood units and clotting-factor concentrates of commercial origin, which were administered for the occurrence of bleeding complications during surgery, as compared to patients treated with blood units alone (10.3%). When clinical features of hepatitis at presentation were compared in the two groups of patients, a shorter incubation period (p less than 0.05) and a higher prevalence of jaundice (p less than 0.01) were found in patients receiving blood and clotting-factors. Persistence of abnormal alanine aminotransferase (ALT) levels after 12 months from onset were found in more than 70% of patients in both groups. Late biochemical remission, however, was observed in 21% of patients receiving blood units alone, but in none of those who received clotting factors. All these latter patients had histologic features of active liver disease during the chronic phase of the illness, as compared to only 46% of patients receiving blood units alone (p = 0.02). Our results show significant differences in the clinical course of non-A, non-B hepatitis transmitted by blood as compared to clotting factors, supporting the hypothesis of different etiological non-A, non-B agents.

[Jaundice and pregnancy. Apropos of 62 cases]

In this study, the authors have attempted to collect files of jaundice in pregnant women. 65 cases were included in this study, over a period of 4 years. Several etiologies of jaundice have been reported but viral hepatitis especially the non A, non B viral hepatitis remain the most frequent. The epidemiology, and the clinical and evolutive criteria of each disease are briefly summarized.

A large outbreak of acupuncture-associated hepatitis B

An epidemiologic investigation of an acupuncturist's practice in Rhode Island identified 35 patients who were infected with hepatitis B virus during 1984. Of 366 patients seen by the acupuncturist during 1984, 316 (86%) completed questionnaires and submitted serum for hepatitis B serology. Use of tests for immunoglobulin M antibody to hepatitis B core antigen (IgM anti-HBc) identified 17 case-patients who otherwise may have gone undetected. Thirty-four of the 35 case-patients were treated in only one of the two clinics run by the acupuncturist. Patients who received a greater number of acupuncture needles during their treatment course were more likely to have been infected; the attack rate for patients who received less than 150 needles was 9%, compared with 33% for patients who received greater than or equal to 450 needles (p less than 0.001). Attack rates were higher during a one-month period when the index case-patient was more likely to have been viremic than during any other period in 1984 (relative risk = 4.1, 95% confidence interval = 2.3-7.3). While observing the acupuncturist's technique, the investigators noted several potential mechanisms for needle contamination. This study highlights the potential for transmission of hepatitis B in situations of repeated needle use.

Inapparent infection of hepatitis A virus

To detect inapparent infection with hepatitis A virus, serial sera were collected from patients with hepatitis A and their contacts in two waterborne epidemics in China. Epidemic 1 occurred in a rural village near Hangzhou during August 1978-January 1979, and epidemic 2 took place in a rural primary school in Pinghu County in Zhejiang in April-May 1985. These sera were tested for antibodies against hepatitis A virus (anti-HAV), serum glutamic pyruvic transaminase (SGPT) activity, and icteric index. Feces also were collected in epidemic 1 to test for hepatitis A virus antigen. Both anti-HAV immunoglobulin M (IgM) and total anti-HAV were assayed in sera from "healthy persons" (symptomless persons without icterus and with normal SGPT level) who were in close contact with hepatitis A patients. In epidemic 1, among 18 "healthy persons", 12 were anti-HAV IgM positive, two were immune, and four susceptibles escaped infection. In epidemic 2, among 32 "healthy children", three were anti-HAV IgM positive, five had been infected by hepatitis A virus in the past, and 24 were not infected. These results demonstrate that inapparent infections occur along with overt and subclinical infections during epidemics of hepatitis A. The proportions of inapparent, subclinical, and overt infections were, respectively, 34.3%, 45.7%, and 20% in epidemic 1, and 25%, 50%, and 25% in epidemic 2. In addition, hepatitis A virus particles were demonstrated in the feces of all infected subjects who were examined and who included all levels of clinical response. These particles were identified with immuno-electron microscopy and enzyme-linked immunoassay.

Hepatitis B infection in a day school for mentally retarded students: transmission from students to staff

We carried out a seroepidemiologic study to evaluate the transmission of hepatitis B virus (HBV) from students to staff in a day school for mentally retarded students. Of 505 students tested, 37 (7.3 per cent) had HBsAg; 74 per cent of HBsAg-positive sera tested were HBeAg-positive. Of 162 staff members tested, 21 (13.0 per cent) were HBV marker positive and two (1.2 per cent) had HBsAg; specialized educators and teachers showed the highest HBV marker prevalence (22.2 per cent and 21.3 per cent, respectively). The prevalence of HBV markers among staff was independently associated with classroom contact with a HBsAg-positive student, duration of employment at the school, and previous work with mentally retarded individuals. The incidence of HBV infection among teaching staff with regular classroom contact, estimated by logistic regression analysis, was 2.6 per cent per year. This observation indicates that teaching staff in schools for mentally retarded students with direct classroom contact may carry an occupational risk of HBV infection.

Crystal-associated cholangiohepatopathy and photosensitisation in lambs

Four outbreaks of hepatogenous photosensitisation occurred in weaned lambs in north eastern Victoria during the summers of 1985 and 1986. Attack rates varied between 7% and 43% and case fatality rates between 60% and 71%. Clinical signs included photosensitisation and jaundice. Serum biochemistry suggested hepatobiliary and hepatoparenchymal damage with impaired renal function. At necropsy livers were an ochre colour and kidneys a mottled brown to khaki. Histopathologically, needle-shaped to lenticular clefts were observed in and around bile ducts and in hepatocytes, hepatic sinusoidal macrophages and renal tubules. Optically active rhomboidal crystals were present in bile sediments. Panicum schinzii was identified as a possible cause in 2 of the 4 outbreaks. The clinical disease was reproduced in 2 of 6 lambs grazed on a toxic paddock. The disease was indistinguishable from geeldikkop except for the fact that Tribulus terrestris was not present on any of the 4 farms.

[Effect of immunoglobulin prophylaxis on the incidence of the development of anicteric forms of hepatitis A]

As the result of the clinico-biochemical examination of children in the foci of hepatitis A, carried out under the conditions of a strictly controlled epidemiological trial, the data on the frequency of the formation of the anicteric forms of hepatitis A in the course of the realization of different tactics of immunoglobulin prophylaxis have been established. The administration of immunoglobulin in a single injection has been shown to decrease the number of both manifest and anicteric forms of hepatitis A two times in comparison with the control. The administration of the preparation on contacts with hepatitis A patients in areas with a high morbidity level has been found to produce no decrease in the frequency of the manifest and anicteric forms of hepatitis A, this frequency remaining on the level registered in the control groups.

An analysis of 12 months admissions to a regional infection unit with an open door admission policy

All admissions to the Aberdeen Infection Unit over a period of 12 months have been analysed. Forty per cent of the patients proved to have non-infectious conditions although most were referred as having an infectious disease. Those patients with infectious diseases were younger and had a shorter stay in hospital. Also there was seasonal variation in the time of their admission as well as a low mortality rate when compared with older patients with non-infectious disease admitted over the same period. Cross infection did not arise in spite of patients sharing accommodation.

Eperythrozoon ovis and copper poisoning as causes of jaundice in lamb carcases

A total of 126 lamb carcases, of which 80 were jaundiced and 46 were grossly normal at routine meat inspection, were examined. Two specific diseases were demonstrated to be associated with jaundiced carcases. Eperythrozoon infection was demonstrated in 65% of jaundiced, and 12% of non-jaundiced carcases from jaundice-affected lots, but not in 5 normal carcases from unaffected killing lots. Copper poisoning was demonstrated in 2 of the jaundiced carcases. Infection with Eperythrozoon ovis was therefore the condition most commonly associated with, and presumably the major cause of jaundice in these lamb carcases. Copper poisoning was a less common cause of jaundice.

Hepatitis A associated with a hardware store water fountain and a contaminated well in Lancaster County, Pennsylvania, 1980

In August-October 1980, a sudden increase occurred in the number of cases of jaundice reported among residents of a rural, agricultural section of Lancaster County, Pennsylvania. Investigation confirmed the cases as hepatitis A and showed that the outbreak was associated with consumption of water from a water fountain in a hardware store and water from the adjacent family home, both of which came from a well contaminated with feces. A total of 49 cases occurred from August 11 to October 21 in store customers, employees, family members, and persons visiting the family residence. Unusual features of the outbreak included an epidemic curve with two peaks, a very high attack rate in susceptibles at highest risk (greater than 90%), a high proportion of cases with jaundice (85%), absence of asymptomatic cases, and a high male to female ratio due to the makeup of the group at risk.

Incidence and prognostic importance of jaundice after cardiopulmonary bypass surgery

In a prospective study of 248 consecutive patients undergoing cardiopulmonary bypass surgery, early postoperative "post-pump" jaundice (PPJ) developed in 49 (20%). Development of PPJ was strongly associated with a bad outcome; 25% of jaundiced patients and 1% of non-jaundiced patients died in the postoperative period. The jaundice was a conjugated hyperbilirubinaemia, and was detectable in 48 out of 49 patients by postoperative day 2. Hypotension, hypoxia, and hypothermia ("shocked liver") were not associated with the development of PPJ, nor was evidence of haemolysis or heart-failure. Although PPJ was significantly associated with multiple valve replacement, higher transfusion requirements, and longer cardiopulmonary bypass time, it also occurred in patients undergoing uncomplicated operations. It is suggested that PPJ is caused by a defect in hepatic excretion of bilirubin.

Hepatitis and jaundice associated with measles in young adults. An analysis of 65 cases

We analyzed the clinical course of 65 adult patients hospitalized because of measles during the years 1975 and 1981-1982. Liver involvement was found in 80% (52/65) of the patients, five patients had clinical jaundice. The disturbances of liver function tests reached their peak values between days 5 and 10 of the disease. In this study of measles in adulthood we have three observations of unusual interest: (1) hepatitis occurs commonly in the more severely ill patients and it may manifest clinically as jaundice; (2) long-term follow-up (up to seven years) shows a clear tendency to complete resolution of the liver damage; (3) there is a clear correlation between the severity of hepatic involvement and the occurrence of secondary bacterial infections.

Causes and characteristics of 500 consecutive cases of jaundice

During approximately 2 years 106 clinical and routine laboratory parameters were obtained from each of 500 jaundiced patients consecutively admitted to the surgical and medical departments in a hospital covering a third of the hospital admissions in the city of Copenhagen. The patients were classified mainly by morphological criteria (397 patients) or the subsequent clinical course (103 patients) into five major diagnostic categories: acute parenchymal jaundice (113 patients), chronic parenchymal jaundice (97 patients), gallstone disease (76 patients), malignant obstructive jaundice (104 patients), and other causes of jaundice (110 patients). The five major categories covered 23 specific diagnoses. Within 3 months of admission 21% of the patients died, and the mortality varied from 4% in acute parenchymal jaundice to 49% in jaundice due to malignant disease.

Fatal jaundice in pregnancy

An epidemic of jaundice in pregnancy is described. The mortality during the first 2 years was 45%, but decreased as the epidemic waned. Biochemical, social and epidemiological investigations revealed that the cause was probably the hepatitis group A virus. No previous epidemics appear to have occurred in South Africa.

Prevalence of intrahepatic cholestasis of pregnancy in Chile

The prevalence of intrahepatic cholestasis of pregnancy was studied immediately postpartum in 869 women from three distant Chilean cities differing in climate and food supply. Cholestatic jaundice of pregnancy was detected in 2.4% and pruritus gravidarum in 13.2%, without significant differences between the three cities. Every woman was then ethnically classified as predominantly Caucasoid, Araucanian Indian, or Aimara Indian. A significantly higher prevalence of cholestatic jaundice of pregnancy (5.5%) and pruritus gravidarum (22.1%) was found in Araucanians than in Caucasoids (2.5% and 12.6% respectively) or in the Aimaras (0 and 11.8% respectively). The prevalence of intrahepatic cholestasis of pregnancy in Araucanians increased directly with the degree of "ethnic purity." Recurrence of the disease in multiparous women was also greater in Araucanians (13.8%) than in Caucasoids (5.5%) or in the Aimaras (3.9%). We propose that an ethnic predisposition to develop intrahepatic cholestasis of pregnancy is present in Araucanian women and that the high prevalence of the disease in Chile is mainly influenced by ethnic admixture with this South American Indian (ethnic) group.

Rocky Mountain spotted fever and jaundice. Two consecutive cases acquired in Florida and a review of the literature on this complication

Rocky mountain spotted fever is increasing in Florida, a state that has had few cases in the past. The typical clinical illness has been well described, but jaundice has been rarely reported. In two patients with illnesses resembling leptospirosis, jaundice appeared on the sixth and ninth day of illness, and peak bilirubin levels were between 7 and 9 mg/100 ml. Liver biopsy specimen from one patient showed a nonspecific hepatitis. Hemolysis and renal dysfunction may have contributed to the production of jaundice in these patients. Fourteen instances of jaundice were reported in 43 autopsied cases as of 1941, but since that time only rare mention of jaundice has been made.

The distribution and significance of hepatitis B surface antigen in a rural population in Kenya

A rural population in Kenya was studied and a prevalence of HBsAg of 5-0% and an antibody prevalence of 50% in HBsAg in negative subjects has been found; 1-2% of the negative subjects converted to positive over a six-month period. A group of HBsAg positive subjects was compared with a matched group of HBsAg negative controls clinically in liver function tests and past medical history. No statistically significant differences were found between the two groups and neither group had experienced in the past significantly more skin scarification, injections or illness with jaundice. Both ad and ay subtypes occurred in the population. This is an unexpected and important finding, which gives scope for further detailed epidemiological studies in this population.

Study of an epidemic of jaundice, presumably due to toxic hepatitis, in Northwest India

An epidemic of jaundice probably due to toxic hepatitis occurred in three adjoining districts of Northwest India during the period November and December, 1974. The dogs of the villages were affected first, then the human beings. Detailed clinical features, appropriate laboratory tests, and liver biopsies were studied. A retrospective epidemiological survey was carried out. The disease had a subacute onset starting with high fever, followed by rapidly progressive jaundice. Ascites appeared simultaneously and soon became quite massive. Hepatomegaly was recorded when ascites decreased. Liver function tests suggested cholestatic jaundice. The mortality rate in the hospital was 10%. Clinical features in dogs were similar, but mortality was almost 100%. Liver histology was characterized by (1) edema and collagenization of the central veins, never with thrombosis, (2) cholangiolar proliferation, (3) moderate to severe ballooning of the hepatocytes, (4) perisinusoidal fibrosis, (5) cholestasis, and finally, (6) cirrhosis with reverse lobulation. Etiology of this epidemic of hepatitis could not be unequivocally established. Critical analysis of the data suggests that some food toxin may have been a factor in the outbreak of this unusual epidemic of toxic hepatitis.

[Intra-hepatic post-traumatic cholestasis. Apropos of 22 cases]

The authors report 22 observations of patients showing an intra-hepatic cholestasis following a traumatism. The frequency of this complication amounted to about 1.5 p. 100. Among the mechanisms of this cholestasis some factors were kept in mind: 1. the severity of the traumatism; 2. the surgical act; 3. the use of massive transfusions, the polyvisceral complications of the traumatic shock, the infectious complications. The pathophysiology of this cholestasis seems to be in relation to an increase of the production of the conjugated bilirubin. This production is associated with a decrease of the biliary excretion depending essentially on hepatic intracellular injury, secondary to: the hemorragic shock, the anoxia, the surgical intervention, the infection. From these different factors, they draw practical conclusions as much in the diagnosis of cholestasis as in the therapeutics.

Efficacy of prophylactic gamma-globulin in preventing non-A, non-B post-transfusion hepatitis

Of 279 cardiac-surgery patients receiving a mean of twelve transfusions, 47 had significantly increased transaminase concentrations 14 to 180 days postoperatively and 10 were icteric. Preoperatively, each patient randomly received high-titre HbsAb gamma-globulin, normal gamma-globulin, or placebo and was followed at intervals for 9 months. Only 3 patients had serological evidence of hepatitis-B infection. 3 additional patients had serological evidence of cytomegalovirus infection, while none had evidence of hepatitis-A or Epstein-Barr infection. Less icteric hepatitis occurred in patients receiving the gamma-globulin preparations (P = 0-003), and the overall frequency of hepatitis was significantly reduced when compared with recipients of placebo. The protective effects of the two gamma-globulin preparations were not significantly different. Most post-transfusion hepatitis tody is neither viral hepatitis type B nor type A, and its severity and transmission are reduced by pre-transfusion gamma-globulin.

The incidence and causes of postoperative jaundice. A prospective study

Jaundice often complicates recovery after surgery. We have studied 180 patients undergoing 218 major operations and found an incidence of 3.7% severe jaundice and 16.5% mild jaundice. The causes of the jaundice were diverse, but the most important was a bilirubin overload (primarily from blood transfusion) which could not be excreted effectively by a liver whose cellular metabolism was disturbed. We found no evidence of a relationship between halothane and liver damage.