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Zhou S, Wang Z, He F, Qiu H, Wang Y, Wang H, Zhou J, Zhou J, Cheng G, Zhou W, Xu R, Wang M. Association of serum bilirubin in newborns affected by jaundice with gut microbiota dysbiosis. J Nutr Biochem 2018; 63:54-61. [PMID: 30342317 DOI: 10.1016/j.jnutbio.2018.09.016] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 09/10/2018] [Accepted: 09/12/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND AIMS Breast milk jaundice (BMJ) is common and benign, but neonatal cholestasis (NC) is rare and not benign, so early differentiation between NC and non-NC jaundice is important and may facilitate diagnosis and treatment. Gut microbiota plays an important role in enterohepatic circulation, which in turn plays an important role in the secretion of bilirubin. We aimed to determine the composition of gut microbiota in patients with NC and BMJ, and to identify the gut microbiota composition associated with NC and BMJ. METHODS Data on age, gender, delivery, feeding mode, serum total bilirubin, direct bilirubin, and liver function were collected for NC patients, BMJ patients and healthy controls, respectively. Shotgun metagenomic sequencing and metagenome-wide association were performed. RESULTS Forty NC patients, 16 patients affected by BMJ, and 14 healthy controls (CON) without jaundice were enrolled. A significant increase in species richness, especially Bacteroides, was found in NC patients. The abundances of potentially pathogenic species and KEGG orthologies (KOs) of virulence factor genes were positively correlated with serum bilirubin level. The abundances of nine species of Bifidobacterium and three KOs of galactose metabolism were significantly decreased in the jaundice group (NC and BMJ) and were negatively correlated with serum bilirubin level. CONCLUSIONS The gut microbiota in NC patients is characterized by a significant increase in species richness, possibly due to the proliferation of potentially pathogenic species. Additionally, the gut microbiota in jaundice patients is characterized by a decreased abundance of Bifidobacterium. Decreased Bifidobacterium has been associated with elevated bilirubin and abnormal gut microbiota galactose metabolic pathway. Further, ten bacteria species were identified as potential biomarker of jaundice. KEY POINTS Question Is there any alteration of gut microbiotain neonatal cholestasis patients? Does gut microbiota have any involvement in the occurrence of neonatal cholestasis or breast milk jaundice? Findings The alteration of gut microbiota in neonatal cholestasis patients mainly manifested as a significant increase in species richness and an increased abundance of potentially pathogenic species, while the main manifestation in jaundice patients was a significant decrease in Bifidobacterium which may be involved in the metabolism of bilirubin through the galactose metabolic pathway. Meaning The results suggest that an imbalance of gut microbiota exist in neonatal cholestasis and breast milk jaundice patients, primarily in the form of a substantial reduction in the abundance of Bifidobacterium, suggesting the possibility of intervention treatment for neonatal cholestasis and breast milk jaundice by supplementing probiotics.
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Affiliation(s)
- Shaoming Zhou
- Division of Gastroenterology, Shenzhen Children's Hospital, Shenzhen, Guangdong, 518038, China.
| | - Zhangxing Wang
- Division of Neonatology, Shenzhen Longhua People's Hospital, Guangdong, 518109, China
| | - Fusheng He
- Imunobio, Shenzhen, Guangdong, China, 518001
| | - Huixian Qiu
- Division of Neonatology, Longgang Central Hospital of Shenzhen, Guangdong, 518116, China
| | - Yan Wang
- Imunobio, Shenzhen, Guangdong, China, 518001
| | - Huihui Wang
- Division of Clinical Nutrition, Shenzhen Children's Hospital, Shenzhen, Guangdong, 518038, China
| | - Jianli Zhou
- Division of Gastroenterology, Shenzhen Children's Hospital, Shenzhen, Guangdong, 518038, China
| | - Jiaxiu Zhou
- Division of Psychology, Shenzhen Children's Hospital, Shenzhen, Guangdong, 518038, China
| | - Guoqiang Cheng
- Division of Neonatology, Children's Hospital of Fudan University, National Center for Children's Health, Shanghai, 201102, China
| | - Wenhao Zhou
- Division of Neonatology, Children's Hospital of Fudan University, National Center for Children's Health, Shanghai, 201102, China
| | - Ruihuan Xu
- Clinical Laboratory, Longgang Central Hospital of Shenzhen, Guangdong, 518116, China.
| | - Mingbang Wang
- Xiamen Branch, Shanghai Key Laboratory of Birth Defects, Division of Neonatology, Children's Hospital of Fudan University, National Center for Children's Health, Shanghai, 201102, China.
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Total Bile Acid Concentration in Duodenal Fluid Is a Useful Preoperative Screening Marker to Rule Out Biliary Atresia. J Pediatr Gastroenterol Nutr 2018; 67:383-387. [PMID: 29851770 DOI: 10.1097/mpg.0000000000002037] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Duodenal tube test (DTT) is used as a preoperative screening to rule out biliary atresia (BA). In previous reports, DTT was assessed by the color of the duodenal fluid, but there were no quantitative criteria. The aim of this study was to examine the efficacy of DTT based on the total bile acid (TBA) concentration in duodenal fluid. METHODS This is a single-center retrospective study of infants with cholestasis who underwent DTT from 2008 to 2016 at the Osaka University Hospital. The cut-off values of maximum TBA in duodenal fluid (dTBA), dTBA/serum TBA ratio (sTBA), and dTBA/serum gamma-glutamyl transpeptidase (sGGT) ratio were assessed for the accuracy in excluding BA. RESULTS A total of 37 infants were included in this study; 16 infants with BA and 21 infants with other causes of intrahepatic cholestasis. dTBA demonstrated sensitivity of 100% and specificity of 90.5% with the cut-off value of 16.8 μmol/L. Specificity was further improved to 95.2% with dTBA/sTBA ratio (cut-off value: 0.088) and 100% with dTBA/sGGT ratio (cut-off value: 0.076 μmol/U). DTT could be performed 0.8 ± 1.4 days after admission. Hypoglycemia was developed in 1 infant. CONCLUSIONS DTT evaluated by dTBA, dTBA/sTBA ratio, and dTBA/sGGT ratio had high accuracy to rule out BA and could avoid unnecessary surgery in some infants.
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Lertudomphonwanit C, Mourya R, Fei L, Zhang Y, Gutta S, Yang L, Bove KE, Shivakumar P, Bezerra JA. Large-scale proteomics identifies MMP-7 as a sentinel of epithelial injury and of biliary atresia. Sci Transl Med 2018; 9:9/417/eaan8462. [PMID: 29167395 DOI: 10.1126/scitranslmed.aan8462] [Citation(s) in RCA: 88] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2017] [Accepted: 10/20/2017] [Indexed: 12/24/2022]
Abstract
Biliary atresia is a progressive infantile cholangiopathy of complex pathogenesis. Although early diagnosis and surgery are the best predictors of treatment response, current diagnostic approaches are imprecise and time-consuming. We used large-scale, quantitative serum proteomics at the time of diagnosis of biliary atresia and other cholestatic syndromes (serving as disease controls) to identify biomarkers of disease. In a discovery cohort of 70 subjects, the lead biomarker was matrix metalloproteinase-7 (MMP-7), which retained high distinguishing features for biliary atresia in two validation cohorts. Notably, the diagnostic performance reached 95% when MMP-7 was combined with γ-glutamyltranspeptidase (GGT), a marker of cholestasis. Using human tissue and an experimental model of biliary atresia, we found that MMP-7 is primarily expressed by cholangiocytes, released upon epithelial injury, and promotes the experimental disease phenotype. Thus, we propose that serum MMP-7 (alone or in combination with GGT) is a diagnostic biomarker for biliary atresia and may serve as a therapeutic target.
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Affiliation(s)
- Chatmanee Lertudomphonwanit
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center and the Department of Pediatrics of the University of Cincinnati College of Medicine, Cincinnati, OH 45229-3031, USA.,Division of Gastroenterology and Hepatology, Department of Pediatrics, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | - Reena Mourya
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center and the Department of Pediatrics of the University of Cincinnati College of Medicine, Cincinnati, OH 45229-3031, USA
| | - Lin Fei
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center and the Department of Pediatrics of the University of Cincinnati College of Medicine, Cincinnati, OH 45229-3031, USA
| | - Yue Zhang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center and the Department of Pediatrics of the University of Cincinnati College of Medicine, Cincinnati, OH 45229-3031, USA
| | - Sridevi Gutta
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center and the Department of Pediatrics of the University of Cincinnati College of Medicine, Cincinnati, OH 45229-3031, USA
| | - Li Yang
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center and the Department of Pediatrics of the University of Cincinnati College of Medicine, Cincinnati, OH 45229-3031, USA.,Division of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Kevin E Bove
- Division of Pathology, Cincinnati Children's Hospital Medical Center and the Department of Pediatrics of the University of Cincinnati College of Medicine, Cincinnati, OH 45229-3031, USA
| | - Pranavkumar Shivakumar
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center and the Department of Pediatrics of the University of Cincinnati College of Medicine, Cincinnati, OH 45229-3031, USA
| | - Jorge A Bezerra
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center and the Department of Pediatrics of the University of Cincinnati College of Medicine, Cincinnati, OH 45229-3031, USA.
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Erdol S, Ozgur T. Vitamin B12 deficiency associated with hyperbilirubinemia and cholestasis in infants. Pak J Med Sci 2018; 34:714-718. [PMID: 30034445 PMCID: PMC6041549 DOI: 10.12669/pjms.343.14564] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective: To study the correlation between vitamin B12 deficiency and hyperbilirubinemia and cholestasis in infants. Methods: The study group consisted of 215 infants who were tested for serum B12 and bilirubin levels out of 335 cases referred to the Centre from June 2011 to 2016 as a part of the screening program established by the Ministry of Health. The following information was obtained from the case files: demographic data; background; family history; serum vitamin B12, folate, plasma homocysteine, and urine methylmalonic acid (MMA) levels; and direct, indirect, and total bilirubin levels. Results: About 48.8 percent of cases had vitamin B12 deficiency. No significant differences were found when those cases with vitamin B12 deficiency and those without vitamin B12 deficiency were compared in terms of total, direct, or indirect bilirubin levels. Only two cases (0.9 percent) had cholestasis. Conclusion: The study suggests vitamin B12 deficiency is a common phenomenon (48.4 percent), similar to what has been suggested by other studies conducted in Turkey. Therefore, the presence of vitamin B12 deficiency in cases with cholestasis or hyperbilirubinemia may show an association. To prove the correlation between them, more studies are required.
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Affiliation(s)
- Sahin Erdol
- Sahin Erdol, MD, Division of Metabolism, Uludag University Faculty of Medicine, Department of Pediatrics, 16059, Gorukle,Bursa, Turkey
| | - Taner Ozgur
- Taner Ozgur, MD, Division of Gastroenterology, Uludag University Faculty of Medicine, Department of Pediatrics, 16059, Gorukle, Bursa, Turkey
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Chaudhry Z, Forget S, Nguyen VH, Ahmed N. The Role of Liver Biopsy in Investigation of Cholestatic Liver Disease in Infancy. J Can Assoc Gastroenterol 2018; 2:51-56. [PMID: 31294365 PMCID: PMC6507280 DOI: 10.1093/jcag/gwy026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Objectives The objective of this study was to assess the diagnostic yield and impact on management of liver biopsy in infants with cholestatic jaundice. Methods A retrospective cohort study of infants with cholestasis who underwent liver biopsy before one year of age between December 2002 and December 2013 at the Montreal Children’s Hospital was conducted. Biopsies were reviewed by a single pathologist. The diagnostic yield of the biopsy was assessed in terms of its role in establishing a diagnosis, excluding an important diagnosis or changing management. Results Seventy-nine biopsies were performed within the time frame outlined, with 58 fulfilling inclusion criteria. Liver biopsies were found to add novel information in 21 cases (36.2%). The diagnostic yield of the biopsy was unrelated to the severity of direct hyperbilirubinemia, age at biopsy, age at admission, co-morbidities, stool color at presentation and TPN exposure. Among infants under 90 days of age, 21 also underwent cholangiography, the results of which were consistent with biopsy findings. There were four (6.9%) documented complications from biopsies, including bleeding and accumulation of free fluid in the peri-hepatic area. Conclusions Liver biopsy is an invasive test used with other clinical modalities to determine the etiology of neonatal cholestasis. These results suggest that biopsy added novel information to the diagnostic workup in 36.2% of cases with a complication rate of 6.9%. Consequently, the role and timing of liver biopsy need to be reassessed to determine which patients would most benefit from this procedure.
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Affiliation(s)
- Zoya Chaudhry
- Department of Ophthalmology, McGill University Health Centre, Montreal, Canada
| | - Sylviane Forget
- Division of Pediatric Gastroenterology, Montreal Children's Hospital, Montreal, Quebec, Canada
| | - Van-Hung Nguyen
- Department of Pathology, McGill University Health Centre, Montreal, Canada
| | - Najma Ahmed
- Division of Pediatric Gastroenterology, Montreal Children's Hospital, Montreal, Quebec, Canada
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Detection of Cytomegalovirus in Liver Tissue by Polymerase Chain Reaction in Infants With Neonatal Cholestasis. Pediatr Infect Dis J 2018; 37:632-636. [PMID: 29389827 DOI: 10.1097/inf.0000000000001889] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
AIM Cytomegalovirus (CMV) is associated with neonatal cholestasis (NC). Diagnosis of CMV infection is most often based on either positive blood CMV IgM or CMV blood polymerase chain reaction (PCR). Isolation of CMV in liver tissues in patients with NC has rarely been reported. This study was undertaken to see if CMV is present in liver tissues of patients with NC and evaluate the correlation between positive CMV PCR in liver tissue with the serology and blood PCR. METHODS This study was conducted in 31 infants with NC from June 2015 to December 2016. All patients underwent blood CMV IgM, blood CMV PCR and liver CMV PCR. Prevalence of CMV in NC based on positive liver CMV PCR was calculated. Sensitivity and specificity of the serologic markers and blood CMV PCR to identify CMV infection in the liver was determined. RESULTS CMV IgM was positive in 13 (42%) patients, CMV IgG was positive in 26 (84%) patients and blood CMV PCR was positive in 23 (74%) patients. Liver CMV PCR was positive in 16 (52%) patients. Fifteen (48%) patients had biliary atresia (BA), 10 (32%) patients had neonatal hepatitis, 5 (16%) had paucity of bile ducts and 1 (3%) had ascending cholangitis. Of the 16 patients with positive liver CMV PCR, 8 (50%) had BA, 4 (25%) had neonatal hepatitis, 3 (19%) had paucity of bile ducts and 1 (6%) had ascending cholangitis. Sensitivity of blood CMV IgM in relation to liver CMV PCR was 69% and specificity was 61%. Sensitivity of blood CMV PCR was 61% and specificity was 71% when compared with liver CMV PCR. CONCLUSION CMV is present in the liver tissues of more than half the patients with NC. Serology or blood CMV PCR is apparently not an accurate marker of CMV in the liver tissue. Also, CMV infection in children seems to be associated equally with BA or non-BA neonatal hepatitis.
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Harpavat S, Lupo PJ, Liwanag L, Hollier J, Brandt ML, Finegold MJ, Shneider BL. Factors Influencing Time-to-diagnosis of Biliary Atresia. J Pediatr Gastroenterol Nutr 2018; 66:850-856. [PMID: 29315162 PMCID: PMC5963977 DOI: 10.1097/mpg.0000000000001887] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVES Diagnosing biliary atresia (BA) quickly is critical, because earlier treatment correlates with delayed or reduced need for liver transplantation. However, diagnosing BA quickly is also difficult, with infants usually treated after 60 days of life. In this study, we aim to accelerate BA diagnosis and treatment, by better understanding factors influencing the diagnostic timeline. METHODS Infants born between 2007 and 2014 and diagnosed with BA at our institution were included (n = 65). Two periods were examined retrospectively: P1, the time from birth to specialist referral, and P2, the time from specialist referral to treatment. How sociodemographic factors associate with P1 and P2 were analyzed with Kaplan-Meier curves and Cox proportional hazard models. In addition, to better characterize P2, laboratory results and early tissue histology were studied. RESULTS P1 associated with race/ethnicity, with shorter times in non-Hispanic white infants compared to non-Hispanic black and Hispanic infants (P = 0.007 and P = 0.004, respectively). P2 associated with referral age, with shorter times in infants referred after 30, 45, or 60 days of life (P < 0.001, P < 0.001, and P = 0.001, respectively). One potential reason for longer P2 in infants referred ≤30 days is that aminotransferase levels were normal or near-normal. However, despite reassuring laboratory values, tissue histology in early cases showed key features of BA. CONCLUSIONS Our findings suggest 2 opportunities to accelerate BA diagnosis and treatment. First, to achieve prompt referrals for all races/ethnicities, universal screening strategies should be considered. Second, to ensure efficient evaluations independent of age, algorithms designed to detect early features of BA can be developed.
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Affiliation(s)
- Sanjiv Harpavat
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and
Nutrition
| | - Philip J. Lupo
- Department of Pediatrics, Division of Hematology and Oncology
| | - Loriel Liwanag
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and
Nutrition
| | - John Hollier
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and
Nutrition
| | | | - Milton J. Finegold
- Department of Pathology, Baylor College of Medicine and Texas
Children’s Hospital
| | - Benjamin L. Shneider
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and
Nutrition
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Wang L, Yang Y, Chen Y, Zhan J. Early differential diagnosis methods of biliary atresia: a meta-analysis. Pediatr Surg Int 2018; 34:363-380. [PMID: 29397405 DOI: 10.1007/s00383-018-4229-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/11/2018] [Indexed: 11/25/2022]
Abstract
PURPOSE To evaluate the accuracy of early differential diagnosis methods of biliary atresia in patients with infantile cholestasis. METHODS We searched PubMed, EMBASE and the Web of Science databases for articles evaluated the early differential diagnosis methods of biliary atresia. The methodological quality of each study was assessed with version 2 of the Quality Assessment of Diagnostic Accuracy Studies tool. Two reviewers extracted data independently. Pooled sensitivity, specificity, positive likelihood ratio (LR +), negative likelihood ratio (LR -), diagnostic odds ratio (DOR) with 95% CIs were calculated to assess each diagnosis method. RESULTS A total of 38 articles were included. Summary sensitivity and specificity were 77% (95% CI 74-80%) and 93% (95% CI 91-94%), respectively, for B-US in 23 studies; 96% (95% CI 92-98%) and 58% (95% CI 51-65%), respectively, for MRCP in five studies; 87% (95% CI 82-91%) and 78% (95% CI 74-82%), respectively, for acholic stool in seven studies; 84% (95% CI 78-89%) and 97% (95% CI 97-98%), respectively, for serum liver function test in seven studies; 96% (95% CI 94-97%) and 73% (95% CI 70-76%), respectively, for hepatobiliary scintigraphy in 18 studies; 98% (95% CI 96-99%) and 93% (95% CI 89-95%), respectively, for percutaneous liver biopsy in 11 studies. CONCLUSION The accuracy rate of percutaneous liver biopsy is better than all of the noninvasive methods. Take into consideration the advantages and disadvantages of the six methods, combination of multidisciplinary noninvasive diagnosis methods is the first choice for differential diagnosis of BA from other causes of neonatal cholestasis.
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Affiliation(s)
- Li Wang
- Department of Pediatric Surgery, Tianjin Children's Hospital, Tianjin, 300134, China
| | - Yuan Yang
- Department of Pediatric Surgery, Tianjin Children's Hospital, Tianjin, 300134, China
| | - Yang Chen
- Department of Pediatric Surgery, Tianjin Children's Hospital, Tianjin, 300134, China
| | - Jianghua Zhan
- Department of Pediatric Surgery, Tianjin Children's Hospital, Tianjin, 300134, China.
- Tianjin Pediatrics Research Institute, Tianjin, 300134, China.
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Clinical Assessment of Differential Diagnostic Methods in Infants with Cholestasis due to Biliary Atresia or Non-Biliary Atresia. Curr Med Sci 2018; 38:137-143. [PMID: 30074163 DOI: 10.1007/s11596-018-1857-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 09/11/2017] [Indexed: 12/15/2022]
Abstract
The different methods in differentiating biliary atresia (BA) from non-BA-related cholestasis were evaluated in order to provide a practical basis for a rapid, early and accurate differential diagnosis of the diseases. 396 infants with cholestatic jaundice were studied prospectively during the period of May 2007 to June 2011. The liver function in all subjects was tested. All cases underwent abdominal ultrasonography and duodenal fluid examination. Most cases were subjected to hepatobiliary scintigraphy, magnetic resonance cholangiopancreatography (MRCP) and a percutaneous liver biopsy. The diagnosis of BA was finally made by cholangiography or histopathologic examination. The accuracy, sensitivity, specificity and predictive values of these various methods were compared. 178 patients (108 males and 70 females with a mean age of 58±30 days) were diagnosed as having BA. 218 patients (136 males and 82 females with a mean age of 61 ±24 days) were diagnosed as having non-BA etiologies of cholestasis jaundice during the follow-up period in which jaundice faded after treatment with medical therapy. For diagnosis of BA, clinical evaluation, hepatomegaly, stool color, serum gamma-glutamyltranspeptidase (GGT), duodenal juice color, bile acid in duodenal juice, ultrasonography (gallbladder), ultrasonography (griangular cord or strip-apparent hyperechoic foci), hepatobiliary scintigraphy, MRCP, liver biopsy had an accuracy of 76.0%, 51.8%, 84.3%, 70.0%, 92.4%, 98.0%, 90.4%, 67.2%, 85.3%, 83.2% and 96.6%, a sensitivity of 83.1%, 87.6%, 96.1%, 73.7%, 90.4%, 100%, 92.7%, 27.5%, 100%, 89.0% and 97.4%, a specificity of 70.2%, 77.5%, 74.8%, 67.0%, 94.0%, 96.3%, 88.5%, 99.5%, 73.3%, 75.4% and 94.3%, a positive predictive value of 69.0%, 72.6%, 75.7%, 64.6%, 92.5%, 95.7%, 86.8%, 98.0%, 75.4%, 82.6% and 98.0%, and a negative predictive value of 83.6%, 8.5%, 95.9%, 75.7%, 92.3%, 100%, 84.2%, 93.7%, 100%, 84.0% and 92.6%, respectively. It was concluded that all the differential diagnosis methods are useful. The test for duodenal drainage and elements is fast and accurate. It is helpful in the differential diagnosis of BA and non-BA etiologies of cholestasis. It shows good practical value clinically.
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SCYL1 variants cause a syndrome with low γ-glutamyl-transferase cholestasis, acute liver failure, and neurodegeneration (CALFAN). Genet Med 2018; 20:1255-1265. [PMID: 29419818 PMCID: PMC5989927 DOI: 10.1038/gim.2017.260] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 11/27/2017] [Indexed: 02/07/2023] Open
Abstract
Purpose Biallelic mutations in SCYL1 were
recently identified as causing a syndromal disorder characterized by peripheral
neuropathy, cerebellar atrophy, ataxia, and recurrent episodes of liver failure.
The occurrence of SCYL1 deficiency among patients with previously undetermined
infantile cholestasis or acute liver failure has not been studied; furthermore,
little is known regarding the hepatic phenotype. Methods We aimed to identify patients with SCYL1 variants within an exome-sequencing study of individuals
with infantile cholestasis or acute liver failure of unknown etiology. Deep
clinical and biochemical phenotyping plus analysis of liver biopsies and
functional studies on fibroblasts were performed. Results Seven patients from five families with biallelic SCYL1 variants were identified. The main clinical
phenotype was recurrent low γ-glutamyl-transferase (GGT) cholestasis or acute
liver failure with onset in infancy and a variable neurological phenotype of
later onset (CALFAN syndrome). Liver crises were triggered by febrile infections
and were transient, but fibrosis developed. Functional studies emphasize that
SCYL1 deficiency is linked to impaired intracellular trafficking. Conclusion SCYL1 deficiency can cause recurrent low-GGT cholestatic liver
dysfunction in conjunction with a variable neurological phenotype. Like NBAS
deficiency, it is a member of the emerging group of congenital disorders of
intracellular trafficking causing hepatopathy.
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Fujishiro J, Sugiyama M, Ishimaru T, Watanabe M, Sato K, Hoshino N, Uotani C, Kutsukake M, Hirata Y, Oka A. Direct hyperbilirubinemia in infants with congenital heart disease. Pediatr Int 2018; 60:179-182. [PMID: 29178522 DOI: 10.1111/ped.13462] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Revised: 10/29/2017] [Accepted: 11/22/2017] [Indexed: 01/21/2023]
Abstract
BACKGROUND The association between congenital heart disease (CHD) and infantile cholestasis, a key finding for the diagnosis of biliary atresia (BA), has not been previously investigated. The aim of this study was therefore to investigate the characteristics of direct hyperbilirubinemia (D-HB) in infants with CHD. METHODS All neonates admitted to the present hospital and diagnosed with CHD in 2015 and 2016 were included. D-HB (direct bilirubin ≥ 2.0 mg/dL) at ≤60 days of age and other clinical parameters were retrospectively reviewed. Statistical analysis according to presence of D-HB was performed using chi-squared test or Wilcoxon rank sum test. RESULTS Seventy-six patients (M:F, 36:40) were included in this study. CHD consisted of ventricular septal defect in 17, patent ductus arteriosus in 10, and other in 49. Thirteen patients (17.1%) had D-HB at ≤60 days of age. Resolution of D-HB (DB < 2.0 mg/dL) occurred in 10 of the 13 patients during the hospital stay, and this occurred in ≤7 days in eight of the 10 patients. Sex, gestational age, birthweight, chromosomal anomalies, need for Fontan operation for CHD repair, and/or cardiac operation were not associated with D-HB at ≤60 days of age. CONCLUSION While D-HB was frequently observed in infants with CHD, the majority of D-HB cases resolved spontaneously in ≤1 week. Neonatal clinical parameters or CHD status was not predictive of D-HB. D-HB lasting >1 week in infants with CHD should be evaluated for the cause.
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Affiliation(s)
- Jun Fujishiro
- Department of Pediatric Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masahiko Sugiyama
- Department of Pediatric Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tetsuya Ishimaru
- Department of Pediatric Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Miho Watanabe
- Department of Pediatric Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kaori Sato
- Department of Pediatric Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Noriko Hoshino
- Department of Pediatric Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Chizue Uotani
- Department of Pediatric Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Mai Kutsukake
- Department of Pediatric Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yoichiro Hirata
- Department of Pediatrics, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Akira Oka
- Department of Pediatrics, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
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Gura KM, Mulberg AE, Mitchell PD, Yap J, Kim CY, Chen M, Potemkin A, Puder M. Pediatric Intestinal Failure-Associated Liver Disease: Challenges in Identifying Clinically Relevant Biomarkers. JPEN J Parenter Enteral Nutr 2018; 42:455-462. [PMID: 29443401 DOI: 10.1177/0148607116671781] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Accepted: 08/19/2016] [Indexed: 01/28/2023]
Abstract
BACKGROUND Intestinal failure-associated liver disease (IFALD) is complex and diagnosed by concurrent use of parenteral nutrition, clinical presentation, and alterations in hepatic biomarkers exclusive of other causes of liver disease. In comparison with individual measures, composite biomarkers may provide a more effective means for assessing disease progression and response to treatment than single parameters. Since IFALD is considered by some to be a type of drug-induced liver injury (DILI), those diagnostic criteria could potentially be used in this population. Using a preexisting database of children treated for IFALD, our aim was to determine if a similar composite biomarker could be applied to this population. STUDY DESIGN Adult DILI criteria were applied at baseline, when treatment for IFALD (ie, direct bilirubin ≥2.0 mg/dL) was initiated. RESULTS A total of 214 patients with IFALD treated at Boston Children's Hospital were identified; 168 patients were eligible for analysis. Most patients analyzed were male (61%) and preterm (87%). Alkaline phosphatase (ALP) ≥2× upper limit of normal (ULN) captured the least amount of DILI (11%), while γ-glutamyltransferase (GGT) ≥1× ULN accounted for the most (62%). Using adult DILI criteria, 60 (39%) patients with IFALD were found to have DILI. Substituting GGT ≥1× ULN for ALP ≥2× ULN improved the sensitivity, with 105 (69%) of patients meeting at least 1 criterion for DILI. CONCLUSION Numerous challenges made it difficult to apply the DILI criteria to children with IFALD. Direct bilirubin, fractionated ALP, and perhaps GGT may be more suitable. Given its complex etiology and the age-based differences due to hepatic immaturity and growth, a more suitable composite marker needs to be developed to assess IFALD in this population.
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Affiliation(s)
- Kathleen M Gura
- Department of Pharmacy, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Andrew E Mulberg
- Division of Gastroenterology and Inborn Error Products, Office of Drug Evaluation III, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Paul D Mitchell
- Clinical Research Center, Boston Children's Hospital, Boston, Massachusetts, USA
| | - John Yap
- Office of Biostatistics/Division of Biometrics 7, Office of Drug Evaluation III, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Clara Y Kim
- Office of Biostatistics/Division of Biometrics 7, Office of Drug Evaluation III, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Minjun Chen
- National Center for Toxicological Research, U.S. Food and Drug Administration, Jefferson, Arizona, USA
| | - Alexis Potemkin
- Department of Nursing, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Mark Puder
- Vascular Biology Program and Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
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Hodgson JM, van Someren VH, Smith C, Goyale A. Direct bilirubin levels observed in prolonged neonatal jaundice: a retrospective cohort study. BMJ Paediatr Open 2018; 2:e000202. [PMID: 29637188 PMCID: PMC5843007 DOI: 10.1136/bmjpo-2017-000202] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 01/15/2018] [Accepted: 01/16/2018] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE Prolonged neonatal jaundice is common and usually benign; however, assessment of bilirubin fractions is recommended to determine the need for further assessment for congenital liver disease, particularly biliary atresia. The direct (conjugated) bilirubin thresholds currently used are variable and poorly evidenced. Hence, we aimed to delineate direct bilirubin levels in disease-free neonates with prolonged jaundice. METHODS We performed a retrospective cohort analysis of split bilirubin levels, and subsequent follow-up, for all neonates initially assessed in our prolonged neonatal jaundice clinic over 2 years. We plotted centile charts for total, direct and direct-total bilirubin ratio levels against age at sampling. The association was assessed using linear regression analysis. RESULTS Data were collected for 420 neonates (501 blood samples) across an age range of 10-70 days. No significant liver disease was found. For each day of older age, total bilirubin fell by 3.72 µmol/L (95% CI 2.46 to 5.00) and direct bilirubin fell by 0.39 µmol/L (0.18 to 0.59). The ratio between the two did not change significantly (-0.0006 to +0.0034). The 95th centile for direct bilirubin was stable at ~25 µmol/L. Direct-total bilirubin ratio was very variable with some 95th centiles >30%. CONCLUSIONS In a clinically relevant population of disease-free neonates with prolonged jaundice both the total and the direct bilirubin decreased with age. The absolute direct bilirubin is more useful clinically than the direct-total bilirubin ratio. Our results support National Institute for Health and Care Excellence guidance that conjugated bilirubin >25 µmol/L, or even more stringent criteria, constitutes an appropriate threshold for further investigation for neonatal liver disease.
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Affiliation(s)
- Joshua Mark Hodgson
- Paediatrics and Child Health, Royal Free London NHS Foundation Trust, London, UK
| | | | - Colette Smith
- Research Department of Infection and Population Health, University College London, London, UK
| | - Atul Goyale
- Clinical Biochemistry, Royal Free London NHS Foundation Trust, London, UK
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The role of endoscopic retrograde cholangiopancreatography in choledochal cysts and/or abnormal pancreatobiliary junction in children. GASTROENTEROLOGY REVIEW 2017; 12:303-309. [PMID: 29359001 PMCID: PMC5771456 DOI: 10.5114/pg.2017.72107] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 03/28/2017] [Indexed: 02/07/2023]
Abstract
Introduction Biliary cysts with an abnormal pancreatobiliary junction are one of the most common pancreatobiliary malformations. The main symptom is cholestasis; endoscopic retrograde cholangiopancreatography (ERCP) plays a key role in diagnosis. Aim Retrospective evaluation of ERCP performed to diagnose abnormalities of the pancreatobiliary junction. Material and methods We retrospectively evaluated ERCP performed to diagnose abnormalities of the pancreatobiliary junction, mainly choledochal cysts, in 112 children between 1990 and 2011. Results We performed 112 examinations of 50 children with abnormal pancreatobiliary junction and choledochal cysts (15 males and 35 females, average age: 5 years, range: 1 month – 15 years). Cysts were associated with a common channel in 37 (74%) cases, were not associated with a common channel in 9 (18%) cases, and in 3 (6%) cases the common channel lacked cysts. We performed endoscopic papilla sphincterotomy on 33 (66%) patients; endoscopic drainage was performed 62 times, including 17 patients without papilla sphincterotomy. In 15 (30%) cases, we only performed sphincterotomy. Extraction of lithiasis was done in 2 (4%) cases. Both ERCP and magnetic resonance cholangiopancreatography (MRCP) were performed on 13 patients. There was concordance of the choledochal cyst and of the type of cyst in both methods; however, common channels could not be observed by MRCP. There was 1 serious complication (perforation after sphincterotomy) and 11 (9%) mild adverse events. Conclusions When performed at an expert centre, ECRP is a safe and reliable procedure for children with choledochal cysts and/or an abnormal pancreatobiliary junction. Endoscopic retrograde cholangiopancreatography remains a reasonable alternative because MRCP has a limited ability to diagnose the precise anomalies of the pancreatobiliary junction and has no therapeutic capabilities.
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Hayashida M, Matsuura T, Kinoshita Y, Esumi G, Yoshimaru K, Yanagi Y, Takahashi Y, Taguchi T. Parameters that help to differentiate biliary atresia from other diseases. Pediatr Int 2017; 59:1261-1265. [PMID: 28802084 DOI: 10.1111/ped.13392] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 08/05/2017] [Accepted: 08/09/2017] [Indexed: 12/27/2022]
Abstract
BACKGROUND The diagnosis of biliary atresia (BA) is still challenging. The aim of this study was to analyze the clinical features and parameters that contribute to a diagnosis of BA. METHODS From January 2000 to December 2013, 37 patients who underwent operative cholangiography were evaluated retrospectively. The patients were divided into two groups: a BA group, and a group with other cholestatic diseases (non-BA group). The demographic data and preoperative liver function test results were analyzed. RESULTS Of the 37 patients, 29 patients were confirmed to have BA. Age at operation was not significantly different between the two groups (P = 0.77). On preoperative liver function tests, only the level of γ-glutamyl transpeptidase (γ-GTP) was significantly higher in the BA group (P = 0.015). The predominant non-BA disease was inspissated bile syndrome (IBS). In the IBS patients, the jaundice was relieved after lavage of the biliary tree. CONCLUSION The preoperative differentiation of cholestasis is difficult based on laboratory data and imaging. Preoperative γ-GTP may be useful for diagnosing BA, but operative cholangiography should be performed when BA is suspected and cannot be ruled out by other methods, given that the most common non-BA disease may be IBS.
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Affiliation(s)
- Makoto Hayashida
- Department of Pediatric Surgery, Reproductive and Developmental Medicine, Graduate School of Medical Sciences, Kyushu University, Higashi, Fukuoka, Japan
| | - Toshiharu Matsuura
- Department of Pediatric Surgery, Reproductive and Developmental Medicine, Graduate School of Medical Sciences, Kyushu University, Higashi, Fukuoka, Japan
| | - Yoshiaki Kinoshita
- Department of Pediatric Surgery, Reproductive and Developmental Medicine, Graduate School of Medical Sciences, Kyushu University, Higashi, Fukuoka, Japan
| | - Genshiro Esumi
- Department of Pediatric Surgery, Reproductive and Developmental Medicine, Graduate School of Medical Sciences, Kyushu University, Higashi, Fukuoka, Japan
| | - Koichiro Yoshimaru
- Department of Pediatric Surgery, Reproductive and Developmental Medicine, Graduate School of Medical Sciences, Kyushu University, Higashi, Fukuoka, Japan
| | - Yusuke Yanagi
- Department of Pediatric Surgery, Reproductive and Developmental Medicine, Graduate School of Medical Sciences, Kyushu University, Higashi, Fukuoka, Japan
| | - Yoshiaki Takahashi
- Department of Pediatric Surgery, Reproductive and Developmental Medicine, Graduate School of Medical Sciences, Kyushu University, Higashi, Fukuoka, Japan
| | - Tomoaki Taguchi
- Department of Pediatric Surgery, Reproductive and Developmental Medicine, Graduate School of Medical Sciences, Kyushu University, Higashi, Fukuoka, Japan
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Abstract
OBJECTIVES Early diagnosis of bile acid synthesis disorders (BASDs) is important because, untreated, these conditions can be fatal. Our objectives were to screen children with cholestasis or unexplained liver disease for BASD and in those with confirmed BASD to evaluate the effectiveness of cholic acid therapy. METHODS A routine serum total bile acid measurement was performed on children with cholestasis, liver cirrhosis, and liver failure. Patients were screened for BASD by fast atom bombardment ionization-mass spectrometry (FAB-MS) analysis of urine, and molecular analysis confirmed diagnosis. Treatment response to oral cholic acid (10-15 mg/kg bw/day) was assessed from liver function tests and fat-soluble vitamin levels. FAB-MS analysis of urine was used to monitor compliance and biochemical response. RESULTS Between 2007 and 2016, 626 patients were evaluated; 450 with infantile cholestasis. Fifteen cases of BASD were diagnosed: 12 presented with infantile cholestasis (2.7%, 7 boys), an 8-year-old boy presented with cirrhosis, and two 18-month-old boys presented with hepatomegaly and rickets. Eleven were caused by 3β-hydroxy-Δ-C27-steroid oxidoreductase dehydrogenase deficiency, 3 from Δ-3-oxosteroid 5β-reductase deficiency, and 1 had Zellweger spectrum disorder. In all but 1, serum total bile acids were normal or low. With cholic acid therapy, 10 are alive and healthy with their native liver. Liver failure developed in 3 infants despite therapy; 2 died and 1 underwent liver transplantation. CONCLUSIONS BASDs are rare but treatable causes of metabolic liver disease in Saudi Arabia. BASD should be considered in infants with cholestasis and low or normal serum total bile acid concentrations.
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Affiliation(s)
- Debra H Pan
- Division of Pediatric Gastroenterology and Nutrition, The Children's Hospital at Montefiore, Bronx, NY
| | - Yolanda Rivas
- Division of Pediatric Gastroenterology and Nutrition, The Children's Hospital at Montefiore, Bronx, NY
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Prevalence of malnutrition and risk of undernutrition in hospitalised children with liver disease. J Nutr Sci 2017; 6:e55. [PMID: 29152259 PMCID: PMC5672325 DOI: 10.1017/jns.2017.56] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 09/04/2017] [Accepted: 09/14/2017] [Indexed: 02/07/2023] Open
Abstract
Nutritional status of 380 hospitalised children aged from 1 month to 5 years with liver disease was evaluated in a single paediatric centre. The total prevalence of stunting (height-for-age Z (HAZ) < −2), underweight (weight-for-age Z (WAZ) < −2) and wasting (weight-for-height Z < −2) was 9·8, 9·0 and 7·9 %, respectively. The overall nutritional risk (−2 ≤ Z < −1) of stunting, underweight and wasting was 11·8, 12·9 and 12·6 %. The prevalence of undernutrition was significantly higher in children with cholestasis than children without cholestasis (stunting, 17·5 %/4·4 %, P < 0·001, and underweight, 14·9 %/4·9 %, P < 0·001). HAZ and WAZ scores were significantly higher in children without cholestasis than children with cholestasis (0·58 (sd 1·59)/−0·68 (sd 1·99), P < 0·001, and 0·37 (sd 1·35)/−0·47 (sd 1·75), P < 0·001). Further multivariate logistic regression analysis strengthened the evidence that cholestasis was significantly associated with undernutrition of stunting (OR = 4·18, P = 0·002) and underweight (OR = 3·26, P = 0·008), and suggested that the prevalence of stunting caused by infection was lower than other aetiologies in hospitalised children with liver disease (OR = 0·10, P = 0·002). We concluded that a high prevalence of malnutrition and risk of undernutrition presents in hospitalised young children with liver disease, especially in children with cholestasis. Nutrition assessment is recommended for hospitalised children with liver disease.
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Chiou FK, Ong C, Phua KB, Chedid F, Kader A. Conjugated hyperbilirubinemia presenting in first fourteen days in term neonates. World J Hepatol 2017; 9:1108-1114. [PMID: 28989567 PMCID: PMC5612842 DOI: 10.4254/wjh.v9.i26.1108] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 07/06/2017] [Accepted: 09/07/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To describe the etiology and characteristics of early-onset conjugated hyperbilirubinemia (ECHB) presenting within 14 d of life in term neonates.
METHODS Retrospective review was performed of term infants up to 28-d-old who presented with conjugated hyperbilirubinemia (CHB) at a tertiary center over a 5-year period from January 2010 to December 2014. CHB is defined as conjugated bilirubin (CB) fraction greater than 15% of total bilirubin and CB greater or equal to 25 μmol/L. ECHB is defined as CHB detected within 14 d of life. “Late-onset” CHB (LCHB) is detected at 15-28 d of life and served as the comparison group.
RESULTS Total of 117 patients were recruited: 65 had ECHB, 52 had LCHB. Neonates with ECHB were more likely to be clinically unwell (80.0% vs 42.3%, P < 0.001) and associated with non-hepatic causes (73.8% vs 44.2%, P = 0.001) compared to LCHB. Multifactorial liver injury (75.0%) and sepsis (17.3%) were the most common causes of ECHB in clinically unwell infants, majority (87.5%) had resolution of CHB with no progression to chronic liver disease. Inborn errors of metabolism were rare (5.8%) but associated with high mortality (100%) in our series. In the subgroup of clinically well infants (n = 13) with ECHB, biliary atresia (BA) was the most common diagnosis (61.5%), all presented initially with normal stools and decline in total bilirubin but with persistent CHB.
CONCLUSION Secondary hepatic injury is the most common reason for ECHB. BA presents with ECHB in well infants without classical symptoms of pale stools and deep jaundice.
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Affiliation(s)
- Fang Kuan Chiou
- Gastroenterology Service, Paediatric Medicine, KK Women’s and Children’s Hospital, Singapore 229899, Singapore
| | - Christina Ong
- Gastroenterology Service, Paediatric Medicine, KK Women’s and Children’s Hospital, Singapore 229899, Singapore
| | - Kong Boo Phua
- Gastroenterology Service, Paediatric Medicine, KK Women’s and Children’s Hospital, Singapore 229899, Singapore
| | - Fares Chedid
- Neonatal Medicine, Al Jalila Children’s Specialty Hospital, Dubai, United Arab Emirates
| | - Ajmal Kader
- Pediatric Gastroenterology, Dubai Hospital, Dubai, United Arab Emirates
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Mandelia A, Lal R, Mutt N. Role of Hepatobiliary Scintigraphy and Preoperative Liver Biopsy for Exclusion of Biliary Atresia in Neonatal Cholestasis Syndrome. Indian J Pediatr 2017; 84:685-690. [PMID: 28687948 DOI: 10.1007/s12098-017-2408-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 06/07/2017] [Indexed: 10/19/2022]
Abstract
All diagnostic algorithms for Neonatal Cholestasis Syndrome (NCS) focus on differentiating numerous medical causes from Biliary Atresia (BA). No preoperative diagnostic algorithm has 100% diagnostic accuracy for BA and yet, timely diagnosis is crucial to optimize surgical outcome. Markers for high index of clinical suspicion for BA are: a "usually" well thriving infant with conjugated hyperbilirubinemia, raised gamma glutamyl transpeptidase, persistently "acholic" stools, firm hepatomegaly with dysmorphic, hypoplastic gall bladder. In the presence of above 'red flag' signs, there has been much debate on diagnostic accuracy of percutaneous liver biopsy (PLB) vs. hepatobiliary scintigraphy (HBS) to substantiate or exclude BA. Recent guidelines suggest a shift towards PLB (91.6% overall diagnostic accuracy) as the diagnostic cornerstone with key differentiating feature being 'bile ductular proliferation'. HBS has a high (98.7%) sensitivity but low specificity (37-74%) with an overall diagnostic accuracy of 67% for BA. Severe hepatocellular disease without anatomic obstruction would also have a non-excretory scan. Thus, while excretory HBS excludes BA, non-excretion does not confirm BA. Hence, diagnostic algorithms relying on non-excretory HBS as the primary standalone benchmark for surgical exploration would be mired by a high negative laparotomy rate revealing a normal peroperative cholangiogram (POC). However, an excretory HBS obviates need for laparotomy in case of equivocal stool color or PLB. A POC continues to be the ultimate gold standard. Hence, with high index of clinical suspicion but equivocal ultrasonography or PLB and a non-excretory HBS, the baby should not be denied a POC within time frame crucial for successful hepatoportoenterostomy.
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Affiliation(s)
- Ankur Mandelia
- Department of Pediatric Surgical Superspecialties, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, 226014, India
| | - Richa Lal
- Department of Pediatric Surgical Superspecialties, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, 226014, India.
| | - Nijagal Mutt
- Department of Pediatric Surgical Superspecialties, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, 226014, India
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Pereira-da-Silva L, Nóbrega S, Rosa ML, Alves M, Pita A, Virella D, Papoila AL, Serelha M, Cordeiro-Ferreira G, Koletzko B. Parenteral nutrition-associated cholestasis and triglyceridemia in surgical term and near-term neonates: A pilot randomized controlled trial of two mixed intravenous lipid emulsions. Clin Nutr ESPEN 2017; 22:7-12. [PMID: 29415837 DOI: 10.1016/j.clnesp.2017.08.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Revised: 06/07/2017] [Accepted: 08/15/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Cholestasis is a common complication in infants receiving prolonged parenteral nutrition (PN). We studied the effects of two intravenous lipid emulsions composed with either 30% soybean oil, 30% medium-chain triglycerides (MCT), 25% olive oil, and 15% fish oil (SMOF) or with 50% MCT and 50% soybean oil n-6 (MCT/SOY) on the incidence of cholestasis in surgical term and near-term neonates. METHODS A single-center, double-blinded, randomized controlled trial compared the incidence of cholestasis using either SMOF or MCT/SOY in neonates born at gestational age ≥34 weeks undergoing major surgery. The primary outcome was the incidence of conjugated serum bilirubin >1 mg/dL. Other liver enzymes were assessed as secondary outcomes. A post-hoc analysis assessed serum triglycerides levels. Odds ratios were estimated by mixed-effects regression models. RESULTS Enrollment was prematurely interrupted because the MCT/SOY became unavailable, thus 49 infants (SMOF 22, MCT/SOY 27) completed the study. The exposure (time on PN, cumulative dose of lipids) was similar in both groups. Similar cumulative incidence rates were found for elevated conjugated bilirubinemia and other liver enzymes. Hypertriglyceridemia >250 mg/dL (12/49) was more frequent in MCT/SOY (37.0%, 95% CI 21.53-55.77) than in SMOF (9.1%, 95% CI 2.53-27.81, p = 0.024). Triglyceridemia at the first assessment (median 8 postnatal days) was significantly higher with MCT/SOY than with SMOF (181 vs. 134 mg/dL, p = 0.006). Over the whole study period, mean triglyceride concentration was 36.5 mg/dL higher with MCT/SOY compared with SMOF (p = 0.013). CONCLUSION Both emulsions had similar effects on the incidence of cholestasis and markers of liver integrity, but MCT/SOY induced higher serum triglyceride concentrations. TRIAL REGISTRATION ClinicalTrials.gov, NCT02633384.
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Affiliation(s)
- Luís Pereira-da-Silva
- Neonatal Intensive Care Unit, Woman, Infant and Adolescent Department, Hospital Dona Estefânia, Centro Hospitalar de Lisboa Central, Lisbon, Portugal.
| | - Sara Nóbrega
- Neonatal Intensive Care Unit, Woman, Infant and Adolescent Department, Hospital Dona Estefânia, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
| | - Maria Luísa Rosa
- Pharmacy Department, Hospital Dona Estefânia, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
| | - Marta Alves
- Research Unit, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
| | - Ana Pita
- Neonatal Intensive Care Unit, Woman, Infant and Adolescent Department, Hospital Dona Estefânia, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
| | - Daniel Virella
- Neonatal Intensive Care Unit, Woman, Infant and Adolescent Department, Hospital Dona Estefânia, Centro Hospitalar de Lisboa Central, Lisbon, Portugal; Research Unit, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
| | - Ana Luísa Papoila
- Research Unit, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
| | - Micaela Serelha
- Neonatal Intensive Care Unit, Woman, Infant and Adolescent Department, Hospital Dona Estefânia, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
| | - Gonçalo Cordeiro-Ferreira
- Neonatal Intensive Care Unit, Woman, Infant and Adolescent Department, Hospital Dona Estefânia, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
| | - Berthold Koletzko
- Ludwig-Maximilians-Universität München, Division Metabolic Diseases and Nutrition, Department of Pediatrics, Dr. von Hauner Children's Hospital, Univ. of Munich Medical Center, Munich, Germany
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72
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Mathiyazhagan G, Jagadisan B. Referral Patterns and Factors Influencing Age at Admission of Infants with Cholestasis in India. Indian J Pediatr 2017; 84:591-596. [PMID: 28397065 DOI: 10.1007/s12098-017-2342-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 03/20/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVES To define the recognition, age at admission, referral time and referral pattern of neonatal cholestasis in India. METHODS This prospective, observational study was conducted from February 2015 through March 2016 in the Pediatric gastroenterology unit of JIPMER, Pondicherry in infants with cholestasis < 6 mo of age. RESULTS Among 64 infants, median age of admission was 52 d (IQR 28-63 d). Fifty of sixty four infants (78.1%) came with parent-reported cholestasis-related symptoms of either jaundice alone (57.8%) or bleeding manifestations (20.3%). In 21.9% infants, jaundice was detected by physicians at a median age of 45 d (IQR 38.5-53.2 d). Two infants had intracranial bleed. Only 34% infants with pale stools were identified by the mother. The median healthcare-seeking time was 5.5 d (IQR 2.5-12 d). Among infants presenting to primary healthcare physicians (PHPs) with cholestasis-related symptoms, median time to referral was 5 d (IQR 2.5-12 d). The first point of healthcare contact in 54.7% was a PHP; 17.1% PHPs had reassured the parents. Herbal preparations were prescribed by 14.3%. Only 11.8% of those with jaundice as the only problem were given vitamin K before referral. Biliary atresia (BA) was missed in neonatal intensive care units in 9 cases. CONCLUSIONS The above issues need to be accounted for before evaluating or implementing screening strategies in India.
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Affiliation(s)
- Gopinathan Mathiyazhagan
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantri Nagar, Pondicherry, 605006, India
| | - Barath Jagadisan
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantri Nagar, Pondicherry, 605006, India.
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Sloane AJ, Nawab US, Carola D, Aghai ZH. Utility of measuring direct bilirubin at first 72 h of age in neonates admitted to the neonatal intensive care unit. J Perinatol 2017; 37:536-540. [PMID: 28125097 PMCID: PMC5646268 DOI: 10.1038/jp.2016.259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Revised: 11/21/2016] [Accepted: 12/14/2016] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To assess the utility of measuring direct bilirubin (DB) during the first 72 h of life in infants admitted to the neonatal intensive care unit (NICU). STUDY DESIGN Infants born between May 2006 and June 2013, and admitted to the NICU were included. Abnormal DB was defined as: DB level⩾1 mg dl-1 with a corresponding TB of ⩽5 mg dl-1 or DB level >20% of the corresponding TB>5 mg dl-1. RESULTS The DB levels were measured in 3715 infants during the first 72 h of life. Sixty-three infants (1.7%) had abnormal DB. In a number of infants with potentially treatable diseases (biliary atresia and choledochal cyst), the only abnormal finding was a mildly elevated DB (1 to 2 mg dl-1) during the first 3 days of life. In 22 infants (35%), the cause for high DB was unknown (16%) or not investigated (19%). CONCLUSIONS Routine measurement of DB in neonates admitted to NICU may be helpful in identifying potentially treatable causes of cholestasis.
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Liao Q, Wan CM, Zhu Y, Yang XY, Shu M. [Current status of research on infantile cholestatic liver disease in China: a visualization analysis]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2017; 19:529-533. [PMID: 28506343 PMCID: PMC7389120 DOI: 10.7499/j.issn.1008-8830.2017.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 02/04/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To investigate the current status of research on infantile cholestatic liver disease in China and future research trends. METHODS A co-word analysis was performed in October 2016. Document retrieval and screening were performed in the Chinese databases CNKI and Wanfang Data using "cholestasis" and "infant" as key words. Excel 2010 was used to establish a co-occurrence matrix of high-frequency key words, and Ucinet 6.0 and Netdraw were used to develop a visualized network of these high-frequency key words. RESULTS A total of 383 articles were included. The co-occurrence analysis showed that "infant" and "cholestasis" were the core of research in this field, and "infantile hepatitis syndrome", "neonate", "intrahepatic", "biliary atresia", "heredity and metabolism", "hepatitis", "cytomegalovirus", "jaundice", and "conjugated bilirubin" were main research topics. Most of the other articles focused on "parenteral nutrition", "hepatobiliary imaging", "gene mutation", and "liver biopsy". There were relatively few articles on surgical diagnostic techniques and treatment for this disease. CONCLUSIONS The research on infantile cholestatic liver disease in China focuses on etiology and differential diagnosis, and genetic diagnosis has become a hot topic in recent years. The research on treatment should be enhanced, and new diagnostic techniques are the research interest in future.
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Affiliation(s)
- Qiong Liao
- Department of Pediatrics, West China Second University Hospital, Sichuan University/Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu 610041, China.
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75
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Hendriksz CJ, Anheim M, Bauer P, Bonnot O, Chakrapani A, Corvol JC, de Koning TJ, Degtyareva A, Dionisi-Vici C, Doss S, Duning T, Giunti P, Iodice R, Johnston T, Kelly D, Klünemann HH, Lorenzl S, Padovani A, Pocovi M, Synofzik M, Terblanche A, Then Bergh F, Topçu M, Tranchant C, Walterfang M, Velten C, Kolb SA. The hidden Niemann-Pick type C patient: clinical niches for a rare inherited metabolic disease. Curr Med Res Opin 2017; 33:877-890. [PMID: 28276873 DOI: 10.1080/03007995.2017.1294054] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 01/31/2017] [Accepted: 02/08/2017] [Indexed: 01/30/2023]
Abstract
BACKGROUND Niemann-Pick disease type C (NP-C) is a rare, inherited neurodegenerative disease of impaired intracellular lipid trafficking. Clinical symptoms are highly heterogeneous, including neurological, visceral, or psychiatric manifestations. The incidence of NP-C is under-estimated due to under-recognition or misdiagnosis across a wide range of medical fields. New screening and diagnostic methods provide an opportunity to improve detection of unrecognized cases in clinical sub-populations associated with a higher risk of NP-C. Patients in these at-risk groups ("clinical niches") have symptoms that are potentially related to NP-C, but go unrecognized due to other, more prevalent clinical features, and lack of awareness regarding underlying metabolic causes. METHODS Twelve potential clinical niches identified by clinical experts were evaluated based on a comprehensive, non-systematic review of literature published to date. Relevant publications were identified by targeted literature searches of EMBASE and PubMed using key search terms specific to each niche. Articles published in English or other European languages up to 2016 were included. FINDINGS Several niches were found to be relevant based on available data: movement disorders (early-onset ataxia and dystonia), organic psychosis, early-onset cholestasis/(hepato)splenomegaly, cases with relevant antenatal findings or fetal abnormalities, and patients affected by family history, consanguinity, and endogamy. Potentially relevant niches requiring further supportive data included: early-onset cognitive decline, frontotemporal dementia, parkinsonism, and chronic inflammatory CNS disease. There was relatively weak evidence to suggest amyotrophic lateral sclerosis or progressive supranuclear gaze palsy as potential niches. CONCLUSIONS Several clinical niches have been identified that harbor patients at increased risk of NP-C.
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Affiliation(s)
- Christian J Hendriksz
- a Salford Royal NHS Foundation Trust , Manchester , UK
- b University of Pretoria , Pretoria , South Africa
| | - Mathieu Anheim
- c University of Strasbourg , Hautepierre Hospital , Strasbourg , France
| | - Peter Bauer
- d Institute of Medical Genetics and Applied Genomics, Tübingen University , Tübingen, Germany
- e CENTOGENE AG , Rostock , Germany
| | | | | | - Jean-Christophe Corvol
- h Sorbonne University , UPMC and Hôpital Pitié-Salpêtrière, Department of Nervous System Diseases , Paris , France
| | | | - Anna Degtyareva
- j Federal State Budget Institution, Research Center for Obstetrics , Gynecology and Perinatology , Moscow , Russia
| | | | - Sarah Doss
- l Charite University Medicine Berlin , Department of Neurology , Berlin , Germany
| | | | - Paola Giunti
- n University College London, Institute of Neurology , London , UK
| | - Rosa Iodice
- o University Federico II Naples , Naples , Italy
| | | | | | - Hans-Hermann Klünemann
- r University Clinic for Psychiatry and Psychotherapy, Regensburg University , Regensburg , Germany
| | - Stefan Lorenzl
- s Ludwig Maximillian University , Munich , Germany
- t Paracelus Medical University , Salzburg , Austria
| | - Alessandro Padovani
- u Neurology Unit, Department of Clinical and Experimental Sciences , University of Brescia , Brescia , Italy
| | | | - Matthis Synofzik
- w Department of Neurodegenerative Diseases , Hertie Institute for Clinical Brain Research , Tübingen, Germany
- x German Center for Neurodegenerative Diseases (DZNE) , Tübingen, Germany
| | | | | | - Meral Topçu
- z Hacettepe University Children's Hospital , Ankara , Turkey
| | | | | | | | - Stefan A Kolb
- ac Actelion Pharmaceuticals Ltd , Allschwil , Switzerland
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76
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Lam L, Musaad S, Kyle C, Mouat S. Utilization of Reflex Testing for Direct Bilirubin in the Early Recognition of Biliary Atresia. Clin Chem 2017; 63:973-979. [DOI: 10.1373/clinchem.2016.268532] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 01/11/2017] [Indexed: 01/21/2023]
Abstract
Abstract
BACKGROUND
Delayed diagnosis of biliary atresia is an important cause of pediatric end-stage liver failure and liver transplantation. We sought to determine whether direct bilirubin is underutilized by retrospectively reviewing patients with biliary atresia. Further, we aimed to determine the role of reflex testing for direct bilirubin in patients suspected for jaundice.
METHODS
The time intervals between total bilirubin and direct bilirubin measurements were retrospectively reviewed in patients with biliary atresia. We also audited the results of two major laboratories that had implemented reflex testing for direct bilirubin. We evaluated the clinical impact and cost of reflex testing in infants with increased direct bilirubin (>1.5 mg/dL; >25 μmol/L).
RESULTS
In patients with known biliary atresia, an isolated total bilirubin measurement preceded direct bilirubin measurement in 46% (40/87) of patients; with a median delay of 19 days (interquartile range 3–44 days). In the community setting, direct bilirubin had a higher clinical specificity for biliary atresia than in the hospital setting. Reporting direct bilirubin results in 1591 infants younger than 2 weeks of age in the community was associated with three admissions to the hospital, one of whom was diagnosed with biliary atresia. The cost for the two laboratories for direct-bilirubin testing was estimated at US$3200 (NZ$4600) for each newly diagnosed case of biliary atresia.
CONCLUSIONS
We identified underutilization of direct bilirubin as a cause of delay in the recognition of biliary atresia and show that reflex testing for direct bilirubin in jaundiced infants is a cost-effective solution.
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Affiliation(s)
- Leo Lam
- Department of Chemical Pathology, Labplus, Auckland City Hospital, Auckland, New Zealand
| | | | - Campbell Kyle
- Department of Chemical Pathology, Labplus, Auckland City Hospital, Auckland, New Zealand
- Department of Biochemistry, Labtests, Auckland, New Zealand
| | - Stephen Mouat
- Department of Paediatric Gastroenterology, Starship Hospital, Auckland, New Zealand
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Santos Silva E, Moreira Silva H, Azevedo Lijnzaat L, Melo C, Costa E, Martins E, Lopes AI. Clinical practices among healthcare professionals concerning neonatal jaundice and pale stools. Eur J Pediatr 2017; 176:361-369. [PMID: 28083674 DOI: 10.1007/s00431-016-2847-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Revised: 12/25/2016] [Accepted: 12/29/2016] [Indexed: 01/23/2023]
Abstract
UNLABELLED Jaundice and pale stools are major indicators of neonatal liver disease. Prognosis depends on timely diagnosis and management. We evaluated the clinical practices among healthcare professionals concerning jaundiced newborns and their ability to recognize pale stools. We supplied a questionnaire and a panel with eight photographs of stools, both locally validated, to physicians and nurses of the National Healthcare Service. Analysis was conducted according to professional status, specialization and years of experience of professionals and level of healthcare. Questionnaires were administered to 266 participants (100 physicians, 166 nurses). The decision to send patients to medical observation depended on the intensity of jaundice for a significant percentage of nurses. Concerning jaundiced newborns breastfed and otherwise healthy, 28.9% of physicians would never request a conjugated bilirubin assay, and only 43.3% would request it after 14 days old; for those with other signs/symptoms of disease, only 69.1% of physicians would request it immediately. Multiple linear regression analysis identified specialization as an independent variable significantly associated with the ability to recognize pale stools. CONCLUSION A significant percentage of healthcare professionals assumed clinical practices that preclude the timely recognition of cholestasis/pale stools, reinforcing the idea of educational needs. Specialization, rather than years of experience of professionals, was associated with better skills and practices. What is Known: • Neonatal cholestasis is a condition with some rare underlying entities having high mortality and morbidity. Early diagnosis is crucial to improve prognosis. Yet, many cases remain late recognized and referred. • Studies evaluating the ability of healthcare professionals to recognize neonatal cholestasis are scarce. What is New: • In this study, a significant percentage of professionals assumed clinical practices that preclude timely recognition of neonatal cholestasis and pale stools, reinforcing the idea of educational needs. • Specialization of professionals was associated with better skills and practices.
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Affiliation(s)
- Ermelinda Santos Silva
- Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Rua Jorge Viterbo Ferreira, nº 228, 4050-313, Porto, Portugal. .,Gastroenterology Unit, Paediatrics Division, Departmento da Criança e do Adolescente, Centro Materno-Infantil do Norte, Centro Hospitalar do Porto, Largo da Maternidade Júlio Dinis, 4050-651, Porto, Portugal.
| | - Helena Moreira Silva
- Paediatrics Division, Departamento da Criança e do Adolescente, Centro Materno-Infantil do Norte, Centro Hospitalar do Porto, Largo da Maternidade Júlio Dinis, 4050-651, Porto, Portugal
| | - Lia Azevedo Lijnzaat
- Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Rua Jorge Viterbo Ferreira, nº 228, 4050-313, Porto, Portugal
| | - Cláudia Melo
- Paediatrics Division, Unidade Hospitalar de Famalicão, Centro Hospitalar do Médio Ave, Rua de Cupertino de Miranda, 4764-958, Vila Nova de Famalicão, Portugal
| | - Elísio Costa
- UCIBIO, Department of Biological Sciences, Faculdade de Farmácia, Universidade do Porto, Rua Jorge Viterbo Ferreira, nº 228, 4050-313, Porto, Portugal
| | - Esmeralda Martins
- Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Rua Jorge Viterbo Ferreira, nº 228, 4050-313, Porto, Portugal.,Metabolic Diseases Unit, Paediatrics Division, Departmento da Criança e do Adolescente, Centro Materno-Infantil do Norte, Centro Hospitalar do Porto, Largo da Maternidade Júlio Dinis, 4050-651, Porto, Portugal
| | - Ana Isabel Lopes
- Gastroenterology Unit, Paediatrics Department, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Av. Prof. Egas Moniz, 1600-190, Lisboa, Portugal.,Faculdade de Medicina, Universidade de Lisboa, Av. Prof. Egas Moniz, 1649-028, Lisboa, Portugal
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78
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Abu Faddan NH, Sherif TMK, Mohammed OA, Nasif KA, El Gezawy EM. Intestinal barrier integrity and function in infants with cholestasis. Intest Res 2017; 15:118-123. [PMID: 28239322 PMCID: PMC5323301 DOI: 10.5217/ir.2017.15.1.118] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 09/08/2016] [Accepted: 09/09/2016] [Indexed: 12/30/2022] Open
Abstract
Background/Aims The safety of the human body is maintained by effective monitoring of the mucosal surface integrity and protection against potentially harmful compounds. This function of the gut called intestinal barrier function can be affected by cholestasis and the absence of bile in the intestinal lumen. We aimed to determine whether the gut barrier integrity is impaired in infants with cholestasis by evaluation of the intestinal fatty acid binding proteins (I-FABP) and ileal bile acid binding protein (I-BABP) as markers of intestinal epithelial cell damage and plasma D-lactate level as a marker of gut wall permeability. Methods This case-control study included 53 infants with cholestasis and 29 controls. Serum levels of I-FABP, I-BABP, and D-lactate were measured in all subjects. Results Both groups of patients with neonatal hepatitis and biliary atresia showed significantly higher levels of I-FABP and I-BABP than the controls. There were no differences in the serum D-lactate level between the cases and controls. There was no difference between the two groups of patients (I and II) regarding any of the parameters studied. No significant correlations between serum levels of I-FABP, I-BABP, or D-lactate and total or direct bilirubin levels were found in the cholestatic infants. Conclusions The intestinal epithelial barrier integrity is breached nearly in all parts of the intestine in infants with cholestasis. Further research is recommended to determine the impact of this finding on the management of these infants. The relationship between physical intestinal barrier damage and its functional failure remains subject for further research.
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Affiliation(s)
- Nagla H Abu Faddan
- Department of Pediatrics, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Tahra M K Sherif
- Department of Clinical Pathology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Omnia A Mohammed
- Department of Clinical Pathology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Khalid A Nasif
- Department of Biochemistry, Faculty of Medicine, Minya University, Minya, Egypt
| | - Ebtesam M El Gezawy
- Department of Clinical Pathology, Faculty of Medicine, Assiut University, Assiut, Egypt
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79
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Peters AL. 50 Years Ago in The Journal of Pediatrics: The Diagnosis of Complete Extrahepatic Obstruction by Rose Bengal I 131. J Pediatr 2017; 180:162. [PMID: 28010790 DOI: 10.1016/j.jpeds.2016.08.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Anna L Peters
- Division of Gastroenterology, Hepatology, and Nutrition Cincinnati Children's Hospital Medical Center Cincinnati, Ohio
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80
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Guideline for the Evaluation of Cholestatic Jaundice in Infants: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr 2017; 64:154-168. [PMID: 27429428 DOI: 10.1097/mpg.0000000000001334] [Citation(s) in RCA: 274] [Impact Index Per Article: 39.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Cholestatic jaundice in infancy affects approximately 1 in every 2500 term infants and is infrequently recognized by primary providers in the setting of physiologic jaundice. Cholestatic jaundice is always pathologic and indicates hepatobiliary dysfunction. Early detection by the primary care physician and timely referrals to the pediatric gastroenterologist/hepatologist are important contributors to optimal treatment and prognosis. The most common causes of cholestatic jaundice in the first months of life are biliary atresia (25%-40%) followed by an expanding list of monogenic disorders (25%), along with many unknown or multifactorial (eg, parenteral nutrition-related) causes, each of which may have time-sensitive and distinct treatment plans. Thus, these guidelines can have an essential role for the evaluation of neonatal cholestasis to optimize care. The recommendations from this clinical practice guideline are based upon review and analysis of published literature and the combined experience of the authors. The committee recommends that any infant noted to be jaundiced after 2 weeks of age be evaluated for cholestasis with measurement of total and direct serum bilirubin, and that an elevated serum direct bilirubin level (direct bilirubin levels >1.0 mg/dL or >17 μmol/L) warrants timely consideration for evaluation and referral to a pediatric gastroenterologist or hepatologist. Of note, current differential diagnostic plans now incorporate consideration of modern broad-based next-generation DNA sequencing technologies in the proper clinical context. These recommendations are a general guideline and are not intended as a substitute for clinical judgment or as a protocol for the care of all infants with cholestasis. Broad implementation of these recommendations is expected to reduce the time to the diagnosis of pediatric liver diseases, including biliary atresia, leading to improved outcomes.
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81
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Pediatric cholangiopathies: diseases of the gallbladder and biliary tract. Abdom Radiol (NY) 2017; 42:69-85. [PMID: 27518785 DOI: 10.1007/s00261-016-0865-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Pediatric gallbladder and bile duct disease encompasses a broad spectrum of processes, from congenital to developmental to neoplastic. We describe normal pediatric biliary anatomy and summarize the most common pathologic entities, with a focus on non-invasive imaging techniques and findings. Ultrasound is the first-line imaging modality in children with suspected biliary pathology based on its widespread availability, cost effectiveness, and lack of ionizing radiation. MRI and MRCP are often used for further evaluation in cases of diagnostic uncertainty and for surgical planning.
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82
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Thomson M, Tringali A, Dumonceau JM, Tavares M, Tabbers MM, Furlano R, Spaander M, Hassan C, Tzvinikos C, Ijsselstijn H, Viala J, Dall'Oglio L, Benninga M, Orel R, Vandenplas Y, Keil R, Romano C, Brownstone E, Hlava Š, Gerner P, Dolak W, Landi R, Huber WD, Everett S, Vecsei A, Aabakken L, Amil-Dias J, Zambelli A. Paediatric Gastrointestinal Endoscopy: European Society for Paediatric Gastroenterology Hepatology and Nutrition and European Society of Gastrointestinal Endoscopy Guidelines. J Pediatr Gastroenterol Nutr 2017; 64:133-153. [PMID: 27622898 DOI: 10.1097/mpg.0000000000001408] [Citation(s) in RCA: 143] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This guideline refers to infants, children, and adolescents ages 0 to 18 years. The areas covered include indications for diagnostic and therapeutic esophagogastroduodenoscopy and ileocolonoscopy; endoscopy for foreign body ingestion; corrosive ingestion and stricture/stenosis endoscopic management; upper and lower gastrointestinal bleeding; endoscopic retrograde cholangiopancreatography; and endoscopic ultrasonography. Percutaneous endoscopic gastrostomy and endoscopy specific to inflammatory bowel disease has been dealt with in other guidelines and are therefore not mentioned in this guideline. Training and ongoing skill maintenance are to be dealt with in an imminent sister publication to this.
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Affiliation(s)
- Mike Thomson
- *International Academy for Paediatric Endoscopy Training, Sheffield Children's Hospital, Weston Bank, Sheffield, UK †Digestive Endoscopy Unit, Catholic University, Rome, Italy ‡Gedyt Endoscopy Center, Buenos Aires, Argentina §Department of Pediatric Gastroenterology, Centro Hospitalar de São João, Porto, Portugal ||Department of Pediatric Gastroenterology, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands ¶Department of Pediatric Gastroenterology and Nutrition, University Children's Hospital Basel, Basel, Switzerland #Department of Gastroenterology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands **Department of Gastroenterology, Nuovo Regina Margherita Hospital, Rome, Italy ††Department of Pediatric Gastroenterology, Alder Hey Children's Hospital, Liverpool, UK ‡‡Department of Pediatric Surgery and Intensive Care, Erasmus MC, Sophia Children's Hospital, Rotterdam, The Netherlands §§Department of Pediatric Gastroenterology, Robert-Debré Hospital, Paris, France ||||Digestive Endoscopy and Surgery Unit, Bambino Gesù Children Hospital-IRCCS, Rome, Italy ¶¶Department of Gastroenterology, Hepatology and Nutrition, University Children's Hospital Ljubljana, Ljubljana, Slovenia ##Pediatric Gastroenterology, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium ***Department of Gastroenterology, Motol University Hospital, Prague, Czech Republic †††Department of Pediatrics, University of Messina, Messina, Italy ‡‡‡IV Medical Department, Rudolfstiftung Hospital, Vienna, Austria §§§Department of General Pediatrics, Children's Hospital Freiburg University, Freiburg, Germany ||||||Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria ¶¶¶Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK ###Department for Pediatric Nephrology and Gastroenterology, Medical University of Vienna, Austria ****GI Endoscopy Unit, OUS, Rikshospitalet University Hospital, Oslo, Norway ††††Gastroenterology and Digestive Endoscopy Unit, Ospedale Nuovo Robbiani di Soresina, Soresina, Italy
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Abstract
Jaundice is a key manifestation of hepatobiliary disease in all age groups. Jaundice is a common finding in the first 2 weeks after birth, occurring in 2.4% to 15% of newborns. The neonatal liver is at increased susceptibility to cholestasis, with an incidence ranging from 1 in 2,500 to 1 in 5,000 live births. Etiologies vary, but the most common is biliary atresia. In 2004, the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition published guidelines for the evaluation of cholestasis that clearly stated any infant with jaundice persisting beyond age 2 weeks (3 weeks in breast-fed infants with an otherwise normal history and physical examination) should be evaluated with a fractionated serum bilirubin level. Prompt evaluation, diagnosis, and intervention are vital to optimize timely intervention and improve clinical outcomes. This article discusses the etiology, diagnosis and evaluation of cholestatis in infants. [Pediatr Ann. 2016;45(12):e414-e419.].
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84
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Russo P, Magee JC, Anders RA, Bove KE, Chung C, Cummings OW, Finegold MJ, Finn LS, Kim GE, Lovell MA, Magid MS, Melin-Aldana H, Ranganathan S, Shehata BM, Wang L, White FV, Chen Z, Spino C. Key Histopathologic Features of Liver Biopsies That Distinguish Biliary Atresia From Other Causes of Infantile Cholestasis and Their Correlation With Outcome: A Multicenter Study. Am J Surg Pathol 2016; 40:1601-1615. [PMID: 27776008 PMCID: PMC5123664 DOI: 10.1097/pas.0000000000000755] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The liver biopsy guides diagnostic investigation and therapy in infants with undiagnosed cholestasis. Histologic features in the liver may also have prognostic value in the patient with biliary atresia (BA). We assessed the relative value of histologic features in 227 liver needle biopsies in discriminating between BA and other cholestatic disorders in infants enrolled in a prospective Childhood Liver Disease Research Network (ChiLDReN) cohort study by correlating histology with clinical findings in infants with and without BA. In addition, we reviewed 316 liver biopsies from clinically proven BA cases and correlated histologic features with total serum bilirubin 6 months after hepatoportoenterostomy (the Kasai procedure, HPE) and transplant-free survival up to 6 years. Review pathologists were blinded to clinical information except age. Semiquantitative scoring of 26 discrete histologic features was based on consensus. Bile plugs in portal bile ducts/ductules, moderate to marked ductular reaction, and portal stromal edema had the largest odds ratio for predicting BA versus non-BA by logistic regression analysis. The diagnostic accuracy of the needle biopsy was estimated to be 90.1% (95% confidence interval [CI]: 85.2%, 94.9%), whereas sensitivity and specificity for a diagnosis of BA are 88.4% (95% CI: 81.4, 93.5) and 92.7% (95% CI: 84.8, 97.3), respectively. No histologic features were associated with an elevated serum bilirubin 6 months after HPE, although it (an elevated serum bilirubin) was associated with an older age at HPE. Higher stages of fibrosis, a ductal plate configuration, moderate to marked bile duct injury, an older age at HPE, and an elevated international normalized ratio were independently associated with a higher risk of transplantation.
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Affiliation(s)
- P Russo
- Department of Pathology and Laboratory Medicine, the Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - JC Magee
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - RA Anders
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - KE Bove
- Division of Pediatric Pathology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - C Chung
- Division of Pathology, The Hospital of Sick Children, Toronto, Canada
| | - OW Cummings
- Department of Pathology, Indiana University School of Medicine, Indianapolis, Indiana
| | - MJ Finegold
- Department of Pathology, Texas Children’s Hospital, Houston, Texas
| | - LS Finn
- Department of Pathology, Seattle Children’s Hospital, Seattle, Washington
| | - GE Kim
- Department of Pathology, University of California San Francisco, San Francisco, California
| | - MA Lovell
- Department of Pathology, Children’s Hospital Colorado, Aurora, Colorado
| | - MS Magid
- Department of Pathology, Kravis Children’s Hospital, Mount Sinai Health System, New York, New York
| | - H Melin-Aldana
- Department of Pathology, Ann & Robert H. Lurie Children’s Hospital, Chicago, Illinois
| | - S Ranganathan
- Department of Pathology, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| | - BM Shehata
- Department of Pathology, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - L Wang
- Department of Pathology, Children’s Hospital Los Angeles, Los Angeles, California
| | - FV White
- Department of Pathology and Immunology, Washington University School of Medicine, St Louis, Missouri
| | - Z Chen
- Quest Diagnostics, Health Informatics, Madison New Jersey
| | - C Spino
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
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Oh SH, Lee BH, Kim GH, Choi JH, Kim KM, Yoo HW. Biochemical and molecular characteristics of citrin deficiency in Korean children. J Hum Genet 2016; 62:305-307. [DOI: 10.1038/jhg.2016.131] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 09/23/2016] [Accepted: 09/26/2016] [Indexed: 11/09/2022]
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86
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Abstract
Biliary disease in infants and children frequently presents diagnostic and therapeutic challenges. Pediatric interventional radiologists are often involved in the multidisciplinary teams who care for these patients. This article reviews several notable causes of biliary disease in children who have not undergone liver transplantation, describes the role of percutaneous interventional procedures in managing these conditions, and details applicable biliary interventional techniques.
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Affiliation(s)
- Lisa H Kang
- Department of Radiology, University of Texas Southwestern Children's Health, Dallas, Texas
| | - Colin N Brown
- Department of Radiology, Texas Scottish Rite Hospital for Children, Dallas, Texas
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Shreef K, Alhelal A. Evaluation of the use of laparoscopic-guided cholecystocholangiography and liver biopsy in definitive diagnosis of neonatal cholestatic jaundice. Afr J Paediatr Surg 2016; 13:181-184. [PMID: 28051047 PMCID: PMC5154223 DOI: 10.4103/0189-6725.194667] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Once it is established that a jaundiced infant has direct hyperbilirubinemia, the principal diagnostic concern is to differentiate hepatocellular from obstructive cholestasis. Traditional tests such as ultrasonography, percutaneous liver biopsy and technetium 99 m hepatobiliary iminodiacetic acid (HIDA) scan are often not sufficiently discriminating. Definitive exclusion of biliary atresia (BA) in the infant with cholestatic jaundice usually requires mini-laparotomy and intra-operative cholangiography. This approach has many drawbacks because those sick infants are subjected to a time-consuming procedure with the probability of negative surgical exploration. AIM OF THE STUDY The aim of this study was to determine the feasibility of laparoscopic-guided cholecystocholangiography (LGCC) and its accuracy and safety in the diagnosis of BA and thus preventing unnecessary laparotomy in infants whose cholestasis is caused by diseases other than BA. PATIENTS AND METHODS Twelve cholestatic infants with direct hyperbilirubinemia subjected to LGCC (age, 7-98 days; mean, 56 days) after ultrasound scan and (99 mTc) HIDA scan and percutaneous liver biopsy failed to provide the definitive diagnosis. RESULTS One patient had completely absent gall bladder (GB) so the laparoscopic procedure was terminated and laparotomy was done (Kasai operation). Four patients had small size GB; they underwent LGCC that showed patent common bile duct with atresia of common hepatic duct, so laparotomy and Kasai operation was performed. Seven patients had well-developed GB, LGCC revealed patent biliary tree, so laparoscopic liver biopsies were taken for histopathology. Five of those patients had neonatal hepatitis, and two had cholestasis as a complication of prolonged TPN. No perioperative complications or mortalities were recorded. CONCLUSION When the diagnosis neonatal cholestasis remains elusive after traditional investigations, LGCC is an accurate and simple method for differentiating BA from hepatocellular causes.
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Affiliation(s)
- Khalid Shreef
- Department of Pediatric Surgery, Zagazig University, Egypt; Department of Pediatric Surgery, Asser Central Hospital and Abha Maternity Children Hospital, Abha, Saudi Arabia
| | - Abdullah Alhelal
- Department of Pediatric Surgery, Asser Central Hospital and Abha Maternity Children Hospital, Abha, Saudi Arabia
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Verkade HJ, Bezerra JA, Davenport M, Schreiber RA, Mieli-Vergani G, Hulscher JB, Sokol RJ, Kelly DA, Ure B, Whitington PF, Samyn M, Petersen C. Biliary atresia and other cholestatic childhood diseases: Advances and future challenges. J Hepatol 2016; 65:631-42. [PMID: 27164551 DOI: 10.1016/j.jhep.2016.04.032] [Citation(s) in RCA: 109] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 04/26/2016] [Accepted: 04/28/2016] [Indexed: 02/08/2023]
Abstract
Biliary Atresia and other cholestatic childhood diseases are rare conditions affecting the function and/or anatomy along the canalicular-bile duct continuum, characterised by onset of persistent cholestatic jaundice during the neonatal period. Biliary atresia (BA) is the most common among these, but still has an incidence of only 1 in 10-19,000 in Europe and North America. Other diseases such as the genetic conditions, Alagille syndrome (ALGS) and Progressive Familial Intrahepatic Cholestasis (PFIC), are less common. Choledochal malformations are amenable to surgical correction and require a high index of suspicion. The low incidence of such diseases hinder patient-based studies that include large cohorts, while the limited numbers of animal models of disease that recapitulate the spectrum of disease phenotypes hinders both basic research and the development of new treatments. Despite their individual rarity, collectively BA and other cholestatic childhood diseases are the commonest indications for liver transplantation during childhood. Here, we review the recent advances in basic research and clinical progress in these diseases, as well as the research needs. For the various diseases, we formulate current key questions and controversies and identify top priorities to guide future research.
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Affiliation(s)
- Henkjan J Verkade
- Department of Paediatrics, University of Groningen, Beatrix Children's Hospital/University Medical Center, Groningen, The Netherlands.
| | - Jorge A Bezerra
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Mark Davenport
- Department of Paediatric Surgery, King's College Hospital, Denmark Hill, London, UK
| | - Richard A Schreiber
- Department of Paediatrics, University of British Columbia, Vancouver, Canada
| | - Georgina Mieli-Vergani
- Paediatric Liver, GI & Nutrition Centre, King's College London School of Medicine at King's College Hospital, London, UK
| | - Jan B Hulscher
- Department of Paediatric Surgery, University of Groningen, Beatrix Children's Hospital-University Medical Center, Groningen, The Netherlands
| | - Ronald J Sokol
- Section of Paediatric Gastroenterology, Hepatology, and Nutrition, Department of Paediatrics, University of Colorado School of Medicine, Digestive Health Institute, Children's Hospital Colorado, Aurora, CO, USA
| | - Deirdre A Kelly
- Liver Unit, Birmingham Children's Hospital NHS Trust, Birmingham, UK
| | - Benno Ure
- Department of Paediatric Surgery, Hannover Medical School, Hannover, Germany
| | - Peter F Whitington
- Department of Paediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Marianne Samyn
- Paediatric Liver, GI & Nutrition Centre, King's College London School of Medicine at King's College Hospital, London, UK
| | - Claus Petersen
- Department of Paediatric Surgery, Hannover Medical School, Hannover, Germany
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Sung S, Jeon TY, Yoo SY, Hwang SM, Choi YH, Kim WS, Choe YH, Kim JH. Incremental Value of MR Cholangiopancreatography in Diagnosis of Biliary Atresia. PLoS One 2016; 11:e0158132. [PMID: 27341698 PMCID: PMC4920379 DOI: 10.1371/journal.pone.0158132] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 06/10/2016] [Indexed: 02/06/2023] Open
Abstract
Purpose To evaluate the incremental value of a combination of magnetic resonance cholangiopancreatography (MRCP) and ultrasonography (US), compared to US alone, for diagnosing biliary atresia (BA) in neonates and young infants with cholestasis. Materials and Methods The institutional review board approved this retrospective study. The US and MRCP studies were both performed on 64 neonates and young infants with BA (n = 41) or without BA (non-BA) (n = 23). Two observers reviewed independently the US alone set and the combined US and MRCP set, and graded them using a five-point scale. Diagnostic performance was compared using pairwise comparison of the receiver operating characteristics (ROC) curve. The sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value were assessed. Results The diagnostic performance (the area under the ROC curve [Az]) for diagnosing BA improved significantly after additional review of MRCP images; Az improved from 0.688 to 0.901 (P = .015) for observer 1 and from 0.676 to 0.901 (P = .011) for observer 2. The accuracy of MRCP combined with US (observer 1, 95% [61/64]; observer 2 92% [59/64]) and PPV (observer 1, 95% [40/42]; observer 2 91% [40/44]) were significantly higher than those of US alone for both observers (accuracy: observer 1, 73% [47/64], P = 0.003; observer 2, 72% [46/64], P = 0.004; PPV: observer 1, 76% [35/46], P = 0.016; observer 2, 76% [34/45], P = 0.013). Interobserver agreement of confidence levels was good for US alone (ĸ = 0.658, P < .001) and was excellent for the combined set of US and MRCP (ĸ = 0.929, P < .001). Conclusion Better diagnostic performance was achieved with the combination of US and MRCP than with US alone for the evaluation of BA in neonates and young infants with cholestasis.
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Affiliation(s)
- Siyoun Sung
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Tae Yeon Jeon
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
- * E-mail:
| | - So-Young Yoo
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Sook Min Hwang
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Young Hun Choi
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea
| | - Woo Sun Kim
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea
| | - Yon Ho Choe
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06531, Korea
| | - Ji Hye Kim
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
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Newborn Direct or Conjugated Bilirubin Measurements As a Potential Screen for Biliary Atresia. J Pediatr Gastroenterol Nutr 2016; 62:799-803. [PMID: 26720765 DOI: 10.1097/mpg.0000000000001097] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Although screening for biliary atresia (BA) is associated with improved outcomes, no screening program currently exists in the United States. In this study, we explore the possibility of a screening strategy based on newborn direct or conjugated bilirubin (DB or CB) measurements. Our objective is to estimate testing's sensitivity and specificity for BA. METHODS Two groups were examined retrospectively. For sensitivity calculations, a BA group consisting of infants born between January 2011 and December 2014, diagnosed with BA, and cared for at a pediatric gastroenterology referral center was examined. For specificity calculations, a non-BA group that comprised of infants born between June 2009 and August 2011 in a hospital with a policy of checking newborn bilirubin concentrations was studied. RESULTS All 35 infants with newborn DB or CB measurements in the BA group had elevated concentrations, translating to a sensitivity of 100% (95% CI 87.7-100). In the non-BA group, 8936 of 9102 infants had DB concentrations within the laboratory's reference interval, translating to a specificity of 98.2% (95% CI 97.9-98.4). Three methods-calculating direct:total bilirubin ratios, using 99% reference intervals, and repeat testing-changed specificity to different degrees. CONCLUSIONS Newborn DB or CB measurements may have a high sensitivity and specificity for BA. Specificity can be further improved by using 99% reference intervals and/or repeat testing. Our findings can serve as the foundation for larger prospective studies, to determine whether newborn DB or CB measurements can be an effective screening strategy for BA.
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Correlation analysis between four serum biomarkers of liver fibrosis and liver function in infants with cholestasis. Biomed Rep 2016; 5:107-112. [PMID: 27347413 DOI: 10.3892/br.2016.681] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 05/12/2016] [Indexed: 12/20/2022] Open
Abstract
The aim of the present study was to investigate the correlation between four serum biomarkers of liver fibrosis and liver function in infants with cholestasis. A total of 30 infants with cholestasis and 20 healthy infants were included in the study. Biochemical assays based on the initial rate method and colorimetric assays were conducted to determine the levels of liver function markers in the serum [such as alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin (TBIL), direct bilirubin (DBIL), indirect bilirubin (IBIL), γ-glutamyl transferase (γ-GT), cholinesterase (CHE) and total bile acids (TBA)] and four serum biomarkers of liver fibrosis were measured using radioimmunoassays [hyaluronic acid (HA), procollagen type III (PCIII), laminin (LN) and collagen type IV (cIV)]. The serum levels of ALT, AST, TBIL, DBIL, IBIL, γ-GT and TBA in the infants with cholestasis were significantly higher compared to the healthy infants (P<0.01); the serum levels of CHE in the infants with cholestasis were significantly lower compared to the healthy infants (P<0.01). The serum levels of HA, PCIII, and cIV in the infants with cholestasis were significantly higher compared to the healthy infants (P<0.01). Correlation analyses between liver function and the four biomarkers of liver fibrosis showed that HA was positively correlated with AST and γ-GT (P<0.05) and negatively correlated with ALT, CHE and TBA (P<0.05). cIV was positively correlated with γ-GT (P<0.05) and negatively correlated with CHE (P<0.05). In conclusion, statistically significant differences were identified for the liver function markers (ALT, AST, TBIL, DBIL, IBIL, γ-GT and TBA) and the biomarkers HA, PCIII and cIV of liver fibrosis between infants with cholestasis and healthy infants. Thus, the serum levels of HA, cIV, γ-GT and CHE are sensitive markers for cholestatic liver fibrosis in infants.
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Rafeey M, Saboktakin L, Hasani JS, Naghashi S. Diagnostic value of anti-smooth muscle antibodies and liver enzymes in differentiation of extrahepatic biliary atresia and idiopathic neonatal hepatitis. Afr J Paediatr Surg 2016; 13:63-8. [PMID: 27251654 PMCID: PMC4955439 DOI: 10.4103/0189-6725.182558] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND We aimed to evaluate the diagnostic value of anti-smooth muscle antibodies (ASMA) and two liver markers (gamma-glutamyl transpeptidase [GGT] and alkaline phosphatase [ALP]) for differentiating between patients with extrahepatic biliary atresia (EHBA) and idiopathic neonatal hepatitis (INH). MATERIALS AND METHODS During April 2010-2011, all infants at 2 weeks of age who were diagnosed with cholestasis and admitted to Children's Hospital of Tabriz were enrolled. Based on the results of physical examination, laboratory, imaging and pathological studies, neonates were divided into two groups (EHBA and INH). Receiver operating characteristics analysis was used to define sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy for ASMA, GGT and ALP. RESULTS Thirty neonates with cholestasis (18 with EHBA and 12 with INH) and mean age of 54.66 25.86 days were enrolled. Total and direct bilirubin, serum glutamic oxaloacetic transaminase, serum glutamic pyruvic transaminase and ASMA titres were highly not significant (P > 0.05) in patients with INH. GGT (P = 0.008) and ALP (P = 0.01) had statistically significant differences that were higher in patients with EHBA. The sensitivity, specificity, PPV and NPV, accuracy, LR+ and LR- of SMA in differentiating cases with BA were 66.7%, 75%, 80% 60%, 70%, 2.68 and 0.44, respectively. For GGT, the values were 88.9%, 66.7%, 80%, 80%, 79.1%, 3.08 and 0.31, respectively. Finally, for ALP, the values were 77.8%, 75%, 82.4%, 69.2%, 80%, 2.66 and 0.24, respectively. CONCLUSION Our study showed that ASMA may be a useful biomarker for differentiation of EHBA from INH. Further studies with larger samples are recommended for confirming the results of this study.
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Affiliation(s)
- Mandana Rafeey
- Liver and Gastrointestinal Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Lida Saboktakin
- Department of Pediatrics, Pediatric Health Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Jamshid Shoa Hasani
- Liver and Gastrointestinal Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Shahnaz Naghashi
- Liver and Gastrointestinal Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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Yinzhihuang attenuates ANIT-induced intrahepatic cholestasis in rats through upregulation of Mrp2 and Bsep expressions. Pediatr Res 2016; 79:589-95. [PMID: 26646631 DOI: 10.1038/pr.2015.252] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 09/16/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND The treatment of intrahepatic cholestasis has been limited, and development of an effective drug is needed. Clinical studies have shown that Yinzhihuang (YZH), a traditional Chinese decoction, enhances bilirubin clearance. The goal of this study was to determine the protective effect of YZH on experimental intrahepatic cholestasis in young rats and to explore its underlying molecular mechanisms. METHODS Intrahepatic cholestasis in rats was induced by α-naphthylisothiocyanate (ANIT) on days 1 and 8. The rats received YZH, ursodeoxycholic acid (UDCA), or vehicle for 9 d and were killed on either day 3 or day 10. Serum biomarkers, liver histology, and the distribution of protein and mRNA expression of Mrp2 and Bsep were analyzed. RESULTS YZH treatment resulted in decreased levels of serum biomarkers except γ-glutamyl transpeptidase, attenuated liver histological injuries, increased protein expressions of Mrp2 and Bsep, and upregulated expressions of Mrp2 and Bsep mRNAs. The effects of YZH on serum biomarkers (aminotransferase, alanine aminotransferase, and direct bilirubin), liver histology, and Mrp2 mRNA expressions were significantly greater and earlier than those of UDCA. CONCLUSION Our results suggest that YZH has protective effect against ANIT-induced intrahepatic cholestasis in rats, through upregulation of Mrp2 and Bsep expressions.
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Togawa T, Sugiura T, Ito K, Endo T, Aoyama K, Ohashi K, Negishi Y, Kudo T, Ito R, Kikuchi A, Arai-Ichinoi N, Kure S, Saitoh S. Molecular Genetic Dissection and Neonatal/Infantile Intrahepatic Cholestasis Using Targeted Next-Generation Sequencing. J Pediatr 2016; 171:171-7.e1-4. [PMID: 26858187 DOI: 10.1016/j.jpeds.2016.01.006] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2015] [Revised: 12/21/2015] [Accepted: 01/05/2016] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To ascertain a molecular genetic diagnosis for subjects with neonatal/infantile intrahepatic cholestasis (NIIC) by the use of next-generation sequencing (NGS) and to perform a genotype-phenotype correlation. STUDY DESIGN We recruited Japanese subjects with NIIC who had no definitive molecular genetic diagnosis. We developed a diagnostic custom panel of 18 genes, and the amplicon library was sequenced via NGS. We then compared clinical data between the molecular genetically confirmed subjects with NIIC. RESULTS We analyzed 109 patients with NIIC ("genetic cholestasis," 31 subjects; "unknown with complications" such as prematurity, 46 subjects; "unknown without complications," 32 subjects), and a molecular genetic diagnosis was made for 28 subjects (26%). The rate of positive molecular genetic diagnosis in each category was 22 of 31 (71%) for the "genetic cholestasis" group, 2 of 46 (4.3%) for the "unknown with complications" group, and 4 of 32 (12.5%) for the "unknown without complications" group. The grouping of the molecular diagnoses in the group with genetic cholestasis was as follows: 12 with Alagille syndrome, 5 with neonatal Dubin-Johnson syndrome, 5 with neonatal intrahepatic cholestasis caused by citrin deficiency, and 6 with progressive familial intrahepatic cholestasis or benign recurrent intrahepatic cholestasis with low gamma-glutamyl transpeptidase levels. Several clinical datasets, including age of onset, direct bilirubin, and aminotransferases, were significantly different between the disorders confirmed using molecular genetic diagnosis. CONCLUSION Targeted NGS can be used for molecular genetic diagnosis in subjects with NIIC. Clinical diagnosis should be accordingly redefined in the view of molecular genetic findings.
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Affiliation(s)
- Takao Togawa
- Department of Pediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Tokio Sugiura
- Department of Pediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan.
| | - Koichi Ito
- Department of Pediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Takeshi Endo
- Department of Pediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Kohei Aoyama
- Department of Pediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Kei Ohashi
- Department of Pediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Yutaka Negishi
- Department of Pediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Toyoichiro Kudo
- Department of Hepatology, National Medical Center for Children and Mothers, National Center for Child Health and Development, Tokyo, Japan
| | - Reiko Ito
- Department of Hepatology, National Medical Center for Children and Mothers, National Center for Child Health and Development, Tokyo, Japan
| | - Atsuo Kikuchi
- Department of Pediatrics, Tohoku University School of Medicine, Sendai, Japan
| | | | - Shigeo Kure
- Department of Pediatrics, Tohoku University School of Medicine, Sendai, Japan
| | - Shinji Saitoh
- Department of Pediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
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Comparison of phenobarbitone and ursodeoxycholic acid in drug-augmented hepatobiliary scintigraphy for excluding the diagnosis of obstructive cholestasis in neonatal cholestasis syndrome. Nucl Med Commun 2016; 36:827-32. [PMID: 25920049 DOI: 10.1097/mnm.0000000000000322] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Neonatal cholestasis is a common cause of jaundice among newborns. Hepatobiliary scintigraphy plays an important role in the diagnosis of neonatal cholestasis by ruling out extrahepatic biliary atresia, which is one of the common causes. Phenobarbitone and ursodeoxycholic acid (UDCA) have been used to improve the specificity of hepatobiliary scintigraphy in ruling out obstructive causes of neonatal cholestasis syndrome (NCS). The present study was undertaken to compare the utility of phenobarbitone and UDCA in augmenting hepatobiliary scintigraphy in the evaluation of NCS. MATERIALS AND METHODS Seventy-four consecutive patients with NCS referred for hepatobiliary scintigraphy were initially subjected to a baseline scan. Twenty patients showed tracer activity in the intestine within 24 h after injection, thus ruling out obstructive cholestasis. Fifty-four patients who did not show any tracer activity in the intestine were categorized as nonexcretors. Four nonexcretors were lost to follow-up and were excluded from the study. Fifty nonexcretors showing scan features suggestive of obstructive cholestasis were further randomized into those receiving phenobarbitone (n=20), UDCA (n=20), or placebo (n=10). These groups were further evaluated with drug-augmented hepatobiliary scintigraphy, after premedication, for any excretory activity in the intestine. RESULTS AND CONCLUSION Out of 50 patients who were evaluated with drug-augmented hepatobiliary scintigraphy two patients from the phenobarbitone group and one patient each from UDCA and placebo groups showed a change in excretory pattern from the baseline scan. However, these results were statistically nonsignificant (P=1.00). In the present study, drug-augmented (phenobarbitone or UDCA) hepatobiliary scintigraphy did not seem to improve the results (negative predictive value) for ruling out an obstructive cause of neonatal cholestasis.
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Khalaf R, Phen C, Karjoo S, Wilsey M. Cholestasis beyond the Neonatal and Infancy Periods. Pediatr Gastroenterol Hepatol Nutr 2016; 19:1-11. [PMID: 27066444 PMCID: PMC4821977 DOI: 10.5223/pghn.2016.19.1.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Revised: 02/14/2016] [Accepted: 02/16/2016] [Indexed: 02/07/2023] Open
Abstract
Cholestasis results from impairment in the excretion of bile, which may be due to mechanical obstruction of bile flow or impairment of excretion of bile components into the bile canaliculus. When present, cholestasis warrants prompt diagnosis and treatment. The differential diagnosis of cholestasis beyond the neonatal period is broad and includes congenital and acquired etiologies. It is imperative that the clinician differentiates between intrahepatic and extrahepatic origin of cholestasis. Treatment may be supportive or curative and depends on the etiology. Recent literature shows that optimal nutritional and medical support also plays an integral role in the management of pediatric patients with chronic cholestasis. This review will provide a broad overview of the pathophysiology, diagnostic approach, and management of cholestasis beyond the neonatal and infancy periods.
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Affiliation(s)
- Racha Khalaf
- Department of Medical Education, Johns Hopkins All Children's Hospital, St. Petersburg, FL, United States
| | - Claudia Phen
- Department of Medical Education, Johns Hopkins All Children's Hospital, St. Petersburg, FL, United States
| | - Sara Karjoo
- Department of Gastroenterology and Nutrition, Johns Hopkins All Children's Hospital, St. Petersburg, FL, United States
| | - Michael Wilsey
- Department of Gastroenterology and Nutrition, Johns Hopkins All Children's Hospital, St. Petersburg, FL, United States
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da Silva FV, Ferri PM, Nascentes Queiroz TC, de Souza Haueisen Barbosa P, Cassiano de Oliveira MC, de Melo Pereira LJ, Simões E Silva AC, Penna FJ, Druve Tavares Fagundes E, Ferreira AR. Nutritional evaluation of children with chronic cholestatic disease. J Pediatr (Rio J) 2016; 92:197-205. [PMID: 26632247 DOI: 10.1016/j.jped.2015.07.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 06/30/2015] [Accepted: 07/13/2015] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To evaluate the nutritional status of children with persistent cholestasis and to compare the anthropometric indices between children with and without liver cirrhosis and children with and without jaundice. METHODS Children with persistent cholestasis, i.e. increased direct bilirrubin or changes in the canalicular enzyme gamma-glutamyl transferase (GGT), were included. The anthropometric measures were weight (W), height or length (H), arm circumference (AC), triceps skinfold thickness (TST), arm muscle circumference (AMC), and body mass index (BMI). RESULTS Ninety-one children with cholestasis, with current median age of 12 months, were evaluated. W/age (A) and H/A indices below -2 Z-scores were observed in 33% and 30.8% of patients, respectively. Concerning the W/H index and BMI, only 12% and 16% of patients, respectively, were below -2 Z-scores. Regarding AC, 43.8% of 89 evaluated patients had some depletion. Observing the TST, 64% of patients had depletion, and 71.1% of the 45 evaluated patients had some degree of depletion regarding the ACM index. CONCLUSION Evaluation using weight in patients with chronic liver diseases may overestimate the nutritional status due to visceromegaly, subclinical edema, or ascites. Indices that correlate weight and height, such as W/H and BMI, may also not show depletion because of the chronic condition in which there are depletion of both weight and height. TST, AC, and ACM are parameters that better estimate nutritional status and should be part of the management of patients with liver diseases and cholestasis.
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Affiliation(s)
- Francislaine Veiga da Silva
- Group of Pediatric Hepatology and Gastroenterology, Hospital das Clínicas, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil; Pediatric Gastroenterology Group, School of Medicine, Hospital das Clínicas, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
| | - Priscila Menezes Ferri
- Pediatric Gastroenterology Group, School of Medicine, Hospital das Clínicas, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil; Department of Pediatrics, School of Medicine, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil.
| | - Thaís Costa Nascentes Queiroz
- Pediatric Gastroenterology Group, School of Medicine, Hospital das Clínicas, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil; Medical Pediatric Gastroenterologist, Brazil
| | | | | | | | - Ana Cristina Simões E Silva
- Department of Pediatrics, School of Medicine, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil; Interdisciplinary Laboratory of Medical Investigation, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
| | - Francisco José Penna
- Pediatric Gastroenterology Group, School of Medicine, Hospital das Clínicas, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil; Department of Pediatrics, School of Medicine, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
| | - Eleonora Druve Tavares Fagundes
- Pediatric Gastroenterology Group, School of Medicine, Hospital das Clínicas, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil; Department of Pediatrics, School of Medicine, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
| | - Alexandre Rodrigues Ferreira
- Pediatric Gastroenterology Group, School of Medicine, Hospital das Clínicas, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil; Department of Pediatrics, School of Medicine, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil.
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