1
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Tenca A, Kolho K, Consonni D, Jokelainen K, Färkkilä M. Dominant stricture in paediatric-onset primary sclerosing cholangitis is associated with impaired prognosis in a long-term follow-up. United European Gastroenterol J 2024; 12:717-725. [PMID: 38733616 PMCID: PMC11249836 DOI: 10.1002/ueg2.12583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 04/08/2024] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The impact of dominant stricture (DS) on the outcomes of paediatric-onset primary sclerosing cholangitis (PSC) is unknown. This study was aimed at investigating the impact of DS on the clinical course and prognosis of patients with paediatric-onset PSC. METHODS Patients with paediatric-onset PSC diagnosed between January 1993 and May 2017 were identified from hospital records or our PSC registry. Data including clinical, laboratory, cholangiography, and cytology at diagnosis and during follow-up (until July 2023) were reviewed. We graphed the Kaplan-Meier failure function and fitted crude and multivariable Cox model to calculate hazard ratios (HR) and 95% confidence intervals (CI) for selected variables. In these analyses, DS was treated as a time-varying variable. RESULTS We identified 68 patients (42 males) with paediatric-onset PSC (median age at diagnosis 15 years). The median follow-up was 13 years and the median age at the last follow-up was 27 years. In total, 35 (51%) had concomitant autoimmune hepatitis. DS was diagnosed in 33 patients (48%): in eight at the time of PSC diagnosis (12%) and in 25 (37%) by the end of follow-up. In patients with DS, two developed cirrhosis, seven were transplanted and one patient was operated for a biliary mass with low-grade dysplasia. In patients without a DS, two developed cirrhosis, and four were transplanted; one female was excluded from survival analysis because she already had cirrhosis at the time of PSC diagnosis. Cirrhosis or biliary dysplasia or needing liver transplantation for these indications were more frequent after the development of DS (10/33, adjusted HR 4.26, 95%CI: 1.26-14.4). No cholangiocarcinomas or deaths occurred during the follow-up. CONCLUSIONS DS was present at diagnosis or developed during follow-up in about half of the patients with paediatric-onset PSC and was associated with impaired outcome.
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Affiliation(s)
- Andrea Tenca
- Abdominal CenterHelsinki University and Helsinki University Hospital HUSHelsinkiFinland
| | - Kaija‐Leena Kolho
- Department of Paediatric GastroenterologyHelsinki University and Children's HospitalHelsinki University Hospital HUSHelsinkiFinland
| | - Dario Consonni
- Epidemiology UnitFondazione IRCCS Ca’ Granda Ospedale Maggiore PoliclinicoMilanItaly
| | - Kalle Jokelainen
- Abdominal CenterHelsinki University and Helsinki University Hospital HUSHelsinkiFinland
| | - Martti Färkkilä
- Abdominal CenterHelsinki University and Helsinki University Hospital HUSHelsinkiFinland
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2
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Ozdogan E, Arikan C. Liver fibrosis in children: a comprehensive review of mechanisms, diagnosis, and therapy. Clin Exp Pediatr 2023; 66:110-124. [PMID: 36550776 PMCID: PMC9989719 DOI: 10.3345/cep.2022.00367] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 09/14/2022] [Indexed: 12/23/2022] Open
Abstract
Chronic liver disease incidence is increasing among children worldwide due to a multitude of epidemiological changes. Most of these chronic insults to the pediatric liver progress to fibrosis and cirrhosis to different degrees. Liver and immune physiology differs significantly in children from adults. Because most of pediatric liver diseases have no definitive therapy, a better understanding of population and disease-specific fibrogenesis is mandatory. Furthermore, fibrosis development has prognostic significance and often guide treatment. Evaluation of liver fibrosis continues to rely on the gold-standard liver biopsy. However, many high-quality studies put forward the high diagnostic accuracy of numerous diagnostic modalities in this setting. Herein, we summarize and discuss the recent literature on fibrogenesis with an emphasis on pediatric physiology along with a detailed outline of disease-specific signatures, noninvasive diagnostic modalities, and the potential for antifibrotic therapies.
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Affiliation(s)
- Elif Ozdogan
- Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
| | - Cigdem Arikan
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Koc University School of Medicine, Istanbul, Turkey
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3
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Hercun J, Willems P, Bilodeau M, Vincent C, Alvarez F. Long-Term Follow-Up into Adulthood of Pediatric-Onset Primary Sclerosing Cholangitis and Autoimmune Sclerosing Cholangitis. JPGN REPORTS 2022; 3:e220. [PMID: 37168634 PMCID: PMC10158455 DOI: 10.1097/pg9.0000000000000220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 05/03/2022] [Indexed: 05/13/2023]
Abstract
Studies on pediatric patients with primary sclerosing cholangitis (PSC) have been limited by short follow-up and inconsistent classification of pediatric patients with autoimmune hepatitis-sclerosing cholangitis overlap (AIC). We conducted a retrospective study of patients diagnosed with AIC or PSC during childhood with extension of follow-up into adulthood. Methods We reviewed records of patients followed for PSC or AIC between 1998 and 2019 at a pediatric referral center. Features at diagnosis, biochemical and liver-related outcomes (cholangitis, liver transplant, and cirrhosis) were compared. Results Forty patients (27 PSC, 13 AIC) were followed for 92 months on average (standard deviation 79 months) with extension into adulthood in 52.5%; 70% had associated inflammatory bowel disease (IBD). The proportion of patients with significant fibrosis and abnormal baseline liver tests (serum bilirubin and transaminase levels) were similar in both groups. One year postdiagnosis, 55% (15/27) of PSC patients had normal liver tests versus only 15% (2/13) in the AIC group (P = 0.02). During follow-up, more liver-related events occurred in the AIC group (69% versus 27%, hazard ratio [HR] = 3.7 [95% confidence interval (CI): 1.4-10] P = 0.01). Baseline elevated serum bilirubin levels (HR = 5.3 [95% CI: 1.7-16.9] P = 0.005) and elevated transaminase levels at 1 year (HR = 9.09 [95% CI: 1.18-66.7) P = 0.03) were predictive of liver-related events, while having IBD was not (HR = 0.48 (95% CI: 0.15-1.5) P = 0.22). Conclusions Pediatric patients with AIC and PSC presented at a similar fibrosis stage, however, with a more severe hepatitis in AIC. In this cohort, AIC was associated with more liver-related events, primarily driven by a higher rate of cirrhosis compared with PSC; transplant rates were similar.
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Affiliation(s)
- Julian Hercun
- From the Liver Unit, Centre hospitalier de l’Université de Montréal, Montréal, Canada
| | - Philippe Willems
- From the Liver Unit, Centre hospitalier de l’Université de Montréal, Montréal, Canada
| | - Marc Bilodeau
- From the Liver Unit, Centre hospitalier de l’Université de Montréal, Montréal, Canada
| | - Catherine Vincent
- From the Liver Unit, Centre hospitalier de l’Université de Montréal, Montréal, Canada
| | - Fernando Alvarez
- Department of Gastroenterology, Hepatology and Nutrition, Centre Hospitalier Universitaire Sainte-Justine, Montréal, Canada
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4
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Mau B, Hakar M, Lin HC, Davis JL. A review of histopathologic features of pediatric autoimmune liver disease. Clin Liver Dis (Hoboken) 2022; 20:116-119. [PMID: 36245682 PMCID: PMC9549299 DOI: 10.1002/cld.1228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 03/23/2022] [Indexed: 02/04/2023] Open
Abstract
Content available: Audio Recording.
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Affiliation(s)
- Brian Mau
- Oregon Health & Science UniversityDepartment of PathologyPortlandOregonUSA
| | - Melanie Hakar
- Oregon Health & Science UniversityDepartment of PathologyPortlandOregonUSA
| | - Henry C. Lin
- Oregon Health & Science UniversityDepartment of PediatricsPortlandOregonUSA
| | - Jessica L. Davis
- Oregon Health & Science UniversityDepartment of PathologyPortlandOregonUSA
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5
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Sathiaseelan M, Bolia R, Barallon R, Alex G, Hardikar W, Rajanayagam J. Impact of ulcerative colitis on liver-related outcomes of children with primary sclerosing cholangitis. J Paediatr Child Health 2022; 58:1221-1227. [PMID: 35373867 DOI: 10.1111/jpc.15954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 03/02/2022] [Accepted: 03/06/2022] [Indexed: 11/26/2022]
Abstract
AIM Primary sclerosing cholangitis (PSC) is a chronic progressive cholestatic disorder associated with ulcerative colitis (UC). Although the inflammatory bowel disease phenotype has been characterised in patients with PSC, the impact of UC on the course and progression of PSC-UC is less clear. We aimed to evaluate the effects of UC on liver-related outcomes in children with PSC. METHODS Retrospective analysis of children aged ≤18 years diagnosed with PSC with/without UC at a single tertiary paediatric liver unit between January 1998 and May 2016. Patients were followed up until transition to an adult service. Outcomes studied included biliary complications, clinically significant portal hypertension, need for liver transplantation and post-transplantation recurrence. RESULTS Fifty-one children (31 female) were diagnosed with PSC (median age - 11.3 years (interquartile range 7)), follow-up median duration 54 months (interquartile range 56). Thirty-seven (73%) patients had concurrent UC, of which 26 had their diagnosis confirmed prior to or within 6 months of PSC diagnosis (early-onset). PSC complications were more common in children with PSC-UC compared with PSC alone (24/37 (65%) vs. 2/14 (14%); P = 0.001). Furthermore, children with endoscopically mild or moderate UC at diagnosis showed a greater propensity for liver-related complications compared with children with severe UC (24/32 vs. 0/5; P = 0.003). Children with late-onset UC had higher rates of clinically significant portal hypertension (5/11 (45%) vs. 3/26 (12%); P = 0.007) and liver transplantation (5/11(45%) vs. 2/26 (8%); P = 0.02). Children with PSC-UC had significantly higher rates of pancolitis, rectal sparing and milder colitis than those with UC alone. CONCLUSION The presence and a later-onset of UC are associated with more significant progression to end-stage liver disease. There is an inverse trend between UC severity and PSC severity in children with concurrent PSC-UC.
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Affiliation(s)
- Mohana Sathiaseelan
- Department of Gastroenterology, Hepatology and Clinical Nutrition, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Rishi Bolia
- Department of Pediatrics, All India Institute of Medical Sciences, Rishikesh, India
| | - Raychel Barallon
- Monash Health, Monash Medical Centre, Victoria, Australia and The University of Melbourne, Department of Medicine, Melbourne, Victoria, Australia
| | - George Alex
- Department of Gastroenterology, Hepatology and Clinical Nutrition, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Winita Hardikar
- Department of Gastroenterology, Hepatology and Clinical Nutrition, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Pediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Jeremy Rajanayagam
- Department of Gastroenterology, Hepatology and Clinical Nutrition, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Microbiology and Immunology, University of Melbourne, Melbourne, Victoria, Australia.,The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
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6
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Di Giorgio A, Vergani D, Mieli-Vergani G. Cutting edge issues in juvenile sclerosing cholangitis. Dig Liver Dis 2022; 54:417-427. [PMID: 34289942 DOI: 10.1016/j.dld.2021.06.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 06/08/2021] [Accepted: 06/23/2021] [Indexed: 12/11/2022]
Abstract
Sclerosing cholangitis (SC) is a rare chronic disorder characterised by inflammation and progressive obliterative fibrosis of the intrahepatic and/or extrahepatic bile ducts. Diagnosis is based on cholangiogram showing bile duct dilatation, narrowing and obliteration of the biliary tree, and histologically, on the presence of inflammatory bile duct damage leading to periductal fibrosis. In children the most common SC is associated with strong autoimmune features, overlapping with those of autoimmune hepatitis (AIH); this form is known as autoimmune sclerosing cholangitis, ASC. Conversely, primary SC (PSC), a condition in which the term "primary" indicates that aetiology and pathogenesis are unknown, is rare in paediatrics. Secondary SC (SSC) defines a cholangiopathy associated with an identifiable aetiology such as immunodeficiencies, infections or haematological disorders. ASC and PSC are strongly associated with inflammatory bowel disease (IBD). ASC responds biochemically well to immunosuppressive drugs and ursodeoxycholic acid (UDCA). Primary forms are exclusively managed with oral UDCA, while in the secondary forms the medical treatment depends on the underlying aetiology. Despite treatment, SC often progresses to biliary cirrhosis and end-stage liver disease requiring liver transplantation. The disease can recur after transplant. Better understanding of pathogenic mechanisms and better treatment modalities are needed to improve the prognosis of this invalidating hepatic disorder.
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Affiliation(s)
- Angelo Di Giorgio
- Paediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII, Bergamo, Italy.
| | - Diego Vergani
- King's College London Faculty of Life Sciences and Medicine, Institute of Liver Studies, Mowat Labs King's College Hospital, London, United Kingdom
| | - Giorgina Mieli-Vergani
- King's College London Faculty of Life Sciences and Medicine, Institute of Liver Studies, Mowat Labs King's College Hospital, London, United Kingdom; Paediatric Liver, Gastrointestinal, and Nutrition Centre, King's College Hospital, London, United Kingdom
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7
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Nguyen CM, Kline KT, Stevenson HL, Khan K, Parupudi S. Small duct primary sclerosing cholangitis: A discrete variant or a bridge to large duct disease, a practical review. World J Hepatol 2022; 14:495-503. [PMID: 35582290 PMCID: PMC9055190 DOI: 10.4254/wjh.v14.i3.495] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 05/12/2021] [Accepted: 02/16/2022] [Indexed: 02/06/2023] Open
Abstract
The natural history, associations with inflammatory bowel disease (IBD), and long-term outcomes of large duct primary sclerosing cholangitis (ldPSC) have been well documented. Small duct primary sclerosing cholangitis (sdPSC) is a much less common and relatively more benign variant. The natural history of sdPSC has been difficult to characterize given the limited number of studies in the literature especially with regards to the subset of patients who progress to large duct involvement. It has been unclear whether sdPSC represented a subset of ldPSC, an earlier staging of ldPSC, or a completely separate and distinct entity of its own. Strong associations between sdPSC and IBD have been established with suspicion that concurrent sdPSC-IBD may be a key prognostic factor in determining which patients are at risk of progression to ldPSC. Little is known regarding the discrete circumstances that predisposes some patients with sdPSC to progress to ldPSC. It has been suspected that progression to large biliary duct involvement subjects this subset of patients to potentially developing life-threatening complications. Here the authors conducted a thorough review of the published sdPSC literature using Pubmed searches and cross-referencing to compile all accessible studies regarding cohorts of sdPSC patients in order better characterize the subset of sdPSC patients who progress to ldPSC and the associated outcomes.
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Affiliation(s)
- Christopher M Nguyen
- Department of Internal Medicine, The University of Texas Medical Branch, Galveston, TX 77555, United States
| | - Kevin T Kline
- Department of Gastroenterology and Hepatology, The University of Texas Medical Branch, Galveston, TX 77555, United States
| | - Heather L Stevenson
- Department of Pathology, University of Texas Medical Branch, Galveston, TX 77555, United States
| | - Kashif Khan
- Department of Gastroenterology and Hepatology, The University of Texas Medical Branch, Galveston, TX 77555, United States
| | - Sreeram Parupudi
- Department of Gastroenterology and Hepatology, The University of Texas Medical Branch, Galveston, TX 77555, United States
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8
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Núñez F P, Castro F, Mezzano G, Quera R, Diaz D, Castro L. Hepatobiliary manifestations in inflammatory bowel disease: A practical approach. World J Hepatol 2022; 14:319-337. [PMID: 35317174 PMCID: PMC8891676 DOI: 10.4254/wjh.v14.i2.319] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 09/10/2021] [Accepted: 01/26/2022] [Indexed: 02/06/2023] Open
Abstract
Inflammatory bowel diseases (IBD) are associated with various hepatobiliary disorders. They can occur at any moment in the course of the disease or associated with the treatment. The prevalence of liver dysfunction can reach up to 50% in different studies. Nonalcoholic fatty liver disease is considered the most common hepatobiliary complication in IBD, while primary sclerosing cholangitis is the most specific. Management of hepatic manifestations in IBD involves a multidisciplinary approach that includes a high index of suspicion and joint management with hepatologists. The medical confrontation with abnormal liver tests must include an exhaustive study to determine if these patterns can be related to IBD, associated diseases or to the therapies used.
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Affiliation(s)
- Paulina Núñez F
- Universidad de los Andes,Inflammatory Bowel Disease Program, Digestive Disease Center, Santiago 7600976, RM, Chile
- Inflammatory Bowel Disease Program, Hospital San Juan de Dios, Universidad de Chile, Santiago 7701230, RM, Chile
| | - Fabiola Castro
- Universidad de los Andes,Hepatology Program, Digestive Disease Center, Santiago 7600976, RM, Chile
| | - Gabriel Mezzano
- Universidad de los Andes,Hepatology Program, Digestive Disease Center, Santiago 7600976, RM, Chile
- Department of Gastroenterology, Hospital del Salvador/Universidad de Chile, Santiago 7600976, RM, Chile
| | - Rodrigo Quera
- Universidad de los Andes,Inflammatory Bowel Disease Program, Digestive Disease Center, Santiago 7600976, RM, Chile
| | - Diego Diaz
- Medicine, Universidad de los Andes, Santiago 770976, RM, Chile
| | - Lorena Castro
- Universidad de los Andes,Hepatology Program, Digestive Disease Center, Santiago 7600976, RM, Chile
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9
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Kemme S, Mack CL. Pediatric Autoimmune Liver Diseases: Autoimmune Hepatitis and Primary Sclerosing Cholangitis. Pediatr Clin North Am 2021; 68:1293-1307. [PMID: 34736590 DOI: 10.1016/j.pcl.2021.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
In chronic hepatitis, a broad differential diagnosis should be considered to accurately identify the cause(s) of liver injury. Autoimmune liver diseases (autoimmune hepatitis, primary sclerosing cholangitis, overlap syndrome) can occur in the setting of limited symptoms; therefore, a high index of suspicion and appropriate diagnostic workup should be performed. Most children with autoimmune hepatitis achieve sustained remission with medical therapy; however, there are no equivalent therapies for primary sclerosing cholangitis that impact the progression of disease. Research should include biomarker studies to predict histologic remission in autoimmune hepatitis and mechanistic studies to define future treatment targets for primary sclerosing cholangitis.
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Affiliation(s)
- Sarah Kemme
- Section of Gastroenterology, Hepatology, and Nutrition, Digestive Health Institute, University of Colorado Denver School of Medicine and Children's Hospital Colorado, 13123 East 16th Avenue, Mailstop B290, Aurora, CO 80045, USA.
| | - Cara L Mack
- Section of Gastroenterology, Hepatology, and Nutrition, Digestive Health Institute, University of Colorado Denver School of Medicine and Children's Hospital Colorado, 13123 East 16th Avenue, Mailstop B290, Aurora, CO 80045, USA
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10
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Hensel KO, Kyrana E, Hadzic N, Mann J, Mieli-Vergani G, Gasparetto M, Heuschkel R, Noble-Jamieson G, Samyn M. Sclerosing Cholangitis in Pediatric Inflammatory Bowel Disease: Early Diagnosis and Management Affect Clinical Outcome. J Pediatr 2021; 238:50-56.e3. [PMID: 34303727 DOI: 10.1016/j.jpeds.2021.07.047] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 07/14/2021] [Accepted: 07/16/2021] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To describe the characteristics and clinical course of children and young persons with inflammatory bowel disease (IBD) and sclerosing cholangitis (SC). STUDY DESIGN Retrospective analysis of clinical characteristics, management, and outcome of two separate cohorts of children and young persons with IBD-SC managed in a tertiary pediatric gastroenterology center and in a tertiary pediatric hepatology center in the UK. RESULTS Eighty-two pediatric patients (31% female) with IBD-SC and a mean age at diagnosis of 11.9 ± 2.8 years were followed up for a mean of 6.8 ± 3.3 years. The most common type of IBD was ulcerative colitis (55%), followed by unclassified IBD (30%) and Crohn's disease (15%). Autoimmune SC (ASC) was diagnosed in 72%, and small duct SC was diagnosed in 28%. Complication-free and native liver survival were 96% and 100%, respectively, at 5 years after diagnosis and 75% and 88%, respectively, at 10 years after diagnosis. Patients in the gastroenterology center, who were diagnosed with liver disease sooner after diagnosis of IBD compared with the hepatology center cohort (mean, 2.7 ± 6.1 months vs 9.3 ± 19.4 months; P = .03), did not develop liver-related complications during follow-up. CONCLUSIONS Our data suggest that children with IBD-SC have better clinical outcomes than have been reported previously, particularly if diagnosed early. We recommend prompt assessment for SC, including liver biopsy and biliary imaging, when liver function abnormalities are detected in a children diagnosed with IBD.
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Affiliation(s)
- Kai O Hensel
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, United Kingdom; Department of Pediatrics, University of Cambridge, Cambridge, United Kingdom
| | - Eirini Kyrana
- Children's Liver Unit, Leeds General Infirmary, Leeds, United Kingdom
| | - Nedim Hadzic
- Pediatric Liver, GI, and Nutrition Center, King's College Hospital, London, United Kingdom
| | - Jake Mann
- Department of Pediatrics, University of Cambridge, Cambridge, United Kingdom
| | - Giorgina Mieli-Vergani
- Pediatric Liver, GI, and Nutrition Center, King's College Hospital, London, United Kingdom
| | - Marco Gasparetto
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Robert Heuschkel
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Gabriele Noble-Jamieson
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Marianne Samyn
- Pediatric Liver, GI, and Nutrition Center, King's College Hospital, London, United Kingdom.
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11
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Martinez M, Perito ER, Valentino P, Mack CL, Aumar M, Broderick A, Draijer LG, Fagundes ED, Furuya KN, Gupta N, Horslen S, Jonas MM, Kamath BM, Kerkar N, Kim KM, Kolho KL, Koot BGP, Laborda TJ, Lee CK, Loomes KM, Miloh T, Mogul D, Mohammed S, Ovchinsky N, Rao G, Ricciuto A, Schwarz KB, Smolka V, Tanaka A, Tessier MEM, Venkat VL, Vitola BE, Woynarowski M, Zerofsky M, Deneau MR, Deneau MR. Recurrence of Primary Sclerosing Cholangitis After Liver Transplant in Children: An International Observational Study. Hepatology 2021; 74:2047-2057. [PMID: 34008252 PMCID: PMC8530456 DOI: 10.1002/hep.31911] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 05/11/2021] [Accepted: 05/12/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND AIMS Recurrent primary sclerosing cholangitis (rPSC) following liver transplant (LT) has a negative impact on graft and patient survival; little is known about risk factors for rPSC or disease course in children. APPROACH AND RESULTS We retrospectively evaluated risk factors for rPSC in 140 children from the Pediatric PSC Consortium, a multicenter international registry. Recipients underwent LT for PSC and had >90 days of follow-up. The primary outcome, rPSC, was defined using Graziadei criteria. Median follow-up after LT was 3 years (interquartile range 1.1-6.1). rPSC occurred in 36 children, representing 10% and 27% of the subjects at 2 years and 5 years following LT, respectively. Subjects with rPSC were younger at LT (12.9 vs. 16.2 years), had faster progression from PSC diagnosis to LT (2.5 vs. 4.1 years), and had higher alanine aminotransferase (112 vs. 66 IU/L) at LT (all P < 0.01). Inflammatory bowel disease was more prevalent in the rPSC group (86% vs. 66%; P = 0.025). After LT, rPSC subjects had more episodes of biopsy-proved acute rejection (mean 3 vs. 1; P < 0.001), and higher prevalence of steroid-refractory rejection (41% vs. 20%; P = 0.04). In those with rPSC, 43% developed complications of portal hypertension, were relisted for LT, or died within 2 years of the diagnosis. Mortality was higher in the rPSC group (11.1% vs. 2.9%; P = 0.05). CONCLUSIONS The incidence of rPSC in this cohort was higher than previously reported, and was associated with increased morbidity and mortality. Patients with rPSC appeared to have a more aggressive, immune-reactive phenotype. These findings underscore the need to understand the immune mechanisms of rPSC, to lay the foundation for developing new therapies and improve outcomes in this challenging population.
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Affiliation(s)
| | | | | | - Cara L Mack
- University of Colorado School of Medicine, Aurora, CO
| | | | - Annemarie Broderick
- Children’s Health Ireland at Crumlin & University College Dublin, Dublin, Ireland
| | | | | | - Katryn N. Furuya
- Mayo Clinic, Rochester, MN and Medical College of Wisconsin, Milwaukee, WI
| | - Nitika Gupta
- Emory University School of Medicine, Atlanta, GA
| | | | - Maureen M Jonas
- Boston Children’s Hospital and Harvard Medical School, Boston, MA
| | | | - Nanda Kerkar
- University of Rochester Medical Center, Rochester, NY
| | | | - Kaija-Leena Kolho
- University of Helsinki Hospital and Tampere University, Helsinki, Finland
| | - Bart GP Koot
- Amsterdam University Medical Center Amsterdam, The Netherlands
| | - Trevor J Laborda
- University of Utah and Intermountain Primary Children’s Hospital, Salt Lake City, UT
| | | | | | | | | | | | - Nadia Ovchinsky
- Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY
| | | | | | - Kathleen B Schwarz
- University of California San Diego, San Diego, CA and Johns Hopkins University, Baltimore, MD
| | | | | | | | | | | | - Marek Woynarowski
- Faculty of Medicine and Health Sciences, UJK Kielce, Poland (former IP CZD Warsaw)
| | | | - Mark R. Deneau
- University of Utah and Intermountain Primary Children’s Hospital, Salt Lake City, UT
| | - Mark R. Deneau
- Department of Pediatrics University of Utah and Intermountain Primary Children’s Hospital Salt Lake City UT
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12
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Mehta TI, Weissman S, Fung BM, Sotiriadis J, Lindor KD, Tabibian JH. Global incidence, prevalence and features of primary sclerosing cholangitis: A systematic review and meta-analysis. Liver Int 2021; 41:2418-2426. [PMID: 34224208 DOI: 10.1111/liv.15007] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 06/03/2021] [Accepted: 06/08/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Primary sclerosing cholangitis (PSC) is an idiopathic, cholestatic liver disease with a diverse range of clinical manifestations. Inter-regional data on PSC are variable, but its global geoepidemiology has not been well-studied. We aimed to examine the worldwide incidence, prevalence and features of PSC and PSC-inflammatory bowel disease (PSC-IBD). METHODS A systematic search of multiple databases was conducted to identify all original, full-text studies until December 2020 with data regarding the incidence rate (IR) and/or prevalence of PSC. Outcomes were PSC IR, prevalence, features and IBD concurrence. Additionally, a meta-analysis of PSC IR was performed. The study was registered in PROSPERO (CRD42021224550). RESULTS Of the 1003 studies identified, 17 studies spanning three continents were included. PSC IR was 0.60 per 100 000 person-years (PY) (95% confidence interval: 0.37-0.88 per 100 000 PY). In pooled subgroup analysis for studies conducted in Europe and North America, PSC IR was 0.62 and 0.53 per 100 000 PY, respectively. PSC prevalence ranged 0-31.7 per 100 000 persons, with notable inter-regional differences. Mean age at PSC diagnosis was bimodally distributed, with relative peaks at 15 and 35 years. Mean concurrence of IBD with PSC was 50%, with 76% having ulcerative colitis, 17% Crohn's disease and 8% indeterminate/unspecified IBD. CONCLUSION While considerable heterogeneity exists in the geoepidemiology of PSC, overall, the classical dogmata of male predilection, bimodal distribution of mean age and high PSC-IBD concurrence appear to hold true. Despite a seemingly stable IR over time, further studies are needed to better understand the geoepidemiology of PSC.
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Affiliation(s)
- Tej I Mehta
- Department of Radiology, Johns Hopkins University Hospital, Baltimore, MD, USA
| | - Simcha Weissman
- Department of Medicine, Hackensack University-Palisades Medical Center, North Bergen, NJ, USA
| | - Brian M Fung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - John Sotiriadis
- Division of Gastroenterology and Hepatology, Hackensack University-Palisades Medical Center, North Bergen, NJ, USA
| | - Keith D Lindor
- College of Health Solutions, Arizona State University, Phoenix, AZ, USA
| | - James H Tabibian
- Division of Gastroenterology, Department of Medicine, Olive View-UCLA Medical Center, Sylmar, CA, USA.,Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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13
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Alvarenga LR, Sandy NS, Gomez GS, Hessel G, DE Tommaso AMA, Bellomo-Brandão MÂ. SYMPTOMATIC CHOLELITHIASIS AS THE PRESENTATION OF PEDIATRIC PRIMARY SCLEROSING CHOLANGITIS - CASE SERIES AND LITERATURE REVIEW. ARQUIVOS DE GASTROENTEROLOGIA 2021; 58:227-233. [PMID: 34287532 DOI: 10.1590/s0004-2803.202100000-41] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 11/25/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Primary sclerosing cholangitis (PSC) is a rare hepatobiliary disorder, whose etiology remains not fully elucidated. Given how rare PSC is in childhood, until the recent publication of a multicenter international collaboration, even data on its characteristics and natural history were scarce. Symptomatic cholelithiasis has not been previously reported as the presentation of PSC. OBJECTIVE The aim of this study was the diagnosis of PSC following the initial unusual presentation with symptomatic cholelithiasis, that followed an atypical clinical course that could not be explained by cholelithiasis alone. A literature review was also conducted. METHODS We conducted a retrospective chart review of three patients, who were diagnosed and/or followed at the Clinics Hospital, University of Campinas - Sao Paulo/ Brazil, between 2014 and 2020. Data analyzed included gender, age of presentation, past medical history, imaging findings, laboratory results, endoscopic evaluation, response to medical therapy and follow-up. RESULTS Age at time of presentation with cholelithiasis varied from 10 to 12 years. In two of the cases reported, a more subacute onset of symptoms preceded the episode of cholelithiasis. Two patients were managed with cholecystectomy, not followed by any surgical complications, one patient was managed conservatively. Percutaneous liver biopsy was performed in all three cases, showing histological findings compatible with PSC. Associated inflammatory bowel disease (IBD) was not seen in any of the patients. The patients have been followed for a mean time of 3.4 years. CONCLUSION PSC and cholelithiasis are both rare in the pediatric population. This study reports on symptomatic cholelithiasis as a presentation of PSC and raises the importance of suspecting an underlying hepatobiliary disorder in children with cholelithiasis without any known predisposing factors and/or that follow an atypical clinical course for cholelithiasis alone.
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Affiliation(s)
- Lucas Rocha Alvarenga
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Departamento de Pediatria, Campinas, SP, Brasil
| | - Natascha Silva Sandy
- University of Toronto, Hospital for Sick Children, Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Toronto, ON, Canada
| | - Gabriela Souza Gomez
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Departamento de Pediatria, Campinas, SP, Brasil
| | - Gabriel Hessel
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Departamento de Pediatria, Campinas, SP, Brasil
| | - Adriana Maria Alves DE Tommaso
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Departamento de Pediatria, Campinas, SP, Brasil
| | - Maria Ângela Bellomo-Brandão
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Departamento de Pediatria, Campinas, SP, Brasil
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14
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Wiecek S, Wojtyniak A, Pindur B, Machnikowska-Sokołowska M, Gruszczyńska K, Grzybowska-Chlebowczyk U. Analysis of the Clinical Course of Primary Sclerosing Cholangitis in Paediatric Population-Single Center Study. ACTA ACUST UNITED AC 2021; 57:medicina57070663. [PMID: 34199130 PMCID: PMC8304821 DOI: 10.3390/medicina57070663] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 06/15/2021] [Accepted: 06/24/2021] [Indexed: 11/25/2022]
Abstract
Background and Objectives: Primary sclerosing cholangitis (PSC) is a rare cholestatic disease of the liver of unknown etiology, severe course and poor prognosis. PSC most often co-occurs with inflammatory bowel diseases (IBD), especially with ulcerative colitis (UC). The aim of the study was the analysis of the clinical course of primary sclerosing cholangitis in children, hospitalized in the Gastroenterology Unit in Katowice. Materials and Methods: The analysis included 30 patients, aged from 7 to 18 years, 21/30 boys (70%) and 9/30 girls (30%), diagnosed with PSC in the years 2009–2019. The analysis included the age at diagnosis, clinical symptoms, course of the disease, coexisting diseases, laboratory and imaging results, and complications. Results: The average age at diagnosis was 13 years. 22/30 (73.3%) patients suffered from UC, 4/30 (13.3%) were diagnosed with Crohn’s disease (CD), 2/30 (6.66%) with Eosinophilic Colitis (EC). 2/30 patients (6.66%) had no clinical evidence of coexistent IBD to date. In addition, 7/30 (23.3%) had an overlap syndrome of primary sclerosing cholangitis/autoimmune hepatitis. When PSC was detected before IBD (6/30–20%), patients had complications more often compared to those diagnosed with IBD first or PSC and IBD at the same time. At the moment of diagnosis 6/30 (20%) patients presented with abdominal pain, which was the most common symptom, 3/30 (10%) jaundice, while 17/30 (56.6%) were asymptomatic but had abnormal results of the laboratory tests. Conclusions: Monitoring liver markers in IBD patients is important since most PSC cases are asymptomatic and their elevation might be the first sign of the disease. Patients diagnosed with PSC before IBD diagnosis are more likely to have a more aggressive course of the disease.
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Affiliation(s)
- Sabina Wiecek
- Department of Paediatrics, Faculty of Medical Sciences, Medical University of Silesia, 16 Medykow Street, 40-752 Katowice, Poland
| | - Alicja Wojtyniak
- Student Scientific Club, Department of Paediatrics, Faculty of Medical Sciences, Medical University of Silesia, 40-752 Katowice, Poland
| | - Barbara Pindur
- Student Scientific Club, Department of Paediatrics, Faculty of Medical Sciences, Medical University of Silesia, 40-752 Katowice, Poland
| | | | - Katarzyna Gruszczyńska
- Department of Radiology and Nuclear Medicine, Faculty of Medical Sciences, Medical University of Silesia, 40-752 Katowice, Poland
| | - Urszula Grzybowska-Chlebowczyk
- Department of Paediatrics, Faculty of Medical Sciences, Medical University of Silesia, 16 Medykow Street, 40-752 Katowice, Poland
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15
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Couchonnal E, Jacquemin E, Lachaux A, Ackermann O, Gonzales E, Lacaille F, Debray D, Boillot O, Guillaud O, Wildhaber BE, Chouik Y, McLin V, Dumortier J. Long-term results of pediatric liver transplantation for autoimmune liver disease. Clin Res Hepatol Gastroenterol 2021; 45:101537. [PMID: 33077391 DOI: 10.1016/j.clinre.2020.08.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 08/19/2020] [Accepted: 08/26/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Autoimmune hepatitis (AIH) and primary sclerosing cholangitis (PSC) are rare indications for liver transplantation (LT) in children. The aim of the present retrospective multicenter study was to evaluate long-term outcome after LT for autoimmune liver disease in childhood. METHODS Retrospective data from 30 children who underwent a first LT from 1988 to 2018 were collected. RESULTS The study population consisted of 18 girls and 12 boys, transplanted for AIH type 1 (n=14), AIH type 2 (n=7) or PSC (n=9). Mean age at LT was 11.8±5.2 years. The main indications for LT were acute (36.7%) or chronic end-stage liver failure (63.3%). Graft rejection occurred in 19 patients (63.3%); 6 pts required retransplantation for chronic rejection. Recurrence of initial disease was observed in 6 patients (20.0%), all of them with type 1 AIH, after a median time of 42 months, requiring retransplantation in 2 cases. Overall patient survival rates were 96.4%, 84.6%, 74.8%, 68.0%, 68.0%, 68.0% and 68.0% at 1, 5, 10, 15, 20, 25 and 30 years, respectively. Age at LT<1year (p<0.0001), LT for fulminant failure (p=0.023) and LT for type 2 AIH (p=0.049) were significant predictive factors of death. CONCLUSION Long-term outcome after LT for pediatric autoimmune liver disease is impaired in patients with AIH because of consistent complications such as rejection and disease recurrence.
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Affiliation(s)
- Eduardo Couchonnal
- Hospices Civils de Lyon, Hôpital Femme-Mère-Enfant, Service d'Hépato-gastroentérologie et Nutrition Pédiatrique, Bron, France
| | - Emmanuel Jacquemin
- Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Hépatologie et Transplantation Hépatique Pédiatriques, Centre National de Référence de l'Atrésie des Voies Biliaires et des Cholestases Génétiques, Université Paris Saclay, Le Kremlin-Bicêtre, France; Inserm U1193, Hepatinov, Université Paris Saclay, Orsay, France
| | - Alain Lachaux
- Hospices Civils de Lyon, Hôpital Femme-Mère-Enfant, Service d'Hépato-gastroentérologie et Nutrition Pédiatrique, Bron, France; Centre National de Référence de l'Atrésie des Voies biliaires et des Cholestases Génétiques de Lyon, France; Université Claude Bernard Lyon 1, Lyon, France
| | - Oanez Ackermann
- Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Hépatologie et Transplantation Hépatique Pédiatriques, Centre National de Référence de l'Atrésie des Voies Biliaires et des Cholestases Génétiques, Université Paris Saclay, Le Kremlin-Bicêtre, France; Inserm U1193, Hepatinov, Université Paris Saclay, Orsay, France
| | - Emmanuel Gonzales
- Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Hépatologie et Transplantation Hépatique Pédiatriques, Centre National de Référence de l'Atrésie des Voies Biliaires et des Cholestases Génétiques, Université Paris Saclay, Le Kremlin-Bicêtre, France; Inserm U1193, Hepatinov, Université Paris Saclay, Orsay, France
| | - Florence Lacaille
- Assistance Publique-Hôpitaux de Paris, Hôpital Necker Enfants malades, Unité d'Hépatologie pédiatrique, Centre de référence de l'Atrèsie des voies biliaires et cholestases génétiques, filière de santé Filfoie, Paris, France
| | - Dominique Debray
- Assistance Publique-Hôpitaux de Paris, Hôpital Necker Enfants malades, Unité d'Hépatologie pédiatrique, Centre de référence de l'Atrèsie des voies biliaires et cholestases génétiques, filière de santé Filfoie, Paris, France; Université-Paris centre, Paris, France
| | - Olivier Boillot
- Université Claude Bernard Lyon 1, Lyon, France; Hospices Civils de Lyon, Hôpital Edouard Herriot, Femme-Mère-Enfant, Service d'Hépato-gastroentérologie, Lyon, France
| | - Olivier Guillaud
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Femme-Mère-Enfant, Service d'Hépato-gastroentérologie, Lyon, France; Ramsay Générale de Santé, Clinique de la Sauvegarde, Lyon, France
| | - Barbara E Wildhaber
- Swiss Pediatric Liver Center, Department of Pediatrics, Gynecology, and Obstetrics, University Hospitals Geneva, University of Geneva, Geneva, Switzerland
| | - Yasmina Chouik
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Femme-Mère-Enfant, Service d'Hépato-gastroentérologie, Lyon, France
| | - Valérie McLin
- Swiss Pediatric Liver Center, Department of Pediatrics, Gynecology, and Obstetrics, University Hospitals Geneva, University of Geneva, Geneva, Switzerland
| | - Jérôme Dumortier
- Université Claude Bernard Lyon 1, Lyon, France; Hospices Civils de Lyon, Hôpital Edouard Herriot, Femme-Mère-Enfant, Service d'Hépato-gastroentérologie, Lyon, France.
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16
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Kumar N, Poddar U, Yadav R, Lal H, Pani K, Yachha SK, Srivastava A, Pandey R. Autoimmune Sclerosing Cholangitis in Children: A Prospective Case-Control Study. Pediatr Gastroenterol Hepatol Nutr 2021; 24:154-163. [PMID: 33833971 PMCID: PMC8007839 DOI: 10.5223/pghn.2021.24.2.154] [Citation(s) in RCA: 3] [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: 03/24/2020] [Revised: 09/07/2020] [Accepted: 11/06/2020] [Indexed: 12/11/2022] Open
Abstract
PURPOSE In children overlap of autoimmune hepatitis (AIH) and primary sclerosing cholangitis is labelled as autoimmune sclerosing cholangitis (ASC). The only prospective pediatric study showed a high prevalence of ASC by using endoscopic retrograde cholangiopancreatography. Aims of our study were to find the prevalence of ASC by using magnetic resonance cholangiography (MRC) in AIH and in non-AIH cirrhosis and to compare clinical presentation and outcome of AIH and ASC. METHODS Prospectively we did MRC in 38 children with AIH (cases) and 19 disease controls (Wilson disease). Multiple biliary strictures with proximal dilatation on MRC were taken as definitive changes of ASC. Detail clinical, laboratory parameters, liver histopathology and treatment outcome were recorded. RESULTS The median age of cases was 11.5 (3-18) years, 22 (57.9%) were girls and 28 (73.7%) were diagnosed as type 1 AIH. MRC was done in 11 children (28.9%) at the time of diagnosis and in 27 (71.1%) after a median follow-up of 2.5 (0.3-10) years. Abnormal MRC changes were seen in 14/38 (36.8%) of AIH and 8/19 (42.1%) of controls. However, definite changes of ASC were present in four (10.5%) children in AIH and none in controls. None of the clinical, laboratory, histological parameters and treatment response were significantly different between ASC and AIH groups. CONCLUSION The prevalence of ASC in children with AIH was just 10.5%. We suggest MRC in select group with cholestatic features, inflammatory bowel disease and in those who showed poor response to immunosuppression instead of all children with AIH.
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Affiliation(s)
- Nagendra Kumar
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Ujjal Poddar
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Rajnikant Yadav
- Department of Radiodiagnosis, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Hira Lal
- Department of Radiodiagnosis, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Krushna Pani
- Department of Pathology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Surender Kumar Yachha
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Anshu Srivastava
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Rakesh Pandey
- Department of Pathology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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Successful response of primary sclerosing cholangitis and associated ulcerative colitis to oral vancomycin may depend on brand and personalized dose: report in an adolescent. Clin J Gastroenterol 2020; 14:684-689. [PMID: 33231850 DOI: 10.1007/s12328-020-01296-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 11/05/2020] [Indexed: 01/16/2023]
Abstract
Primary sclerosing cholangitis (PSC) is a rare, progressive liver disease characterized by cholestasis and bile duct fibrosis that has no accepted therapy known to delay or arrest its progression. We report a 23-year-old female patient who at age 14 was diagnosed with moderate pancolonic ulcerative colitis (UC) and at age 15 with small-duct PSC unresponsive to conventional therapy. The patient began single drug therapy with the antibiotic oral vancomycin (OVT) and achieved normalization of liver enzymes and resolution of UC symptoms with colonic mucosal healing. These improvements have persisted over 8 years. There has been no colon dysplasia, liver fibrosis or failure, bile duct stricture, or cancer. Of note, the patient's response was dependent on the brand of oral vancomycin capsule, as well as dose. This raised the questions of possible differences in bioequivalence of different commercial versions of the drug and whether this factor might play into the variability of efficacy seen in published trials. Evidence suggests that oral vancomycin both alters the intestinal microbiome and has immunomodulatory effects. Its striking effectiveness in this and other patients supports further investigation in randomized trials, with careful attention to its bioavailability profile in the gut.
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18
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Lam S, Singh R, Dillman JR, Trout AT, Serai SD, Sharma D, Sheridan R, Su W, Fei L, Karns R, Haramija MM, Ridgway G, Goldfinger M, Squires JE, Denson LA, Hyams JS, Miethke AG. Serum Matrix Metalloproteinase 7 Is a Diagnostic Biomarker of Biliary Injury and Fibrosis in Pediatric Autoimmune Liver Disease. Hepatol Commun 2020; 4:1680-1693. [PMID: 33163837 PMCID: PMC7603534 DOI: 10.1002/hep4.1589] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 07/08/2020] [Accepted: 07/11/2020] [Indexed: 12/17/2022] Open
Abstract
In autoimmune liver disease (AILD), including autoimmune hepatitis (AIH), primary sclerosing cholangitis (PSC), and overlap syndrome of AIH and PSC (ASC), the presence of biliary injury portends a worse prognosis. We studied serum matrix metalloproteinase 7 (sMMP7) as a biomarker for pediatric sclerosing cholangitis (SC). We prospectively enrolled 54 children (median age, 16 years) with AILD (AIH, n = 26; ASC, n = 16; and PSC, n = 12) at our center. The sMMP7 concentrations were higher in patients with SC compared to those without cholangiopathy (P < 0.001). An sMMP7 concentration >23.7 ng/mL had a sensitivity and specificity of 79% and 96%, respectively, and outperformed alkaline phosphatase (ALP) and gamma-glutamyltransferase (GGT) in segregating patients with SC. Serum concentrations correlated with liver gene expression levels for MMP7 (r = 0.70; P < 0.001). Using immunofluorescence, MMP7 was localized primarily to the cholangiocytes of patients with SC. In 46 subjects with liver biopsy available for blinded review, elevation in sMMP7 concentrations segregated with the presence of lymphocytic and neutrophilic cholangitis and periductal fibrosis and correlated with Ishak, Ludwig, and Nakanuma scoring systems. Liver stiffness measured by magnetic resonance elastography also correlated with sMMP7 concentrations (r = 0.56; P < 0.01). Using magnetic resonance cholangiopancreatography plus (MRCP+), sMMP7 in 34 patients correlated with the number of biliary dilatations (r = 0.54; P < 0.01) and strictures (r = 0.56; P < 0.01). MMP7 as a marker of biliary injury was validated in an independent cohort of children with ulcerative colitis. Higher sMMP7 concentrations also correlated with a history of SC-related complication. Conclusion: MMP7 is a promising biomarker for pediatric SC that diagnostically outperforms ALP and GGT. sMMP7 may directly reflect biliary injury and fibrosis, the main drivers of disease progression in SC.
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Affiliation(s)
- Simon Lam
- Division of Gastroenterology, Hepatology and NutritionCincinnati Children's Hospital Medical CenterCincinnatiOHUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOHUSA
- Section of Pediatric GastroenterologyDepartment of PediatricsAlberta Children’s HospitalUniversity of CalgaryCalgaryCanada
| | - Ruchi Singh
- Division of Gastroenterology, Hepatology and NutritionCincinnati Children's Hospital Medical CenterCincinnatiOHUSA
| | - Jonathan R. Dillman
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOHUSA
- Department of RadiologyCincinnati Children's Hospital Medical CenterUniversity of Cincinnati College of MedicineCincinnatiOHUSA
| | - Andrew T. Trout
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOHUSA
- Department of RadiologyCincinnati Children's Hospital Medical CenterUniversity of Cincinnati College of MedicineCincinnatiOHUSA
| | - Suraj D. Serai
- Department of RadiologyChildren’s Hospital of PhiladelphiaPhiladelphiaPAUSA
| | - Divya Sharma
- Division of PathologyUniversity of CincinnatiCincinnatiOHUSA
| | - Rachel Sheridan
- Department of PathologyDayton Children’s HospitalDaytonOHUSA
| | - Weizhe Su
- Division of Biostatistics and EpidemiologyCincinnati Children's Hospital Medical CenterCincinnatiOHUSA
| | - Lin Fei
- Division of Biostatistics and EpidemiologyCincinnati Children's Hospital Medical CenterCincinnatiOHUSA
| | - Rebekah Karns
- Division of Gastroenterology, Hepatology and NutritionCincinnati Children's Hospital Medical CenterCincinnatiOHUSA
| | | | - Ged Ridgway
- Perspectum Diagnostics Ltd.South San FranciscoCAUSA
| | | | | | - Lee A. Denson
- Division of Gastroenterology, Hepatology and NutritionCincinnati Children's Hospital Medical CenterCincinnatiOHUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOHUSA
| | - Jeffery S. Hyams
- Division of Digestive DiseasesHepatology, and NutritionConnecticut Children’s Hospital Medical CenterHartfordCTUSA
| | - Alexander G. Miethke
- Division of Gastroenterology, Hepatology and NutritionCincinnati Children's Hospital Medical CenterCincinnatiOHUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOHUSA
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19
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Ali AH, Damman J, Shah SB, Davies Y, Hurwitz M, Stephen M, Lemos LM, Carey EJ, Lindor KD, Buness CW, Alrabadi L, Berquist WE, Cox KL. Open-label prospective therapeutic clinical trials: oral vancomycin in children and adults with primary sclerosing cholangitis. Scand J Gastroenterol 2020; 55:941-950. [PMID: 32633158 DOI: 10.1080/00365521.2020.1787501] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Oral vancomycin (OV) in primary sclerosing cholangitis (PSC) has been evaluated as a potential therapeutic agent. We report the long-term biochemical course and outcomes of patients with PSC treated with OV. METHODS Patients were enrolled in 2 open-label clinical trials (ClinicalTrials.gov Identifier: NCT01802073 and NCT01322386) and offered OV at 50 mg/kg/day in 3 divided doses if weight <30kg, and 500 mg 3 times/day if weight ≥30kg. Patients with biliary strictures requiring stenting or awaiting liver transplant were excluded. Liver biochemistry, MRCP and histology were documented at baseline and while on OV. The primary outcome was a decrease in elevated gamma glutamyl transferase (GGT), alkaline phosphatase (ALP), and/or alanine aminotransferase (ALT) from baseline. RESULTS 30 subjects were enrolled, and 29 additional subjects who learned of the clinical trial requested OV (total n = 59; median age was 13.5 years [range, 1.5-44 years]; 64.4% were male; and 94.9% had inflammatory bowel disease [IBD]). The median treatment duration was 2.7 years (range, 0.2-14 years). Ninety-six percent (57/59), 81.3% (48/59), and 94.9% (56/59) experienced reduction of GGT, ALP, and ALT, respectively. Furthermore, 39% (23/59), 22% (13/59), and 55.9% (33/59) experienced normalization of GGT, ALP, and ALT, respectively, within the first 6 months of OV treatment. One patient underwent liver transplantation 8 years after beginning OV treatment, and one developed biliary strictures requiring endoscopic intervention. OV was well-tolerated by patients, and no patient developed treatment-related adverse events. CONCLUSION In PSC, OV was well-tolerated and was associated with improvement in liver chemistry. A randomized placebo-controlled clinical trial is warranted.
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Affiliation(s)
- Ahmad Hassan Ali
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ, USA.,Division of Hepatology, University of Missouri-Columbia, Columbia, MO, USA.,Texas Tech University Health Sciences Center, Amarillo, TX, USA
| | - Jennifer Damman
- Lucile Packard Children's Hospital, Stanford University, Palo Alto, CA, USA
| | - Shamita B Shah
- Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, CA, USA.,Division of Gastroenterology, Ochsner Clinic Foundation, New Orleans, LA, USA
| | - Yinka Davies
- Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, CA, USA
| | - Melissa Hurwitz
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Stanford University, Palo Alto, CA, USA
| | - Mariam Stephen
- Lucile Packard Children's Hospital, Stanford University, Stanford, CA, USA
| | - Leta M Lemos
- Sacramento Pediatric Gastroenterology, Sacramento, CA, USA
| | - Elizabeth J Carey
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ, USA
| | - Keith D Lindor
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ, USA.,College of Health Solutions, Arizona State University, Phoenix, AZ, USA
| | - Cynthia W Buness
- National Patient Advocate Foundation, Arizona State University, Phoenix, AZ, USA
| | - Leina Alrabadi
- Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, CA, USA
| | - William E Berquist
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Stanford University, Palo Alto, CA, USA
| | - Kenneth L Cox
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Stanford University, Palo Alto, CA, USA
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Umetsu S, Notohara K, Nakazawa T, Tsunoda T, Sogo T, Komatsu H, Tanaka A, Tazuma S, Takikawa H, Inui A, Fujisawa T. Long-term outcomes of pediatric-onset primary sclerosing cholangitis: A single-center experience in Japan. Hepatol Res 2019; 49:1386-1397. [PMID: 31408920 DOI: 10.1111/hepr.13421] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 07/27/2019] [Accepted: 08/05/2019] [Indexed: 01/11/2023]
Abstract
AIM Primary sclerosing cholangitis (PSC) is very rare in Japan. Although a large-scale cohort study of 781 pediatric-onset PSC patients in Europe and North America showed that the 5-year survival with native liver was 88%, the long-term outcomes of pediatric-onset PSC in Japan are unknown. Here, we evaluated the clinical outcomes of pediatric-onset PSC in Japan. METHODS We carried out a retrospective cohort study with a medical records review of pediatric PSC patients diagnosed between 1986 and 2017 at a single center. The PSC diagnoses were based on cholangiography, liver histology, and biochemical findings. The patients' survival was analyzed using the Kaplan-Meier method. Prognostic factors were determined by univariate and multivariate analyses using the Cox proportional hazards regression model. RESULTS We identified 39 pediatric-onset PSC patients (22 boys, 17 girls). The median age at diagnosis was 9 years (interquartile range 6.0-13.5 years). The median follow-up period was 5.5 years (interquartile range 3.4-8.7 years). The phenotypes of PSC-autoimmune hepatitis, PSC-inflammatory bowel disease, and small-duct PSC were diagnosed in 13 (33.3%), 36 out of 38 (94.8%), and three (7.7%) patients, respectively. The 5-year liver transplantation-free survival of the whole cohort was 93.5%. Nine patients underwent liver transplantation, and four of these nine cases resulted in death. Both the univariate and multivariate analyses showed that the phenotype of "PSC-autoimmune hepatitis overlap" was an independent poor prognostic factor. CONCLUSIONS The overall survival of pediatric-onset PSC in Japan was comparable to those in Western countries. The phenotype of PSC-autoimmune hepatitis was identified as a prognostic factor associated with a poorer long-term outcome.
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Affiliation(s)
- Shuichiro Umetsu
- Department of Pediatric Hepatology and Gastroenterology, Saiseikai Yokohama-shi Tobu Hospital, Yokohama, Japan.,Department of Hepatology and Gastroenterology for Growth and Health, Toho University Graduate School of Medicine, Tokyo, Japan
| | - Kenji Notohara
- Department of Anatomic Pathology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Takahiro Nakazawa
- Department of Gastroenterology, Japanese Red Cross Nagoya Daini Hospital, Nagoya, Japan
| | - Tomoyuki Tsunoda
- Department of Pediatric Hepatology and Gastroenterology, Saiseikai Yokohama-shi Tobu Hospital, Yokohama, Japan
| | - Tsuyoshi Sogo
- Department of Pediatric Hepatology and Gastroenterology, Saiseikai Yokohama-shi Tobu Hospital, Yokohama, Japan
| | - Haruki Komatsu
- Department of Pediatrics, Toho University Sakura Hospital, Sakura, Japan
| | - Atsushi Tanaka
- Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Susumu Tazuma
- Department of General Medicine, Hiroshima University Graduate School of Medical Science, Programs of Applied Medicine, Clinical Pharmacotherapy, Hiroshima, Japan
| | - Hajime Takikawa
- Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Ayano Inui
- Department of Pediatric Hepatology and Gastroenterology, Saiseikai Yokohama-shi Tobu Hospital, Yokohama, Japan.,Department of Hepatology and Gastroenterology for Growth and Health, Toho University Graduate School of Medicine, Tokyo, Japan
| | - Tomoo Fujisawa
- Department of Pediatric Hepatology and Gastroenterology, Saiseikai Yokohama-shi Tobu Hospital, Yokohama, Japan
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21
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Joosse ME, Haisma SM, Sterk MFM, van Munster KN, Ponsioen CIJ, Houwen RHJ, Koot BGP, de Meij T, van Rheenen PF, de Koning BAE. Disease progression in paediatric- and adult-onset sclerosing cholangitis: Results from two independent Dutch registries. Liver Int 2019; 39:1768-1775. [PMID: 31152478 DOI: 10.1111/liv.14159] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 05/15/2019] [Accepted: 05/20/2019] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Sclerosing cholangitis (SC) is a severe liver disease leading to destruction of bile ducts. It is believed to run a milder course in children than in adults. To test this assumption, we evaluated time-to-complication curves in two independent paediatric-onset cohorts from the same geographical area. METHODS Short-term disease outcomes were evaluated with an online clinical registry that was filled with data on children with SC diagnosed between 2000 and 2017 and who were followed bi-annually thereafter. Long-term disease outcomes were evaluated in a paediatric-onset subcohort derived from a previously published population-based study from the Netherlands. Time-to-complication in the first cohort was defined as the time from diagnosis until portal hypertension, biliary obstructions and infections, development of malignancy, or liver transplantation, whichever came first. In the second cohort time-to-complication was defined as the time until liver transplantation or PSC-related death. RESULTS Median age at diagnosis in the first cohort (n = 86) was 12.3 years. In the first 5 years post-diagnosis 23% of patients developed complications. The patients in the population-based study (n = 683) were stratified into those diagnosed before the age of 18 years ('paediatric-onset' subcohort, n = 43) and those diagnosed after the age of 18 years ('adult-onset' subcohort, n = 640). Median age at diagnosis was 14.6 and 40.2 years, respectively. Median time-to-complication in the paediatric-onset and adult-onset subcohorts was not statistically different. CONCLUSION Paediatric and adult-onset SC run a similar long-term disease course. Paediatricians who treat children with SC should monitor them closely to recognize early complications and control long-term sequelae.
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Affiliation(s)
- Maria E Joosse
- Department of Pediatric Gastroenterology, Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Sjoukje M Haisma
- University of Groningen, University Medical Center Groningen, Pediatric Gastroenterology Hepatology and Nutrition, Groningen, the Netherlands
| | - Marlou F M Sterk
- Department of Pediatric Gastroenterology, Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Kim N van Munster
- Department of Gastroenterology & Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Cyriel I J Ponsioen
- Department of Gastroenterology & Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Roderick H J Houwen
- Department of Pediatric Gastroenterology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Bart G P Koot
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Tim de Meij
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Pediatric Gastroenterology, VU University Medical Center, Amsterdam, The Netherlands
| | - Patrick F van Rheenen
- University of Groningen, University Medical Center Groningen, Pediatric Gastroenterology Hepatology and Nutrition, Groningen, the Netherlands
| | - Barbara A E de Koning
- Department of Pediatric Gastroenterology, Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands
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22
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Black DD, Mack C, Kerkar N, Miloh T, Sundaram SS, Anand R, Gupta A, Alonso E, Arnon R, Bulut P, Karpen S, Lin CH, Rosenthal P, Ryan M, Squires RH, Valentino P, Elsea SH, Shneider BL. A Prospective Trial of Withdrawal and Reinstitution of Ursodeoxycholic Acid in Pediatric Primary Sclerosing Cholangitis. Hepatol Commun 2019; 3:1482-1495. [PMID: 31701072 PMCID: PMC6824074 DOI: 10.1002/hep4.1421] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 07/27/2019] [Indexed: 12/15/2022] Open
Abstract
Ursodeoxycholic acid (UDCA) is commonly used to treat several liver disorders in adults and children, including primary sclerosing cholangitis (PSC) for which it is not U.S. Food and Drug Administration approved. UDCA treatment has an uncertain impact on disease outcomes and has been reported in high doses to be associated with worse outcome in adults with PSC. In this context, controlled withdrawal and reintroduction of UDCA in children with PSC were studied. Prior to study initiation, participants were required to have alanine aminotransferase (ALT) and gamma‐glutamyl transpeptidase (GGT) <2 times the upper limit of normal on stable UDCA dosing. The study included four phases: I (stable dosing), II (50% UDCA reduction), III (UDCA discontinuation), IV (UDCA reintroduction), with a primary endpoint of change in ALT and GGT between phases I and III. We enrolled 27 participants (22 completed) between March 2011 and June 2016. Changes in mean ALT and GGT between phases I and III were ALT, +29.5 IU/L (P = 0.105) and GGT, +60.4 IU/L (P = 0.003). In 7 participants, ALT and GGT ≤29 IU/L did not rise above 29 IU/L (null response group). Eight participants had increases of ALT or GGT >100 IU/L (flare group). None developed elevated bilirubin. All flares responded to UDCA reinstitution. Serum GGT, interleukin‐8, and tumor necrosis factor α levels were higher in the flare group at baseline. Liver biochemistries increased in children with PSC during controlled UDCA withdrawal; one third increased above 100 IU/L and one third remained normal during UDCA withdrawal. Conclusion: The impact of prolonged UDCA use in childhood PSC and the significance of a biochemical flare are unclear. Further studies of the natural history and treatment of pediatric PSC and UDCA use are needed.
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Affiliation(s)
- Dennis D Black
- Pediatrics University of Tennessee Health Science Center Memphis TN
| | - Cara Mack
- Pediatrics University of Colorado School of Medicine Aurora CO
| | - Nanda Kerkar
- Pediatrics University of Rochester Medical Center Rochester NY.,Pediatrics Keck School of Medicine of University of Southern California Los Angeles CA
| | - Tamir Miloh
- Pediatrics Baylor College of Medicine Houston TX
| | | | | | | | - Estella Alonso
- Pediatrics Northwestern University College of Medicine Chicago IL
| | - Ronen Arnon
- Pediatrics Mount Sinai Icahn School of Medicine New York NY
| | - Pinar Bulut
- Pediatrics Phoenix Children's Hospital Phoenix AZ
| | - Saul Karpen
- Pediatrics Emory University School of Medicine Atlanta GA
| | - Chuan-Hao Lin
- Pediatrics Keck School of Medicine of University of Southern California Los Angeles CA
| | - Philip Rosenthal
- Pediatrics School of Medicine University of California, San Francisco San Francisco CA
| | - Matthew Ryan
- Pediatrics Children's Hospital of Philadelphia Philadelphia PA
| | - Robert H Squires
- Pediatrics University of Pittsburgh School of Medicine Pittsburgh PA
| | | | - Sarah H Elsea
- Molecular and Human Genetics Baylor College of Medicine Houston TX
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23
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Tenca A, Jaakkola T, Färkkilä M, Arola J, Kolho KL. Impact of paediatric onset primary sclerosing cholangitis on clinical course and outcome of inflammatory bowel disease: a case-control population-based study in Finland. Scand J Gastroenterol 2019; 54:984-990. [PMID: 31402720 DOI: 10.1080/00365521.2019.1648547] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Introduction and aim: The aim of this study was to investigate the outcome of a paediatric onset of inflammatory bowel disease (IBD) in a cohort of subjects with primary sclerosing cholangitis (PSC) and in a matched-age population-based control group without PSC. Methods: We identified 28 IBD-PSC cases (median age at IBD diagnosis 12.5 years, 25-75th: 10-16 years) and selected three IBD controls for each case matched for age and year of IBD diagnosis. All data regarding the gastrointestinal tract and liver were collected at diagnosis and at last follow-up (median 15 years). Results: At diagnosis the prevalence of pancolitis was similar between the groups (78% and 79%, respectively p = -.30), but histologic inflammation was milder in IBD-PSC (61% vs 30%, p = .06). At last follow-up (median age 29 years) pancolitis was less frequent (6% and 33%, respectively p = .04) and the remission higher (76% and 47%, respectively p = .08) in IBD-PSC patients than in IBD patients. Panproctolectomy (32% in IBD-PSC and 34% in IBD, p = 1.0) and the rate of pouchitis (62% and 70%, respectively p = .8) were similar. Conclusions: The outcome of paediatric onset IBD in patients with PSC in adulthood seems to be comparable to those with IBD only.
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Affiliation(s)
- Andrea Tenca
- Department of Medicine, Clinic of Gastroenterology, University of Helsinki and Helsinki University Hospital , Helsinki , Finland
| | - Tytti Jaakkola
- Department of Pediatric Gastroenterology, University of Helsinki and Children's Hospital , Helsinki , Finland
| | - Martti Färkkilä
- Department of Medicine, Clinic of Gastroenterology, University of Helsinki and Helsinki University Hospital , Helsinki , Finland
| | - Johanna Arola
- Department of Pathology, Helsinki University and Helsinki University Hospital , Helsinki , Finland
| | - Kaija-Leena Kolho
- Department of Pediatric Gastroenterology, University of Helsinki and Children's Hospital , Helsinki , Finland
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24
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Lee WS, Karthik SV, Ng RT, Ong SY, Ong C, Chiou FK, Wong SY, Quak SH, Aw MM. Characteristics and outcome of primary sclerosing cholangitis associated with inflammatory bowel disease in Asian children. Pediatr Neonatol 2019; 60:396-404. [PMID: 31409456 DOI: 10.1016/j.pedneo.2018.09.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 07/04/2018] [Accepted: 09/28/2018] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Current knowledge on the clinical features and natural history of childhood primary sclerosing cholangitis - inflammatory bowel disease in Asia is limited. We described the presenting features and natural history of primary sclerosing cholangitis-inflammatory bowel disease seen in a cohort of Southeast Asian children. METHODS We conducted a retrospective review of childhood primary sclerosing cholangitis-inflammatory bowel disease from three tertiary centers in Singapore and Malaysia. RESULTS Of 24 patients (boys, 58%; median age at diagnosis: 6.3 years) with primary sclerosing cholangitis-inflammatory bowel disease (ulcerative colitis, n = 21; Crohn's disease, n = 1; undifferentiated, n = 2), 63% (n = 15) were diagnosed during follow-up for colitis, and 21% (n = 5) presented with acute or chronic hepatitis, 17% (n = 4) presented simultaneously. Disease phenotype of liver involvement showed 79% had sclerosing cholangitis-autoimmune hepatitis overlap, 54% large duct disease, and 46% small duct disease. All patients received immunosuppression therapy. At final review after a median [±S.D.] duration follow-up of 4.7 [±3.8] years, 12.5% patients had normal liver enzymes, 75% persistent disease, and 12.5% liver failure. The proportion of patients with liver cirrhosis increased from 13% at diagnosis to 29%; 21% had portal hypertension, and 17% had liver dysfunction. One patient required liver transplant. Transplant-free survival was 95%. For colitis, 95% had pancolitis, 27% rectal sparing, and 11% backwash ileitis at initial presentation. At final review, 67% patients had quiescent bowel disease with immunosuppression. One patient who had UC with pancolitis which was diagnosed at 3 years old developed colorectal cancer at 22 years of age. All patients survived. CONCLUSIONS Liver disease in primary sclerosing cholangitis-inflammatory bowel disease in Asian children has variable severity. With immunosuppression, two-thirds of patients have quiescent bowel disease but the majority have persistent cholangitis and progressive liver disease.
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Affiliation(s)
- Way Seah Lee
- Department of Paediatrics, University Malaya Medical Center, Kuala Lumpur, Malaysia; Paediatric and Child Health Research Group, University Malaya, Kuala Lumpur, Malaysia.
| | | | - Ruey Terng Ng
- Department of Paediatrics, University Malaya Medical Center, Kuala Lumpur, Malaysia
| | - Sik Yong Ong
- Department of Paediatrics, University Malaya Medical Center, Kuala Lumpur, Malaysia
| | - Christina Ong
- Gastroenterology Service, Department of Paediatric Medicine, KK Women's and Children's Hospital, Bukit Timah Road, Singapore
| | - Fang K Chiou
- Gastroenterology Service, Department of Paediatric Medicine, KK Women's and Children's Hospital, Bukit Timah Road, Singapore
| | - Shin Yee Wong
- Department of Paediatrics, University Malaya Medical Center, Kuala Lumpur, Malaysia
| | - Seng Hock Quak
- Khoo Teck Puat National University Children's Medical Institute, National University Hospital, Singapore; Department of Paediatrics, National University of Singapore, Kent Ridge Road, Singapore
| | - Marion Margaret Aw
- Khoo Teck Puat National University Children's Medical Institute, National University Hospital, Singapore; Department of Paediatrics, National University of Singapore, Kent Ridge Road, Singapore
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25
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Malik A, Kardashian AA, Zakharia K, Bowlus CL, Tabibian JH. Preventative care in cholestatic liver disease: Pearls for the specialist and subspecialist. LIVER RESEARCH 2019; 3:118-127. [PMID: 32042471 PMCID: PMC7008979 DOI: 10.1016/j.livres.2019.04.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Cholestatic liver diseases (CLDs) encompass a variety of disorders of abnormal bile formation and/or flow. CLDs often lead to progressive hepatic insult and injury and following the development of cirrhosis and associated complications. Many such complications are clinically silent until they manifest with severe sequelae, including but not limited to life-altering symptoms, metabolic disturbances, cirrhosis, and hepatobiliary diseases as well as other malignancies. Primary sclerosing cholangitis (PSC) and primary biliary cholangitis (PBC) are the most common CLDs, and both relate to mutual as well as unique complications. This review provides an overview of PSC and PBC, with a focus on preventive measures aimed to reduce the incidence and severity of disease-related complications.
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Affiliation(s)
- Adnan Malik
- Department of Public Health and Business Administration, The University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Internal Medicine, Beaumont Hospital, Dearborn, MI, USA
| | - Ani A. Kardashian
- University of California Los Angeles Gastroenterology Fellowship Training Program, Vatche and Tamar Manoukian Division of Digestive Diseases, Los Angeles, CA, USA
| | - Kais Zakharia
- Division of Gastroenterology and Hepatology, University of Iowa, Iowa, IA, USA
| | - Christopher L. Bowlus
- Division of Gastroenterology and Hepatology, University of California Davis, Sacramento, CA, USA
| | - James H. Tabibian
- Division of Gastroenterology, Department of Medicine, Olive View-University of California Los Angeles Medical Center, Sylmar, CA, USA
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26
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Jebran AF, Schmidt WE, Kahraman A, Canbay A, Bulut K. Sarcoidosis of the Intra- and Extrahepatic Bile Ducts with Concomitant Cholangitis in a Patient with Ulcerative Colitis. Case Rep Gastroenterol 2019; 13:153-158. [PMID: 31097931 PMCID: PMC6489028 DOI: 10.1159/000497470] [Citation(s) in RCA: 3] [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: 07/31/2018] [Accepted: 01/31/2019] [Indexed: 12/14/2022] Open
Abstract
Cholangitis in patients with ulcerative colitis (UC) can lead to misdiagnosis of primary sclerosing cholangitis (PSC). Furthermore, it can mimic cholangiocellular carcinoma, which also can lead to inappropriate and potentially harmful treatment of the patient. An 18-year-old male patient with known UC presented with pain in his right upper abdomen and elevation of the cholestatic liver enzymes (alkaline phosphatase: 197 U/L, γ-glutamyltransferase: 229 U/L) and increased inflammatory parameters (leukocytosis and CrP of 13.6 mg/L). Magnetic resonance cholangiopancreatography revealed unclear stenosis in the bifurcation of the main hepatic bile duct as well as in the prepapillary bile duct. Ultrasound (US) examination and endoscopic retrograde cholangiopancreatography showed dilatation of the intra -and extrahepatic bile ducts, which raised the suspicion of PSC. US image with dilated intra- and extrahepatic dilatation of the bile duct was also suggestive for autoimmune cholangitis. However, serum analysis revealed an elevated soluble interleukin-II receptor (1,305 U/mL), while immunoglobulin G4 was within normal ranges. Liver biopsy demonstrated hepatic inflammation and presence of granulomatous cells within the portal fields - convenient to sarcoidosis. After starting treatment with steroids, we observed a rapid clinical response with improvement of the dilated bile ducts and decrease of the initially elevated cholestatic liver enzymes. Sarcoidosis within the bile duct is a rare condition. Steroids are the treatment of choice and - along with the histology - are furthermore helpful to differentiate between several potential differential diagnoses like IgG4 cholangitis, primary biliary cholangitis, or PSC.
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Affiliation(s)
- Ahmad Fasel Jebran
- Clinic for Internal Medicine and Gastroenterology, St. Clemens-Hospital Geldern, Geldern, Germany
| | - Wolfgang E. Schmidt
- St. Josef Hospital Bochum, Hospital of Ruhr-University, Department of Internal Medicine, Bochum, Germany
| | - Alisan Kahraman
- Department of Gastroenterology and Hepatology, University Clinic of Essen, Essen, Germany
| | - Ali Canbay
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University, Magdeburg, Germany
| | - Kerem Bulut
- Clinic for Internal Medicine and Gastroenterology, St. Clemens-Hospital Geldern, Geldern, Germany
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27
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Kerkar N, Chan A. Autoimmune Hepatitis, Sclerosing Cholangitis, and Autoimmune Sclerosing Cholangitis or Overlap Syndrome. Clin Liver Dis 2018; 22:689-702. [PMID: 30266157 DOI: 10.1016/j.cld.2018.06.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Autoimmune hepatitis (AIH) is characterized by elevated serum aminotransferases, immunoglobulin G, autoantibodies, and interface hepatitis, in the absence of a known diagnosis. Presentation is varied. Therapy is with immunosuppression. There is inflammation of the intrahepatic and/or extrahepatic bile ducts in Sclerosing cholangitis (SC) and when associated with inflammatory bowel disease, it is known as primary SC, with Ursodeoxycholic acid used for therapy. The overlap of clinical, biochemical and histological features of AIH and PSC is known as autoimmune sclerosing cholangitis (ASC) or overlap syndrome. Liver transplantation is performed when medical treatment fails and both AIH and PSC may recur post-transplantation.
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Affiliation(s)
- Nanda Kerkar
- Division of Gastroenterology, Hepatology and Nutrition, Golisano Children's Hospital, University of Rochester Medical Center, 601 Elmwood Avenue, Box 667, Rochester, NY 14642, USA.
| | - Albert Chan
- Division of Gastroenterology, Hepatology and Nutrition, Golisano Children's Hospital, University of Rochester Medical Center, 601 Elmwood Avenue, Box 667, Rochester, NY 14642, USA; Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Florida, PO Box 100296, Gainesville, FL 32610, USA
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28
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Autoimmune sclerosing cholangitis: Evidence and open questions. J Autoimmun 2018; 95:15-25. [PMID: 30366655 DOI: 10.1016/j.jaut.2018.10.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 10/13/2018] [Indexed: 02/06/2023]
Abstract
Juvenile sclerosing cholangitis is a rare chronic hepatobiliary disorder characterized by inflammation of the intra- and/or extrahepatic bile ducts, bile duct dilatation, narrowing and obliteration, and, histologically, by inflammatory bile duct damage leading to periductular fibrosis. The diagnosis is based on endoscopic retrograde cholangiopancreatography or magnetic resonance cholangiopancreatography. In children, it may be associated to a variety of systemic and hepatic conditions: thus, the term "primary" sclerosing cholangitis should be reserved for the rare cases without a known cause. Small duct disease is diagnosed in the presence of histological features diagnostic of sclerosing cholangitis and normal cholangiography. Autoimmune sclerosing cholangitis (ASC) is a form of sclerosing cholangitis with strong autoimmune features overlapping with those of autoimmune hepatitis (AIH). It is a well-recognized nosological entity in paediatrics, where it accounts for the majority of sclerosing cholangitis cases. It is as prevalent as AIH in children, is equally frequent in males and females, half of the patients have concomitant inflammatory bowel disease, virtually all patients have raised immunoglobulin G levels and positive anti-nuclear and/or anti-smooth muscle antibodies. Half of the ASC patients respond well to standard immunosuppressive treatment for AIH with the addition of ursodeoxycholic acid, but the transplant rate is higher than in AIH, and post-transplant recurrence is frequent. A number of open questions remain: are ASC and AIH distinct entities or different manifestations of the same condition? What is the role of histology? Is small duct disease a specific entity? What is the relationship between ASC and adult primary sclerosing cholangitis? What is the role of inflammatory bowel disease? In addition, validated diagnostic criteria for ASC are needed.
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29
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Adike A, Carey EJ, Lindor KD. Primary sclerosing cholangitis in children versus adults: lessons for the clinic. Expert Rev Gastroenterol Hepatol 2018; 12:1025-1032. [PMID: 30199272 DOI: 10.1080/17474124.2018.1521719] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Primary sclerosing cholangitis (PSC) is a rare cholestatic disorder that presents with multifocal biliary strictures. PSC has a variable course but often leads to progressive liver disease, and most patients will eventually require liver transplantation. PSC has a strong association with inflammatory bowel disease and autoimmune liver disease. Areas covered: The objective of this article is to compare and contrast the clinical features and natural history of PSC in children to adults. We performed a PubMed search of the English literature using keywords 'primary sclerosing cholangitis', 'PSC', 'children', and 'pediatric.' Expert commentary: While certain features of PSC are similar in the pediatric and adult population, there are unique features of pediatric PSC. More longitudinal studies are needed to better understand the natural history of pediatric PSC. It is conceivable that treatment for PSC that will alter the course of disease may become available in the future.
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Affiliation(s)
- Abimbola Adike
- a Division of Gastroenterology and Hepatology , Mayo Clinic , Phoenix , AZ , USA
| | - Elizabeth J Carey
- a Division of Gastroenterology and Hepatology , Mayo Clinic , Phoenix , AZ , USA
| | - Keith D Lindor
- a Division of Gastroenterology and Hepatology , Mayo Clinic , Phoenix , AZ , USA
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30
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Deneau MR, Mack C, Abdou R, Amin M, Amir A, Auth M, Bazerbachi F, Marie Broderick A, Chan A, DiGuglielmo M, El-Matary W, El-Youssef M, Ferrari F, Furuya KN, Gottrand F, Gupta N, Homan M, Jensen MK, Kamath BM, Mo Kim K, Kolho KL, Konidari A, Koot B, Iorio R, Martinez M, Mohan P, Palle S, Papadopoulou A, Ricciuto A, Saubermann L, Sathya P, Shteyer E, Smolka V, Tanaka A, Valentino PL, Varier R, Venkat V, Vitola B, Vos MB, Woynarowski M, Yap J, Miloh T. Gamma Glutamyltransferase Reduction Is Associated With Favorable Outcomes in Pediatric Primary Sclerosing Cholangitis. Hepatol Commun 2018; 2:1369-1378. [PMID: 30411083 PMCID: PMC6211333 DOI: 10.1002/hep4.1251] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 07/13/2018] [Indexed: 12/15/2022] Open
Abstract
Adverse clinical events in primary sclerosing cholangitis (PSC) happen too slowly to capture during clinical trials. Surrogate endpoints are needed, but no such validated endpoints exist for children with PSC. We evaluated the association between gamma glutamyltransferase (GGT) reduction and long-term outcomes in pediatric PSC patients. We evaluated GGT normalization (< 50 IU/L) at 1 year among a multicenter cohort of children with PSC who did or did not receive treatment with ursodeoxycholic acid (UDCA). We compared rates of event-free survival (no portal hypertensive or biliary complications, cholangiocarcinoma, liver transplantation, or liver-related death) at 5 years. Of the 287 children, mean age of 11.4 years old, UDCA was used in 81% at a mean dose of 17 mg/kg/day. Treated and untreated groups had similar GGT at diagnosis (314 versus 300, P= not significant [NS]). The mean GGT was reduced at 1 year in both groups, with lower values seen in treated (versus untreated) patients (99 versus 175, P= 0.002), but 5-year event-free survival was similar (74% versus 77%, P= NS). In patients with GGT normalization (versus no normalization) by 1 year, regardless of UDCA treatment status, 5-year event-free survival was better (91% versus 67%, P< 0.001). Similarly, larger reduction in GGT over 1 year (> 75% versus < 25% reduction) was also associated with improved outcome (5-year event-free survival 88% versus 61%, P= 0.005). Conclusion:A GGT < 50 and/or GGT reduction of > 75% by 1 year after PSC diagnosis predicts favorable 5-year outcomes in children. GGT has promise as a potential surrogate endpoint in future clinical trials for pediatric PSC.
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Affiliation(s)
| | - Cara Mack
- University of Colorado School of Medicine Aurora CO
| | - Reham Abdou
- Nassau University Medical Center East Meadow NY
| | | | - Achiya Amir
- Dana-Dwek Children's Hospital, Tel-Aviv Medical Center, Tel-Aviv University Tel Aviv Israel
| | - Marcus Auth
- Alder Hey Children's Hospital Liverpool United Kingdom
| | | | | | - Albert Chan
- University of Rochester Medical Center Rochester NY
| | | | | | | | | | | | | | | | | | | | | | | | | | - Anastasia Konidari
- University of Liverpool Liverpool United Kingdom.,University of Manchester Manchester United Kingdom
| | - Bart Koot
- Academic Medical Centre Amsterdam the Netherlands
| | | | | | | | | | | | | | | | - Pushpa Sathya
- Memorial University St. John's, Newfoundland and Labrador Canada
| | | | | | | | | | - Raghu Varier
- Northwest Pediatric Gastroenterology LLC Portland OR
| | - Veena Venkat
- University of Pittsburgh Medical Center Pittsburgh PA
| | | | | | | | - Jason Yap
- University of Alberta Edmonton Canada
| | - Tamir Miloh
- Phoenix Children's Hospital Phoenix AZ.,Texas Children's Hospital Houston TX
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Ponsioen CY, Lindor KD, Mehta R, Dimick-Santos L. Design and Endpoints for Clinical Trials in Primary Sclerosing Cholangitis. Hepatology 2018; 68:1174-1188. [PMID: 29574971 DOI: 10.1002/hep.29882] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 02/11/2018] [Accepted: 03/13/2018] [Indexed: 12/15/2022]
Abstract
Primary sclerosing cholangitis (PSC) is a rare and chronic liver disease for which there is no effective therapy. Interest has grown in developing treatments for this condition, with several agents proposed as potential therapies. However, there is a lack of clarity about how to measure clinical benefit in trials involving patients with this complex and rare disease. This article reviews regulatory information, the available literature on natural history, as well as potential candidate clinical and surrogate endpoints for PSC. (Hepatology 2018; 00:000-000).
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Affiliation(s)
- Cyriel Y Ponsioen
- Department of Gastroenterology & Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Keith D Lindor
- College of Health Solutions, Arizona State University, Phoenix, AZ
| | - Ruby Mehta
- Division of Gastroenterology and Inborn Errors Products, United States Food and Drug Administration, Silver Spring, MD
| | - Lara Dimick-Santos
- Division of Gastroenterology and Inborn Errors Products, United States Food and Drug Administration, Silver Spring, MD
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Abstract
PURPOSE OF REVIEW Review the current knowledge about recurrent primary sclerosing cholangitis (rPSC) after transplant in children. RECENT FINDINGS Recurrent PSC is a significant complication that afflicts 16% of children after liver transplantation for primary sclerosing cholangitis (PSC) at a median onset of 38 months post-transplant. Possible risk factors include younger age at PSC diagnosis or transplant, the presence of overlap syndrome or IBD, and post-transplant induction with thymoglobulin. rPSC impairs the patient's quality of life and can be detrimental to the graft. Preventive options and therapeutic measures are limited. Ursodeoxycholic acid is widely used, but its effect on long-term outcome is unknown. Vancomycin can improve the biochemical profile of rPSC, but it remains unknown whether it halts the disease progression. Pediatric liver transplant for primary sclerosis cholangitis can be complicated by recurrence of the disease, which portends poor outcomes. Although few risk factors have been implicated, larger studies with longer follow-ups are needed to characterize cardinal risk factors for rPSC, as well as evaluate possible preventative and therapeutic options.
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Affiliation(s)
- Nisreen Soufi
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Southern California, Los Angeles, CA, USA
| | - Fateh Bazerbachi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Mark Deneau
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Utah, Salt Lake City, UT, 84113, USA.
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Evolving Practice and Changing Phenotype in Pediatric Autoimmune Liver Disease: Outcomes From an Australian Center. J Pediatr Gastroenterol Nutr 2018; 67:80-85. [PMID: 29470284 DOI: 10.1097/mpg.0000000000001927] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Autoimmune liver disease (AILD) incorporates primary sclerosing cholangitis (PSC), autoimmune hepatitis (AIH), and autoimmune sclerosing cholangitis (ASC). ASC is a condition that includes overlap of AIH and PSC. We investigate changes in practice in relation to diagnosis and phenotype over 2 time periods. METHODS Retrospective chart review was conducted from January 2000 to 2016. Data were divided into two 8-year cohorts, CI and C2. RESULTS Data were collected in 75 children, 29 in 2000-2007 (C1) and 46 in 2008-2016 (C2). Presenting AILD type was AIH in 59%, ASC in 10%, and PSC in 31%. Final AILD type was AIH in 53%, ASC in 16%, and PSC in 31%. When comparing C1 to C2, those with AIH decreased (65% vs 45%) and those with ASC increased (14% vs 18%). Use of magnetic resonance cholangio-pancreatography increased from 34% in C1 to 65% in C2. Advanced liver disease on biopsy was noted in 53% of all children at presentation. Only 5 female children progressed to liver transplant (3 ASC-IBD [inflammatory bowel disease]; 1 PSC-IBD; 1 AIH). Colonoscopy performance increased from 48% in C1 to 63% in C2 with diagnosis of AILD-IBD increasing from 31% to 52%. Right-sided disease was present in 46% and macroscopic rectal sparing in 36% of those with ulcerative colitis (UC). Colectomy was required in 3 children with large duct PSC-IBD. CONCLUSIONS PSC and ASC are increasing in relevance along with IBD and reflect increasing performance of magnetic resonance cholangio-pancreatography and colonoscopy. Large duct PSC and ASC with IBD are risk factors for colectomy and along with female gender, for liver transplant.
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Ferrari F, Ranucci G, Aloi M, Della Volpe L, Viola F, Miele E, Cucchiara S, Iorio R. A promising medium-term follow-up of pediatric sclerosing cholangitis: Mild phenotype or early diagnosis? Hepatol Res 2018; 48:556-565. [PMID: 29316057 DOI: 10.1111/hepr.13059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 01/02/2018] [Accepted: 01/05/2018] [Indexed: 12/24/2022]
Abstract
AIM Sclerosing cholangitis (SC) is a chronic cholestatic liver disease that is being increasingly diagnosed in childhood. The long-term course and prognosis of pediatric SC are poorly described. METHODS We reviewed data of pediatric SC patients, followed in two referral centers, during a period of up to 20 years. We aimed to evaluate long-term outcomes according to SC phenotype. RESULTS Among 45 patients (median age, 10.4 years; male patients, 73.4%) 29 (64.4%) were asymptomatic at presentation. Twenty patients (44%) had a concomitant inflammatory bowel disease (SC/IBD). Autoimmune features were found in 20 patients (44%). Liver biopsy showed severe fibrosis or cirrhosis in 32% of cases. Patients with SC alone had a higher rate of interface hepatitis at liver biopsy than SC/IBD patients. All children received ursodeoxycholic acid at diagnosis, and 17 received steroids and/or azathioprine. After a mean follow-up of 8.7 ± 5.6 years, all patients were alive and seven developed at least one liver-related complication. At the end of follow-up, 10 patients stopped immunosuppressants and two had no therapy. Only two patients underwent liver transplantation. Complication-free survival did not differ between SC/IBD and SC patients, but survival was longer in patients without autoimmune features. CONCLUSIONS In our early diagnosed cohort, the 9-year survival with native liver was better than that reported in other studies. Approximately 15% of patients developed liver-related disease complications, less than previously reported. The long-term course of SC was negatively influenced by the presence of autoimmune features, but not by concomitant IBD.
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Affiliation(s)
- Federica Ferrari
- Pediatric Gastroenterology and Liver Unit, Department of Pediatrics, Sapienza University of Rome, Italy
| | - Giusy Ranucci
- Department of Translational Medical Science, Section of Pediatrics, University of Naples Federico II, Naples, Italy
| | - Marina Aloi
- Pediatric Gastroenterology and Liver Unit, Department of Pediatrics, Sapienza University of Rome, Italy
| | - Luca Della Volpe
- Department of Translational Medical Science, Section of Pediatrics, University of Naples Federico II, Naples, Italy
| | - Franca Viola
- Pediatric Gastroenterology and Liver Unit, Department of Pediatrics, Sapienza University of Rome, Italy
| | - Erasmo Miele
- Department of Translational Medical Science, Section of Pediatrics, University of Naples Federico II, Naples, Italy
| | - Salvatore Cucchiara
- Pediatric Gastroenterology and Liver Unit, Department of Pediatrics, Sapienza University of Rome, Italy
| | - Raffaele Iorio
- Department of Translational Medical Science, Section of Pediatrics, University of Naples Federico II, Naples, Italy
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Umetsu S, Inui A, Sogo T, Komatsu H, Fujisawa T. Usefulness of serum Wisteria floribunda agglutinin-positive Mac-2 binding protein in children with primary sclerosing cholangitis. Hepatol Res 2018; 48:355-363. [PMID: 29168311 DOI: 10.1111/hepr.13004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 11/13/2017] [Accepted: 11/18/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND Wisteria floribunda agglutinin-positive Mac-2 binding protein (WFA+ -M2BP) is a novel serum marker of hepatic fibrosis in adults with chronic hepatitis C. However, it remains unclear whether serum WFA+ -M2BP levels are associated with the progression of liver histology in primary sclerosing cholangitis (PSC). METHODS Twenty-eight children and adolescents with pediatric-onset PSC (male : female patient ratio, 20:8; median age at diagnosis, 9 years) were enrolled in this study. The relation between serum WFA+ -M2BP levels and clinical characteristics was retrospectively evaluated. Moreover, receiver operating characteristic (ROC) analysis was used to determine whether serum WFA+ -M2BP levels could be a reliable marker to identify PSC patients with advanced liver histology. RESULTS According to the Ludwig classification of liver histological stage, 28 patients were classified into the four stages. The WFA+ -M2BP level, aspartate aminotransferase (AST) to platelet ratio index (APRI), and hyaluronic acid correlated significantly with liver histological stage. Moreover, WFA+ -M2BP showed a significant positive correlation (P < 0.05) with autoimmune hepatitis overlap, AST, alanine aminotransferase (ALT), γ-glutamyltransferase, total bilirubin, immunoglobulin G, APRI, and hyaluronic acid. A ROC analysis was undertaken to distinguish the patients with advanced stage disease (stage 3-4) from those with early stage disease (stage 0-2). It showed that WFA+ -M2BP yielded the highest area under the ROC curve value (0.898) among four surrogate makers (APRI, 0.850; Fibrosis-4 index, 0.806; and AST/ALT ratio, 0.802). Moreover, WFA+ -M2BP yielded the highest sensitivity, specificity, positive predictive value, and negative predictive value among the four markers. CONCLUSIONS Serum WFA+ -M2BP levels are useful to identify patients with advanced liver histology in pediatric PSC.
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Affiliation(s)
- Shuichiro Umetsu
- Department of Pediatric Hepatology and Gastroenterology, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan
| | - Ayano Inui
- Department of Pediatric Hepatology and Gastroenterology, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan
| | - Tsuyoshi Sogo
- Department of Pediatric Hepatology and Gastroenterology, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan
| | - Haruki Komatsu
- Department of Pediatrics, Toho University Medical Center Sakura Hospital, Sakura, Japan
| | - Tomoo Fujisawa
- Department of Pediatric Hepatology and Gastroenterology, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan
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Damman JL, Rodriguez EA, Ali AH, Buness CW, Cox KL, Carey EJ, Lindor KD. Review article: the evidence that vancomycin is a therapeutic option for primary sclerosing cholangitis. Aliment Pharmacol Ther 2018; 47:886-895. [PMID: 29411404 DOI: 10.1111/apt.14540] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Revised: 11/06/2017] [Accepted: 01/08/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS PSC is an autoimmune biliary inflammatory disorder that is often associated with inflammatory bowel disease (IBD), with 50%-75% of patients with PSC having coexisting IBD, most commonly ulcerative colitis. Currently, no medical therapies have been shown to improve the disease course or slow its progression. However, ongoing research has resulted in a growing interest in the use of antibiotics for treatment of PSC, of which vancomycin is the most studied. In this review, we summarise the current evidence on the use of vancomycin in PSC and comment on future research areas of interest. METHODS A comprehensive PUBMED and EMBASE literature search for articles on vancomycin, PSC, therapeutic options and microbiome was performed. RESULTS Two randomised clinical trials, three case series and two case reports were included in the study. These include uncontrolled data from at least 98 patients that include promising improvements in biochemistry and imaging. Optimal dosing regimens are unclear. CONCLUSION Vancomycin is one of the most studied antibiotics used in the treatment of PSC with promising results. There is not currently sufficient evidence to support treatment recommendations. Further research is needed to establish if vancomycin is a PSC treatment.
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Affiliation(s)
- J L Damman
- Pediatrics/Gastroenterology and Hepatology, Stanford University, Stanford, CA, USA
| | - E A Rodriguez
- Gastroenterology and Hepatology, Mayo Clinic, Arizona, USA
| | - A H Ali
- Hepatology, Mayo Clinic, Arizona, USA
| | - C W Buness
- National Patient Advocate Foundation, Paradise Valley, AZ, USA
| | - K L Cox
- Pediatric Gastroenterology and Hepatology, Stanford University, Stanford, CA, USA
| | - E J Carey
- Gastroenterology and Hepatology, Mayo Clinic, Arizona, USA
| | - K D Lindor
- Gastroenterology and Hepatology, Arizona State University and Mayo Clinic, Arizona, USA
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Abstract
PURPOSE OF REVIEW To review the characteristics of IBD and PSC that occur in association, as well as their reciprocal influences on disease evolution, in adult and pediatric populations. RECENT FINDINGS IBD co-existing with PSC is genetically and clinically distinct from IBD alone. It is frequently characterized by pancolitis, rectal sparing, and possibly backwash ileitis, as well as a threefold increased risk of colorectal dysplasia. Adults and children with colitis and PSC appear to be at increased risk of active endoscopic and histologic disease in the absence of symptoms compared to individuals without PSC. PSC occurring with Crohn's disease has been observed to be less severe than PSC co-existing with ulcerative colitis, independent of its association with small duct disease. Recent studies suggest that colectomy is associated with a decreased risk of recurrent PSC after liver transplantation, challenging the traditional teaching that PSC and IBD evolve independently. While much about the gut-liver axis in PSC-IBD remains poorly understood, the IBD associated with PSC has a unique phenotype, of which subclinical inflammation is an important component. Additional research is needed to characterize further the potentially protective role of colectomy against recurrent PSC post-liver transplantation and to investigate the influence of IBD control and/or colectomy on PSC progression.
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Affiliation(s)
- Amanda Ricciuto
- Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, M5G1X8, Canada.
| | - Binita M Kamath
- Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, M5G1X8, Canada
| | - Anne M Griffiths
- Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, M5G1X8, Canada
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Mieli-Vergani G, Vergani D, Baumann U, Czubkowski P, Debray D, Dezsofi A, Fischler B, Gupte G, Hierro L, Indolfi G, Jahnel J, Smets F, Verkade HJ, Hadžić N. Diagnosis and Management of Pediatric Autoimmune Liver Disease: ESPGHAN Hepatology Committee Position Statement. J Pediatr Gastroenterol Nutr 2018; 66:345-360. [PMID: 29356770 DOI: 10.1097/mpg.0000000000001801] [Citation(s) in RCA: 173] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Paediatric autoimmune liver disease is characterized by inflammatory liver histology, circulating autoantibodies, and increased levels of IgG, in the absence of a known etiology. Three conditions have a likely autoimmune pathogenesis: autoimmune hepatitis (AIH), autoimmune sclerosing cholangitis, and de novo AIH after liver transplantation. Two types of pediatric AIH are recognized according to seropositivity for smooth muscle and/or antinuclear antibody (AIH-1) or liver kidney microsomal type 1 and/or anti-liver cytosol type 1 antibodies (AIH-2).Pertinent issues addressing the diagnosis, treatment, and long-term follow-up were formulated by a core group of ESPGHAN members. They have commissioned the first authors with execution of this project. Initially, they have performed a systematic literature search on MEDLINE, ResearchGate, and Mendeley databases during the last 30 years and produced a document focusing on prospective and retrospective studies in children. The ESPGHAN core group and ESPGHAN Hepatology Committee members voted on each recommendation, using a formal voting technique.
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Affiliation(s)
| | - Diego Vergani
- MowatLabs, Paediatric Liver, GI & Nutrition Centre, King's College Hospital, London, UK
| | - Ulrich Baumann
- Pädiatrische Gastroenterologie und Hepatologie, Medizinische Hochschule, Hannover, Germany
| | - Piotr Czubkowski
- Department of Gastroenterology, Hepatology, Nutrition Disturbances and Pediatrics, The Children's Memorial Health Institute, Warsaw, Poland
| | - Dominique Debray
- Pediatric Hepatology Unit, AP-HP-Hôpital Necker Enfants Malades, Paris, France
| | - Antal Dezsofi
- First Department of Paediatrics, Semmelweis University, Budapest, Hungary
| | - Björn Fischler
- Department of Pediatrics, Karolinska University Hospital, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Girish Gupte
- Liver Unit (Including Small Bowel Transplantation), Department of Gastroenterology and Nutrition, Birmingham Children's Hospital, Birmingham, UK
| | - Loreto Hierro
- Hospital Infantil Universitario La Paz, Madrid, Spain
| | - Giuseppe Indolfi
- Paediatric and Liver Unit, Meyer Children's University Hospital of Florence, Firenze, Italy
| | - Jörg Jahnel
- Division of General Pediatrics, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Françoise Smets
- UCL, Cliniques Universitaires Saint-Luc, Pediatric Gastroenterology and Hepatology, Brussels, Belgium
| | - Henkjan J Verkade
- Dept of Pediatrics, Center for Liver, Digestive, and Metabolic Diseases, University Medical Center Groningen, Groningen, the Netherlands
| | - Nedim Hadžić
- MowatLabs, Paediatric Liver, GI & Nutrition Centre, King's College Hospital, London, UK
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Lack of Correlation of Liver Tests With Fibrosis Stage at Diagnosis in Pediatric Primary Sclerosing Cholangitis. J Pediatr Gastroenterol Nutr 2018; 66:227-233. [PMID: 29356767 DOI: 10.1097/mpg.0000000000001789] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES The aims of this study were to characterize pediatric primary sclerosing cholangitis (PSC) at a regional referral-based institution, including scoring of biliary stricturing and liver fibrosis and correlation analyses of scores with serum liver tests, to identify biomarkers of disease severity. METHODS A retrospective review of 39 PSC subjects was performed, with collection of demographic and outcomes data. Magnetic resonance cholangiopancreaticogram (MRCP) and liver biopsies were re-reviewed and scores of stricturing and fibrosis were correlated with serum liver tests. RESULTS Average age at PSC diagnosis was 11.2 years, 74% had inflammatory bowel disease and 51% had autoimmune hepatitis. Despite 83% with symptoms at presentation, only ∼1/3 were symptomatic at a mean follow-up of 4.1 years. Using a validated MRCP biliary scoring system, the mean intrahepatic score was 1.1 (out of 4) and extrahepatic score was 1.0 (out of 3). The mean Ishak liver fibrosis stage was 3.5 (out of 6) and 33% had cirrhosis. 92% were alive with their native liver and 5% had a liver transplant. Serum biomarker analyses revealed no correlation between Ishak liver fibrosis stage or MRCP score and laboratory values. CONCLUSIONS Pediatric PSC patients cared for at a regional referral center had relatively mild disease compared with previously published reports, with low MRCP stricture scores despite significant liver fibrosis. Liver tests at presentation did not correlate with MRCP stricture score or liver fibrosis stage, suggesting the need for future studies to identify potential biomarkers of disease severity.
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FAGUNDES EDT, FERREIRA AR, HOSKEN CC, QUEIROZ TCN. PRIMARY SCLEROSING CHOLANGITIS IN CHILDREN AND ADOLESCENTS. ARQUIVOS DE GASTROENTEROLOGIA 2017; 54:286-291. [DOI: 10.1590/s0004-2803.201700000-50] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 08/16/2017] [Indexed: 12/15/2022]
Abstract
ABSTRACT BACKGROUND: Primary sclerosing cholangitis is a rare disease, but its prevalence has been underestimated in children and adolescents due to broad variation in clinical presentation as well as diagnostic challenges in this life period. OBJECTIVE: To evaluate children and adolescents with primary sclerosing cholangitis and to describe their clinical, laboratorial, histopathological, and cholangiography conditions. METHODS: This is an observational descriptive research that took place from 2005 to 2016 and included all the patients seen in the Outpatient Unit for Pediatric Hepatology of Hospital das Clinicas of UFMG who had been diagnosed with primary sclerosing cholangitis before the age of 18. Diagnosis was established through clinical, laboratory, radiographic and/or histopathologic criteria. Other chronic liver diseases were excluded, as well as secondary causes of cholangitis. Data analysis used statistic resources in SPSS software. Variables were expressed as averages, standard deviation, absolute frequency, and percentage. RESULTS: Twenty-one patients fulfilled criteria to be included in the research sample. Male patients predominated (3.2:1) and average age at diagnosis was 6.7±3.9 years. Five (23.8%) patients had associated inflammatory bowel disease, four had ulcerative colitis and one indeterminate colitis. Signs and symptoms vary and are usually discrete at presentation. The most frequent symptom was abdominal pain (47.6%) followed less frequently by jaundice (28.6%) and itching (14.3%). The reason for medical investigation was asymptomatic or oligosymptomatic enzyme alterations in 33.3% of patients. All patients presented increased hepatic enzymes: aminotransferases, gamma glutamyl transferase, and alkaline phosphatase. Twenty patients had alterations compatible to primary sclerosing cholangitis in their cholangiography exam; one patient had no alterations at magnetic resonance cholangiography, but presented histopathologic alterations that were compatible to small duct cholangitis. Hepatic fibrosis was present in 60% of 15 patients who were biopsied upon admission; cirrhosis being present in four (26.7%) patients. A total of 28.5% of patients had unfavorable outcomes, including two (9.5%) deaths and four (19%) transplants. CONCLUSION: Primary sclerosing cholangitis is a rare disease in childhood and adolescence and its initial diagnosis may be delayed or overlooked due to asymptomatic or unspecific clinical manifestations. The association with inflammatory bowel disease is common. Prognosis may be unfavorable as the disease progresses and hepatic transplant is the definitive treatment.
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Unique Inflammatory Bowel Disease Phenotype of Pediatric Primary Sclerosing Cholangitis: A Single-Center Study. J Pediatr Gastroenterol Nutr 2017; 65:404-409. [PMID: 28141677 PMCID: PMC5533626 DOI: 10.1097/mpg.0000000000001531] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES In adults, primary sclerosing cholangitis (PSC), a cholestatic liver disease characterized by inflammation/fibrosis of intra/extrahepatic bile ducts, associates with a milder form of inflammatory bowel disease (IBD), particularly ulcerative colitis (UC). The pediatric PSC-IBD phenotype is less well characterized. METHODS We performed a retrospective, single-center study examining patients with PSC-IBD at Texas Children's Hospital between 2000 and 2015. IBD-phenotype (Modified Montreal Classification), medications, laboratory values, endoscopic records, and IBD-based hospital admissions were collected. PSC-UC phenotype was compared to UC, non-PSC patients (n = 95) from Texas Children's Hospital. Elevated gamma-glutamyl transpeptidase levels were compared to calprotectin levels and IBD-flare activity, that is, gastrointestinal symptoms resulting in office/emergency department visits or hospital admission. RESULTS Of 39 patients with PSC-IBD, 34 (87.2%) had UC (PSC-UC) and 5 (12.8%) had Crohn disease. Pancolitis was more common in PSC-UC than UC, non-PSC (96.3%, 64%, P = 0.0009). Patients with PSC-UC required less treatment with steroids (76.5%, 91.6%, P = 0.0326) or infliximab (8.8%, 37.9%, P = 0.0011), and fewer had at least 1 IBD-related hospital admission (32.4%, 63.2%, P = 0.0025) than UC, non-PSC. Progression to colectomy was significantly less (5.8%, 24.2%, P = 0.0223) in PSC-UC. Median diagnosis-to-colectomy time tended to be longer in PSC-UC (6.37, 2.5 years, P = 0.0792). In 2 smaller subsets, gamma-glutamyl transpeptidase did not correlate with calprotectin in PSC-UC (n = 11, P = 0.7922) and less strongly associated with IBD-flares in PSC-UC than UC, non-PSC (n = 33, n = 67; 15.2%, 41.8%, P = 0.0120). CONCLUSIONS Pediatric PSC appears to associate with milder pancolitic-UC. PSC and IBD activity do not appear to correlate. Our findings may provide useful information toward etiology and management of pediatric PSC-IBD.
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Eaton JE, McCauley BM, Atkinson EJ, Juran BD, Schlicht EM, de Andrade M, Lazaridis KN. Variations in primary sclerosing cholangitis across the age spectrum. J Gastroenterol Hepatol 2017; 32:1763-1768. [PMID: 28245345 PMCID: PMC5573663 DOI: 10.1111/jgh.13774] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 02/01/2017] [Accepted: 02/20/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Primary sclerosing cholangitis (PSC) typically develops in middle-age adults. Little is known about phenotypic differences when PSC is diagnosed at various ages. Therefore, we sought to compare the clinical characteristics of a large PSC cohort based on the age when PSC was diagnosed. METHODS We performed a multicenter retrospective review to compare the features of PSC among those diagnosed between 1-19 (n = 95), 20-59 (n = 662), and 60-79 years (n = 102). RESULTS Those with an early diagnosis (ED) of PSC were more likely to have small-duct PSC (13%) than those with a middle-age diagnosis (MD) (5%) and late diagnosis (LD) groups (2%), P < 0.01, and appeared to have a decrease risk of hepatobiliary malignancies: ED versus MD: hazard ratio (HR), 0.25; 95% confidence interval (CI) 0.06-1.03, and ED versus LD: HR, 0.07; 95% CI 0.01-0.62. Cholangiocarcinoma was diagnosed in 78 subjects (ED n = 0, MD n = 66, and LD n = 12) and was more likely to be diagnosed within a year after the PSC diagnosis among those found to have PSC late in life: ED 0% (0/95), MD 2% (14/662), and LD 6% (6/102), P = 0.02. Similarly, hepatic decompensation was more common among those with LD-PSC versus younger individuals: LD versus MD: HR, 1.64; 95% CI 0.98-2.70, and LD versus ED: HR, 2.26; 95% CI 1.02-5.05. CONCLUSIONS Those diagnosed with PSC early in life are more likely to have small-duct PSC and less likely to have disease-related complications. Clinicians should be vigilant for underlying cholangiocarcinoma among those with PSC diagnosed late in life.
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Affiliation(s)
- John E. Eaton
- Division of Gastroenterology & Hepatology Mayo Clinic, Rochester, MN
| | - Bryan M. McCauley
- Division of Biomedical Statistics and Informatics Mayo Clinic, Rochester, MN
| | | | - Brian D. Juran
- Division of Gastroenterology & Hepatology Mayo Clinic, Rochester, MN
| | - Erik M. Schlicht
- Division of Gastroenterology & Hepatology Mayo Clinic, Rochester, MN
| | - Mariza de Andrade
- Division of Biomedical Statistics and Informatics Mayo Clinic, Rochester, MN
| | - Konstantinos N. Lazaridis
- Division of Gastroenterology & Hepatology Mayo Clinic, Rochester, MN,Corresponding Author: Konstantinos N. Lazaridis, M.D, Professor of Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, , Phone: 507-284-1006, Fax: 507-284-0762
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Mieli-Vergani G, Vergani D. The Riddle of Juvenile Sclerosing Cholangitis. Hepatology 2017; 66:315-317. [PMID: 28407274 DOI: 10.1002/hep.29208] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 04/06/2017] [Indexed: 12/24/2022]
Affiliation(s)
- Giorgina Mieli-Vergani
- Paediatric Liver, GI and Nutrition Centre, MowatLabs, Faculty of Life Sciences & Medicine at King's College Hospital, London, United Kingdom
| | - Diego Vergani
- Paediatric Liver, GI and Nutrition Centre, MowatLabs, Faculty of Life Sciences & Medicine at King's College Hospital, London, United Kingdom
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Deneau MR, El-Matary W, Valentino PL, Abdou R, Alqoaer K, Amin M, Amir AZ, Auth M, Bazerbachi F, Broderick A, Chan A, Cotter J, Doan S, El-Youssef M, Ferrari F, Furuya KN, Gottrand M, Gottrand F, Gupta N, Homan M, Kamath BM, Kim KM, Kolho KL, Konidari A, Koot B, Iorio R, Ledder O, Mack C, Martinez M, Miloh T, Mohan P, O'Cathain N, Papadopoulou A, Ricciuto A, Saubermann L, Sathya P, Shteyer E, Smolka V, Tanaka A, Varier R, Venkat V, Vitola B, Vos MB, Woynarowski M, Yap J, Jensen MK. The natural history of primary sclerosing cholangitis in 781 children: A multicenter, international collaboration. Hepatology 2017; 66:518-527. [PMID: 28390159 DOI: 10.1002/hep.29204] [Citation(s) in RCA: 126] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 02/07/2017] [Accepted: 04/04/2017] [Indexed: 12/14/2022]
Abstract
UNLABELLED There are limited data on the natural history of primary sclerosing cholangitis (PSC) in children. We aimed to describe the disease characteristics and long-term outcomes of pediatric PSC. We retrospectively collected all pediatric PSC cases from 36 participating institutions and conducted a survival analysis from the date of PSC diagnosis to dates of diagnosis of portal hypertensive or biliary complications, cholangiocarcinoma, liver transplantation, or death. We analyzed patients grouped by disease phenotype and laboratory studies at diagnosis to identify objective predictors of long-term outcome. We identified 781 patients, median age 12 years, with 4,277 person-years of follow-up; 33% with autoimmune hepatitis, 76% with inflammatory bowel disease, and 13% with small duct PSC. Portal hypertensive and biliary complications developed in 38% and 25%, respectively, after 10 years of disease. Once these complications developed, median survival with native liver was 2.8 and 3.5 years, respectively. Cholangiocarcinoma occurred in 1%. Overall event-free survival was 70% at 5 years and 53% at 10 years. Patient groups with the most elevated total bilirubin, gamma-glutamyltransferase, and aspartate aminotransferase-to-platelet ratio index at diagnosis had the worst outcomes. In multivariate analysis PSC-inflammatory bowel disease and small duct phenotypes were associated with favorable prognosis (hazard ratios 0.6, 95% confidence interval 0.5-0.9, and 0.7, 95% confidence interval 0.5-0.96, respectively). Age, gender, and autoimmune hepatitis overlap did not impact long-term outcome. CONCLUSION PSC has a chronic, progressive course in children, and nearly half of patients develop an adverse liver outcome after 10 years of disease; elevations in bilirubin, gamma-glutamyltransferase, and aspartate aminotransferase-to-platelet ratio index at diagnosis can identify patients at highest risk; small duct PSC and PSC-inflammatory bowel disease are more favorable disease phenotypes. (Hepatology 2017;66:518-527).
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Affiliation(s)
| | | | | | - Reham Abdou
- State University of New York Buffalo, Buffalo, NY
| | - Khaled Alqoaer
- Prince Salman North West Armed Forces Hospital, Tabuk, Saudi Arabia
| | - Mansi Amin
- University of California San Francisco, San Francisco, CA, and Texas Children's Hospital, Houston, TX
| | - Achiya Z Amir
- The Dana-Dwek Children's Hospital, The Tel-Aviv Medical Center, Tel-Aviv University, Tel Aviv, Israel
| | - Marcus Auth
- Alder Hey Children's Hospital, Liverpool, UK
| | | | | | - Albert Chan
- University of Rochester Medical Center, Rochester, NY
| | | | | | | | | | - Katryn N Furuya
- Mayo Clinic, Rochester, MN.,Nemours Alfred I duPont Hospital For Children, Wilmington, DE
| | | | | | - Nitika Gupta
- Emory University School of Medicine, Atlanta, GA
| | | | | | | | | | - Anastasia Konidari
- University of Liverpool, Liverpool, and University of Manchester, Manchester, UK
| | - Bart Koot
- Academic Medical Centre, Amsterdam, The Netherlands
| | | | - Oren Ledder
- Shaare Zedek Medical Center, Jerusalem, Israel
| | - Cara Mack
- University of Colorado School of Medicine, Aurora, CO
| | - Mercedes Martinez
- Columbia University College of Physicians and Surgeons, New York, NY
| | - Tamir Miloh
- Texas Children's Hospital, Houston, TX, and Phoenix Children's Hospital, Phoenix, AZ
| | | | | | | | | | | | - Pushpa Sathya
- Memorial University, St. John's, Newfoundland and Labrador, Canada
| | | | | | | | - Raghu Varier
- Northwest Pediatric Gastroenterology LLC, Portland, OR
| | - Veena Venkat
- University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | - Miriam B Vos
- Emory University School of Medicine, Atlanta, GA
| | | | - Jason Yap
- University of Alberta, Edmonton, Alberta, Canada
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Hepatic Issues and Complications Associated With Inflammatory Bowel Disease: A Clinical Report From the NASPGHAN Inflammatory Bowel Disease and Hepatology Committees. J Pediatr Gastroenterol Nutr 2017; 64:639-652. [PMID: 27984347 DOI: 10.1097/mpg.0000000000001492] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Hepatobiliary disorders are common in patients with inflammatory bowel disease (IBD), and persistent abnormal liver function tests are found in approximately 20% to 30% of individuals with IBD. In most cases, the cause of these elevations will fall into 1 of 3 main categories. They can be as a result of extraintestinal manifestations of the disease process, related to medication toxicity, or the result of an underlying primary hepatic disorder unrelated to IBD. This latter possibility is beyond the scope of this review article, but does need to be considered in anyone with elevated liver function tests. This review is provided as a clinical summary of some of the major hepatic issues that may occur in patients with IBD.
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Liver Transplantation for Children With Primary Sclerosing Cholangitis and Autoimmune Hepatitis: UNOS Database Analysis. J Pediatr Gastroenterol Nutr 2017; 64:e83-e87. [PMID: 27755342 DOI: 10.1097/mpg.0000000000001438] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Autoimmune hepatitis (AIH) and primary sclerosing cholangitis (PSC) are progressive immune-mediated inflammatory diseases that may require liver transplant (LT). Outcomes in children undergoing LT for these diseases are poorly studied in the pediatric end-stage liver disease era. We aimed to characterize the outcome of LT in children with AIH and PSC. METHODS Children 18 years or younger with PSC or AIH who had a first, isolated LT from 2002 to 2012 were identified from the United Network for Organ Sharing database. Graft and patient outcomes were studied. RESULTS A total of 174 children with AIH and 113 with PSC were transplanted in the study period. One-year patient survival was 95.4% for AIH and 97.3% for PSC. Five-year patient survival was 91.4% for AIH and 92.9% for PSC. Patient survival was not significantly different between the 2 groups. Forty-four (25.2%) children with AIH were listed as status 1 for transplant (fulminant hepatic failure at presentation or acute-on-chronic disease). Patients transplanted as status 1 had significantly lower patient survival compared with patients transplanted with AIH and end-stage liver disease. The one- and five-year graft survival rates were not significantly different between patients with AIH and PSC. CONCLUSION Children with AIH transplanted as status 1 had significantly lower patient survival rates but similar graft survival rates to children with chronic AIH. Children transplanted for AIH versus PSC showed no significant differences in patient or graft survival at both 1 and 5 years.
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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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Ali AH, Tabibian JH, Lindor KD. Update on pharmacotherapies for cholestatic liver disease. Hepatol Commun 2016; 1:7-17. [PMID: 29404429 PMCID: PMC5747033 DOI: 10.1002/hep4.1013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 10/30/2016] [Indexed: 12/20/2022] Open
Abstract
Cholestatic liver diseases are conditions with impaired bile formation and/or flow due to genetic, immunologic, environmental, or other causes. Unless successfully treated, this can lead to chronic liver injury and end‐stage liver disease. Primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC) embody the most prominent adult cholestatic liver diseases with regard to incidence, morbidity, and mortality. A considerable proportion of patients with PBC and PSC experience progressive liver disease and ultimately liver‐related death due to a paucity of effective pharmacotherapy; however, novel pharmacologic developments offer substantial promise in this regard. Here, we provide a brief review and update on current and emerging pharmacotherapies for PBC and PSC. (Hepatology Communications 2017;1:7–17)
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Affiliation(s)
- Ahmad H Ali
- Division of Gastroenterology and Hepatology Mayo Clinic Scottsdale AZ
| | - James H Tabibian
- Division of Gastroenterology and Hepatology University of California, Davis Medical Center Sacramento CA
| | - Keith D Lindor
- Division of Gastroenterology and Hepatology Mayo Clinic Scottsdale AZ.,College of Health Solutions Arizona State University Phoenix AZ
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The Natural History of Primary Sclerosing Cholangitis in Children: A Large Single-Center Longitudinal Cohort Study. J Pediatr Gastroenterol Nutr 2016; 63:603-609. [PMID: 27504812 DOI: 10.1097/mpg.0000000000001368] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Data regarding pediatric primary sclerosing cholangitis (PSC) natural history are limited. We describe a large pediatric PSC cohort with longitudinal follow-up. METHODS The present study records review of pediatric patients with PSC diagnosed between 1984 and 2014. RESULTS N = 120 (63% M) ages 1 to 21 years (median 14 years) at diagnosis. 27% (31/113) had autoimmune sclerosing cholangitis (ASC), 24% had exclusive small duct PSC, METAVIR stage was F3-F4 in 41%. Eighty-one percent of patients with PSC had inflammatory bowel disease (IBD); most had ulcerative/indeterminate colitis (72/97), typically pancolitis (40/72). PSC-IBD was more common than ASC-IBD (85% vs 68%, P = 0.03). Median follow-up was 3.7 years (interquartile range [IQR] 1.5, 6.9). Median gamma glutamyl transferase decreased from baseline of 221 U/L (IQR 110, 425) to 104 U/L by 1 year postdiagnosis ([IQR 18,229], P < 0.0001), and then changed little. Mean fibrosis stage at diagnosis was 2.3 ± 1.4 (N = 91), and at 1 to 5 years was 2.6 ± 1.3 (N = 20). Transplant-free survival at 10 year was 89%; there were 6 liver transplants, 2 in patients with small duct PSC and 4 with diffuse large duct PSC. Although the cirrhosis rate was not significantly different in PSC with IBD versus without (22% vs 41%, P = 0.06), the former had a lower rate of liver transplantation (2% vs 18%, P = 0.01). The rate of cirrhosis was lower in patients diagnosed with IBD before PSC (15% vs 31%, P = 0.05). CONCLUSIONS In this largest reported pediatric PSC cohort, liver transplantation rate at 10 years was lower than that reported in adults. ASC and PSC had similar biochemical abnormalities and degree of fibrosis at diagnosis. PSC that developed after IBD diagnosis had a milder course, possibly reflecting earlier disease detection or milder phenotype.
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Jagadisan B, Srivastava A. Child with Jaundice and Pruritus: How to Evaluate? Indian J Pediatr 2016; 83:1311-1320. [PMID: 26932879 DOI: 10.1007/s12098-016-2058-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 02/01/2016] [Indexed: 12/01/2022]
Abstract
Jaundice with pruritus is a manifestation of cholestasis. The defective biliary drainage causes accumulation of substances that are usually excreted in bile, which in turn causes pruritus. The exact nature of the pruritogen is under evaluation. However, lysophosphatidic acid is the current favourite. The causes of cholestasis can be broadly classified as intra or extrahepatic, with intrahepatic disorders being more often associated with pruritus. Cholestatic phase of acute viral hepatitis, progressive familial intrahepatic cholestasis, syndromic and non-syndromic paucity of intralobular bile ductules, drug induced cholestasis and sclerosing cholangitis (SC) are the common causes in children. An algorithmic approach facilitates early etiological diagnosis by careful clinical evaluation combined with investigations including gamma glutamyl transpeptidase, radiological imaging (ultrasonography, magnetic resonance cholangiopancreatography), liver biopsy and genetic analysis. Management is largely supportive and includes nutritional rehabilitation with supplement of fat soluble vitamins and calcium, stepwise therapy of pruritus with drugs (ursodeoxycholic acid, rifampicin, bile acid sequestrants and/or opioid antagonists) and biliary diversion surgery. Complications of advanced liver disease and portal hypertension need to be addressed. Liver transplantation is required in children with refractory pruritus affecting the quality of life or those with end stage liver disease. Relief of biliary obstruction by endoscopy or surgery and treatment of diseases associated with SC like histiocytosis may be rewarding. Long-term follow-up for development of complications of liver disease and hepatocellular/ cholangiocarcinoma is essential. Thus, an early diagnosis and stepwise treatment with an understanding of the pathogenesis of pruritus in cholestatic disorders may decrease morbidity and mortality.
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Affiliation(s)
- Barath Jagadisan
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | - Anshu Srivastava
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226014, Uttar Pradesh, India.
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