1
|
Lai MW. Challenges in the diagnosis of biliary atresia in cholestatic neonates. Pediatr Neonatol 2023; 64:3-4. [PMID: 36550017 DOI: 10.1016/j.pedneo.2022.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 12/07/2022] [Indexed: 12/23/2022] Open
Affiliation(s)
- Ming-Wei Lai
- Division of Pediatric Gastroenterology, Department of Pediatrics, Chang Gung Memorial Hospital, Linkou Branch, Taiwan; Liver Research Center, Chang Gung Memorial Hospital, Linkou Branch, Taiwan; Chang Gung University College of Medicine, Taiwan.
| |
Collapse
|
2
|
Diagnostic Efficacy of Advanced Ultrasonography Imaging Techniques in Infants with Biliary Atresia (BA): A Systematic Review and Meta-Analysis. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9111676. [PMID: 36360404 PMCID: PMC9688715 DOI: 10.3390/children9111676] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 10/24/2022] [Accepted: 10/27/2022] [Indexed: 11/06/2022]
Abstract
The early diagnosis of biliary atresia (BA) in cholestatic infants is critical to the success of the treatment. Intraoperative cholangiography (IOC), an invasive imaging technique, is the current strategy for the diagnosis of BA. Ultrasonography has advanced over recent years and emerging techniques such as shear wave elastography (SWE) have the potential to improve BA diagnosis. This review sought to evaluate the diagnostic efficacy of advanced ultrasonography techniques in the diagnosis of BA. Six databases (CINAHL, Medline, PubMed, Google Scholar, Web of Science (core collection), and Embase) were searched for studies assessing the diagnostic performance of advanced ultrasonography techniques in differentiating BA from non-BA causes of infantile cholestasis. The meta-analysis was performed using Meta-DiSc 1.4 and Comprehensive Meta-analysis v3 software. Quality Assessment of Diagnostic Accuracy Studies tool version 2 (QUADAS-2) assessed the risk of bias. Fifteen studies consisting of 2185 patients (BA = 1105; non-BA = 1080) met the inclusion criteria. SWE was the only advanced ultrasonography technique reported and had a good pooled diagnostic performance (sensitivity = 83%; specificity = 77%; AUC = 0.896). Liver stiffness indicators were significantly higher in BA compared to non-BA patients (p < 0.000). SWE could be a useful tool in differentiating BA from non-BA causes of infantile cholestasis. Future studies to assess the utility of other advanced ultrasonography techniques are recommended.
Collapse
|
3
|
Kuebler JF, Madadi-Sanjani O, Pfister ED, Baumann U, Fortmann D, Leonhardt J, Ure BM, Manns MP, Taubert R, Petersen C. Adjuvant Therapy with Budesonide Post-Kasai Reduces the Need for Liver Transplantation in Biliary Atresia. J Clin Med 2021; 10:jcm10245758. [PMID: 34945055 PMCID: PMC8704494 DOI: 10.3390/jcm10245758] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 11/26/2021] [Accepted: 12/03/2021] [Indexed: 12/12/2022] Open
Abstract
Based on the hypothesis that autoimmunological factors coregulate the pathomechanism in biliary atresia (BA), adjuvant therapy with steroids has become routine, although its efficacy has never been proven. In 2010, a study on the advantages of budesonide compared to prednisolone in autoimmune hepatitis gave rise to experimental therapy using budesonide as an adjuvant BA treatment. Ninety-five BA patients prospectively received a budesonide 2 mg/dose rectal foam daily for three months (SG). A case-matched control group (CG: 81) was retrospectively recruited. The outcome measures were survival with native liver (SNL), determined at six months and two years after the Kasai procedure. The follow-up rate was 100%. At six months, SNL was statistically not different but became so after two years (SG: 54%; CG: 32%; p < 0.001). No steroid-related side effects were observed, except for eight patients with finally caught-up growth retardation. This study demonstrates for the first time a significantly longer survival with native liver in patients with BA after adjuvant therapy. However, indication, dosage, and duration of any budesonide application is not given in neonates with BA. Hence, we suggest extending the postoperative use of budesonide in a multicenter observational study with a clearly defined follow-up protocol, particularly in terms of potentially underestimated side effects.
Collapse
Affiliation(s)
- Joachim F. Kuebler
- Department of Pediatric Surgery, Hannover Medical School, 30625 Hannover, Germany; (J.F.K.); (O.M.-S.); (D.F.); (B.M.U.)
| | - Omid Madadi-Sanjani
- Department of Pediatric Surgery, Hannover Medical School, 30625 Hannover, Germany; (J.F.K.); (O.M.-S.); (D.F.); (B.M.U.)
| | - Eva D. Pfister
- Department of Paediatric Gastroenterology and Hepatology, Hannover Medical School, 30625 Hannover, Germany; (E.D.P.); (U.B.)
| | - Ulrich Baumann
- Department of Paediatric Gastroenterology and Hepatology, Hannover Medical School, 30625 Hannover, Germany; (E.D.P.); (U.B.)
| | - David Fortmann
- Department of Pediatric Surgery, Hannover Medical School, 30625 Hannover, Germany; (J.F.K.); (O.M.-S.); (D.F.); (B.M.U.)
| | - Johannes Leonhardt
- Clinic for Pediatric Surgery, Klinikum Braunschweig, 38118 Braunschweig, Germany;
| | - Benno M. Ure
- Department of Pediatric Surgery, Hannover Medical School, 30625 Hannover, Germany; (J.F.K.); (O.M.-S.); (D.F.); (B.M.U.)
| | - Michael P. Manns
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, 30625 Hannover, Germany; (M.P.M.); (R.T.)
| | - Richard Taubert
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, 30625 Hannover, Germany; (M.P.M.); (R.T.)
| | - Claus Petersen
- Department of Pediatric Surgery, Hannover Medical School, 30625 Hannover, Germany; (J.F.K.); (O.M.-S.); (D.F.); (B.M.U.)
- Correspondence: ; Tel.: +49-511-532-9047; Fax: +49-511-532-9059
| |
Collapse
|
4
|
Tagawa M, Morita A, Imagawa K, Mizokami Y. Endoscopic retrograde cholangiopancreatography and endoscopic ultrasound in children. Dig Endosc 2021; 33:1045-1058. [PMID: 33423305 DOI: 10.1111/den.13928] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 01/04/2021] [Accepted: 01/06/2021] [Indexed: 12/13/2022]
Abstract
Gastrointestinal endoscopy is fundamental to diagnostic and therapeutic procedures in pediatric gastroenterology. In the decades since endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) for hepatobiliary and pancreatic disease were introduced into clinical practice, there has been increasing interest in these procedures, and practice guidelines and position papers that clearly define the role of ERCP and EUS in children have been published. Based on the distinction of endoscopy between children and adults, this review focuses on the current state of ERCP and EUS procedures in children, including the types of endoscopes used in children, general anesthesia and radiation exposure, biliary and pancreatic indications, considerations of education and training for ERCP and EUS procedures in children, and expectations for development of endoscopes for children.
Collapse
Affiliation(s)
- Manabu Tagawa
- Department of Child Health, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Atsushi Morita
- Department of Child Health, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Kazuo Imagawa
- Department of Child Health, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Yuji Mizokami
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan.,Endoscopic Center, University of Tsukuba Hospital, Ibaraki, Japan
| |
Collapse
|
5
|
Åvitsland TL, Aabakken L. Endoscopic retrograde cholangiopancreatography in infants and children. Endosc Int Open 2021; 9:E292-E296. [PMID: 33655024 PMCID: PMC7892276 DOI: 10.1055/a-1337-2212] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 11/19/2020] [Indexed: 01/20/2023] Open
Abstract
Background and study aims Previous reports have suggested that endoscopic retrograde cholangiopancreatography (ERCP) in pediatric patients are safe. However, the total number of cases presented in the literature remains small. We present results regarding safety and outcomes in pediatric patients undergoing ERCP at Oslo University Hospital. Patients and methods Patients < 18 years who underwent ERCP between April 1999 and November 2017 were identified using procedure codes. Medical records were examined for age, gender, diagnosis, indications, type of sedation, findings, interventions, and complications. Results A total of 244 procedures were performed in 158 patients. Fifty-six of these were in 53 infants (age ≤ 1 year). Mean age was 8.8 years. The youngest patient was 8 days old. Mean weight was 5.0 kg in infants, the smallest weighing 2.9 kg. Cannulation failed in 19 (7.8 %). The main indication in infants was suspicion of biliary atresia (n = 38). Six of the procedures (10.7 %) were therapeutic. In children the main indications were biliary stricture (n = 64) and investigation of primary sclerosing cholangitis (PSC) (n = 45). 119 (63.2 %) of these procedures were therapeutic. Complications were uncommon in infants; only two episodes of infection were registered. In children (> 1 year) post-ERCP pancreatitis were seen in 10.4 %. Conclusions Our retrospective series of ERCP procedures includes 56 procedures in infants, which is one of the largest series presented. Complications in infants are rare and post-ERCP pancreatitis was not seen. In older children 10.4 % experienced post-ERCP pancreatitis. In expert hands, ERCP was shown to be acceptably feasible and safe in infants and children.
Collapse
Affiliation(s)
- Tone Lise Åvitsland
- Section for Gastroenterology, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Lars Aabakken
- Section for Gastroenterology, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| |
Collapse
|
6
|
Martin M, Holmes S, Sim J, Hassan M, Mathew R, Bensen R, Barakat M. Foregone Inclusion: Neonatal CMV Hepatitis and Cholestasis. Dig Dis Sci 2019; 64:3092-3095. [PMID: 31187327 DOI: 10.1007/s10620-019-05691-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Melissa Martin
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Lucille Packard Children's Hospital at Stanford, Stanford, CA, 94305, USA.
| | - Signy Holmes
- Division of Radiology, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Jordan Sim
- Division of Pathology, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Maheen Hassan
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Lucille Packard Children's Hospital at Stanford, Stanford, CA, 94305, USA
| | - Roshni Mathew
- Division of Pediatric Infectious Diseases, Lucille Packard Children's Hospital at Stanford, Stanford, CA, 94305, USA
| | - Rachel Bensen
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Lucille Packard Children's Hospital at Stanford, Stanford, CA, 94305, USA
| | - Monique Barakat
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Lucille Packard Children's Hospital at Stanford, Stanford, CA, 94305, USA
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, 94305, USA
| |
Collapse
|
7
|
Goetz M, Andersen P, Bergman J, Frei N, Schmidt A, Kähler G, Martus P, Dechêne A. ERCP in babies: Low risk of post-ERCP pancreatitis - results from a multicentre survey. United European Gastroenterol J 2019; 8:77-80. [PMID: 32213056 DOI: 10.1177/2050640619874187] [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] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND AND AIMS Endoscopic retrograde cholangiopancreatography (ERCP) is rarely performed in newborns, and the risk of post-ERCP pancreatitis (PEP) has not been defined in this age group. We therefore performed a European multicentre analysis of PEP rates and risk factors in children aged ≤1 year. PATIENTS AND METHODS Based on a sample size estimation, 135 consecutive ERCPs in 126 children aged ≤1 year were evaluated from five European centres, and the first ERCP per child analysed. All ERCPs and clinical reports were reviewed manually for PEP and associated risk factors. All ERCPs were performed by endoscopists with high ERCP expertise. RESULTS No PEP was observed (0/126, 0.0%, CI 0-2.9%) despite the formal presence of multiple risk factors and despite lack of PEP prophylaxis (except one patient having received a pancreatic duct stent). The PEP rate was significantly lower than the PEP rate expected in adults with similar risk factors. CONCLUSIONS ERCP in children aged ≤1 year is safe in terms of PEP. The PEP risk is significantly lower in children aged ≤1 year than in adults, therefore no PEP prophylaxis seems to be needed in young children. Risk factors from adults may not apply to children under 1 year. Reluctance to perform diagnostic ERCP in suspected biliary anomalies should not be based on presumed PEP risk.
Collapse
Affiliation(s)
- Martin Goetz
- Innere Medizin I, Universitätsklinikum Tübingen, Tübingen, Germany.,Medizinische Klinik IV, Kliniken Böblingen, Böblingen, Germany
| | - Philipp Andersen
- Innere Medizin I, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Jacques Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Nicola Frei
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Arthur Schmidt
- Department of Medicine II, Faculty of Medicine, University of Freiburg; Medical Centre, Freiburg, Germany
| | - Georg Kähler
- Central Interdisciplinary Endoscopy, Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Peter Martus
- Institut für Klinische Epidemiologie und Angewandte Biometrie (IKEaB), Universität Tübingen, Tübingen, Germany
| | - Alexander Dechêne
- Klinik für Innere Medizin 6, Klinikum Nürnberg, Universitätsklinik der Paracelsus Medizinischen Privatuniversität, Nürnberg, Germany.,Klinik für Gastroenterologie und Hepatologie, Universitätsklinikum Essen, Essen, Germany
| |
Collapse
|
8
|
Pandita A, Gupta V, Gupta G. Neonatal Cholestasis: A Pandora's Box. CLINICAL MEDICINE INSIGHTS-PEDIATRICS 2018; 12:1179556518805412. [PMID: 30574003 PMCID: PMC6295748 DOI: 10.1177/1179556518805412] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 08/29/2018] [Indexed: 12/15/2022]
Abstract
Neonatal cholestasis (NC) is a diagnostic dilemma frequently countered in a neonatal care unit. Early diagnosis is vital for achieving an optimal patient outcome as many causes of cholestasis such as biliary atresia are time-sensitive and amenable to treatment if analyzed and treated early. Nonetheless, it is not generally simple to analyze these cases right on time as some of them are regularly missed due to the presence of pigmented stools, lack of newborn metabolic screening, and named as instances of prolonged jaundice. In this manner, we prescribe to explore all reasons for prolonged jaundice stretching out past 14 days in neonates. Besides, we suggest that stool card ought to be a piece of release rundown for all newborn children being released from the nursery. This is of most extreme significance in the nation like India where guaranteeing customary follow-up is as yet a tough assignment. These stool cards will help in the early determination of patients with NC particularly biliary atresia and guarantee their auspicious cure. Another reason which needs exceptional say is parenteral nutrition–associated liver illness, as the proportion of preterm babies is getting greater and greater with better neonatal care. These extreme preterm infants are in the requirement for prolonged (>14 days) total parenteral nourishment because of which they are at high hazard for NC contrasted with their more developed peers. In this survey, we will give an understanding of clinical approach, differential diagnosis, and clinical review of NC.
Collapse
Affiliation(s)
- Aakash Pandita
- Department of Neonatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Vishal Gupta
- Department of Neonatology, Max Hospital, New Delhi, India
| | - Girish Gupta
- Department of Neonatology, Max Hospital, New Delhi, India
| |
Collapse
|
9
|
Abstract
Biliary atresia (BA) is a rare disease of unknown origin and unsatisfying outcome. Single, multicenter and national evaluations of epidemiological and outcome data on BA have been periodically published over the course of decades. However, the diversity of the registered parameters and outcome measures impede comparability and cumulative analysis of these very worthwhile studies. Taking into account the fact that BA is a good example of translational research and transition of patients from pediatric surgery and hepatology to transplant surgery and hepatology in general, the interdisciplinary community should make every effort to develop a common platform upon which further activities are conducted. Extending this topic to BA-related diseases might increase the acceptance of research studies and enhance the effectiveness of any recommendations outlined therein. The use of the Internet-based communication platform and registry on http://www.bard-online.com represents the first step in this direction, and the database should be viewed as a helpful tool that guides further activities.
Collapse
Affiliation(s)
- Claus Petersen
- Department of Pediatric Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hanover, Germany.
| |
Collapse
|
10
|
Gu YH, Matsui A. Long-term native liver survival in infants with biliary atresia and use of a stool color card: Case-control study. Pediatr Int 2017; 59:1189-1193. [PMID: 28688191 DOI: 10.1111/ped.13360] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 06/10/2017] [Accepted: 07/05/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND So far, there has been no epidemiological study on whether long-term native liver survival (NLS) in infants with biliary atresia (BA) is associated with use of a stool color card (SCC). METHODS A case-control study was performed, involving two associations for patients with BA in Japan. Participants were patients with BA who were born and underwent their first open Kasai procedures (KP) between August 1994 and March 2011, and who were also members of either of two associations for patients with BA in Japan. SCC users were classified as cases and SCC non-users as controls. RESULTS Mean age at the time of the first open KP was 59.7 and 68.2 days in SCC users and non-users, respectively (P < 0.05). According to Kaplan-Meier analysis, the probability of NLS at 12.5 years was 48.5% and 36.6% in SCC users and non-users (P < 0.05), respectively. On Cox proportional hazard modeling, not using an SCC was harmful to long-term NLS (hazard ratio, 2.61; 95% CI: 1.20-5.70; P = 0.016), adjusted for sex, age of timing of KP and type of BA. CONCLUSIONS Long-term NLS is associated with SCC for early detection, but not associated with age or a threshold of age at KP (<90 days) in patients with BA.
Collapse
Affiliation(s)
- Yan-Hong Gu
- Department of Hygiene and Public Health, Osaka Medical College, Osaka, Japan
| | - Akira Matsui
- Department of Hepatology, National Medical Center for Children and Mothers, National Center for Child Health and Development, Tokyo, Japan
| |
Collapse
|
11
|
Felux J, Sturm E, Busch A, Zerabruck E, Graepler F, Stüker D, Manger A, Kirschner HJ, Blumenstock G, Malek NP, Goetz M. ERCP in infants, children and adolescents is feasible and safe: results from a tertiary care center. United European Gastroenterol J 2017; 5:1024-1029. [PMID: 29163969 DOI: 10.1177/2050640616687868] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 12/09/2016] [Indexed: 12/15/2022] Open
Abstract
Background Indications for endoscopic retrograde cholangiopancreatography (ERCP) in children differ from adults. Paucity of data and concerns about potential lower effectiveness and more side effects limit its use even in high volume centers. We retrospectively analyzed indications, success rates, limitations, and side effects of ERCPs in children <18 years. Methods From January 2012 to March 2015, 54 ERCPs were performed in 31 children (median age 11 (0-17) years; median weight 22 (3.3-142.7) kg) with suspected choledocholithiasis (n = 13 interventions in 9 patients), post-transplantation anastomotic stenosis (10/4), malignancy (10/5), chronic pancreatitis (7/1), biliary atresia (6/6), anomaly (2/2), leak (4/3), or primary sclerosing cholangitis (PSC) (2/1). All patients were followed up as inpatients. Results Thirty-six therapeutic and 18 diagnostic procedures were performed by adult ERCP expert endoscopists. Successful intervention was achieved in 90.7% of cases. Failed cannulation (n = 4) was associated with lower body weight (p = 0.023). In children younger than 1 year, ERCP was significantly more often diagnostic than in patients >1 year (p < 0.001). In three of six infants with suspected atresia, surgical exploration was avoided. Five complications were recorded (9.3%), and included four episodes of mild pancreatitis (7.4% post-ERCP pancreatitis (PEP) rate) and one cholangitis in PSC. A trend towards a protective effect of pancreatic stents on PEP was observed. All complications were managed conservatively. No complications were attributed to mechanical stress on the gastrointestinal tract. Conclusions ERCP in newborns, infants, and adolescents can be safely performed with high technical and clinical success. Endoscopists must be aware of differing spectrum of pediatric diseases. Failed cannulation was associated with lower body weight of young children. Complications were similar to rates reported in adults.
Collapse
Affiliation(s)
- Jasmin Felux
- Innere Medizin I, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Ekkehard Sturm
- Klinik für Kinder- und Jugendmedizin, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Andreas Busch
- Klinik für Kinder- und Jugendmedizin, Universitätsklinikum Tübingen, Tübingen, Germany
| | | | - Florian Graepler
- Innere Medizin I, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Dietmar Stüker
- Allgemeine, Viszeral- und Transplantationsmedizin, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Andreas Manger
- Anästhesiologie und Intensivmedizin, Universitätsklinikum Tübingen, Tübingen, Germany
| | | | - Gunnar Blumenstock
- Klinische Epidemiologie und angewandte Biometrie, University of Tübingen, Tübingen, Germany
| | - Nisar P Malek
- Innere Medizin I, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Martin Goetz
- Innere Medizin I, Universitätsklinikum Tübingen, Tübingen, Germany
| |
Collapse
|
12
|
Thomson M, Tringali A, Dumonceau JM, Tavares M, Tabbers MM, Furlano R, Spaander M, Hassan C, Tzvinikos C, Ijsselstijn H, Viala J, Dall'Oglio L, Benninga M, Orel R, Vandenplas Y, Keil R, Romano C, Brownstone E, Hlava Š, Gerner P, Dolak W, Landi R, Huber WD, Everett S, Vecsei A, Aabakken L, Amil-Dias J, Zambelli A. Paediatric Gastrointestinal Endoscopy: European Society for Paediatric Gastroenterology Hepatology and Nutrition and European Society of Gastrointestinal Endoscopy Guidelines. J Pediatr Gastroenterol Nutr 2017; 64:133-153. [PMID: 27622898 DOI: 10.1097/mpg.0000000000001408] [Citation(s) in RCA: 143] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This guideline refers to infants, children, and adolescents ages 0 to 18 years. The areas covered include indications for diagnostic and therapeutic esophagogastroduodenoscopy and ileocolonoscopy; endoscopy for foreign body ingestion; corrosive ingestion and stricture/stenosis endoscopic management; upper and lower gastrointestinal bleeding; endoscopic retrograde cholangiopancreatography; and endoscopic ultrasonography. Percutaneous endoscopic gastrostomy and endoscopy specific to inflammatory bowel disease has been dealt with in other guidelines and are therefore not mentioned in this guideline. Training and ongoing skill maintenance are to be dealt with in an imminent sister publication to this.
Collapse
Affiliation(s)
- Mike Thomson
- *International Academy for Paediatric Endoscopy Training, Sheffield Children's Hospital, Weston Bank, Sheffield, UK †Digestive Endoscopy Unit, Catholic University, Rome, Italy ‡Gedyt Endoscopy Center, Buenos Aires, Argentina §Department of Pediatric Gastroenterology, Centro Hospitalar de São João, Porto, Portugal ||Department of Pediatric Gastroenterology, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands ¶Department of Pediatric Gastroenterology and Nutrition, University Children's Hospital Basel, Basel, Switzerland #Department of Gastroenterology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands **Department of Gastroenterology, Nuovo Regina Margherita Hospital, Rome, Italy ††Department of Pediatric Gastroenterology, Alder Hey Children's Hospital, Liverpool, UK ‡‡Department of Pediatric Surgery and Intensive Care, Erasmus MC, Sophia Children's Hospital, Rotterdam, The Netherlands §§Department of Pediatric Gastroenterology, Robert-Debré Hospital, Paris, France ||||Digestive Endoscopy and Surgery Unit, Bambino Gesù Children Hospital-IRCCS, Rome, Italy ¶¶Department of Gastroenterology, Hepatology and Nutrition, University Children's Hospital Ljubljana, Ljubljana, Slovenia ##Pediatric Gastroenterology, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium ***Department of Gastroenterology, Motol University Hospital, Prague, Czech Republic †††Department of Pediatrics, University of Messina, Messina, Italy ‡‡‡IV Medical Department, Rudolfstiftung Hospital, Vienna, Austria §§§Department of General Pediatrics, Children's Hospital Freiburg University, Freiburg, Germany ||||||Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria ¶¶¶Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK ###Department for Pediatric Nephrology and Gastroenterology, Medical University of Vienna, Austria ****GI Endoscopy Unit, OUS, Rikshospitalet University Hospital, Oslo, Norway ††††Gastroenterology and Digestive Endoscopy Unit, Ospedale Nuovo Robbiani di Soresina, Soresina, Italy
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
13
|
Usatin D, Fernandes M, Allen IE, Perito ER, Ostroff J, Heyman MB. Complications of Endoscopic Retrograde Cholangiopancreatography in Pediatric Patients; A Systematic Literature Review and Meta-Analysis. J Pediatr 2016; 179:160-165.e3. [PMID: 27663215 PMCID: PMC5123955 DOI: 10.1016/j.jpeds.2016.08.046] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 07/13/2016] [Accepted: 08/12/2016] [Indexed: 01/15/2023]
Abstract
OBJECTIVES To systematically review risks and summarize reported complication rates associated with the performance of endoscopic retrograde cholangiopancreatography (ERCP) in children during the past 2 decades. STUDY DESIGN A systematic literature search of MEDLINE, Embase, and Web of Science from January 1995 to January 2016 was conducted for observational studies published in English. Studies reporting ERCP complications in patients <21 years without history of liver transplant or cholecystectomy were included. A summary estimate of the proportion of children who experienced complications following ERCP was derived via a random effects meta-analysis. RESULTS Thirty-two studies involving 2612 children and 3566 procedures were included. Subjects' ages ranged from 3 days to 21 years. Procedures were performed for biliary (54%), pancreatic (38%), and other (8%) indications; 56% of ERCPs were interventional. The pooled complication rate was 6% (95% CI 4%- 8%). Procedural complications included post-ERCP pancreatitis (166, 4.7%), bleeding (22, 0.6%), and infections (27, 0.8%). The pooled estimate of post-ERCP pancreatitis was 3% (95% CI 0.02-0.05), and other complications were 1% (95% CI 0.02-0.05). In the subgroup with neonatal cholestasis, the pooled complication rate was 3% (95% CI 0.01-0.07). Adult and pediatric gastroenterologists and surgeons performed the ERCPs. Available data limited the ability to report differences between pediatric-trained and other endoscopists. CONCLUSIONS Complications associated with pediatric ERCP range widely in severity and are reported inconsistently. Our review suggests 6% of pediatric ERCPs have complications. Further studies that use systematic and standardized methodologies are needed to determine the frequency and risk factors for ERCP-related complications.
Collapse
Affiliation(s)
- Danielle Usatin
- Department of Pediatrics, University of California, San Francisco
| | | | - Isabel E. Allen
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Emily R. Perito
- Department of Pediatrics, University of California, San Francisco,Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - James Ostroff
- Department of Medicine, University of California, San Francisco
| | - Melvin B. Heyman
- Department of Pediatrics, University of California, San Francisco
| |
Collapse
|
14
|
Abstract
Biliary disease in infants and children frequently presents diagnostic and therapeutic challenges. Pediatric interventional radiologists are often involved in the multidisciplinary teams who care for these patients. This article reviews several notable causes of biliary disease in children who have not undergone liver transplantation, describes the role of percutaneous interventional procedures in managing these conditions, and details applicable biliary interventional techniques.
Collapse
Affiliation(s)
- Lisa H Kang
- Department of Radiology, University of Texas Southwestern Children's Health, Dallas, Texas
| | - Colin N Brown
- Department of Radiology, Texas Scottish Rite Hospital for Children, Dallas, Texas
| |
Collapse
|
15
|
Tringali A, Balassone V, De Angelis P, Landi R. Complications in pediatric endoscopy. Best Pract Res Clin Gastroenterol 2016; 30:825-839. [PMID: 27931639 DOI: 10.1016/j.bpg.2016.09.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 08/17/2016] [Accepted: 09/06/2016] [Indexed: 02/07/2023]
Abstract
The experience of the "endoscopic community" in pediatric patients is limited, but during recent years increased skills of the endoscopists and technological improvements lead to a standardization of pediatric endoscopy and the development of specialized pediatric endoscopy unit. Adverse events related to diagnostic and therapeutic endoscopy in children are usually rare. Diagnosis, prevention and treatment of complications in pediatric endoscopy is crucial when dealing with benign diseases in children. The complication rate of diagnostic EGD and colonoscopy in children are extremely low. Therapeutic procedures have obviously an increased rate of adverse events. Esophageal dilations are the most common indication for endoscopic therapy in children and can lead to perforations which requires prompt diagnosis and management. Complications of ERCP in pediatric age are similar to those reported in adults. The experience in pediatric emergency endoscopy (mainly foreign body removal) is consolidated and related adverse events extremely rare. Sedation of children during endoscopy maybe needs further evaluation and standardization, to reduce the rate of specific complications.
Collapse
Affiliation(s)
| | - Valerio Balassone
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children Hospital, IRCCS, Rome, Italy.
| | - Paola De Angelis
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children Hospital, IRCCS, Rome, Italy.
| | - Rosario Landi
- Digestive Endoscopy Unit, Catholic University, Rome, Italy.
| |
Collapse
|
16
|
Verkade HJ, Bezerra JA, Davenport M, Schreiber RA, Mieli-Vergani G, Hulscher JB, Sokol RJ, Kelly DA, Ure B, Whitington PF, Samyn M, Petersen C. Biliary atresia and other cholestatic childhood diseases: Advances and future challenges. J Hepatol 2016; 65:631-42. [PMID: 27164551 DOI: 10.1016/j.jhep.2016.04.032] [Citation(s) in RCA: 109] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 04/26/2016] [Accepted: 04/28/2016] [Indexed: 02/08/2023]
Abstract
Biliary Atresia and other cholestatic childhood diseases are rare conditions affecting the function and/or anatomy along the canalicular-bile duct continuum, characterised by onset of persistent cholestatic jaundice during the neonatal period. Biliary atresia (BA) is the most common among these, but still has an incidence of only 1 in 10-19,000 in Europe and North America. Other diseases such as the genetic conditions, Alagille syndrome (ALGS) and Progressive Familial Intrahepatic Cholestasis (PFIC), are less common. Choledochal malformations are amenable to surgical correction and require a high index of suspicion. The low incidence of such diseases hinder patient-based studies that include large cohorts, while the limited numbers of animal models of disease that recapitulate the spectrum of disease phenotypes hinders both basic research and the development of new treatments. Despite their individual rarity, collectively BA and other cholestatic childhood diseases are the commonest indications for liver transplantation during childhood. Here, we review the recent advances in basic research and clinical progress in these diseases, as well as the research needs. For the various diseases, we formulate current key questions and controversies and identify top priorities to guide future research.
Collapse
Affiliation(s)
- Henkjan J Verkade
- Department of Paediatrics, University of Groningen, Beatrix Children's Hospital/University Medical Center, Groningen, The Netherlands.
| | - Jorge A Bezerra
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Mark Davenport
- Department of Paediatric Surgery, King's College Hospital, Denmark Hill, London, UK
| | - Richard A Schreiber
- Department of Paediatrics, University of British Columbia, Vancouver, Canada
| | - Georgina Mieli-Vergani
- Paediatric Liver, GI & Nutrition Centre, King's College London School of Medicine at King's College Hospital, London, UK
| | - Jan B Hulscher
- Department of Paediatric Surgery, University of Groningen, Beatrix Children's Hospital-University Medical Center, Groningen, The Netherlands
| | - Ronald J Sokol
- Section of Paediatric Gastroenterology, Hepatology, and Nutrition, Department of Paediatrics, University of Colorado School of Medicine, Digestive Health Institute, Children's Hospital Colorado, Aurora, CO, USA
| | - Deirdre A Kelly
- Liver Unit, Birmingham Children's Hospital NHS Trust, Birmingham, UK
| | - Benno Ure
- Department of Paediatric Surgery, Hannover Medical School, Hannover, Germany
| | - Peter F Whitington
- Department of Paediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Marianne Samyn
- Paediatric Liver, GI & Nutrition Centre, King's College London School of Medicine at King's College Hospital, London, UK
| | - Claus Petersen
- Department of Paediatric Surgery, Hannover Medical School, Hannover, Germany
| |
Collapse
|
17
|
Troendle DM, Barth BA. Pediatric Considerations in Endoscopic Retrograde Cholangiopancreatography. Gastrointest Endosc Clin N Am 2016; 26:119-36. [PMID: 26616900 DOI: 10.1016/j.giec.2015.08.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Endoscopic retrograde cholangiopancreatography is a technically challenging endoscopic technique that provides a minimally invasive way of evaluating and treating pathologic abnormality in the bile ducts and pancreas. Its utilization in children is increasing rapidly, broadening the understanding of its pediatric indications, clinical utility, and technical limitations. This article updates providers about specific considerations of endoscopic retrograde cholangiopancreatography in children as they relate to appropriate indications, patient preparation, available equipment, as well as expected technical and clinical outcomes following the procedure in pediatric populations.
Collapse
Affiliation(s)
- David M Troendle
- Division of Pediatric Gastroenterology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8548, USA.
| | - Bradley A Barth
- Division of Pediatric Gastroenterology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8548, USA
| |
Collapse
|
18
|
Jancelewicz T, Barmherzig R, Chung CTS, Ling SC, Kamath BM, Ng VL, Amaral J, O'Connor C, Fecteau A, Langer JC. A screening algorithm for the efficient exclusion of biliary atresia in infants with cholestatic jaundice. J Pediatr Surg 2015; 50:363-70. [PMID: 25746690 DOI: 10.1016/j.jpedsurg.2014.08.014] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Revised: 07/31/2014] [Accepted: 08/16/2014] [Indexed: 01/22/2023]
Abstract
BACKGROUND Neonates with cholestasis may undergo many tests before biliary atresia (BA) or an alternative diagnosis is reached, and delayed intervention may worsen outcomes. An optimal diagnostic approach to reduce risk, cost, and delay has yet to be defined. The purpose of this study was to develop an algorithm that rapidly and accurately excludes BA for infants with cholestatic jaundice. METHODS A single-center retrospective comparison of diagnostic workup was made between cholestatic infants with BA, and those without BA who underwent hepatobiliary iminodiacetic acid (HIDA) scan during admission. Patients were born between 2000 and 2010 and those older than 100days at assessment were excluded. Sensitivity and specificity analysis of predictive variables was performed and an algorithm constructed. RESULTS There were 45 BA and 167 non-BA patients. Some variables were 100% sensitive for the exclusion of BA: conjugated bilirubin <2.5mg/dL, gamma-glutamyl transpeptidase <150U/L, excretion on HIDA, or a normal percutaneous cholangiogram. Clinical variables and ultrasound were less useful as screening tests owing to low specificity and sensitivity, respectively. Liver biopsy was 98% sensitive and 84% specific in the diagnosis of BA. An algorithm was constructed that rules out BA with a negative laparotomy rate of 3-22%. CONCLUSION We propose a screening algorithm for infants with conjugated hyperbilirubinemia that permits efficient exclusion of BA with minimal invasive testing and with a low risk of negative laparotomy. This algorithm now requires prospective evaluation to determine its diagnostic accuracy and its ability to reduce hospital costs, patient morbidity, and time to Kasai portoenterostomy in patients with BA.
Collapse
Affiliation(s)
- Tim Jancelewicz
- Division of Pediatric Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
| | - Rebecca Barmherzig
- Division of Pediatric Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Catherine T-S Chung
- Division of Pathology and Pediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Simon C Ling
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Binita M Kamath
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Vicky L Ng
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Joao Amaral
- Department of Diagnostic Imaging, Division of Image Guided Therapy, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Constance O'Connor
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Annie Fecteau
- Division of Pediatric Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Jacob C Langer
- Division of Pediatric Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
19
|
Götze T, Blessing H, Grillhösl C, Gerner P, Hoerning A. Neonatal Cholestasis - Differential Diagnoses, Current Diagnostic Procedures, and Treatment. Front Pediatr 2015; 3:43. [PMID: 26137452 PMCID: PMC4470262 DOI: 10.3389/fped.2015.00043] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2014] [Accepted: 04/29/2015] [Indexed: 12/18/2022] Open
Abstract
Cholestatic jaundice in early infancy is a complex diagnostic problem. Misdiagnosis of cholestasis as physiologic jaundice delays the identification of severe liver diseases. In the majority of infants, prolonged physiologic jaundice represent benign cases of breast milk jaundice, but few among them are masked and caused by neonatal cholestasis (NC) that requires a prompt diagnosis and treatment. Therefore, a prolonged neonatal jaundice, longer than 2 weeks after birth, must always be investigated because an early diagnosis is essential for appropriate management. To rapidly identify the cases with cholestatic jaundice, the conjugated bilirubin needs to be determined in any infant presenting with prolonged jaundice at 14 days of age with or without depigmented stool. Once NC is confirmed, a systematic approach is the key to reliably achieve the diagnosis in order to promptly initiate the specific, and in many cases, life-saving therapy. This strategy is most important to promptly identify and treat infants with biliary atresia, the most common cause of NC, as this requires a hepatoportoenterostomy as soon as possible. Here, we provide a detailed work-up approach including initial treatment recommendations and a clinically oriented overview of possible differential diagnoses in order to facilitate the early recognition and a timely diagnosis of cholestasis. This approach warrants a broad spectrum of diagnostic procedures and investigations including new methods that are described in this review.
Collapse
Affiliation(s)
- Thomas Götze
- Department for Pediatric and Adolescent Medicine, Friedrich-Alexander University of Erlangen-Nuremberg , Erlangen , Germany
| | - Holger Blessing
- Department for Pediatric and Adolescent Medicine, Friedrich-Alexander University of Erlangen-Nuremberg , Erlangen , Germany
| | - Christian Grillhösl
- Department for Pediatric and Adolescent Medicine, Friedrich-Alexander University of Erlangen-Nuremberg , Erlangen , Germany
| | - Patrick Gerner
- Department for Pediatric and Adolescent Medicine, Albert-Ludwigs-University Freiburg , Freiburg , Germany
| | - André Hoerning
- Department for Pediatric and Adolescent Medicine, Friedrich-Alexander University of Erlangen-Nuremberg , Erlangen , Germany
| |
Collapse
|
20
|
Pfister ED, Petersen C, Kübler J, Baumann U. A diagnostic score for biliary atresia. J Hepatol 2014; 61:1440. [PMID: 25195553 DOI: 10.1016/j.jhep.2014.07.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2014] [Accepted: 07/22/2014] [Indexed: 12/04/2022]
Affiliation(s)
- Eva-Doreen Pfister
- Pediatric Gastroenterology and Hepatology, Pediatric Surgery, Hannover Medical School, Hannover, Germany.
| | - Claus Petersen
- Pediatric Gastroenterology and Hepatology, Pediatric Surgery, Hannover Medical School, Hannover, Germany
| | - Joachim Kübler
- Pediatric Gastroenterology and Hepatology, Pediatric Surgery, Hannover Medical School, Hannover, Germany
| | - Ulrich Baumann
- Pediatric Gastroenterology and Hepatology, Pediatric Surgery, Hannover Medical School, Hannover, Germany
| |
Collapse
|
21
|
A prospective pilot study: can the biliary tree be visualized in children younger than 3 months on Magnetic Resonance Cholangiopancreatography? Pediatr Radiol 2014; 44:1077-84. [PMID: 24710862 DOI: 10.1007/s00247-014-2953-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2013] [Revised: 02/03/2014] [Accepted: 02/26/2014] [Indexed: 01/19/2023]
Abstract
BACKGROUND Magnetic resonance cholangiopancreatography (MRCP) could aid in the diagnosis of biliary atresia, a hepatic pathology with thin, irregular or interrupted biliary ducts. There is little published evidence of MRCP appearances in normal neonates and young infants. OBJECTIVE To assess the use of MR cholangiopancreatography in visualizing the biliary tree in neonates and infants younger than 3 months with no hepatobiliary disorder, and to assess this visibility in relationship to the child's age, weight, and sedation and fasting states. MATERIALS AND METHODS Between December 2008 and October 2010 our department performed MRI of the brain, orbits and face on 16 full-term neonates and infants. Each child was younger than 3 months (90 days) and without any hepatobiliary disorders. The children were scanned with a respiratory-gated 0.54 × 0.51 × 0.4-mm(3) 3-D MRCP sequence. We used a reading grid to assess subjectively the visibility of the extrahepatic bile ducts along with extrahepatic bile duct confluence. The visibility of the extrahepatic bile duct confluence was assessed against age, weight, and sedation and fasting states. RESULTS The extrahepatic bile duct confluence was seen in 10 children out of 16 (62.5%). In the neonate sub-group (corrected age younger than 30 days), the MRCP was technically workable and the extrahepatic bile duct confluence was seen in four cases out of eight (50%). This visualization was up to 75% in the subgroup older than 30 days. However, statistically there was no significant difference in visibility of the extrahepatic bile duct confluence in relationship to age, weight or MRCP performance conditions (feeding, fasting or sedation). CONCLUSION The complete normal biliary system (extrahepatic bile duct confluence included) is not consistently visualized in infants younger than 3 months old on non-enhanced MRCP. Thus the use of MRCP to exclude a diagnosis of biliary atresia is compromised at optimal time of surgery.
Collapse
|
22
|
Thiel C, Steinbach S, Schmidt M, Amort K, Zahn N, Kramer M, Moritz A. Extrahepatic Biliary Atresia in a 4-Week-Old Pug. Vet Surg 2014. [DOI: 10.1111/j.1532-950x.2014.22210.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Cetina Thiel
- Department of Veterinary Clinical Sciences, Clinic for Small Animals, Surgery; Justus-Liebig-University; Giessen Germany
| | - Sarah Steinbach
- Department of Veterinary Clinical Sciences, Clinic for Small Animals, Internal Medicine; Justus-Liebig-University; Giessen Germany
| | - Martin Schmidt
- Department of Veterinary Clinical Sciences, Clinic for Small Animals, Surgery; Justus-Liebig-University; Giessen Germany
| | - Kerstin Amort
- Department of Veterinary Clinical Sciences, Clinic for Small Animals, Surgery; Justus-Liebig-University; Giessen Germany
| | - Nanette Zahn
- Department of Veterinary Clinical Sciences, Clinic for Small Animals, Surgery; Justus-Liebig-University; Giessen Germany
| | - Martin Kramer
- Department of Veterinary Clinical Sciences, Clinic for Small Animals, Surgery; Justus-Liebig-University; Giessen Germany
| | - Andreas Moritz
- Department of Veterinary Clinical Sciences, Clinic for Small Animals, Internal Medicine; Justus-Liebig-University; Giessen Germany
| |
Collapse
|
23
|
Hoerning A, Raub S, Dechêne A, Brosch MN, Kathemann S, Hoyer PF, Gerner P. Diversity of disorders causing neonatal cholestasis - the experience of a tertiary pediatric center in Germany. Front Pediatr 2014; 2:65. [PMID: 25003101 PMCID: PMC4066316 DOI: 10.3389/fped.2014.00065] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 06/01/2014] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Rapidly establishing the cause of neonatal cholestasis is an urgent matter. The aim of this study was to report on the prevalence and mortality of the diverse disorders causing neonatal cholestasis in an academic center in Germany. METHODS Clinical chemistry and cause of disease were retrospectively analyzed in 82 infants (male n = 42, 51%) that had presented with neonatal cholestasis to a tertiary medical center from January 2009 to April 2013. RESULTS Altogether, 19 disorders causing neonatal cholestasis were identified. Biliary atresia was the most common diagnosis (41%), followed by idiopathic cases (13%), progressive familial intrahepatic cholestasis (PFIC, 10%), cholestasis in preterm infants (10%), α1AT deficiency, Alagille syndrome, portocaval shunts, mitochondriopathy, biliary sludge (all 2%), and others. Infants with biliary atresia were diagnosed with a mean age of 62 days, they underwent Kasai portoenterostomy ~66 days after birth. The majority of these children (~70%) received surgery within 10 weeks of age and 27% before 60 days. The 2-year survival with their native liver after Kasai procedure was 12%. The time span between Kasai surgery and liver transplantation was 176 ± 73 days. Six children (7%), of whom three patients had a syndromic and one a non-syndromic biliary atresia, died prior to liver transplantation. The pre- and post-transplant mortality rate for children with biliary atresia was ~12 and ~17%, respectively. CONCLUSION Neonatal cholestasis is a severe threat associated with a high risk of complications in infancy and it therefore requires urgent investigation in order to initiate life saving therapy. Although in the last 20 years new causes such as the PFICs have been identified and newer diagnostic tools have been introduced into the clinical routine biliary atresia still represents the major cause.
Collapse
Affiliation(s)
- André Hoerning
- Department for Pediatric Nephrology, Gastroenterology, Endocrinology and Transplant Medicine, Clinic for Pediatrics II, University Children's Hospital Essen, University Duisburg-Essen , Essen , Germany ; Department of Pediatrics and Adolescent Medicine, University Children's Hospital Erlangen, Friedrich-Alexander University , Erlangen , Germany
| | - Simon Raub
- Department for Pediatric Nephrology, Gastroenterology, Endocrinology and Transplant Medicine, Clinic for Pediatrics II, University Children's Hospital Essen, University Duisburg-Essen , Essen , Germany
| | - Alexander Dechêne
- Department of Gastroenterology and Hepatology, University Hospital Essen, University Duisburg-Essen , Essen , Germany
| | - Michelle N Brosch
- Department for Pediatric Nephrology, Gastroenterology, Endocrinology and Transplant Medicine, Clinic for Pediatrics II, University Children's Hospital Essen, University Duisburg-Essen , Essen , Germany
| | - Simone Kathemann
- Department for Pediatric Nephrology, Gastroenterology, Endocrinology and Transplant Medicine, Clinic for Pediatrics II, University Children's Hospital Essen, University Duisburg-Essen , Essen , Germany
| | - Peter F Hoyer
- Department for Pediatric Nephrology, Gastroenterology, Endocrinology and Transplant Medicine, Clinic for Pediatrics II, University Children's Hospital Essen, University Duisburg-Essen , Essen , Germany
| | - Patrick Gerner
- Department of Pediatrics and Adolescent Medicine, University Children's Hospital , Freiburg , Germany
| |
Collapse
|
24
|
Friedt M, Welsch S. An update on pediatric endoscopy. Eur J Med Res 2013; 18:24. [PMID: 23885793 PMCID: PMC3751043 DOI: 10.1186/2047-783x-18-24] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Accepted: 07/15/2013] [Indexed: 12/12/2022] Open
Abstract
Advances in endoscopy and anesthesia have enabled gastrointestinal endoscopy for children since 1960. Over the past decades, the number of endoscopies has increased rapidly. As specialized teams of pediatric gastroenterologists, pediatric intensive care physicians and pediatric endoscopy nurses are available in many medical centers, safe and effective procedures have been established. Therefore, diagnostic endoscopies in children are routine clinical procedures. The most frequently performed endoscopies are esophagogastroduodenoscopy (EGD), colonoscopy and endoscopic retrograde cholangiopancreaticography (ERCP). Therapeutic interventions include variceal bleeding ligation, foreign body retrieval and percutaneous endoscopic gastrostomy. New advances in pediatric endoscopy have led to more sensitive diagnostics of common pediatric gastrointestinal disorders, such as Crohn's disease, ulcerative colitis and celiac disease; likewise, new diseases, such as eosinophilic esophagitis, have been brought to light.Upcoming modalities, such as capsule endoscopy, double balloon enteroscopy and narrow band imaging, are being established and may contribute to diagnostics in pediatric gastroenterology in the future.
Collapse
Affiliation(s)
- Michael Friedt
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, Division of Pediatric Gastroenterology University Children's Hospital, Moorenstr, 5, D-40225, Duesseldorf, Germany.
| | | |
Collapse
|
25
|
Liu QY, Nguyen V. Endoscopic approach to the patient with congenital anomalies of the biliary tract. Gastrointest Endosc Clin N Am 2013; 23:505-18. [PMID: 23540973 DOI: 10.1016/j.giec.2012.12.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Congenital biliary tract anomalies typically present with neonatal cholestasis. In children and adults, endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound are used to evaluate and treat choledochal cysts. Contrarily, endoscopy has traditionally played a minor role in the diagnosis of the cholestatic infant. Recent studies support the incorporation of ERCP into the diagnostic algorithm for biliary atresia and neonatal cholestasis. But at present, most pediatric liver centers do not consider its use essential. This article reviews the congenital biliary tract anomalies in which endoscopy has been shown to contribute to the evaluation of the cholestatic infant.
Collapse
Affiliation(s)
- Quin Y Liu
- Keck School of Medicine, University of Southern California, Children's Hospital Los Angeles, Los Angeles, CA 90027, USA.
| | | |
Collapse
|
26
|
Detection of hepatotropic viruses has no impact on the prognosis after Kasai procedure. J Pediatr Surg 2012; 47:1828-32. [PMID: 23084192 DOI: 10.1016/j.jpedsurg.2012.04.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2011] [Revised: 04/02/2012] [Accepted: 04/21/2012] [Indexed: 11/20/2022]
Abstract
BACKGROUND/PURPOSE A viral origin of biliary atresia (BA) is discussed, and several studies have demonstrated different viral strains in liver biopsies of patients undergoing Kasai portoenterostomy. We hypothesized that the presence of hepatotropic viruses in patients undergoing portoenterostomy contributes to the progression of the disease and negatively affect the outcome. METHODS Liver biopsies were prospectively taken from 70 patients undergoing portoenterostomy in our department from April 1996 to April 2004. Samples were screened by polymerase chain reaction for all common hepatic viruses. Primary outcome parameter was survival with the native liver. Secondary parameters were postoperative serum activity of liver enzymes and serum bilirubin levels at different time points. Patients underwent regular follow-up until October 2008. RESULTS Twenty-eight patients (40%) were positive for 1 or more hepatotropic viruses. Four patients were lost to follow-up. In the remaining 66 patients, there was no significant difference in survival with their native liver between virus-positive and virus-negative patients. After a mean follow-up of 7.7 years (range, 4.6-16.1 years), 15 (23%) of 66 patients still lived with their native liver. There was no difference in liver enzymes, C-reactive protein, or bilirubin at any time point between both groups. CONCLUSION A significant number of our patients tested positive for hepatotropic viruses in liver biopsies at the time of the Kasai procedure, but the presence of virus had no influence on the course of BA. This suggests that the ongoing inflammatory process of BA leading to liver cirrhosis in most Kasai-treated patients is not affected by hepatotropic viruses. Our data question the necessity to aggressively screen for and treat viral infections in patients with BA.
Collapse
|
27
|
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is not as widely used in children as in adults and is performed in few specialized centers. The aim of the present study was to review the experience of ERCP in children younger than 3 months in a national referral center. METHODS A retrospective chart review was performed of all of the babies younger than 3 months who underwent ERCP between 2000 and 2010. Data on demographics, diagnosis, type of anesthesia, treatments, and complications were collected. RESULTS A total of 27 babies, 14 boys, were examined. Median age was 55 days (range 33-89). Ultrasound was normal in 16 infants, whereas others included small gallbladder (4), biliary stones (3), and dilated bile ducts (3). Thirteen infants underwent earlier liver biopsy, which was inconclusive. ERCP led to the diagnosis of biliary atresia in 13 infants who had subsequent surgery. In others, ERCP showed choledochal cyst (1), biliary stones (2), dilated bile ducts (1), and normal examination (6); there were 5 failures. The final diagnoses in our cohort were extrahepatic biliary atresia (15), biliary stones (5), neonatal hepatitis (4), choledochal cyst (1), paucity of intrahepatic bile duct (1), and congenital hepatic fibrosis (1). Diagnoses in the failed ERCP group included biliary atresia (2), bile duct paucity (1), and biliary stones (2). In 4 (19%) infants with clinical suspicion of extrahepatic biliary atresia, a normal ERCP ruled out the diagnosis and avoided an intraoperative cholangiogram. No complications, including pancreatitis, were reported. CONCLUSIONS ERCP in infants is feasible and has no complications. It may serve as an additional diagnostic tool in neonatal cholestasis in inconclusive cases and may prevent more invasive procedures. ERCP may be part of the algorithm of neonatal cholestasis when it is available and other investigations fail to confirm a diagnosis.
Collapse
|
28
|
Lee SY, Kim GC, Choe BH, Ryeom HK, Jang YJ, Kim HJ, Park JY, Cho SM. Efficacy of US-guided Percutaneous Cholecystocholangiography for the Early Exclusion and Type Determination of Biliary Atresia. Radiology 2011; 261:916-22. [DOI: 10.1148/radiol.11110665] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
29
|
Extrahepatische Gallenwegserkrankungen im Säuglingsalter. Monatsschr Kinderheilkd 2011. [DOI: 10.1007/s00112-010-2364-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
30
|
Abstract
Biliary atresia (BA) is a progressive fibro-obliterative cholangiopathy of unclear etiology affecting varying degrees of both extra- and intrahepatic biliary tree resulting in obstructive bile flow and cholestasis in neonates. The diagnostic work-up is designed to diagnose or rule out BA without any unnecessary delay. Kasai portoenterostomy is a palliative operation performed to establish bile drainage from microscopic bile ductules that remain in the porta hepatis. It is advantageous to perform portoenterostomy as early after birth as possible for better chances of success. Actuarial native liver 5-year survival rates range from 30% to 60% after portoenterostomy, and about 20% of all patients undergoing Kasai portoenterostomy during infancy survive into adulthood with their native liver. Portoenterostomy remains as the first line operative treatment in BA while liver transplantation serves as a salvage treatment when portoenterostomy fails or liver function gradually deteriorates after initially successful establishment of bile flow.
Collapse
Affiliation(s)
- M P Pakarinen
- Section of Pediatric Surgery, Hospital for Children and Adolescents, University of Helsinki, Helsinki, Finland.
| | | |
Collapse
|
31
|
|
32
|
Hadzic N, Harrison PM. Selective rather than routine approach to endosopic retrograde cholangio-pancreatography in diagnosis of biliary atresia. J Hepatol 2010; 52:777. [PMID: 20347498 DOI: 10.1016/j.jhep.2010.01.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2010] [Accepted: 01/20/2010] [Indexed: 12/04/2022]
|