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Chen X, Zhao D, Ji H, Chen Y, Li Y, Zuo Z. Predictive modeling for early detection of biliary atresia in infants with cholestasis: Insights from a machine learning study. Comput Biol Med 2024; 174:108439. [PMID: 38643596 DOI: 10.1016/j.compbiomed.2024.108439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 03/26/2024] [Accepted: 04/07/2024] [Indexed: 04/23/2024]
Abstract
Cholestasis, characterized by the obstruction of bile flow, poses a significant concern in neonates and infants. It can result in jaundice, inadequate weight gain, and liver dysfunction. However, distinguishing between biliary atresia (BA) and non-biliary atresia in these young patients presenting with cholestasis poses a formidable challenge, given the similarity in their clinical manifestations. To this end, our study endeavors to construct a screening model aimed at prognosticating outcomes in cases of BA. Within this study, we introduce a wrapper feature selection model denoted as bWFMVO-SVM-FS, which amalgamates the water flow-based multi-verse optimizer (WFMVO) and support vector machine (SVM) technology. Initially, WFMVO is benchmarked against eleven state-of-the-art algorithms, with its efficiency in searching for optimized feature subsets within the model validated on IEEE CEC 2017 and IEEE CEC 2022 benchmark functions. Subsequently, the developed bWFMVO-SVM-FS model is employed to analyze a cohort of 870 consecutively registered cases of neonates and infants with cholestasis (diagnosed as either BA or non-BA) from Xinhua Hospital and Shanghai Children's Hospital, both affiliated with Shanghai Jiao Tong University. The results underscore the remarkable predictive capacity of the model, achieving an accuracy of 92.639 % and specificity of 88.865 %. Gamma-glutamyl transferase, triangular cord sign, weight, abnormal gallbladder, and stool color emerge as highly correlated with early symptoms in BA infants. Furthermore, leveraging these five significant features enhances the interpretability of the machine learning model's performance outcomes for medical professionals, thereby facilitating more effective clinical decision-making.
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Affiliation(s)
- Xuting Chen
- Department of Neonatology, Xinhua Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Dongying Zhao
- Department of Neonatology, Xinhua Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Haochen Ji
- The Seventh Research Division, Beihang University (BUAA), Beijing, China
| | - Yihuan Chen
- Department of Neonatology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yahui Li
- Department of Neonatology, Xinhua Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Zongyu Zuo
- The Seventh Research Division, Beihang University (BUAA), Beijing, China.
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Lerer R, Barash L, Nafday S, Kogan Liberman D, Ovchinsky N. Evaluation of Newborn Direct Bilirubin As Screening for Cholestatic Liver Disease. JPGN REPORTS 2023; 4:e345. [PMID: 38034462 PMCID: PMC10684158 DOI: 10.1097/pg9.0000000000000345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 05/24/2023] [Indexed: 12/02/2023]
Abstract
Background Biliary atresia (BA) remains the most common indication for pediatric liver transplantation. Early diagnosis is essential for a favorable long-term prognosis for patients with BA. Preliminary data suggests that measurement of direct bilirubin (DB) in newborns may be an effective screening tool for neonatal cholestasis, particularly BA, allowing for early referral and diagnosis. The objective of our study was to establish a cutoff DB value to predict diagnosis of cholestatic liver disease (CLD) with high sensitivity and specificity, as well as, to evaluate whether newborns with elevated DB received appropriate follow-up in our health system. Methods Baseline data were collected on infants born between 2016 and 2019 who had serum total bilirubin and DB drawn in the nursery, and who continued to follow in our health system. Sensitivity, specificity, and positive and negative predictive values were examined using cutoff values of 0.5, 0.6, and 0.7 mg/dL for identifying infants at risk for CLD. Patients' charts were reviewed to note whether they had follow-up levels drawn by their pediatrician or by the hepatology team within 2 months of age and whether they were diagnosed with CLD. Results Serum total bilirubin and DB levels were drawn from 11 965 infants during their hospitalizations. Three infants from this cohort were diagnosed with CLD: 2 with BA and 1 with Alagille syndrome. DB cutoff values of 0.5, 0.6, and 0.7 mg/dL had sensitivity of 100% and specificity of 96.83% (95% confidence interval [CI], 96.69%-97.53%), 99.08% (95% CI, 98.81%-99.30%), and 99.63% (95% CI, 99.4%-99.7%), respectively. Given that a DB of 0.6 mg/dL had a sensitivity of 100% and specificity of 99%, this value was chosen as the cutoff value to monitor for DB follow-up and diagnosis of CLD. Out of 60 infants who met criteria for DB ≥0.6 mg/dL, only 15 (25%) had a repeat level drawn after nursery discharge; 3 (5%) were eventually diagnosed with CLD. Conclusions A DB cutoff value of 0.6 mg/dL yielded high sensitivity and specificity for identifying patients with CLD. All 3 patients diagnosed with CLD had elevated DB at hospital discharge. The data revealed that the majority (75%) of eligible newborns did not receive follow-up for their elevated DB in the outpatient setting.
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Affiliation(s)
- Rikah Lerer
- From the Division of Gastroenterology, Hepatology, and Nutrition, Cohen Children’s Medical Center, Queens, NY
| | - Lily Barash
- Division of Gastroenterology, Hepatology, and Nutrition, Children’s Hospital at Montefiore, Bronx, NY
| | - Suhas Nafday
- Division of Neonatology, Children’s Hospital at Montefiore, Bronx, NY
| | - Debora Kogan Liberman
- Division of Gastroenterology, Hepatology, and Nutrition, Children’s Hospital at Montefiore, Bronx, NY
| | - Nadia Ovchinsky
- Division of Gastroenterology, Hepatology, and Nutrition, Children’s Hospital at Montefiore, Bronx, NY
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Findings in percutaneous trans-hepatic cholecysto-cholangiography in neonates and infants presenting with conjugated hyperbilirubinemia: emphasis on differential diagnosis and cholangiographic patterns. BMC Pediatr 2023; 23:22. [PMID: 36639762 PMCID: PMC9840309 DOI: 10.1186/s12887-022-03816-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 12/21/2022] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Biliary atresia (BA) is one of the causes of conjugated hyperbilirubinemia in infants which if untreated leads to end-stage liver disease and death. Percutaneous Trans-hepatic Cholecysto-Cholangiography (PTCC) is a minimally invasive study which can be utilized in the diagnostic work-up of these patients. This study's purpose is to describe the experience with PTCC in neonates, the imaging findings encountered, and the abnormal patterns which warrant further investigation. METHODS A 16-year single-center retrospective study of patients with persistent neonatal cholestasis (suspected BA) undergoing PTCC. Patient demographics, laboratory values, PTCC images, pathology and surgical reports were reviewed. RESULTS 73 patients underwent PTCC (68% male, mean age 8.7 weeks, mean weight 4.0 Kg). The majority of studies were normal (55%). Abnormal patterns were identified in 33 cases, 79% were diagnosed with BA and 12% with Alagille syndrome. Non-opacification of the common hepatic duct with a narrowed common bile duct (42%) and isolated small gallbladder (38%) were the most common patterns in BA. CONCLUSION PTCC is a minimally invasive study in the diagnostic work-up of infants presenting with conjugated hyperbilirubinemia (suspected BA). Further invasive investigations or surgery can be avoided when results are normal.
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Lim YZ, Chaudhary U, Issioui Y, Corbitt N. Kasai portoenterostomy delays: Is a HIDA scan worth the wait? J Pediatr Surg 2023:S0022-3468(23)00005-2. [PMID: 36754771 DOI: 10.1016/j.jpedsurg.2023.01.003] [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: 07/20/2022] [Revised: 12/26/2022] [Accepted: 01/05/2023] [Indexed: 01/11/2023]
Abstract
BACKGROUND Biliary Atresia (BA), an obstructive cholangiopathy, is the most common cause of end-stage liver disease and liver transplantation in children. Timely differentiation of BA from other causes of neonatal jaundice remains a challenge, yet is critical to improving outcomes. METHODS Clinical characteristics including demographics, age at jaundice presentation, age at hepatobiliary scintigraphy, age at surgery, severity of liver fibrosis, and native-liver survival were reviewed in infants with hyperbilirubinemia and suspected BA for this single center retrospective cohort study. We investigated the accuracy of hepatobiliary scintigraphy as well as elapsed time from jaundice presentation to diagnostic intervention. RESULTS BA was suspected in 234 infants. BA was identified in 17% of infants with hepatobiliary scintigraphy and 72% of infants who underwent operative exploration without hepatobiliary scintigraphy. Elapsed time from jaundice presentation to Kasai Portoenterostomy (KPE) for BA patients was 2.1x longer if hepatobiliary scintigraphy was obtained (p = 0.084). The mean age at KPE for this cohort was 66.8 days (n = 54), with a significantly higher mean age at KPE (75.2 days) for infants who were later listed or underwent liver transplantation (p = 0.038). Histologically, the lowest liver fibrosis scores were seen in infants undergoing KPE <30 days old and worsened significantly with increased age (p < 0.001). CONCLUSION Hepatobiliary scintigraphy compared to operative exploration for the diagnostic evaluation of infants with suspected BA introduces significant time delays to KPE but enables avoidance of surgery in some infants. The temporal pattern of worsening cholestatic liver injury from BA with each day of increased age highlights the importance of intervening as early as possible for the best prognosis. TYPE OF STUDY Retrospective study, Level of evidence: III.
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Affiliation(s)
- Yi Zou Lim
- Children's Research Institute at UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Usamah Chaudhary
- UT Southwestern Medical School, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Yacine Issioui
- UT Southwestern Medical School, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Natasha Corbitt
- Division of Pediatric Surgery, UT Southwestern Medical Center, 1935 Medical District Drive, Suite D2000, Dallas, TX 75235, USA.
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Salvi PS, Fawaz R, Cowles RA. Comparing Serum Matrix Metalloproteinase-7 in Parenteral Nutrition-Associated Liver Disease and Biliary Atresia. J Pediatr 2022; 249:97-100. [PMID: 35714967 DOI: 10.1016/j.jpeds.2022.06.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 05/17/2022] [Accepted: 06/09/2022] [Indexed: 11/26/2022]
Abstract
In this cross-sectional study, serum matrix metalloproteinase-7 levels were significantly lower in infants with jaundice and parenteral nutrition-associated liver disease compared with those with confirmed biliary atresia. Serum metalloproteinase-7 may aid in excluding biliary atresia and thus may minimize invasive testing in infants with a history of parenteral nutrition.
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Affiliation(s)
- Pooja S Salvi
- Department of Surgery, Division of Pediatric Surgery, Yale School of Medicine, New Haven, CT
| | - Rima Fawaz
- Section of Pediatric Gastroenterology and Hepatology, Yale-New Haven Hospital, New Haven, CT
| | - Robert A Cowles
- Department of Surgery, Division of Pediatric Surgery, Yale School of Medicine, New Haven, CT.
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Tanimizu N. The neonatal liver: Normal development and response to injury and disease. Semin Fetal Neonatal Med 2022; 27:101229. [PMID: 33745829 DOI: 10.1016/j.siny.2021.101229] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The liver emerges from the ventral foregut endoderm around 3 weeks in human and 1 week in mice after fertilization. The fetal liver works as a hematopoietic organ and then develops functions required for performing various metabolic reactions in late fetal and neonatal periods. In parallel with functional differentiation, the liver establishes three dimensional tissue structures. In particular, establishment of the bile excretion system consisting of bile canaliculi of hepatocytes and bile ducts of cholangiocytes is critical to maintain healthy tissue status. This is because hepatocytes produce bile as they functionally mature, and if allowed to remain within the liver tissue can lead to cytotoxicity. In this review, we focus on epithelial tissue morphogenesis in the perinatal period and cholestatic liver diseases caused by abnormal development of the biliary system.
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Affiliation(s)
- Naoki Tanimizu
- Department of Tissue Development and Regeneration, Research Institute for Frontier Medicine, Sapporo Medical University School of Medicine, S-1, W-17, Chuo-ku, Sapporo, 060-8556, Japan.
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Ranucci G, Della Corte C, Alberti D, Bondioni MP, Boroni G, Calvo PL, Cananzi M, Candusso M, Clemente MG, D'Antiga L, Degrassi I, De Ville De Goyet J, Di Dato F, Di Giorgio A, Vici CD, Ferrari F, Francalanci P, Fuoti M, Fusaro F, Gaio P, Grimaldi C, Iascone M, Indolfi G, Iorio R, Maggiore G, Mandato C, Matarazzo L, Monti L, Mosca F, Nebbia G, Nuti F, Paolella G, Pinon M, Roggero P, Sciveres M, Serranti D, Spada M, Vajro P, Nicastro E. Diagnostic approach to neonatal and infantile cholestasis: A position paper by the SIGENP liver disease working group. Dig Liver Dis 2022; 54:40-53. [PMID: 34688573 DOI: 10.1016/j.dld.2021.09.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 08/23/2021] [Accepted: 09/12/2021] [Indexed: 12/11/2022]
Abstract
Neonatal and infantile cholestasis (NIC) can represent the onset of a surgically correctable disease and of a genetic or metabolic disorder worthy of medical treatment. Timely recognition of NIC and identification of the underlying etiology are paramount to improve outcomes. Upon invitation by the Italian National Institute of Health (ISS), an expert working grouped was formed to formulate evidence-based positions on current knowledge about the diagnosis of NIC. A systematic literature search was conducted to collect evidence about epidemiology, etiology, clinical aspects and accuracy of available diagnostic tests in NIC. Evidence was scored using the GRADE system. All recommendations were approved by a panel of experts upon agreement of at least 75% of the members. The final document was approved by all the panel components. This position document summarizes the collected statements and defines the best-evidence diagnostic approach to cholestasis in the first year of life.
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Affiliation(s)
- Giusy Ranucci
- Department of Pediatrics, Santobono-Pausilipon Children's Hospital AORN, Naples, Italy
| | - Claudia Della Corte
- Hepatology, Gastroenterology, Nutrition and Liver transplantation Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | | | - Maria Pia Bondioni
- Pediatric Radiology, University of Brescia, ASST Spedali Civili di Brescia, Brescia, Italy
| | | | - Pier Luigi Calvo
- Pediatric Gastroenterology Unit, Regina Margherita Children's Hospital, Azienda Ospedaliera-Universitaria Città della Salute e della Scienza, Turin, Italy
| | - Mara Cananzi
- Unit of Gastroenterology, Digestive Endoscopy, Hepatology and Care of Children with Liver Transplantation, University Hospital of Padova, Padova, Italy
| | - Manila Candusso
- Hepatology, Gastroenterology, Nutrition and Liver transplantation Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Maria Grazia Clemente
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Lorenzo D'Antiga
- Hepatology, Gastroenterology and Transplantation Unit, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Irene Degrassi
- Service of Paediatric Hepatology, Department of Paediatrics, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Jean De Ville De Goyet
- Pediatric Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, ISMETT UPMC, Palermo, Italy
| | - Fabiola Di Dato
- Department di Translational Medical Science, School of Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Angelo Di Giorgio
- Hepatology, Gastroenterology and Transplantation Unit, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Carlo Dionisi Vici
- Division of Metabolism and Metabolic Diseases Research Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | | | - Paola Francalanci
- Department of Pathology, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Maurizio Fuoti
- Pediatric Gastroenterology and Endoscopy Unit Children's Hospital, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Fabio Fusaro
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Paola Gaio
- Unit of Gastroenterology, Digestive Endoscopy, Hepatology and Care of Children with Liver Transplantation, University Hospital of Padova, Padova, Italy
| | - Chiara Grimaldi
- Division of Abdominal Transplantation and Hepatobiliopancreatic Surgery, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Maria Iascone
- Medical Genetics Laboratory, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Giuseppe Indolfi
- Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Raffaele Iorio
- Department di Translational Medical Science, School of Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Giuseppe Maggiore
- Hepatology, Gastroenterology, Nutrition and Liver transplantation Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Claudia Mandato
- Department of Pediatrics, Santobono-Pausilipon Children's Hospital AORN, Naples, Italy
| | | | - Lidia Monti
- Department of Radiology, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Fabio Mosca
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Gabriella Nebbia
- Service of Paediatric Hepatology, Department of Paediatrics, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Federica Nuti
- Service of Paediatric Hepatology, Department of Paediatrics, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giulia Paolella
- Service of Paediatric Hepatology, Department of Paediatrics, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Michele Pinon
- Pediatric Gastroenterology Unit, Regina Margherita Children's Hospital, Azienda Ospedaliera-Universitaria Città della Salute e della Scienza, Turin, Italy
| | - Paola Roggero
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marco Sciveres
- Pediatric Hepatology and Liver Transplantation, ISMETT UPMC, Palermo, Italy
| | - Daniele Serranti
- Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Marco Spada
- Division of Abdominal Transplantation and Hepatobiliopancreatic Surgery, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Pietro Vajro
- Department of Medicine, Surgery and Dentistry, "Scuola Medica Salernitana" University of Salerno, Baronissi, Italy
| | - Emanuele Nicastro
- Hepatology, Gastroenterology and Transplantation Unit, Hospital Papa Giovanni XXIII, Bergamo, Italy
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Yang P, Tang Y, Wang H, Zhang X, Yang B. Latest diagnostic performance of different ultrasonic features for biliary atresia. Acta Radiol 2021; 63:1593-1602. [PMID: 34854739 DOI: 10.1177/02841851211055820] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Early diagnosis of biliary atresia (BA) is an important clinical challenge. PURPOSE To summarize the latest diagnostic performance of different ultrasonic (US) features for BA. MATERIAL AND METHODS MeSH terms "biliary atresia" and "ultrasonography" and related hyponyms were used to search PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials. Eligible articles were included and data were retrieved. The methodologic quality was assessed by version 2 of the Quality Assessment of Diagnostic Accuracy Studies tool. Estimated sensitivity and specificity of each US feature were calculated by Stata 14.0. RESULTS Fifty eligible studies on 5622 patients were included. Respective summary sensitivity and specificity were 77% (95% CI=69-84) and 98% (95% CI=96-99) for triangular cord sign (TCS) in 32 studies, 86% (95% CI=78-92) and 86% (95% CI=72-94) for shear wave elastography (SWE) in seven studies, 75% (95% CI=65-83) and 92% (95% CI=86-95) for gallbladder and biliary system abnormality (GBA) in 25 studies, and 81% (95% CI=69-90) and 79% (95% CI=67-87) for hepatic artery (HA) enlargement in seven studies. The overall US features from 11 studies yielded a summary sensitivity of 84% (95% CI=72-92) and specificity of 86% (95% CI=77-92). CONCLUSION TCS and GBA were the two most widely accepted US features currently used for differential diagnosis of BA. The newly developed SWE was an objective and convenient method with good diagnostic performance. HA enlargement can be used as an auxiliary sign.
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Affiliation(s)
- Pan Yang
- Department of Medical Ultrasonics, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, PR China
| | - Yajie Tang
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, PR China
| | - Hongying Wang
- Department of Medical Ultrasonics, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, PR China
| | - Xiangxiang Zhang
- Department of Medical Ultrasonics, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, PR China
| | - Boyang Yang
- Department of Medical Ultrasonics, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, PR China
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Rabbani T, Guthery SL, Himes R, Shneider BL, Harpavat S. Newborn Screening for Biliary Atresia: a Review of Current Methods. Curr Gastroenterol Rep 2021; 23:28. [PMID: 34817690 DOI: 10.1007/s11894-021-00825-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2021] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Biliary atresia is a serious neonatal liver disease due to obstructed bile ducts that has better outcomes when detected and treated in the first 30-45 days of life. This review examines different methods to screen newborns for biliary atresia as well as discusses observations from ongoing screening programs implemented in parts of the United States. RECENT FINDINGS Screening strategies for biliary atresia include detecting persistent jaundice, examining stool color, testing fractionated bilirubin levels, or measuring bile acid levels from dried blood spot cards. The stool color card program is the most widely used screening strategy worldwide. An alternative approach under investigation in the United States measures fractionated bilirubin levels, which are abnormal in newborns with biliary atresia. Fractionated bilirubin screening programs require laboratories to derive reference ranges, nurseries to implement universal testing, and healthcare systems to develop infrastructure that identifies and acts upon abnormal results. Biliary atresia meets the disease-specific criteria for newborn screening. Current studies focus on developing a strategy which also meets all test-specific criteria. Such a strategy, if implemented uniformly, has the potential to accelerate treatment and reduce biliary atresia's large liver transplant burden.
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Affiliation(s)
- Tebyan Rabbani
- Department of Pediatrics, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Stephen L Guthery
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, University of Utah and Intermountain Primary Children's Hospital, Salt Lake City, UT, USA
| | - Ryan Himes
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Ochsner Health, New Orleans, LA, USA
| | - Benjamin L Shneider
- Department of Pediatrics, Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Baylor College of Medicine and Texas Children's Hospital, 6621 Fannin Street, CCC 1010, Houston, TX, 77030, USA
| | - Sanjiv Harpavat
- Department of Pediatrics, Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Baylor College of Medicine and Texas Children's Hospital, 6621 Fannin Street, CCC 1010, Houston, TX, 77030, USA.
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Management of a Biliary Sludge Ball in an Infant with Giant Omphalocele. J Vasc Interv Radiol 2021; 32:1623-1625. [PMID: 34363939 DOI: 10.1016/j.jvir.2021.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 07/22/2021] [Accepted: 07/27/2021] [Indexed: 11/21/2022] Open
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Caruso M, Di Dato F, Mollica C, Vallone G, Romeo V, Liuzzi R, Mainenti PP, Petretta M, Iorio R, Brunetti A, Maurea S. Imaging prediction with ultrasound and MRI of long-term medical outcome in native liver survivor patients with biliary atresia after kasai portoenterostomy: a pilot study. Abdom Radiol (NY) 2021; 46:2595-2603. [PMID: 33532908 DOI: 10.1007/s00261-021-02958-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 01/07/2021] [Accepted: 01/15/2021] [Indexed: 12/13/2022]
Abstract
PURPOSE To comparatively assess the role of abdominal ultrasound (US) and magnetic resonance imaging (MRI) in predicting long-term medical outcome in native liver survivor patients with biliary atresia (BA) after Kasai portoenterostomy (KP). METHODS Twenty-four retrospectively enrolled patients were divided in two groups according to clinical and laboratory data at initial evaluation after KP (median follow-up = 9.7 years; range = 5-25 years) as with ideal (Group 1; n = 15) or non-ideal (Group 2; n = 9) medical outcome. All patients were re-evaluated for a period of additional 4 years using clinical and laboratory indices. US and MRI studies were qualitatively analyzed assessing imaging signs suggestive of chronic liver disease (CLD). RESULTS At re-evaluation, 6 patients (40%) of Group 1 changed their medical outcome in non-ideal (Group 1A); the other 9 patients (60%) remained stable (Group 1B); the mean time to change the medical outcome in non-ideal status at re-evaluation was 43.5 ± 2.3 months. The area under the ROC curve was 0.84 and 0.87 for US and MRI scores to predict long-term medical outcome with the best cut-off value score > 4 for both modalities (p = 0.89). In Group 2, 6 (67%) patients showed a clinical progression (Group 2A) with a mean time of 39.8 ± 3.8 months; in the other 3 (33%) patients, no clinical progression was observed (Group 2B). CONCLUSION In BA patients with ideal medical outcome after KP, US and MRI may both predict long-term outcome. US, non-invasive and widely available technique, should be preferred.
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Affiliation(s)
- Martina Caruso
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Via S. Pansini, 5, 80131, Naples, Italy.
| | - Fabiola Di Dato
- Department of Translational Medical Sciences, University of Naples "Federico II", Via S. Pansini, 5, 80131, Naples, Italy
| | - Carmine Mollica
- Institute of Bio-Structures and Bio-Imaging of the National Research Council (CNR), Via Tommaso De Amicis, 80145, Napless, Italy
| | - Gianfranco Vallone
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Via S. Pansini, 5, 80131, Naples, Italy
| | - Valeria Romeo
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Via S. Pansini, 5, 80131, Naples, Italy
| | - Raffaele Liuzzi
- Institute of Bio-Structures and Bio-Imaging of the National Research Council (CNR), Via Tommaso De Amicis, 80145, Napless, Italy
| | - Pier Paolo Mainenti
- Institute of Bio-Structures and Bio-Imaging of the National Research Council (CNR), Via Tommaso De Amicis, 80145, Napless, Italy
| | - Mario Petretta
- Department of Translational Medical Sciences, University of Naples "Federico II", Via S. Pansini, 5, 80131, Naples, Italy
| | - Raffaele Iorio
- Department of Translational Medical Sciences, University of Naples "Federico II", Via S. Pansini, 5, 80131, Naples, Italy
| | - Arturo Brunetti
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Via S. Pansini, 5, 80131, Naples, Italy
| | - Simone Maurea
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Via S. Pansini, 5, 80131, Naples, Italy
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12
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Neonatale Cholestase. Monatsschr Kinderheilkd 2021. [DOI: 10.1007/s00112-020-01042-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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13
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Zhao D, Gu S, Gong X, Li Y, Sun X, Chen Y, Deng Z, Zhang Y. Web-based calculator for biliary atresia screening in neonates and infants with cholestasis. Transl Pediatr 2021; 10:225-235. [PMID: 33708508 PMCID: PMC7944186 DOI: 10.21037/tp-20-170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Distinguishing biliary atresia from non-biliary atresia in patients with cholestasis is challenging, as these conditions have a similar clinical presentation. We developed and externally validated a screening model for biliary atresia and devised a web-based calculator for use in clinical settings. METHODS A screening model was developed based on data from 227 cholestatic infants (82 and 145 with and without biliary atresia, respectively) and validated in 234 infants (90 and 144 with and without biliary atresia, respectively) admitted to three hospitals. Variables were selected from routine examination results using the least absolute shrinkage and selection operator method and entered into a logistic regression model to construct a biliary-atresia-risk-predicting equation. Cutoff values for risk stratification were estimated using model sensitivity, derived from the receiver-operating characteristic curves. RESULTS The final screening model included seven variables (i.e., weight at admission, clay-colored stools, γ-glutamyl transpeptidase and albumin levels at admission, abnormal gallbladder, triangular cord sign, and change in total bilirubin levels). The model generated an area under the curve of 0.94 with a sensitivity of 91.46 and specificity of 86.62 in the derivation cohort. This was confirmed in the validation cohort, as we found an area under the curve of 0.93 with a sensitivity of 93.1 and specificity of 80.15. Patients were stratified into three risk groups (low-, moderate-, and high-risk groups). Biliary atresia was excluded in the low-risk group. The high-risk group showed a higher detection rate of biliary atresia compared to the stool color screening method alone. This model was integrated into a user-friendly web-based system. CONCLUSIONS The screening tool had a high predictive value and may help in decision-making by physicians at tertiary and community hospitals.
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Affiliation(s)
- Dongying Zhao
- Department of Neonatology, Xinhua Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Shengli Gu
- Department of Ultrasound, Xinhua Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Xiaohui Gong
- Department of Neonatology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yahui Li
- Department of Neonatology, Xinhua Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Xiaoang Sun
- Department of Pediatric Digestive Diseases, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yan Chen
- Department of Neonatology, Xinhua Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Zhaohui Deng
- Department of Pediatric Digestive Diseases, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yongjun Zhang
- Department of Neonatology, Xinhua Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
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14
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Tanpowpong P, Lertudomphonwanit C, Phuapradit P, Treepongkaruna S. Value of the International Classification of Diseases code for identifying children with biliary atresia. Clin Exp Pediatr 2021; 64:80-85. [PMID: 32882783 PMCID: PMC7873393 DOI: 10.3345/cep.2020.00423] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 07/25/2020] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Although identifying cases in large administrative databases may aid future research studies, previous reports demonstrated that the use of the International Classification of Diseases, Tenth Revision (ICD-10) code alone for diagnosis leads to disease misclassification. PURPOSE We aimed to assess the value of the ICD-10 diagnostic code for identifying potential children with biliary atresia. METHODS Patients aged <18 years assigned the ICD-10 code of biliary atresia (Q44.2) between January 1996 and December 2016 at a quaternary care teaching hospital were identified. We also reviewed patients with other diagnoses of code-defined cirrhosis to identify more potential cases of biliary atresia. A proposed diagnostic algorithm was used to define ICD-10 code accuracy, sensitivity, and specificity. RESULTS We reviewed the medical records of 155 patients with ICD-10 code Q44.2 and 69 patients with other codes for biliary cirrhosis (K74.4, K74.5, K74.6). The accuracy for identifying definite/probable/possible biliary atresia cases was 80%, while the sensitivity was 88% (95% confidence interval [CI], 82%-93%). Three independent predictors were associated with algorithm-defined definite/probable/possible cases of biliary atresia: ICD-10 code Q44.2 (odds ratio [OR], 2.90; 95% CI, 1.09-7.71), history of pale stool (OR, 2.78; 95% CI, 1.18-6.60), and a presumed diagnosis of biliary atresia prior to referral to our hospital (OR, 17.49; 95% CI, 7.01-43.64). A significant interaction was noted between ICD-10 code Q44.2 and a history of pale stool (P<0.05). The area under the curve was 0.87 (95% CI, 0.84-0.89). CONCLUSION ICD-10 code Q44.2 has an acceptable value for diagnosing biliary atresia. Incorporating clinical data improves the case identification. The use of this proposed diagnostic algorithm to examine data from administrative databases may facilitate appropriate health care allocation and aid future research investigations.
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Affiliation(s)
- Pornthep Tanpowpong
- Division of Gastroenterology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chatmanee Lertudomphonwanit
- Division of Gastroenterology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pornpimon Phuapradit
- Division of Gastroenterology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Suporn Treepongkaruna
- Division of Gastroenterology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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15
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Ho A, Sacks MA, Sapra A, Khan FA. The Utility of Gallbladder Absence on Ultrasound for Children With Biliary Atresia. Front Pediatr 2021; 9:685268. [PMID: 34268279 PMCID: PMC8275825 DOI: 10.3389/fped.2021.685268] [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: 03/24/2021] [Accepted: 05/12/2021] [Indexed: 11/15/2022] Open
Abstract
Background: Biliary Atresia (BA) is congenital condition, where infant intra- and extrahepatic bile ducts become obliterated, leading to cholestasis, and cirrhosis if untreated. This study aims to assess the predictive measure of absent gallbladder on ultrasounds (US) performed in infants with cholestasis for diagnosing BA. Method: After Institutional Review Board approval, retrospective chart reviews of 61 infants with cholestasis found 43 (70.5%) were diagnosed with BA. A pediatric radiologist provided interpretations of all ultrasounds in a blinded fashion. Statistical analysis was used to assess the utility of absence of gallbladder on US in predicting BA, confirmed intraoperatively. Results: Absent gallbladder on US predicts absent gallbladder with 77% accuracy, 92% sensitivity, 73% specificity, PPV 43%, and NPV 97% (P < 0.001, Fisher exact test). To diagnose BA, absent gallbladder on US has 66% accuracy, 53% sensitivity, 94% specificity, 96% PPV, and 46% NPV (P < 0.001, Fisher exact test). Conclusion: Sonographic gallbladder absence has high specificity and PPV, indicating utility for BA diagnosis; however, it is not useful for ruling out BA given its low sensitivity.
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Affiliation(s)
- Andrea Ho
- Department of Pediatrics, Loma Linda University Children's Hospital, Loma Linda, CA, United States
| | - Marla A Sacks
- Division of Pediatric Surgery, Department of Surgery, Loma Linda University, Loma Linda, CA, United States
| | - Amita Sapra
- Division of Pediatric Radiology, Department of Radiology, Loma Linda University, Loma Linda, CA, United States
| | - Faraz A Khan
- Department of Pediatrics, Loma Linda University Children's Hospital, Loma Linda, CA, United States.,Division of Pediatric Surgery, Department of Surgery, Loma Linda University, Loma Linda, CA, United States
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16
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Ling DXH, Bolisetty S, Krishnan U. Cholestatic jaundice in neonates: How common is biliary atresia? Experience at an Australian tertiary centre. J Paediatr Child Health 2021; 57:87-95. [PMID: 32808395 DOI: 10.1111/jpc.15131] [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: 02/18/2020] [Revised: 07/17/2020] [Accepted: 07/26/2020] [Indexed: 11/27/2022]
Abstract
AIM To (i) review the aetiologies of neonatal cholestasis among term and preterm neonates at a single tertiary centre in Australia; (ii) identify clinical variables associated with biliary atresia (BA) and non-BA aetiology of neonatal cholestasis; (iii) investigate the utility of hepatobiliary scintigraphy in predicting BA among term and preterm neonates. METHODS A retrospective cohort study of neonates born and investigated for cholestasis at two co-located neonatal and children facilities from January 2013 to December 2017. RESULTS Of the 139 neonates with cholestasis, BA and intestinal-failure-associated liver-disease was the most common cause of neonatal cholestasis in term (18%) and preterm (66%) cohorts, respectively. Incidence of BA was higher in term (1:6) than preterm (1:50) neonates (OR 10.29; 95% CI 2.06-49.97, P = 0.0024). Higher birthweight, acholic stool, absent or abnormal gallbladder on ultrasound was significantly associated with BA while gestational age ≤32 weeks, total parenteral nutrition ≥14 days and low albumin were associated with non-BA aetiology of cholestasis. In diagnosing BA, non-draining hepatobiliary scintigraphy demonstrated a lower specificity (73% vs. 90%) and lower positive predictive value (25% vs. 78%) in preterm compared to term neonates. CONCLUSION Aetiology of cholestasis among preterm neonates differs from those in term neonates and currently existing diagnostic algorithm for neonatal cholestasis may need to be modified for preterm cohort, taking into account the prevalence for each aetiology, potential predictors and cost-efficiency.
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Affiliation(s)
- David X H Ling
- School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Srinivas Bolisetty
- School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,Department of Newborn Care, Royal Hospital for Women, Sydney, New South Wales, Australia
| | - Usha Krishnan
- School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,Department of Gastroenterology, Sydney Children Hospital, Sydney, New South Wales, Australia
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17
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Caruso M, Cuocolo R, Di Dato F, Mollica C, Vallone G, Romeo V, Petretta M, Liuzzi R, Mainenti PP, Iorio R, Brunetti A, Maurea S. Ultrasound, shear-wave elastography, and magnetic resonance imaging in native liver survivor patients with biliary atresia after Kasai portoenterostomy: correlation with medical outcome after treatment. Acta Radiol 2020; 61:1300-1308. [PMID: 32008344 DOI: 10.1177/0284185120902379] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Biliary atresia (BA) is a rare obliterative cholangiopathy and Kasai portoenterostomy (KP) represents its first-line treatment; clinical and laboratory parameters together with abdominal ultrasound (US) are usually performed during the follow-up. Shear-wave elastography (SWE) is able to evaluate liver parenchyma stiffness; magnetic resonance imaging (MRI) has also been proposed to study these patients. PURPOSE To correlate US, SWE, and MRI imaging findings with medical outcome in patients with BA who are native liver survivors after KP. MATERIAL AND METHODS We retrospectively enrolled 24 patients. They were divided in two groups based on "ideal" (n = 15) or "non-ideal" (n = 9) medical outcome. US, SWE, and MRI exams were analyzed qualitatively and quantitatively for imaging signs suggestive of chronic liver disease (CLD). RESULTS Significant differences were found in terms of liver surface (P = 0.007) and morphology (P = 0.013), portal vein diameter (P = 0.012) and spleen size (P = 0.002) by US, liver signal intensity (P = 0.013), portal vein diameter (P = 0.010), presence of portosystemic collaterals (P = 0.042), and spleen size (P = 0.001) by MRI. The evaluation of portal vein diameter (moderate, κ = 0.44), of portosystemic collaterals (good, κ = 0.78), and spleen size (very good, κ = 0.92) showed the best agreement between US and MRI. A significant (P = 0.01) difference in liver parenchyma stiffness by SWE was also found between the two groups (cut-off = 9.6 kPa, sensitivity = 55.6%, specificity = 100%, area under the ROC curve = 0.82). CONCLUSION US, SWE, and MRI findings correlate with the medical outcome in native liver survivor patients with BA treated with KP.
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Affiliation(s)
- Martina Caruso
- Department of Advanced Biomedical Sciences, University of Naples “Federico II,” Naples, Italy
| | - Renato Cuocolo
- Department of Advanced Biomedical Sciences, University of Naples “Federico II,” Naples, Italy
| | - Fabiola Di Dato
- Department of Translational Medical Sciences, University of Naples “Federico II,” Naples, Italy
| | - Carmine Mollica
- Institute of Bio-Structures and Bio-Imaging of the National Research Council (CNR), Naples, Italy
| | - Gianfranco Vallone
- Department of Advanced Biomedical Sciences, University of Naples “Federico II,” Naples, Italy
| | - Valeria Romeo
- Department of Advanced Biomedical Sciences, University of Naples “Federico II,” Naples, Italy
| | - Mario Petretta
- Department of Translational Medical Sciences, University of Naples “Federico II,” Naples, Italy
| | - Raffaele Liuzzi
- Institute of Bio-Structures and Bio-Imaging of the National Research Council (CNR), Naples, Italy
| | - Pier Paolo Mainenti
- Institute of Bio-Structures and Bio-Imaging of the National Research Council (CNR), Naples, Italy
| | - Raffaele Iorio
- Department of Translational Medical Sciences, University of Naples “Federico II,” Naples, Italy
| | - Arturo Brunetti
- Department of Advanced Biomedical Sciences, University of Naples “Federico II,” Naples, Italy
| | - Simone Maurea
- Department of Advanced Biomedical Sciences, University of Naples “Federico II,” Naples, Italy
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Adeyemi A, States L, Wann L, Lin HC, Rand EB. Biliary Excretion Noted on Hepatobiliary Iminodiacetic Acid Scan Does Not Exclude Diagnosis of Biliary Atresia. J Pediatr 2020; 220:245-248. [PMID: 32111380 DOI: 10.1016/j.jpeds.2019.12.055] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 11/27/2019] [Accepted: 12/20/2019] [Indexed: 01/14/2023]
Abstract
A hepatobiliary iminodiacetic acid (HIDA) scan is frequently used in an attempt to exclude biliary atresia in infants who are cholestatic. We present 6 cases of confirmed biliary atresia in infants who had biliary patency reported on HIDA scan. We demonstrate that misinterpreted HIDA scans led to delayed diagnosis and surgical intervention for biliary atresia.
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Affiliation(s)
- Adebowale Adeyemi
- Division of Gastroenterology, Hepatology and Nutrition, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE.
| | - Lisa States
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Leslie Wann
- The University of Pennsylvania School of Arts and Sciences, Philadelphia, PA
| | - Henry C Lin
- Division of Pediatric Gastroenterology, Doernbecher Children's Hospital, Portland, OR
| | - Elizabeth B Rand
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA
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19
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Chen Y, Zhao D, Gu S, Li Y, Pan W, Zhang Y. Three-color risk stratification for improving the diagnostic accuracy for biliary atresia. Eur Radiol 2020; 30:3852-3861. [PMID: 32162000 DOI: 10.1007/s00330-020-06751-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 02/10/2020] [Accepted: 02/14/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVES It is challenging to early differentiate biliary atresia from other causes of cholestasis. We aimed to develop an algorithm with risk stratification to distinguish biliary atresia from infantile cholestasis. METHODS In this study, we enrolled infants with cholestasis into 2 subgroups from January 2010 to April 2019. A prospective cohort (subgroup 2) of 187 patients (107 with biliary atresia and 80 without biliary atresia) underwent acoustic radiation force impulse elastography. Stepwise regression was used to identify significant predictors of biliary atresia. A sequential algorithm with risk stratification was constructed. RESULTS Among 187 patients, shear wave speed > 1.35 m/s and presence of the triangular cord sign were considered high risk for biliary atresia (red), in which 73 of 78 patients (accuracy of 93.6%) with biliary atresia were identified. Afterwards, γ-GT, abnormal gallbladder, and clay stool were introduced into the algorithm and 55 intermediate-risk infants were identified (yellow) with a diagnostic accuracy of 60% for biliary atresia. Of the remaining 54 infants who were classified as low-risk patients (green), the accuracy for excluding biliary atresia was 98.1%. By applying a three-color risk stratification tool, 70.6% patients were identified as either high risk or low risk for biliary atresia (area under the curve, 0.983; sensitivity, 98.7%; specificity, 91.4%). We also estimated the risk of biliary atresia in different color groups, which was 94.7% (95%CI, 94.3-95.5%) in the red group and 7.2% (95%CI, 6.6-8.3%) in the green group. CONCLUSIONS Our simple noninvasive approach was able to identify biliary atresia with high accuracy. KEY POINTS • Five predictors, namely shear wave speed, triangle cord sign, γ-glutamyl transferase, abnormal gallbladder, and clay stool, were selected to identify biliary atresia in cholestasis. • Shear wave speed > 1.35 m/s and presence of the triangle cord sign were considered high-risk patients with a diagnostic accuracy of 93.6% for biliary atresia. • Risk for biliary atresia was high (red), intermediate (yellow), or low (green). In the red and green group, we achieved an extremely high diagnostic performance (area under the curve, 0.983; sensitivity, 98.7%; specificity, 91.4%).
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Affiliation(s)
- Yan Chen
- Department of Neonatology, Xinhua Hospital, Shanghai JiaoTong University School of Medicine, 1665 Kong Jiang Road, Shanghai, 200092, China
| | - Dongying Zhao
- Department of Neonatology, Xinhua Hospital, Shanghai JiaoTong University School of Medicine, 1665 Kong Jiang Road, Shanghai, 200092, China
| | - Shengli Gu
- Department of Ultrasound, Xinhua Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Yahui Li
- Department of Neonatology, Xinhua Hospital, Shanghai JiaoTong University School of Medicine, 1665 Kong Jiang Road, Shanghai, 200092, China
| | - Weihua Pan
- Department of Pediatric Surgery, Xinhua Hospital, Shanghai JiaoTong University School of Medicine, 1665 Kong Jiang Road, Shanghai, 200092, China.
| | - Yongjun Zhang
- Department of Neonatology, Xinhua Hospital, Shanghai JiaoTong University School of Medicine, 1665 Kong Jiang Road, Shanghai, 200092, China.
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20
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Normal Gamma Glutamyl Transferase Levels at Presentation Predict Poor Outcome in Biliary Atresia. J Pediatr Gastroenterol Nutr 2020; 70:350-355. [PMID: 31738295 DOI: 10.1097/mpg.0000000000002563] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVES Gamma-glutamyl transferase levels (GGT) are typically elevated in biliary atresia (BA), but normal GGT levels have been observed. This cohort of "normal GGT" BA has neither been described nor has the prognostic value of GGT level on outcomes in BA. We aimed to describe outcomes of a single-centre Australian cohort of infants with BA and assess the impact of GGT level at presentation on outcomes in BA. METHODS Infants diagnosed with BA between 1991 and 2017 were retrospectively analysed. Outcomes were defined as survival with native liver, liver transplantation (LT), and death. Patients were categorized into normal (<200I U/L) or high GGT groups based on a mean of 3 consecutive GGT values done before Kasai portoenterostomy (KPE). Baseline parameters, age at surgery, clearance of jaundice (COJ), and outcomes were compared between the 2 groups. RESULTS One hundred thirteen infants underwent KPE at median 61 (30-149) days. At a median follow-up of 14.2 (0.9-26.3) years, 35% (39/113) patients were surviving with native liver, 55% (62/113) underwent LT and 11% (12/113) died pretransplant. 12.3% (14/113) patients had normal GGT. Age at KPE and time to COJ were similar between normal and high GGT groups. Normal GGT group had shorter time from KPE to LT (11 vs 18 months, P = 0.02), underwent LT at a younger age (14 vs 20 months, P = 0.04), and had poorer transplant-free survival (P = 0.04) than high GGT group. CONCLUSIONS 12.3% of infants with BA had normal GGT levels at diagnosis. Low GGT levels at presentation in BA was associated with a poorer outcome.
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Okazaki T, Ochi T, Nakamura H, Tsukui T, Koga H, Urao M, Lane GJ, Yamataka A. Needle liver biopsy has potential for delaying Kasai portoenterostomy and Is obsolete for diagnosing biliary atresia in the laparoscopic era. J Pediatr Surg 2019; 54:2570-2573. [PMID: 31522798 DOI: 10.1016/j.jpedsurg.2019.08.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Accepted: 08/24/2019] [Indexed: 01/11/2023]
Abstract
AIM Early diagnosis is essential for the successful management of biliary atresia (BA). We assessed the efficacy of our diagnostic strategies for BA in the laparoscopic era. METHODS A retrospective review of the medical records of 132 infants presenting with suspected BA between 1998 and 2018 was performed to assess the efficacy of "basic" tests (blood biochemistry, abdominal ultrasound, and Tc-99m N-pyrydoxyl-5-methyltriptophane liver scintigraphy) and the value of laparoscopic assessment of the porta hepatis and/or cholangiography for choosing between Kasai portoenterostomy (PE) or cholangiodrainage (CD) for treatment. RESULTS BA was excluded on "basic" tests in 7 cases: 109/125 had BA diagnosed laparoscopically and proceeded immediately to PE. Nonatrophic gallbladder cases (n = 10) had CD and other morbidity diagnosed on liver biopsy (Bx; n = 6). Sensitivity, specificity, and accuracy of diagnosis using "basic" tests were 100%, 30.4%, and 87.9%, respectively. Accuracy of laparoscopy without Bx was 100%, allowing immediate progression to PE without waiting for Bx results or trauma from Bx to heal. "Basic" tests and laparoscopy can be completed within one week. CONCLUSIONS A combination of "basic" tests and laparoscopy can diagnose BA promptly and accurately without Bx. Bx is essentially unnecessary for diagnosing BA if laparoscopy is performed. TYPE OF STUDY Study of diagnostic test. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Tadaharu Okazaki
- Department of Pediatric Surgery, Juntendo University Urayasu Hospital, Urayasu-shi, Chiba, Japan.
| | - Takanori Ochi
- Department of Pediatric General and Urogenital Surgery, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Hiroki Nakamura
- Department of Pediatric General and Urogenital Surgery, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Takafumi Tsukui
- Department of Pediatric General and Urogenital Surgery, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Hiroyuki Koga
- Department of Pediatric General and Urogenital Surgery, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Masahiko Urao
- Department of Pediatric Surgery, Juntendo University Nerima Hospital, Tokyo, Japan
| | - Geoffrey J Lane
- Department of Pediatric General and Urogenital Surgery, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Atsuyuki Yamataka
- Department of Pediatric General and Urogenital Surgery, Juntendo University Graduate School of Medicine, Tokyo, Japan
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Biliary Atresia as a Disease Starting In Utero: Implications for Treatment, Diagnosis, and Pathogenesis. J Pediatr Gastroenterol Nutr 2019; 69:396-403. [PMID: 31335837 PMCID: PMC6942669 DOI: 10.1097/mpg.0000000000002450] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Biliary atresia (BA) is the most common reason for pediatric liver transplant. BA's varied presentation, natural history, and treatment with the Kasai portoenterostomy have been well described; however, when BA starts relative to birth has not been clearly defined. In this review, we discuss laboratory, imaging, and clinical data which suggest that most if not all forms of BA may start before birth. This early onset has implications in terms of delivering treatments earlier and identifying possible factors underlying BA's etiology.
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Abstract
BACKGROUND Patients with gastroschisis and prolonged total (or partial) parenteral nutrition (PN) commonly develop direct hyperbilirubinemia (DH). OBJECTIVE To quantify the prevalence and severity of DH in newborns with gastroschisis and characterize the diagnostic work-up for DH in this patient population. DESIGN/METHODS Retrospective chart review of patients born with gastroschisis between 2005 and 2015 for the first 6 months of life. RESULTS 29 patients were identified with gastroschisis. Mean gestational age and birthweight were 36.4 (± 1.8) weeks and 2.5 (± 0.6) kg. 41% were treated with primary reduction versus staged closure. Peak total and direct bilirubin (DB) levels were 10.17 ± 6.21 mg/dL and 5.58 ± 3.94 mg/dL, respectively. 23 patients (79.3%) were diagnosed with DH and 78.2% underwent additional work-up for hyperbilirubinemia consisting of imaging and laboratory studies, none of which revealed a cause for DH other than the presumed PN-associated cholestasis. In all patients, DB began to decline within 1-10 days of initiation of enteral feeds. CONCLUSION(S) DH is common in patients with gastroschisis and is unlikely to be associated with pathology aside from PN. Additional work-up may lead to unnecessary resource utilization. LEVELS OF EVIDENCE Case series with no comparison group, Level IV.
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Lertudomphonwanit C, Mourya R, Fei L, Zhang Y, Gutta S, Yang L, Bove KE, Shivakumar P, Bezerra JA. Large-scale proteomics identifies MMP-7 as a sentinel of epithelial injury and of biliary atresia. Sci Transl Med 2018; 9:9/417/eaan8462. [PMID: 29167395 DOI: 10.1126/scitranslmed.aan8462] [Citation(s) in RCA: 88] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2017] [Accepted: 10/20/2017] [Indexed: 12/24/2022]
Abstract
Biliary atresia is a progressive infantile cholangiopathy of complex pathogenesis. Although early diagnosis and surgery are the best predictors of treatment response, current diagnostic approaches are imprecise and time-consuming. We used large-scale, quantitative serum proteomics at the time of diagnosis of biliary atresia and other cholestatic syndromes (serving as disease controls) to identify biomarkers of disease. In a discovery cohort of 70 subjects, the lead biomarker was matrix metalloproteinase-7 (MMP-7), which retained high distinguishing features for biliary atresia in two validation cohorts. Notably, the diagnostic performance reached 95% when MMP-7 was combined with γ-glutamyltranspeptidase (GGT), a marker of cholestasis. Using human tissue and an experimental model of biliary atresia, we found that MMP-7 is primarily expressed by cholangiocytes, released upon epithelial injury, and promotes the experimental disease phenotype. Thus, we propose that serum MMP-7 (alone or in combination with GGT) is a diagnostic biomarker for biliary atresia and may serve as a therapeutic target.
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Affiliation(s)
- Chatmanee Lertudomphonwanit
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center and the Department of Pediatrics of the University of Cincinnati College of Medicine, Cincinnati, OH 45229-3031, USA.,Division of Gastroenterology and Hepatology, Department of Pediatrics, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | - Reena Mourya
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center and the Department of Pediatrics of the University of Cincinnati College of Medicine, Cincinnati, OH 45229-3031, USA
| | - Lin Fei
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center and the Department of Pediatrics of the University of Cincinnati College of Medicine, Cincinnati, OH 45229-3031, USA
| | - Yue Zhang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center and the Department of Pediatrics of the University of Cincinnati College of Medicine, Cincinnati, OH 45229-3031, USA
| | - Sridevi Gutta
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center and the Department of Pediatrics of the University of Cincinnati College of Medicine, Cincinnati, OH 45229-3031, USA
| | - Li Yang
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center and the Department of Pediatrics of the University of Cincinnati College of Medicine, Cincinnati, OH 45229-3031, USA.,Division of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Kevin E Bove
- Division of Pathology, Cincinnati Children's Hospital Medical Center and the Department of Pediatrics of the University of Cincinnati College of Medicine, Cincinnati, OH 45229-3031, USA
| | - Pranavkumar Shivakumar
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center and the Department of Pediatrics of the University of Cincinnati College of Medicine, Cincinnati, OH 45229-3031, USA
| | - Jorge A Bezerra
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center and the Department of Pediatrics of the University of Cincinnati College of Medicine, Cincinnati, OH 45229-3031, USA.
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Chaudhry Z, Forget S, Nguyen VH, Ahmed N. The Role of Liver Biopsy in Investigation of Cholestatic Liver Disease in Infancy. J Can Assoc Gastroenterol 2018; 2:51-56. [PMID: 31294365 PMCID: PMC6507280 DOI: 10.1093/jcag/gwy026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Objectives The objective of this study was to assess the diagnostic yield and impact on management of liver biopsy in infants with cholestatic jaundice. Methods A retrospective cohort study of infants with cholestasis who underwent liver biopsy before one year of age between December 2002 and December 2013 at the Montreal Children’s Hospital was conducted. Biopsies were reviewed by a single pathologist. The diagnostic yield of the biopsy was assessed in terms of its role in establishing a diagnosis, excluding an important diagnosis or changing management. Results Seventy-nine biopsies were performed within the time frame outlined, with 58 fulfilling inclusion criteria. Liver biopsies were found to add novel information in 21 cases (36.2%). The diagnostic yield of the biopsy was unrelated to the severity of direct hyperbilirubinemia, age at biopsy, age at admission, co-morbidities, stool color at presentation and TPN exposure. Among infants under 90 days of age, 21 also underwent cholangiography, the results of which were consistent with biopsy findings. There were four (6.9%) documented complications from biopsies, including bleeding and accumulation of free fluid in the peri-hepatic area. Conclusions Liver biopsy is an invasive test used with other clinical modalities to determine the etiology of neonatal cholestasis. These results suggest that biopsy added novel information to the diagnostic workup in 36.2% of cases with a complication rate of 6.9%. Consequently, the role and timing of liver biopsy need to be reassessed to determine which patients would most benefit from this procedure.
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Affiliation(s)
- Zoya Chaudhry
- Department of Ophthalmology, McGill University Health Centre, Montreal, Canada
| | - Sylviane Forget
- Division of Pediatric Gastroenterology, Montreal Children's Hospital, Montreal, Quebec, Canada
| | - Van-Hung Nguyen
- Department of Pathology, McGill University Health Centre, Montreal, Canada
| | - Najma Ahmed
- Division of Pediatric Gastroenterology, Montreal Children's Hospital, Montreal, Quebec, Canada
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26
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Harpavat S, Lupo PJ, Liwanag L, Hollier J, Brandt ML, Finegold MJ, Shneider BL. Factors Influencing Time-to-diagnosis of Biliary Atresia. J Pediatr Gastroenterol Nutr 2018; 66:850-856. [PMID: 29315162 PMCID: PMC5963977 DOI: 10.1097/mpg.0000000000001887] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVES Diagnosing biliary atresia (BA) quickly is critical, because earlier treatment correlates with delayed or reduced need for liver transplantation. However, diagnosing BA quickly is also difficult, with infants usually treated after 60 days of life. In this study, we aim to accelerate BA diagnosis and treatment, by better understanding factors influencing the diagnostic timeline. METHODS Infants born between 2007 and 2014 and diagnosed with BA at our institution were included (n = 65). Two periods were examined retrospectively: P1, the time from birth to specialist referral, and P2, the time from specialist referral to treatment. How sociodemographic factors associate with P1 and P2 were analyzed with Kaplan-Meier curves and Cox proportional hazard models. In addition, to better characterize P2, laboratory results and early tissue histology were studied. RESULTS P1 associated with race/ethnicity, with shorter times in non-Hispanic white infants compared to non-Hispanic black and Hispanic infants (P = 0.007 and P = 0.004, respectively). P2 associated with referral age, with shorter times in infants referred after 30, 45, or 60 days of life (P < 0.001, P < 0.001, and P = 0.001, respectively). One potential reason for longer P2 in infants referred ≤30 days is that aminotransferase levels were normal or near-normal. However, despite reassuring laboratory values, tissue histology in early cases showed key features of BA. CONCLUSIONS Our findings suggest 2 opportunities to accelerate BA diagnosis and treatment. First, to achieve prompt referrals for all races/ethnicities, universal screening strategies should be considered. Second, to ensure efficient evaluations independent of age, algorithms designed to detect early features of BA can be developed.
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Affiliation(s)
- Sanjiv Harpavat
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and
Nutrition
| | - Philip J. Lupo
- Department of Pediatrics, Division of Hematology and Oncology
| | - Loriel Liwanag
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and
Nutrition
| | - John Hollier
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and
Nutrition
| | | | - Milton J. Finegold
- Department of Pathology, Baylor College of Medicine and Texas
Children’s Hospital
| | - Benjamin L. Shneider
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and
Nutrition
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27
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Wang L, Yang Y, Chen Y, Zhan J. Early differential diagnosis methods of biliary atresia: a meta-analysis. Pediatr Surg Int 2018; 34:363-380. [PMID: 29397405 DOI: 10.1007/s00383-018-4229-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/11/2018] [Indexed: 11/25/2022]
Abstract
PURPOSE To evaluate the accuracy of early differential diagnosis methods of biliary atresia in patients with infantile cholestasis. METHODS We searched PubMed, EMBASE and the Web of Science databases for articles evaluated the early differential diagnosis methods of biliary atresia. The methodological quality of each study was assessed with version 2 of the Quality Assessment of Diagnostic Accuracy Studies tool. Two reviewers extracted data independently. Pooled sensitivity, specificity, positive likelihood ratio (LR +), negative likelihood ratio (LR -), diagnostic odds ratio (DOR) with 95% CIs were calculated to assess each diagnosis method. RESULTS A total of 38 articles were included. Summary sensitivity and specificity were 77% (95% CI 74-80%) and 93% (95% CI 91-94%), respectively, for B-US in 23 studies; 96% (95% CI 92-98%) and 58% (95% CI 51-65%), respectively, for MRCP in five studies; 87% (95% CI 82-91%) and 78% (95% CI 74-82%), respectively, for acholic stool in seven studies; 84% (95% CI 78-89%) and 97% (95% CI 97-98%), respectively, for serum liver function test in seven studies; 96% (95% CI 94-97%) and 73% (95% CI 70-76%), respectively, for hepatobiliary scintigraphy in 18 studies; 98% (95% CI 96-99%) and 93% (95% CI 89-95%), respectively, for percutaneous liver biopsy in 11 studies. CONCLUSION The accuracy rate of percutaneous liver biopsy is better than all of the noninvasive methods. Take into consideration the advantages and disadvantages of the six methods, combination of multidisciplinary noninvasive diagnosis methods is the first choice for differential diagnosis of BA from other causes of neonatal cholestasis.
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Affiliation(s)
- Li Wang
- Department of Pediatric Surgery, Tianjin Children's Hospital, Tianjin, 300134, China
| | - Yuan Yang
- Department of Pediatric Surgery, Tianjin Children's Hospital, Tianjin, 300134, China
| | - Yang Chen
- Department of Pediatric Surgery, Tianjin Children's Hospital, Tianjin, 300134, China
| | - Jianghua Zhan
- Department of Pediatric Surgery, Tianjin Children's Hospital, Tianjin, 300134, China.
- Tianjin Pediatrics Research Institute, Tianjin, 300134, China.
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Ørntoft N, Frisch K, Ott P, Keiding S, Sørensen M. Functional assessment of hepatobiliary secretion by 11C-cholylsarcosine positron emission tomography. Biochim Biophys Acta Mol Basis Dis 2017; 1864:1240-1244. [PMID: 29197661 DOI: 10.1016/j.bbadis.2017.11.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 11/23/2017] [Accepted: 11/24/2017] [Indexed: 01/26/2023]
Abstract
Positron emission tomography (PET) with 11C-cholylsarcosine (11C-CSar), a radiolabelled synthetic N-methylglycine (sarcosine) conjugate of cholic acid, is a novel molecular imaging technique that enables quantitative assessment of the individual transport steps involved in hepatic secretion of conjugated bile acids. Here, we present the method and discuss its potential clinical and scientific applications based on findings in the first human study of healthy subjects and patients with cholestasis. We also present a clinical example of a patient studied during and six months after an episode of drug-induced cholestatic liver injury.
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Affiliation(s)
- Nikolaj Ørntoft
- Department of Hepatology & Gastroenterology, Aarhus University Hospital, Denmark
| | - Kim Frisch
- Department of Nuclear Medicine & PET Centre, Aarhus University Hospital, Denmark
| | - Peter Ott
- Department of Hepatology & Gastroenterology, Aarhus University Hospital, Denmark
| | - Susanne Keiding
- Department of Hepatology & Gastroenterology, Aarhus University Hospital, Denmark; Department of Nuclear Medicine & PET Centre, Aarhus University Hospital, Denmark
| | - Michael Sørensen
- Department of Hepatology & Gastroenterology, Aarhus University Hospital, Denmark.
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29
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Shneider BL, Moore J, Kerkar N, Magee JC, Ye W, Karpen SJ, Kamath BM, Molleston JP, Bezerra JA, Murray KF, Loomes KM, Whitington PF, Rosenthal P, Squires RH, Guthery SL, Arnon R, Schwarz KB, Turmelle YP, Sherker AH, Sokol RJ. Initial assessment of the infant with neonatal cholestasis-Is this biliary atresia? PLoS One 2017; 12:e0176275. [PMID: 28493866 PMCID: PMC5426590 DOI: 10.1371/journal.pone.0176275] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 04/07/2017] [Indexed: 01/29/2023] Open
Abstract
Introduction Optimizing outcome in biliary atresia (BA) requires timely diagnosis. Cholestasis is a presenting feature of BA, as well as other diagnoses (Non-BA). Identification of clinical features of neonatal cholestasis that would expedite decisions to pursue subsequent invasive testing to correctly diagnose or exclude BA would enhance outcomes. The analytical goal was to develop a predictive model for BA using data available at initial presentation. Methods Infants at presentation with neonatal cholestasis (direct/conjugated bilirubin >2 mg/dl [34.2 μM]) were enrolled prior to surgical exploration in a prospective observational multi-centered study (PROBE–NCT00061828). Clinical features (physical findings, laboratory results, gallbladder sonography) at enrollment were analyzed. Initially, 19 features were selected as candidate predictors. Two approaches were used to build models for diagnosis prediction: a hierarchical classification and regression decision tree (CART) and a logistic regression model using a stepwise selection strategy. Results In PROBE April 2004-February 2014, 401 infants met criteria for BA and 259 for Non-BA. Univariate analysis identified 13 features that were significantly different between BA and Non-BA. Using a CART predictive model of BA versus Non-BA (significant factors: gamma-glutamyl transpeptidase, acholic stools, weight), the receiver operating characteristic area under the curve (ROC AUC) was 0.83. Twelve percent of BA infants were misclassified as Non-BA; 17% of Non-BA infants were misclassified as BA. Stepwise logistic regression identified seven factors in a predictive model (ROC AUC 0.89). Using this model, a predicted probability of >0.8 (n = 357) yielded an 81% true positive rate for BA; <0.2 (n = 120) yielded an 11% false negative rate. Conclusion Despite the relatively good accuracy of our optimized prediction models, the high precision required for differentiating BA from Non-BA was not achieved. Accurate identification of BA in infants with neonatal cholestasis requires further evaluation, and BA should not be excluded based only on presenting clinical features.
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Affiliation(s)
- Benjamin L. Shneider
- Pediatric Gastroenterology, Hepatology, and Nutrition; Baylor College of Medicine; Houston, Texas, United States
- * E-mail:
| | - Jeff Moore
- Department of Biostatistics; University of Michigan; Ann Arbor, Michigan, United States
| | - Nanda Kerkar
- Children’s Hospital of Los Angeles; Los Angeles, California, United States
- Mount Sinai; New York, New York, United States
| | - John C. Magee
- University of Michigan Medical School; Ann Arbor, Michigan, United States
| | - Wen Ye
- Department of Biostatistics; University of Michigan; Ann Arbor, Michigan, United States
| | - Saul J. Karpen
- Pediatric Gastroenterology, Hepatology, and Nutrition; Emory University School of Medicine/Children’s Healthcare of Atlanta; Atlanta, Georgia, United States
| | - Binita M. Kamath
- Division of Gastroenterology, Hepatology, and Nutrition; Hospital for Sick Children and University of Toronto; Toronto, Ontario, Canada
| | - Jean P. Molleston
- Pediatric Gastroenterology, Hepatology, and Nutrition; Indiana University School of Medicine/Riley Hospital for Children; Indianapolis, Indiana, United States
| | - Jorge A. Bezerra
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition; Cincinnati Children’s Hospital Medical Center; Cincinnati, Ohio, United States
| | - Karen F. Murray
- Division of Gastroenterology and Hepatology; University of Washington Medical Center; Seattle Children’s; Seattle, Washington, United States
| | - Kathleen M. Loomes
- Pediatric Gastroenterology, Hepatology, and Nutrition; Children’s Hospital of Philadelphia; Philadelphia, Pennsylvania, United States
| | - Peter F. Whitington
- Pediatrics Division of Gastroenterology, Hepatology, and Nutrition; Ann and Robert H. Lurie Children’s Hospital of Chicago; Chicago, Illinois, United States
| | - Philip Rosenthal
- Division of Gastroenterology, Hepatology, and Nutrition; Department of Pediatrics; University of California San Francisco; San Francisco, California, United States
| | - Robert H. Squires
- Children’s Hospital of Pittsburgh; Pittsburgh, Pennsylvania, United States
| | - Stephen L. Guthery
- Pediatric Gastroenterology, Hepatology, and Nutrition; University of Utah; Salt Lake City, Utah, United States
| | - Ronen Arnon
- Mount Sinai; New York, New York, United States
| | | | - Yumirle P. Turmelle
- Washington University School of Medicine; St. Louis, Missouri, United States
| | - Averell H. Sherker
- Liver Diseases Research Branch; National Institute of Diabetes and Digestive and Kidney Diseases; National Institutes of Health; Bethesda, Maryland, United States
| | - Ronald J. Sokol
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics; University of Colorado School of Medicine; Children’s Hospital Colorado; Aurora, Colorado, United States
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30
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Stagg H, Cameron BH, Ahmed N, Butler A, Jimenez-Rivera C, Yanchar NL, Martin SR, Emil S, Anthopoulos G, Schreiber RA, Laberge JM. Variability of diagnostic approach, surgical technique, and medical management for children with biliary atresia in Canada - Is it time for standardization? J Pediatr Surg 2017; 52:802-806. [PMID: 28189446 DOI: 10.1016/j.jpedsurg.2017.01.041] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 01/23/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND The Canadian 4-year native liver survival rate for biliary atresia (BA) after Kasai Portoenterostomy (KP) is 39%. The Canadian Biliary Atresia Registry (CBAR) was used to examine variability of surgical and medical management of BA. METHODS Gastroenterologists and surgeons in all 14 Canadian pediatric tertiary centers were invited to complete an online survey of their BA management practices. RESULTS Of gastroenterologists, diagnostic procedures included liver biopsy (92%), HIDA scan (58%), and percutaneous cholangiogram (46%). Surgeons reported Roux-en-Y lengths of 20-50cm with 78% avoiding diathermy at the portal plate; 16% performed laparoscopic exploration, but none laparoscopic KP. Postoperative corticosteroids and antibiotics were used by 24% and 85% of gastroenterologists, respectively, with similar rates for surgeons. At discharge, gastroenterologists prescribed oral antibiotics (80%), and ursodeoxycholic acid (95%), while surgeons reported lower rates (62% and 55%). Considerable variation existed in follow-up monitoring. No center had a standard protocol for evaluating suspected cholangitis. There was a lack of consensus for defining failed KP and referral criteria for transplant evaluation. CONCLUSION In Canada, treatment of BA is not centralized, and there is variability in diagnostic approaches and management. Collaboration through CBAR will allow for implementation and evaluation of standardized surgical and medical management with a goal to improve outcomes. LEVEL OF EVIDENCE Survey study. Level IV evidence.
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Affiliation(s)
- Hayden Stagg
- Department of Pediatric Surgery, Montreal Children's Hospital, Montreal, QC, Canada H4A 3J1
| | - Brian H Cameron
- Division of Pediatric Surgery, McMaster Children's Hospital, Hamilton, ON, Canada L8N3Z5
| | - Najma Ahmed
- Division of Pediatric Gastroenterology, Montreal Children's Hospital, Montreal, QC, Canada H4A 3J1
| | - Alison Butler
- Department of Pediatrics, University of British Columbia, BC Children's Hospital, Vancouver, BC, Canada V6H 3V4
| | - Carolina Jimenez-Rivera
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada K1H 8L1
| | - Natalie L Yanchar
- Division of Pediatric Surgery, IWK Health Centre, Halifax, Nova Scotia, Canada B3K 6R8
| | - Steve R Martin
- Division of Pediatric Gastroenterology, Alberta Children's Hospital, Calgary, AB, Canada T3B 6A8
| | - Sherif Emil
- Department of Pediatric Surgery, Montreal Children's Hospital, Montreal, QC, Canada H4A 3J1
| | | | - Richard A Schreiber
- Division of Pediatric Gastroenterology, Department of Pediatrics, University of British Columbia, BC Children's Hospital, Vancouver, BC, Canada V6H 3V4
| | - Jean-Martin Laberge
- Department of Pediatric Surgery, Montreal Children's Hospital, Montreal, QC, Canada H4A 3J1.
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Abstract
This review highlights the complications and their risk factors encountered in pediatric hepatobiliary surgery, specifically in the context of pediatric hepatic resection, excision of choledochal cyst, and the Kasai hepatoportoenterostomy procedure for biliary atresia as well as other procedures potentially affecting the biliary tree. With the understanding that these are relatively rare procedures, case reports and small case series are included in addition to larger series when available. The review focuses on publications in English over the past 15 years. Complications included both surgery-specific pathology, such as biliary stricture after excision of choledochal cyst, and disease-specific entities, such as malnutrition in biliary atresia. This review may be useful when considering a particular procedure or in the discussion thereof with a patient and family. Additionally, it illuminates the need for additional work with larger patient databases to refine and expand our knowledge of these complications and precipitating risk factors.
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Affiliation(s)
- Gabriella Grisotti
- Department of Surgery, Yale School of Medicine, 333 Cedar St, FMB 131, P.O. Box 208062, New Haven, Connecticut 06520
| | - Robert A Cowles
- Department of Surgery, Yale School of Medicine, 333 Cedar St, FMB 131, P.O. Box 208062, New Haven, Connecticut 06520.
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32
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Abstract
Biliary disease in infants and children frequently presents diagnostic and therapeutic challenges. Pediatric interventional radiologists are often involved in the multidisciplinary teams who care for these patients. This article reviews several notable causes of biliary disease in children who have not undergone liver transplantation, describes the role of percutaneous interventional procedures in managing these conditions, and details applicable biliary interventional techniques.
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Affiliation(s)
- Lisa H Kang
- Department of Radiology, University of Texas Southwestern Children's Health, Dallas, Texas
| | - Colin N Brown
- Department of Radiology, Texas Scottish Rite Hospital for Children, Dallas, Texas
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Verkade HJ, Bezerra JA, Davenport M, Schreiber RA, Mieli-Vergani G, Hulscher JB, Sokol RJ, Kelly DA, Ure B, Whitington PF, Samyn M, Petersen C. Biliary atresia and other cholestatic childhood diseases: Advances and future challenges. J Hepatol 2016; 65:631-42. [PMID: 27164551 DOI: 10.1016/j.jhep.2016.04.032] [Citation(s) in RCA: 109] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 04/26/2016] [Accepted: 04/28/2016] [Indexed: 02/08/2023]
Abstract
Biliary Atresia and other cholestatic childhood diseases are rare conditions affecting the function and/or anatomy along the canalicular-bile duct continuum, characterised by onset of persistent cholestatic jaundice during the neonatal period. Biliary atresia (BA) is the most common among these, but still has an incidence of only 1 in 10-19,000 in Europe and North America. Other diseases such as the genetic conditions, Alagille syndrome (ALGS) and Progressive Familial Intrahepatic Cholestasis (PFIC), are less common. Choledochal malformations are amenable to surgical correction and require a high index of suspicion. The low incidence of such diseases hinder patient-based studies that include large cohorts, while the limited numbers of animal models of disease that recapitulate the spectrum of disease phenotypes hinders both basic research and the development of new treatments. Despite their individual rarity, collectively BA and other cholestatic childhood diseases are the commonest indications for liver transplantation during childhood. Here, we review the recent advances in basic research and clinical progress in these diseases, as well as the research needs. For the various diseases, we formulate current key questions and controversies and identify top priorities to guide future research.
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Affiliation(s)
- Henkjan J Verkade
- Department of Paediatrics, University of Groningen, Beatrix Children's Hospital/University Medical Center, Groningen, The Netherlands.
| | - Jorge A Bezerra
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Mark Davenport
- Department of Paediatric Surgery, King's College Hospital, Denmark Hill, London, UK
| | - Richard A Schreiber
- Department of Paediatrics, University of British Columbia, Vancouver, Canada
| | - Georgina Mieli-Vergani
- Paediatric Liver, GI & Nutrition Centre, King's College London School of Medicine at King's College Hospital, London, UK
| | - Jan B Hulscher
- Department of Paediatric Surgery, University of Groningen, Beatrix Children's Hospital-University Medical Center, Groningen, The Netherlands
| | - Ronald J Sokol
- Section of Paediatric Gastroenterology, Hepatology, and Nutrition, Department of Paediatrics, University of Colorado School of Medicine, Digestive Health Institute, Children's Hospital Colorado, Aurora, CO, USA
| | - Deirdre A Kelly
- Liver Unit, Birmingham Children's Hospital NHS Trust, Birmingham, UK
| | - Benno Ure
- Department of Paediatric Surgery, Hannover Medical School, Hannover, Germany
| | - Peter F Whitington
- Department of Paediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Marianne Samyn
- Paediatric Liver, GI & Nutrition Centre, King's College London School of Medicine at King's College Hospital, London, UK
| | - Claus Petersen
- Department of Paediatric Surgery, Hannover Medical School, Hannover, Germany
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Chen F, Tu XL. Revaluation of vanishing bile duct syndrome. Shijie Huaren Xiaohua Zazhi 2016; 24:3445-3453. [DOI: 10.11569/wcjd.v24.i23.3445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Vanishing bile duct syndrome (VBDS) can result from multiple etiologies, including congenital and genetic diseases, ischemic causes, neoplastic disorders, infections, immune disorders, drugs, idiopathic adulthood ductopenia (IAD) and so on. Recently, lymphoma, HIV/AIDS and drugs were identified to be major etiologies in the reported cases, some of which presented complex clinical course and were contributed by more than one etiological factor. Hepatic biopsy must be done for the diagnosis of VBDS and immunohistochemical staining for cytokeratin 7 (CK7) and CK19 has contributed to the establishment of diagnosis of VBDS. VBDS can be usually treated with symptomatic and supportive therapy, etiological therapy, liver transplantation, ursodeoxycholic acid and immunosuppressive agents. Glucocorticoids can be tried to switch to mycophemolate mofeil or tacrolimus when their effects are poor or side effects are severe. Severe cases ought to receive multimodality therapy besides plasmapheresis.
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Wang X, Qian L, Jia L, Bellah R, Wang N, Xin Y, Liu Q. Utility of Shear Wave Elastography for Differentiating Biliary Atresia From Infantile Hepatitis Syndrome. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2016; 35:1475-1479. [PMID: 27229132 DOI: 10.7863/ultra.15.08031] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 10/19/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVES The purpose of this study was to investigate the potential utility of shear wave elastography (SWE) for diagnosis of biliary atresia and for differentiating biliary atresia from infantile hepatitis syndrome by measuring liver stiffness. METHODS Thirty-eight patients with biliary atresia and 17 patients with infantile hepatitis syndrome were included, along with 31 healthy control infants. The 3 groups underwent SWE. The hepatic tissue of each patient with biliary atresia had been surgically biopsied. Statistical analyses for mean values of the 3 groups were performed. Optimum cutoff values using SWE for differentiation between the biliary atresia and control groups were calculated by a receiver operating characteristic (ROC) analysis. RESULTS The mean SWE values ± SD for the 3 groups were as follows: biliary atresia group, 20.46 ± 10.19 kPa; infantile hepatitis syndrome group, 6.29 ± 0.99 kPa; and control group, 6.41 ± 1.08 kPa. The mean SWE value for the biliary atresia group was higher than the values for the control and infantile hepatitis syndrome groups (P < .01). The mean SWE values between the control and infantile hepatitis syndrome groups were not statistically different. The ROC analysis showed a cutoff value of 8.68 kPa for differentiation between the biliary atresia and control groups. The area under the ROC curve was 0.997, with sensitivity of 97.4%, specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 96.9%. Correlation analysis suggested a positive correlation between SWE values and age for patients with biliary atresia, with a Pearson correlation coefficient of 0.463 (P < .05). CONCLUSIONS The significant increase in liver SWE values in neonates and infants with biliary atresia supports their application for differentiating biliary atresia from infantile hepatitis syndrome.
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Affiliation(s)
- Xiaoman Wang
- Department of Ultrasound, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Linxue Qian
- Department of Ultrasound, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Liqun Jia
- Department of Ultrasound, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Richard Bellah
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia Pennsylvania USA
| | - Ning Wang
- Department of Ultrasound, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Yue Xin
- Department of Ultrasound, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Qinglin Liu
- Department of Ultrasound, Beijing Children's Hospital, Capital Medical University, Beijing, China
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Nguyen M, Dossa A, Zagory J, Golden J, Roberts A, Fu X, Wang K, Gayer CP. Liquid chromatography-mass spectroscopy as a tool in the rapid diagnosis of biliary atresia: a pilot study. J Pediatr Surg 2016; 51:923-6. [PMID: 26995515 DOI: 10.1016/j.jpedsurg.2016.02.053] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 02/26/2016] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Biliary atresia (BA) is a neonatal obstructive cholangiopathy requiring rapid intervention to prevent end-stage liver failure and death. Low bile acid levels in stool, detectable with high-performance liquid chromatography-mass spectroscopy, may reflect extrahepatic biliary obstruction in cholestasis. HYPOTHESIS Stool bile acid content can differentiate BA from non-BA forms of cholestasis. METHODS Stool samples from four healthy and nine cholestatic patients were collected following internal review board approval. Bile acids were extracted and separated on a 4000-Q-Trap HPLC-MS system. RESULTS Total bile acid content was highest in samples from healthy relative to cholestatic patients: 3354.01 ± 2102.56, 1476.27 ± 1361.07, and 34.29 ± 10.30 μM/mg of stool in healthy, total parenteral nutrition-associated cholestasis, and BA samples, respectively. Mean cholic acid and chenodeoxycholic acid concentrations in healthy samples (2017.5 ± 1413.6 and 876.83 ± 660.60 μM/mg) were higher than in TPN cholestatic samples (93.99±131.55 and 232.34 ± 293.41 μM/mg). The most dramatic reduction in cholic acid and chenodeoxycholic acid was observed in BA samples (0.65 ± 0.47 and 1.22 ± 0.80 μM/mg). CONCLUSION Bile acid content in stool is reduced in cholestatic patients relative to healthy patients with the most dramatic reduction observed in BA-patients.
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Rafeey M, Saboktakin L, Hasani JS, Naghashi S. Diagnostic value of anti-smooth muscle antibodies and liver enzymes in differentiation of extrahepatic biliary atresia and idiopathic neonatal hepatitis. Afr J Paediatr Surg 2016; 13:63-8. [PMID: 27251654 PMCID: PMC4955439 DOI: 10.4103/0189-6725.182558] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND We aimed to evaluate the diagnostic value of anti-smooth muscle antibodies (ASMA) and two liver markers (gamma-glutamyl transpeptidase [GGT] and alkaline phosphatase [ALP]) for differentiating between patients with extrahepatic biliary atresia (EHBA) and idiopathic neonatal hepatitis (INH). MATERIALS AND METHODS During April 2010-2011, all infants at 2 weeks of age who were diagnosed with cholestasis and admitted to Children's Hospital of Tabriz were enrolled. Based on the results of physical examination, laboratory, imaging and pathological studies, neonates were divided into two groups (EHBA and INH). Receiver operating characteristics analysis was used to define sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy for ASMA, GGT and ALP. RESULTS Thirty neonates with cholestasis (18 with EHBA and 12 with INH) and mean age of 54.66 25.86 days were enrolled. Total and direct bilirubin, serum glutamic oxaloacetic transaminase, serum glutamic pyruvic transaminase and ASMA titres were highly not significant (P > 0.05) in patients with INH. GGT (P = 0.008) and ALP (P = 0.01) had statistically significant differences that were higher in patients with EHBA. The sensitivity, specificity, PPV and NPV, accuracy, LR+ and LR- of SMA in differentiating cases with BA were 66.7%, 75%, 80% 60%, 70%, 2.68 and 0.44, respectively. For GGT, the values were 88.9%, 66.7%, 80%, 80%, 79.1%, 3.08 and 0.31, respectively. Finally, for ALP, the values were 77.8%, 75%, 82.4%, 69.2%, 80%, 2.66 and 0.24, respectively. CONCLUSION Our study showed that ASMA may be a useful biomarker for differentiation of EHBA from INH. Further studies with larger samples are recommended for confirming the results of this study.
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Affiliation(s)
- Mandana Rafeey
- Liver and Gastrointestinal Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Lida Saboktakin
- Department of Pediatrics, Pediatric Health Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Jamshid Shoa Hasani
- Liver and Gastrointestinal Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Shahnaz Naghashi
- Liver and Gastrointestinal Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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Togawa T, Sugiura T, Ito K, Endo T, Aoyama K, Ohashi K, Negishi Y, Kudo T, Ito R, Kikuchi A, Arai-Ichinoi N, Kure S, Saitoh S. Molecular Genetic Dissection and Neonatal/Infantile Intrahepatic Cholestasis Using Targeted Next-Generation Sequencing. J Pediatr 2016; 171:171-7.e1-4. [PMID: 26858187 DOI: 10.1016/j.jpeds.2016.01.006] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2015] [Revised: 12/21/2015] [Accepted: 01/05/2016] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To ascertain a molecular genetic diagnosis for subjects with neonatal/infantile intrahepatic cholestasis (NIIC) by the use of next-generation sequencing (NGS) and to perform a genotype-phenotype correlation. STUDY DESIGN We recruited Japanese subjects with NIIC who had no definitive molecular genetic diagnosis. We developed a diagnostic custom panel of 18 genes, and the amplicon library was sequenced via NGS. We then compared clinical data between the molecular genetically confirmed subjects with NIIC. RESULTS We analyzed 109 patients with NIIC ("genetic cholestasis," 31 subjects; "unknown with complications" such as prematurity, 46 subjects; "unknown without complications," 32 subjects), and a molecular genetic diagnosis was made for 28 subjects (26%). The rate of positive molecular genetic diagnosis in each category was 22 of 31 (71%) for the "genetic cholestasis" group, 2 of 46 (4.3%) for the "unknown with complications" group, and 4 of 32 (12.5%) for the "unknown without complications" group. The grouping of the molecular diagnoses in the group with genetic cholestasis was as follows: 12 with Alagille syndrome, 5 with neonatal Dubin-Johnson syndrome, 5 with neonatal intrahepatic cholestasis caused by citrin deficiency, and 6 with progressive familial intrahepatic cholestasis or benign recurrent intrahepatic cholestasis with low gamma-glutamyl transpeptidase levels. Several clinical datasets, including age of onset, direct bilirubin, and aminotransferases, were significantly different between the disorders confirmed using molecular genetic diagnosis. CONCLUSION Targeted NGS can be used for molecular genetic diagnosis in subjects with NIIC. Clinical diagnosis should be accordingly redefined in the view of molecular genetic findings.
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Affiliation(s)
- Takao Togawa
- Department of Pediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Tokio Sugiura
- Department of Pediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan.
| | - Koichi Ito
- Department of Pediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Takeshi Endo
- Department of Pediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Kohei Aoyama
- Department of Pediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Kei Ohashi
- Department of Pediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Yutaka Negishi
- Department of Pediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Toyoichiro Kudo
- Department of Hepatology, National Medical Center for Children and Mothers, National Center for Child Health and Development, Tokyo, Japan
| | - Reiko Ito
- Department of Hepatology, National Medical Center for Children and Mothers, National Center for Child Health and Development, Tokyo, Japan
| | - Atsuo Kikuchi
- Department of Pediatrics, Tohoku University School of Medicine, Sendai, Japan
| | | | - Shigeo Kure
- Department of Pediatrics, Tohoku University School of Medicine, Sendai, Japan
| | - Shinji Saitoh
- Department of Pediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
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Laparoscopy-Assisted Percutaneous Cholangiography in Biliary Atresia Diagnosis: Comparison with Open Technique. Gastroenterol Res Pract 2016; 2016:5637072. [PMID: 26819607 PMCID: PMC4706908 DOI: 10.1155/2016/5637072] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 07/28/2015] [Indexed: 01/09/2023] Open
Abstract
Introduction. Biliary atresia is a surgical cause of prolonged jaundice, which needs to be diagnosed with cholangiography that has traditionally been performed via laparotomy. Laparoscopic assistance has lately been introduced to avoid unnecessary laparotomy. We aim to evaluate the benefits of the laparoscopy-assisted cholangiography and compare it to the traditional procedure via laparotomy. Patients and Method. The medical records of the cases who had undergone cholangiography for prolonged jaundice between 2007 and 2014 were analyzed. The patients were grouped according to cholangiography technique (laparotomy/laparoscopy). The laparoscopy and laparotomy groups with patent bile ducts were focused and compared in terms of operation duration, postoperative initiation time of enteral feeding, and full enteral feeding achievement time. Results. Sixty-one infants with prolonged jaundice were evaluated between 2007 and 2014. Among the patients with patent bile ducts, operation duration, postoperative enteral feeding initiation time, and the time to achieve full enteral feeding were shorter in laparoscopy group. Conclusion. Laparoscopic cholangiography is safe and less time-consuming compared to laparotomy, with less postoperative burden. As early age of operation is a very important prognostic factor, laparoscopic evaluation should be an early option in work-up of the infants with prolonged jaundice with direct hyperbilirubinemia, for diagnosis/exclusion of biliary atresia.
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