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Population-based incidence and risk factors for cholestasis in hemolytic disease of the fetus and newborn. J Perinatol 2022; 42:702-707. [PMID: 35194159 PMCID: PMC9184269 DOI: 10.1038/s41372-022-01345-1] [Citation(s) in RCA: 1] [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] [Received: 08/05/2021] [Revised: 01/26/2022] [Accepted: 02/03/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To estimate the incidence of cholestasis in neonates with hemolytic disease of the fetus and newborn (HDFN) and investigate risk factors and long-term liver disease. STUDY DESIGN A population-based cohort study of all infants born with HDFN within the Stockholm region between 2006 and 2015. The study period was the first 90 days of life, and presence of any chronic liver disease was evaluated at two years of age. RESULTS Cholestasis occurred in 7% (11/149). Median age at detection was 1.1 days. Intrauterine blood transfusions and maternal alloimmunization with multiple red blood cell antibodies including D-, c- or K-antibodies were independent risk factors for cholestasis. No infant had chronic liver disease at two years of age. CONCLUSIONS Infants with severe HDFN have increased risk for cholestasis, particularly those requiring multiple intrauterine transfusions. Early and repeated screening for conjugated hyperbilirubinemia in the first week of life is needed to ensure adequate management.
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Sherwani P, Bolia R, Kaushik A, Kumar S, Kishore S, Chauhan U. An Unusual Cause of Cholestasis in an Infant: Biliary Atresia Type IIB. Indian J Radiol Imaging 2021; 31:689-692. [PMID: 34790315 PMCID: PMC8590570 DOI: 10.1055/s-0041-1736165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Biliary atresia (BA) is a progressive destructive cholangiopathy of unknown etiology that presents in early infancy. It has a worldwide frequency of 1:8,000–1:15,000 and is common in Asia than in the west. Based on the level at which the lumen of the extrahepatic duct is obliterated, BA is classified into three types. Type III is the commonest (∼85%) type and has the most proximal level of obstruction in the porta hepatis, while type II in which the atresia is at the level of the common hepatic duct, is the least common (∼2.5%) and has been rarely reported. Here, we report the imaging features of an infant with type IIB biliary atresia.
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Affiliation(s)
- Poonam Sherwani
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Rishi Bolia
- Department of Pediatrics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Ashish Kaushik
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Sumit Kumar
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Sanjeev Kishore
- Department of Pathology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Udit Chauhan
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
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Mugarab Samedi V, Rahimi M, Kalaniti K, Lyon M, Daspal S. Rainbow of colors: Inspissated bile syndrome secondary to hemolytic disease of the newborn and concomitant serum dynamics. SAGE Open Med Case Rep 2021; 9:2050313X211025435. [PMID: 34188935 PMCID: PMC8212369 DOI: 10.1177/2050313x211025435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 05/27/2021] [Indexed: 11/17/2022] Open
Abstract
The recent clinical experience with hemolytic disease of the newborn and its
post-icteric sequelae is limited among high-income countries because of nearly
over four decades of effective prevention care. In this case, we will discuss
the sequelae of a baby born with hemolytic disease of the newborn to an Rh
negative mother with no prenatal care from remote northern Saskatchewan.
Inspissated bile syndrome is a rare but serious complication of hemolytic
disease of the newborn. The concentration of hemolytic products parallels with
serum color changes.
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Affiliation(s)
- Veronica Mugarab Samedi
- Veronica Mugarab Samedi, Royal University
Hospital, 103 Hospital Dr., Saskatoon, SK S7N 0W8, Canada.
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He L, Ip DKM, Tam G, Lui VCH, Tam PKH, Chung PHY. Biomarkers for the diagnosis and post-Kasai portoenterostomy prognosis of biliary atresia: a systematic review and meta-analysis. Sci Rep 2021; 11:11692. [PMID: 34083585 PMCID: PMC8175424 DOI: 10.1038/s41598-021-91072-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 05/18/2021] [Indexed: 12/11/2022] Open
Abstract
To evaluate the accuracy of biomarkers for the early diagnosis of biliary atresia (BA) and prognostic stratification after Kasai portoenterostomy (KPE). We conducted a systematic review of PubMed, Web of Science, Embase, Scopus and OVID for English literature reporting BA biomarkers published before August 2020. Screening, data extraction, and quality assessment were performed in duplicate. A total of 51 eligible studies were included in the systematic review, and data from 12 (4182 subjects) were extracted for meta-analysis regarding the following 2 domains: (1) serum matrix metallopeptidase-7 (MMP-7), interleukin33 (IL-33) and γ-glutamyl transferase (GGT) to differentiate BA from non-BA; (2) the aspartate aminotransferase to platelet ratio index (APRi) to predict post-KPE liver fibrosis/cirrhosis. The summary sensitivity, specificity and area under the curve (AUC) of MMP-7 for diagnosing BA were 96%, 91% and 0.9847, respectively, and those of GGT were 80%, 79% and 0.9645, respectively. The summary sensitivity and specificity of IL-33 for diagnosing BA were 77% and 85%, respectively. The summary sensitivity and specificity of APRi for predicting post-KPE liver fibrosis were 61% and 80%, respectively, and the summary sensitivity, specificity and AUC of APRi for predicting post-KPE cirrhosis were 78%, 83% and 0.8729, respectively. Moreover, good evidence was shown in investigations of serum IL-18 and IL-33 in distinguishing BA from healthy controls, serum IL-18 for prognosis of post-KPE persistent jaundice, and serum hyaluronic acid and MMP-7 for prognosis of post-KPE significant liver fibrosis. MMP-7, IL-33 and GGT are useful biomarkers to assist in the diagnosis of BA. APRi might be used to predict post-KPE significant liver fibrosis and cirrhosis. These noninvasive biomarkers can be integrated into the management protocol of BA.
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Affiliation(s)
- Lin He
- Department of Radiotherapy, Tangdu Hospital, Air Force Military Medical University, Xi'an, China
| | - Dennis Kai Ming Ip
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong, SAR
| | - Greta Tam
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong, SAR
| | - Vincent Chi Hang Lui
- Departmet of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong, SAR
| | - Paul Kwong Hang Tam
- Departmet of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong, SAR
| | - Patrick Ho Yu Chung
- Departmet of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong, SAR.
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Laparoscopic Kasai portoenterostomy for cystic biliary atresia: midterm follow-up results of 35 patients. Surg Today 2021; 51:1924-1931. [PMID: 33977383 DOI: 10.1007/s00595-021-02297-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 03/10/2021] [Indexed: 02/05/2023]
Abstract
PURPOSE To investigate the clinical characteristics of cystic biliary atresia (CBA) and evaluate the midterm follow-up outcomes after laparoscopic treatment. METHODS We analyzed and compared data retrospectively on CBA patients (group A) and nonsyndromic type III biliary atresia (BA) patients (group B), who underwent laparoscopic Kasai portoenterostomy (LKPE) during the same period. RESULTS There were no significant differences in operative time, conversion rate, or the incidence of any postoperative complications between groups A and B (P > 0.05). The mean age at surgery (P < 0.01), rates of clearance of jaundice (CJ), cholangitis (P < 0.05), and 5-year survival with a native liver (SNL) were significantly lower in group A than in group B. Among the 35 patients with CBA, the CJ and 5-year SNL rates were significantly better in those with type I (n = 27) than in those with type IIId (n = 8) (P < 0.05). CONCLUSIONS LKPE is a feasible and safe procedure for CBA. The 5-year SNL after LKPE was better in patients with CBA than in those with nonsyndromic type III BA. The 5-year SNL after LKPE for type I CBA was better than that for type IIId CBA.
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6
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Single Procedure Saline Lavage for Treatment of Inspissated Bile. Case Rep Radiol 2020; 2020:8816599. [PMID: 32802545 PMCID: PMC7415119 DOI: 10.1155/2020/8816599] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 06/24/2020] [Accepted: 07/16/2020] [Indexed: 11/18/2022] Open
Abstract
Inspissated bile syndrome is a rare cause of cholestatic jaundice in infancy, occurring due to obstruction of the biliary ducts and gallbladder by biliary sludge. Traditional methods of treatment include surgical drainage or cholecystostomy drain placement. Both can be associated with complications and prolonged admission. We present 2 cases treated with a single percutaneous needle puncture of the gallbladder followed by saline lavage. Two neonates presented with cholestatic jaundice and sonographic evidence of biliary sludge and dilation of the common bile duct. Single sonographic-guided needle puncture of the gallbladder was followed by irrigation with saline. Clearing of the biliary sludge was confirmed by sonography and cholecystocholangiography. There was resolution of the cholestatic jaundice, with no complications or repeat procedures.
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7
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Total laparoscopic management of spontaneous biliary perforation. Clin J Gastroenterol 2020; 13:818-822. [PMID: 32270435 DOI: 10.1007/s12328-020-01122-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 03/31/2020] [Indexed: 10/24/2022]
Abstract
Spontaneous biliary perforation (SBP) in pediatrics is rare and historically has been treated with laparotomy for attempted repair and cholecystectomy. In recent years, management has evolved into a conservative approach, opting for cholecystostomy and peritoneal drainage over cholecystectomy. In this case, we report the first successful conservative management of SBP using an exclusively laparoscopic approach without cholecystectomy in a pediatric patient.
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Ghazy RM, Khedr MA. Neonatal cholestasis: recent insights. EGYPTIAN PEDIATRIC ASSOCIATION GAZETTE 2019. [DOI: 10.1186/s43054-019-0009-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
AbstractBackgroundNeonatal physiological jaundice is a common benign condition that rarely extends behind the second week of life; however, it may interfere with the diagnosis of a pathological condition termed neonatal cholestasis (NC). The latter is a critical, uncommon problem characterized by conjugated hyperbilirubinaemia. This review aims to highlight the differences between physiological and pathological jaundice, identify different causes of NC, and provide a recent approach to diagnosis and management of this serious condition.Main textNC affects 1/2500 live births, resulting in life-threatening complications due to associated hepatobiliary or metabolic abnormalities. NC is rarely benign and indicates the presence of severe underlying disease. If jaundice extends more than 14 days in full-term infants or 21 days in preterm infants, the serum bilirubin level fractionated into conjugated (direct) and unconjugated (indirect) bilirubin should be measured. A stepwise diagnostic approach starts with obtaining a complete history, and a physical examination which are valuable for the rapid diagnosis of the underlying disease. The most frequently diagnosed causes of NC are biliary atresia (BA) and idiopathic neonatal hepatitis (INH). The early diagnosis of NC ensures more accurate management and better prognosis. Despite the unavailability of any specific treatments for some causes of NC, the patient can benefit from nutritional management and early medical intervention. Future research should attempt to shed light on methods of screening for NC, especially for causes that can be effectively treated either through proper nutritional support, appropriate chemotherapeutic management, or timely surgical intervention.ConclusionFurther attention should be paid for diagnosis and treatment of NC as it may be misdiagnosed as physiological jaundice; this may delay the proper management of the underlying diseases and aggravates its complications.
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9
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Hopper L, Hao SB, Rodeberg D, Longshore S. Spontaneous bile duct perforation in a neonate. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2018. [DOI: 10.1016/j.epsc.2018.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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10
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Chang SH, Joo SM, Yoon CS, Lee KH, Lee SM. Percutaneous Transhepatic Biliary Drainage in a Two-Month-Old Infant with Inspissated Bile Syndrome. Yonsei Med J 2018; 59:904-907. [PMID: 30091325 PMCID: PMC6082986 DOI: 10.3349/ymj.2018.59.7.904] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 07/06/2018] [Accepted: 07/15/2018] [Indexed: 11/27/2022] Open
Abstract
Inspissated bile syndrome (IBS) is a relatively rare condition. Many treatment options are available, including medication, surgery, and surgical interventions, such as insertion of cholecystostomy drain, endoscopic retrograde cholangiopancreatography, internal biliary drainage, and percutaneous transhepatic biliary drainage (PTBD). We herein report the first case of IBS that was successfully treated with PTBD in a two-month-old infant in Korea. PTBD was initiated on postnatal day 72. On postnatal day 105, we confirmed complete improvement and successfully removed the catheters. This report suggests that PTBD is a viable and safe treatment option for obstructive jaundice in very young infants.
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Affiliation(s)
- Sung Hui Chang
- Department of Pediatrics, Yonsei University College of Medicine, Gangnam Severance Hospital, Seoul, Korea
| | - Seung Moon Joo
- Department of Radiology, Yonsei University College of Medicine, Gangnam Severance Hospital, Seoul, Korea
| | - Choon Sik Yoon
- Department of Radiology, Yonsei University College of Medicine, Gangnam Severance Hospital, Seoul, Korea
| | - Kwang Hun Lee
- Department of Radiology, Yonsei University College of Medicine, Gangnam Severance Hospital, Seoul, Korea
| | - Soon Min Lee
- Department of Pediatrics, Yonsei University College of Medicine, Gangnam Severance Hospital, Seoul, Korea.
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11
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Yoon HM, Suh CH, Kim JR, Lee JS, Jung AY, Cho YA. Diagnostic Performance of Sonographic Features in Patients With Biliary Atresia: A Systematic Review and Meta-analysis. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2017; 36:2027-2038. [PMID: 28556285 DOI: 10.1002/jum.14234] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 12/30/2016] [Indexed: 06/07/2023]
Abstract
OBJECTIVES To evaluate the diagnostic performance of sonographic features of biliary atresia in patients with infantile cholestasis. METHODS The Ovid-MEDLINE and EMBASE databases were searched for studies of the diagnostic performance of sonographic features of biliary atresia in patients with infantile cholestasis. A meta-analysis was performed to evaluate the diagnostic performance of the triangular cord sign and other sonographic features in patients with biliary atresia. RESULTS Seventeen eligible studies with 1444 patients were included. The triangular cord sign had high accuracy for diagnosing biliary atresia: the meta-analytic summary sensitivity and specificity were 85% (95% confidence interval, 77%-90%) and 97% (95% confidence interval, 94%-99%), respectively. The area under the hierarchical summary receiver operating characteristic curve was 0.97. Meta-regression analysis revealed that the cutoff thickness of the triangular cord sign (3 or 4 mm) was a significant factor affecting study heterogeneity (P < .01). The proportions of nonidentification of the gallbladder (GB) ranged from 0% to 53%. Abnormal GB morphologic characteristics, nonvisualization of the common bile duct, and the presence of hepatic subcapsular flow showed relatively high sensitivities and specificities. CONCLUSIONS The triangular cord sign and other sonographic features, including abnormal GB morphologic characteristics, nonvisualization of the common bile duct, and the presence of hepatic subcapsular flow, had high diagnostic performance for the diagnosis of biliary atresia.
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Affiliation(s)
- Hee Mang Yoon
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Chong Hyun Suh
- Department of Radiology, Namwon Medical Center, Namwon, Korea
| | - Jeong Rye Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jin Seong Lee
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Ah Young Jung
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Young Ah Cho
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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12
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Pediatric cholangiopathies: diseases of the gallbladder and biliary tract. Abdom Radiol (NY) 2017; 42:69-85. [PMID: 27518785 DOI: 10.1007/s00261-016-0865-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Pediatric gallbladder and bile duct disease encompasses a broad spectrum of processes, from congenital to developmental to neoplastic. We describe normal pediatric biliary anatomy and summarize the most common pathologic entities, with a focus on non-invasive imaging techniques and findings. Ultrasound is the first-line imaging modality in children with suspected biliary pathology based on its widespread availability, cost effectiveness, and lack of ionizing radiation. MRI and MRCP are often used for further evaluation in cases of diagnostic uncertainty and for surgical planning.
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Jun WY, Cho MJ, Han HS, Bae SH. Use of Omega-3 Polyunsaturated Fatty Acids to Treat Inspissated Bile Syndrome: A Case Report. Pediatr Gastroenterol Hepatol Nutr 2016; 19:286-290. [PMID: 28090475 PMCID: PMC5234414 DOI: 10.5223/pghn.2016.19.4.286] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Revised: 02/02/2016] [Accepted: 02/15/2016] [Indexed: 11/14/2022] Open
Abstract
Inspissated bile syndrome (IBS) is a rare condition in which thick intraluminal bile, including bile plugs, sludge, or stones, blocks the extrahepatic bile ducts in an infant. A 5-week-old female infant was admitted for evaluation of jaundice and acholic stool. Diagnostic tests, including ultrasound sonography, magnetic resonance cholangiopancreatography, and a hepatobiliary scan, were not conclusive. Although the diagnosis was unclear, the clinical and laboratory findings improved gradually on administration of urodeoxycholic acid and lipid emulsion containing omega-3 polyunsaturated fatty acids (PUFAs) for 3 weeks. However, a liver biopsy was suggestive of biliary atresia. This finding forced us to perform intraoperative cholangiography, which revealed a patent common bile duct with impacted thick bile. We performed normal saline irrigation and the symptom was improved, the final diagnosis was IBS. Thus, we herein report that IBS can be treated with omega-3 PUFAs as an alternative to surgical intervention.
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Affiliation(s)
- Woo Young Jun
- Department of Pediatrics, Konkuk University Medical Center, Seoul, Korea
| | - Min Jeng Cho
- Department of Pediatric Surgery, Konkuk University Medical Center, Seoul, Korea
| | - Hye Seung Han
- Department of Pathology, Konkuk University Medical Center, Seoul, Korea
| | - Sun Hwan Bae
- Department of Pediatrics, Konkuk University Medical Center, Seoul, Korea
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Bollu BK, Dawrant MJ, Thacker K, Thomas G, Chenapragadda M, Gaskin K, Shun A. Inspissated bile syndrome; Safe and effective minimally invasive treatment with percutaneous cholecystostomy in neonates and infants. J Pediatr Surg 2016; 51:2119-2122. [PMID: 27712892 DOI: 10.1016/j.jpedsurg.2016.09.053] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Revised: 09/06/2016] [Accepted: 09/07/2016] [Indexed: 11/24/2022]
Abstract
PURPOSE Inspissated bile syndrome (IBS) is a rare cause of obstructive jaundice in neonates and infants with several treatment options reported. We present our experience with the use of minimally invasive ultrasound-guided percutaneous cholecystostomy drain catheter placement with ongoing saline lavage in neonates and infants. METHODS Retrospective chart review of patients treated with percutaneous cholecystostomy, from February 2010 till June 2015. We reviewed the technical and clinical success along with complications of the procedure. RESULTS There were 6 patients, mean age 17weeks (range 4-40). Most had significant risk factors for IBS presenting with biliary obstruction. A total of 7 procedures performed on the 6 patients, with a technical success rate of 6/7. One patient required cannulation of the intrahepatic biliary system. Drains were flushed for a median of 26days (10-70). Clinical success was achieved in all patients. 3 had displacement of the drain, one of which required re-insertion. Another developed a small sub-hepatic collection post procedure with pyrexia. On long term follow up one was found to have a forme fruste choledochal cyst. CONCLUSION Centers with suitable interventional radiology services ultrasound-guided percutaneous cholecystostomy drain catheter placement with ongoing saline lavage is a safe and effective minimally invasive treatment for IBS in neonates and infants.
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Affiliation(s)
- Bapesh K Bollu
- Department of Paediatric Surgery, The Children's Hospital at Westmead, Sydney, Australia.
| | - Michael J Dawrant
- Department of Paediatric Surgery, The Children's Hospital at Westmead, Sydney, Australia
| | - Kunal Thacker
- Department of Gastroenterology, The Children's Hospital at Westmead, Sydney, Australia
| | - Gordon Thomas
- Department of Paediatric Surgery, The Children's Hospital at Westmead, Sydney, Australia
| | | | - Kevin Gaskin
- Department of Gastroenterology, The Children's Hospital at Westmead, Sydney, Australia
| | - Albert Shun
- Department of Paediatric Surgery, The Children's Hospital at Westmead, Sydney, Australia
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15
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Recent Trends in the Diagnosis and Management of Biliary Atresia in Developing Countries. Indian Pediatr 2016; 52:871-9. [PMID: 26499012 DOI: 10.1007/s13312-015-0735-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
NEED AND PURPOSE OF REVIEW Biliary atresia is a progressive obstructive cholangiopathy and is fatal if left untreated within 2 years of life. Delay in referral is because of difficulties in differentiating it from physiologic jaundice and identifying an abnormal stool color. This paper presents an overview on the diagnosis and discusses the current strategies in the management of this disease in developing countries. METHODS Articles were retrieved from the PubMed database using the terms biliary atresia, Kasai portoenterostomy and pediatric liver transplantation. Contents of the article are also based on personal experience of the authors. CONCLUSION A national screening program using stool color cards as part of standard care in the neonatal period will greatly improve early detection of biliary atresia. Outcomes will improve if it is diagnosed at the earliest after birth, the child is referred to an experienced pediatric hepatobiliary unit for evaluation, and undergoes an early Kasai procedure. If an early Kasai portoenterostomy is performed, nearly half of all children survive into adolescence, and about one-third are likely to have a long-term, symptom-free life with normal liver biochemistry. Sequential treatment combining Kasai as first line and liver transplantation as second line results in 90% survival for children with biliary atresia.
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16
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Wardi G, Ishimine P, Lasoff D, Yuan C, Campbell C. An unusual case of an icteric infant with abdominal distention. J Emerg Med 2014; 47:18-20. [PMID: 24657256 DOI: 10.1016/j.jemermed.2014.01.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Revised: 10/31/2013] [Accepted: 01/30/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND Jaundiced infants are uncommon in most emergency departments (EDs). Biliary rupture remains one of the more rare and less described causes of this condition. CASE REPORT A 5-month-old male presented to our ED with scleral icterus, increasing abdominal distention, and increased irritability. A bedside ultrasound revealed a moderate amount of ascites and further imaging suggested he had a rupture of his common bile duct. Surgical exploration confirmed this and revealed the presence of choledocholithiasis, which was the likely cause of the rupture. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Biliary rupture remains a rare but serious condition in very young patients. Emergency physicians should consider bedside ultrasound as an adjunct in undifferentiated abdominal distention or jaundice in this patient population.
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Affiliation(s)
- Gabriel Wardi
- Department of Emergency Medicine, UC San Diego Health System, San Diego, California
| | - Paul Ishimine
- Department of Emergency Medicine, UC San Diego Health System, San Diego, California; Division of Pediatric Emergency Medicine, Rady's Children Hospital, San Diego, California
| | - Daniel Lasoff
- Department of Emergency Medicine, UC San Diego Health System, San Diego, California
| | - Chao Yuan
- Department of Emergency Medicine, UC San Diego Health System, San Diego, California
| | - Colleen Campbell
- Department of Emergency Medicine, UC San Diego Health System, San Diego, California
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Patel RV, Durell J, Dagash H, Patwardhan N. Neonatal spontaneous bile duct perforation presenting as giant intraabdominal cyst. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2013. [DOI: 10.1016/j.epsc.2013.02.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
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18
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Lieber J, Piersma FE, Sturm E, Schäfer JF, Fuchs J, Szavay PO. Surgical treatment of inspissated bile syndrome using a 2-stage pure laparoscopic approach: a case report. J Pediatr Surg 2012; 47:e47-50. [PMID: 23217917 DOI: 10.1016/j.jpedsurg.2012.09.043] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2012] [Revised: 09/03/2012] [Accepted: 09/06/2012] [Indexed: 11/29/2022]
Abstract
We describe a 99-day old girl with inspissated bile syndrome (IBS) unresponsive to treatment with oral ursodeoxycholic acid. We performed a pure laparoscopic 2-stage procedure, consisting of cholecystostomy and insertion of an indwelling balloon catheter for local ursodeoxycholic acid flushing for 13 consecutive days. Subsequently, the cholecystostomy was removed, preserving the gallbladder using the same laparoscopical approach when bilirubin values returned to normal and bile duct obstruction was no longer detectable radiologically. This is the first report of an exclusively laparoscopic management of IBS.
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Affiliation(s)
- Justus Lieber
- University Children's Hospital, Department of Pediatric Surgery and Pediatric Urology, Hoppe-Seyler-Strasse 1, D-72076 Tuebingen, Germany.
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19
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Gao ZG, Shao M, Xiong QX, Tou JF, Liu WG. Laparoscopic cholecystostomy and bile duct lavage for treatment of inspissated bile syndrome: a single-center experience. World J Pediatr 2011; 7:269-71. [PMID: 21822994 DOI: 10.1007/s12519-011-0321-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2011] [Accepted: 07/20/2011] [Indexed: 11/24/2022]
Abstract
BACKGROUND We aim to describe our experience of laparoscopic cholecystostomy and bile duct lavage in the treatment of inspissated bile syndrome. METHODS Between January 2005 and December 2009, 16 infants with inspissated bile syndrome underwent laparoscopic cholecystostomy and bile duct lavage in our department. They were 7 males and 9 females, aged 40 days to 3 months, with an average of 65±23.4 days. A laparoscopic aided cholecystostomy was done. Cholangiography and bile duct lavage were performed during the operation. One week after the operation, bile duct lavage with saline was repeated every 2 to 3 days. According to bilirubin levels and liver function, the tube was kept for 2-4 weeks. RESULTS The level of bilirubin decreased and liver function was greatly improved after bile duct lavage. Direct bilirubin level, aspartate aminotransferase and γ-GT were significantly decreased 1-2 months after the operation compared with those before surgery (P<0.05). CONCLUSIONS The treatment strategy for inspissated bile syndrome with laparoscopic cholecystostomy and biliary duct lavage is feasible and effective.
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Affiliation(s)
- Zhi-Gang Gao
- Department of Pediatric Surgery, Children's Hospital, Zhejiang University School of Medicine, 57 Zhugan Xiang, Hangzhou, 310003, China
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20
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Abstract
Biliary atresia (BA) is a cholangiodestructive disease affecting biliary tract, which ultimately leads to cirrhosis, liver failure and death if not treated. The incidence is higher in Asian countries than in Europe. Up to 10% of cases have other congenital anomalies, such as polysplenia, asplenia, situs inversus, absence of inferior vena cava and pre-duodenal portal vein, for which we have coined the term Biliary Atresia Splenic Malformation (BASM) syndrome. For these infants the aetiology lies within the first trimester of gestation. For others affected with BA, aetiology is more obscure and perinatal destruction of fully-formed ducts perhaps by the action of hepatotropic viruses has been suggested. Whatever the cause, the lumen of the extrahepatic duct is obliterated at a variable level and this forms the basis for the commonest classification (Types I, II, III). All patients with BA present with varying degree of conjugated jaundice, pale non-pigmented stools and dark urine. Key diagnostic tests include ultrasonography, biochemical liver function tests, viral serology, and (in our centre) a percutaneous liver biopsy. In some centres, duodenal intubation and measurement of intralumenal bile is the norm. Currently BA is being managed in two stages. The first stage involves the Kasai operation, which essentially excises all extrahepatic biliary remnants leaving a transected portal plate, followed by biliary reconstruction using a Roux loop onto that plate as a portoenterostomy. If bile flow is not restored by Kasai procedure or life-threatening complications of cirrhosis ensue then consideration should be given to liver transplantation as a second stage. The outcome following the Kasai operation can be assessed in two ways: clearance of jaundice to normal values and the proportion who survive with their native liver. Clearance of jaundice (<2 mg/dL or <34 µmol/L) after Kasai has been reported to be around 60%, whereas five years survival with native liver ranges from 40% to 65%.
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Affiliation(s)
- C K Sinha
- Department of Pediatric Surgery, King's College Hospital, Denmak Hill, London SE5 9RS UK
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21
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Santore MT, Deans KJ, Behar BJ, Blinman TA, Adzick NS, Flake AW. Laparoscopic Hepaticoduodenostomy Versus Open Hepaticoduodenostomy for Reconstruction After Resection of Choledochal Cyst. J Laparoendosc Adv Surg Tech A 2011; 21:375-8. [DOI: 10.1089/lap.2010.0478] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Matthew T. Santore
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Katherine J. Deans
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Brittany J. Behar
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Thane A. Blinman
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - N. Scott Adzick
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Alan W. Flake
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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22
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Santore MT, Behar BJ, Blinman TA, Doolin EJ, Hedrick HL, Mattei P, Nance ML, Adzick NS, Flake AW. Hepaticoduodenostomy vs hepaticojejunostomy for reconstruction after resection of choledochal cyst. J Pediatr Surg 2011; 46:209-13. [PMID: 21238669 DOI: 10.1016/j.jpedsurg.2010.09.092] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2010] [Accepted: 09/30/2010] [Indexed: 11/20/2022]
Abstract
PURPOSE Roux-en-Y hepaticojejunostomy (HJ) is currently the favored reconstructive procedure after resection of choledochal cysts. Hepaticoduodenostomy (HD) has been argued to be more physiologically and technically easier but is feared to have associated complications. Here we compare outcomes of the 2 procedures. METHODS A retrospective chart review identified 59 patients who underwent choledochal cyst resection within our institution from 1999 to 2009. Demographic and outcome data were compared using t tests, Mann-Whitney U tests, and Pearson χ(2) tests. RESULTS Fifty-nine patients underwent repair of choledochal cyst. Biliary continuity was restored by HD in 39 (66%) and by HJ in 20 (34%). Open HD patients required less total operative time than HJ patients (3.9 vs 5.1 hours, P = .013), tolerated a diet faster (4.8 days compared with 6.1 days, P = .08), and had a shorter hospital stay (7.05 days for HD vs 9.05 days for HJ, P = .12). Complications were more common in HJ (HD = 7.6%, HJ = 20%, P = .21). Three patients required reoperation after HJ, but only one patient required reoperation after HD for a stricture (HD = 2.5%, HJ = 20%, P = .037). CONCLUSIONS In this series, HD required less operative time, allowed faster recovery of bowel function, and produced fewer complications requiring reoperation.
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Affiliation(s)
- Matthew T Santore
- The Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
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23
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Shanmugam NP, Harrison PM, Devlin J, Peddu P, Knisely AS, Davenport M, Hadzić N. Selective use of endoscopic retrograde cholangiopancreatography in the diagnosis of biliary atresia in infants younger than 100 days. J Pediatr Gastroenterol Nutr 2009; 49:435-41. [PMID: 19680152 DOI: 10.1097/mpg.0b013e3181a8711f] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES We investigated the role and safety of endoscopic retrograde cholangiopancreatography (ERCP) in diagnosing biliary atresia (BA) in prolonged neonatal cholestasis, when standard workup was inconclusive. PATIENTS AND METHODS We reviewed notes of 48 cholestatic infants younger than 100 days undergoing ERCP from 1997 to 2007. RESULTS Amongst approximately 3300 infants evaluated for liver disease during the study, 224 (6.8%) were diagnosed with BA. Forty-eight children underwent ERCP. Findings at liver biopsy (n=47) included nonspecific cholestasis (n=19, 40%), giant-cell hepatitis (n=12, 26%), "large bile duct obstruction" (n=9, 19%) in the presence of pigmented stools, and mixed cholestatic/hepatitic features (n=7, 15%). ERCP demonstrated a patent biliary tree in 20 infants (42%). BA was confirmed at exploratory laparotomy in all 3 infants (6%) in whom cannulation failed. The remaining 25 infants (52%) also proceeded to exploratory laparotomy, in which BA was confirmed in 22 (46%). Amongst the 20 children in whom ERCP ruled out BA, 8 (17%) had normal biliary anatomy, whilst 12 (25%) had an abnormal biliary tree, including 6 (12.5%) with neonatal sclerosing cholangitis. After ERCP none developed clinical pancreatitis or peritonitis. CONCLUSIONS ERCP is a safe procedure for diagnosing BA even in the smallest infants with high positive and negative predictive values.
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Affiliation(s)
- Naresh P Shanmugam
- Paediatric Liver Centre, Institute of Liver Studies, Department of Radiology, King's College Hospital, London, UK
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24
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Liu SL, Li L, Hou WY, Zhang J, Huang LM, Li X, Xie HW, Cheng W. Laparoscopic excision of choledochal cyst and Roux-en-Y hepaticojejunostomy in symptomatic neonates. J Pediatr Surg 2009; 44:508-11. [PMID: 19302849 DOI: 10.1016/j.jpedsurg.2008.08.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2008] [Revised: 07/30/2008] [Accepted: 08/02/2008] [Indexed: 01/30/2023]
Abstract
PURPOSE Choledochal cysts require surgical excision, preferably before the onset of cholangitis. Recently, it has become feasible to accomplish the excision laparoscopically in adults and older children. Yet, whether laparoscopic excision of choledochal cyst can be performed safely in symptomatic neonates with choledochal cyst is unclear. We herewith reviewed our experience of laparoscopic excision of choledochal cysts in neonates. METHODS We managed 9 neonates with choledochal cysts between April 2003 and February 2007. The choledochal cysts were excised laparoscopically. The Roux-en-Y hepaticojejunostomy was fashioned extracorporeally by exteriorizing the jejunum through the extended umbilical port site. End-to-side anastomosis between the common hepatic duct stump and Roux loop was carried out intracorporeally. The patients were followed up for an average of 26 months. RESULTS The patients presented with jaundice, pale stool, and deranged liver function tests. The diagnosis was confirmed with ultrasonography postnatally. The median operation time was 3.6 hours. There was no operative complication and no conversion. The blood loss was minimal. The recovery was uneventful, and the median hospital stay was 6 days. The liver function tests normalized 3 to 16 weeks postoperatively. No complication was detected at the follow-up visits. CONCLUSIONS Our preliminary results show that laparoscopic excision of choledochal cyst and Roux-en-Y hepaticojejunostomy in neonates is both feasible and safe. It curtails further complication of the cysts and reverses the derangement of liver function. In addition, the laparoscopic approach minimizes surgical trauma.
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Affiliation(s)
- Shu-Li Liu
- Department of Pediatric Surgery, Peking University First Hospital, Beijing 100034, China
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25
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Caponcelli E, Knisely AS, Davenport M. Cystic biliary atresia: an etiologic and prognostic subgroup. J Pediatr Surg 2008; 43:1619-24. [PMID: 18778995 DOI: 10.1016/j.jpedsurg.2007.12.058] [Citation(s) in RCA: 109] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2007] [Revised: 11/29/2007] [Accepted: 12/19/2007] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Cystic biliary atresia (CBA) is an uncommon variant of biliary atresia (BA) in which prognosis may be relatively favorable but liable to misdiagnosis as choledochal cyst, and potentially offers insights into the etiology of BA. Because some cases can be detected antenatally, CBA in general may have its origins in utero life. We assessed our experience with CBA. METHODS Single-center retrospective review of infants with CBA over a 13-year period (January 1994 to December 2006) was done. Data are given as medians (range). RESULTS Of 270 infants with BA, 29 (9 male) were identified as CBA. Antenatal ultrasonography had detected an abnormality in 12 (41%) infants at a median of 22 weeks (17-34 weeks) of gestation. All infants underwent postnatal excision and Kasai portoenterostomy (KP). Those with antenatally detected CBA came to surgery younger (36 [14-67] vs 48 days [35-147 days], P = .004). Twenty cysts (69%) had a fibroinflammatory wall with no biliary epithelial lining and 6 (26%) contained bile. Age at KP was significantly and positively correlated (r = 0.46, P = .01) with liver fibrosis, as assessed in liver biopsy materials obtained at KP, but not with grade of "hepatocyte disarray" (P = .74). Twenty infants (69%) cleared their jaundice (bilirubin <20 mumol/L) within 6 months after KP. Age at KP markedly affected outcome. CONCLUSION Cystic BA is a clinically distinct variant of BA. Despite onset in prenatal life, earlier than presumed for isolated BA, it has a better prognosis, particularly with early surgery.
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Affiliation(s)
- Enrica Caponcelli
- Department of Paediatric Surgery, King's College Hospital, SE5 9RS London, UK
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26
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Gunnarsdóttir A, Holmqvist P, Arnbjörnsson E, Kullendorff CM. Laparoscopic aided cholecystostomy as a treatment of inspissated bile syndrome. J Pediatr Surg 2008; 43:e33-5. [PMID: 18405698 DOI: 10.1016/j.jpedsurg.2007.12.068] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2007] [Accepted: 12/18/2007] [Indexed: 11/15/2022]
Abstract
We report a case of a newborn girl with inspissated bile syndrome (IBS) that did not respond to treatment with oral ursodeoxycholic acid (Ursofalk). A solution was found using laparoscopic aided cholecystostomy with an indwelling catheter for local Ursofalk flushing in the gallbladder and the choledochus. This is the first report of a laparoscopic aided management of IBS without cholecystectomy or exploration of the bile ducts. This minimal invasive approach showed a clear advantage for the patient. There were no complications. The method is recommended in the treatment of IBS.
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Affiliation(s)
- Anna Gunnarsdóttir
- Department of Pediatric Surgery, Lund University Hospital, 221 85 Lund, Sweden.
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Livesey E, Davenport M. Spontaneous perforation of the biliary tract and portal vein thrombosis in infancy. Pediatr Surg Int 2008; 24:357-9. [PMID: 17639421 DOI: 10.1007/s00383-007-1954-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/18/2007] [Indexed: 10/23/2022]
Abstract
Spontaneous biliary perforation (SBP) is an uncommon cause of surgical jaundice in the first few weeks of life and is characterised by the occurrence of a punched-out defect in the bile duct, typically where the cystic duct joins the common hepatic duct. In most cases the site occurs anteriorly and bile leaks into the general peritoneal cavity. We now describe two cases of SBP where the perforation occurred posteriorly, limiting the leak and resulting in delayed recognition. Surgical management in both cases consisted of hepaticojejunostomy-en-Roux. Both cases were complicated, although not immediately, by portal vein thrombosis and one by chylous ascites. Posterior SBP, presumably due to their intimate anatomical relation with the portal vein, seem predisposed to such complications.
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Affiliation(s)
- Emily Livesey
- Department of Paediatric Surgery, King's College Hospital, Denmark Hill, London, SE5 9RS, UK
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28
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Helin R, Bhat R, Rao B. Ultrasound-guided percutaneous cholecystostomy for acute neonatal biliary obstruction. Neonatology 2007; 91:266-70. [PMID: 17568158 DOI: 10.1159/000098174] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2006] [Accepted: 08/15/2006] [Indexed: 11/19/2022]
Abstract
Use of a percutaneously-inserted cholecystostomy drainage tube is an effective therapeutic option for acute hyperbilirubinemia in severely-ill adult patients, but to our knowledge has not been previously reported in infants. We describe an infant who developed acute extrahepatic biliary tract obstruction with marked conjugated (direct) hyperbilirubinemia, and who was determined to be an unsuitable surgical candidate. Ultrasound-guided percutaneous cholecystostomy was performed and resulted in prompt, significant, and sustained decline in serum bilirubin levels. Potential risks and benefits, as well as suggested indications for the procedure are discussed.
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Affiliation(s)
- Radley Helin
- Department of Pediatrics, University of Illinois Medical Center, Chicago, IL 60612, USA.
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29
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Abstract
Untreated, biliary atresia remains a fatal condition of the newborn. Most present within four to six weeks of conjugated jaundice and acholic stools and, although still a challenging diagnosis to make, therein lies the opportunity of changing the course of this otherwise inexorable disease. The aim of surgery is to restore bile flow, alleviate jaundice and abbreviate the cholangiodestructive process within the liver. The Kasai portoenterostomy, introduced almost 50 years ago in Japan, aims to expose microscopic biliary ductules within the fibroinflammatory mass at the porta hepatis and restore bile drainage into a mobilised Roux loop. About 50% of infants with BA will be able to clear their jaundice following Kasai alone, given appropriately experienced surgeons and if performed prior to the onset of overt cirrhosis. They have a reasonable expectation of long-term survival to adulthood with a good quality-of-life. The remainder may be candidates for liver transplantation (where available) although donor organ shortage and immunosuppresion-related complications remain significant problems.
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Affiliation(s)
- Mark Davenport
- Department of Pediatric Surgery, King's College Hospital, London SE5 9RS, United Kingdom.
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31
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Abstract
Biliary atresia (BA) remains a devastating disease of infants. It is still a disease of largely unknown etiology although many hypotheses such as an aberrant early bile duct development, perinatal viral infection, aberrant immune response, and abnormalities of bile acids have all been suggested as possibly etiologically important. Although recent studies, using the techniques of molecular biology and immunohistochemistry, have improved the understanding of some of the inflammatory elements of BA, there is a lack of understanding of how many such disparate elements interact and relate. Clinically, the management in the majority of cases should consist of a primary portoenterostomy (Kasai procedure) to try and restore bile flow and alleviate jaundice. Transplantation should be reserved for those who develop chronic liver disease and its attendant complications. Recent series would suggest that over 50% of infants in large centers will be able to clear their jaundice and therefore have a reasonable expectation of long-term survival with a good quality-of-life.
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Affiliation(s)
- Mark Davenport
- Department of Paediatric Surgery, Kings College Hospital, London, UK.
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