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Huynh N, Selvadurai H, Arbuckle S, Cheah E, Dutt S, Thomas G. Severe obstructive biliopathy mimicking biliary atresia in an infant with cystic fibrosis. J Paediatr Child Health 2022; 58:343-346. [PMID: 33818837 DOI: 10.1111/jpc.15475] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Revised: 02/22/2021] [Accepted: 03/25/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Nguyen Huynh
- Department of Paediatric Surgery, The Children's Hospital at Westmead, Sydney, New South Wales, Australia.,Discipline of Paediatrics and Child Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Hiran Selvadurai
- Discipline of Paediatrics and Child Health, The University of Sydney, Sydney, New South Wales, Australia.,Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Susan Arbuckle
- Department of Histopathology, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Eric Cheah
- Discipline of Paediatrics and Child Health, The University of Sydney, Sydney, New South Wales, Australia.,Department of Gastroenterology and Hepatology, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Shoma Dutt
- Discipline of Paediatrics and Child Health, The University of Sydney, Sydney, New South Wales, Australia.,Department of Gastroenterology and Hepatology, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Gordon Thomas
- Department of Paediatric Surgery, The Children's Hospital at Westmead, Sydney, New South Wales, Australia.,Discipline of Paediatrics and Child Health, The University of Sydney, Sydney, New South Wales, Australia
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Bove KE, Bernieh A, Picarsic J, Cox JP, Yang E, Mantor PC, Thaker A, Lazar L, Sathe M, Megison S. Hypoplasia of Extrahepatic Biliary Tree and Intrahepatic Cholangiolopathy in Cystic Fibrosis Imperfectly Mimic Biliary Atresia in 4 Infants With Cystic Fibrosis and Kasai Portoenterostomy. Am J Surg Pathol 2021; 45:1499-1508. [PMID: 34510112 DOI: 10.1097/pas.0000000000001803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Four male infants with cystic fibrosis and prolonged neonatal jaundice underwent Kasai procedure to relieve biliary obstruction due to apparent biliary atresia. The excised remnants had viscid mucus accumulation in hypoplastic gallbladders and distended peribiliary glands. Main hepatic ducts were narrow and/or malformed. Microscopic differences between the gallbladder and extrahepatic bile ducts in cystic fibrosis and sporadic biliary atresia were unequivocal, despite some histologic overlap; no erosive or fibro-obliterative lesions typical of biliary atresia were seen. Common in liver, biopsies were small duct cholangiopathy with intense focal cholangiolitis and massive accumulation of ceroid pigment within damaged cholangiocytes, and in portal macrophages, portal fibrosis, and unequivocal features of large duct obstruction were inconspicuous compared with biliary atresia. Plugs of bile in small ducts tended to be pale and strongly periodic acid-Schiff-reactive in cystic fibrosis. Distinguishing the liver lesion from that of biliary atresia is challenging but possible. Liver biopsies from 2 additional infants with cystic fibrosis and prolonged jaundice that spontaneously resolved showed a similar small duct cholangiopathy. Small gallbladders and extrahepatic ducts challenge surgical judgment as findings in liver biopsies challenge the pathologist. The decision to perform a Kasai procedure is reasonable when mimicry of biliary atresia is grossly complete. We hypothesize that a disorder of bile volume/flow during development and/or early infancy linked to the CFTR mutation alone or in combination with the stresses of neonatal intensive care causes destructive cholangiolitis and intrahepatic reduction of bile flow with secondary hypoplasia of extrahepatic biliary structures.
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MESH Headings
- Bile Ducts, Extrahepatic/pathology
- Bile Ducts, Extrahepatic/surgery
- Biliary Atresia/pathology
- Biliary Atresia/surgery
- Biopsy
- Cholestasis, Extrahepatic/etiology
- Cholestasis, Extrahepatic/pathology
- Cholestasis, Extrahepatic/surgery
- Cystic Fibrosis/complications
- Cystic Fibrosis/diagnosis
- Diagnosis, Differential
- Fatal Outcome
- Female
- Humans
- Infant
- Infant, Newborn
- Jaundice, Neonatal/etiology
- Jaundice, Neonatal/pathology
- Jaundice, Neonatal/surgery
- Male
- Portoenterostomy, Hepatic
- Predictive Value of Tests
- Treatment Outcome
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Affiliation(s)
| | | | | | - Joseph P Cox
- Department of Pediatric Surgery, Cincinnati Children's Hospital, Cincinnati, OH
| | - Edmund Yang
- Department of Surgery, PeaceHealth Sacred Heart Medical Center, Springfield, OR
| | - Philip C Mantor
- Department of Surgery, University of Oklahoma, Oklahoma City, OK
| | | | | | | | - Stephen Megison
- Surgery, Children's Health and University of Texas Southwestern Medical Center, Dallas, TX
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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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Microgallbladder: Self-Remitting Acute Cholecystitis-Like Condition Unique to Patients with Cystic Fibrosis. Case Rep Radiol 2019; 2019:6737428. [PMID: 31321111 PMCID: PMC6607729 DOI: 10.1155/2019/6737428] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 05/11/2019] [Accepted: 06/01/2019] [Indexed: 12/07/2022] Open
Abstract
Microgallbladder is a nonsurgical medical condition characterized by chronic inflammation and atrophy of the gallbladder, which is considered a highly specific imaging finding unique to patients with cystic fibrosis (CF), and has been incidentally reported on abdominal imaging in up to 45% of cases with CF. The impairment of exocrine water efflux in CF leads to the production of hyperviscous biliary secretions, cholestasis, and transient cystic duct obstruction of the microgallbladder causing microcholecystitis-interestingly a self-remitting acute cholecystitis-like condition without surgical intervention. We present a case report of a 22-year-old male patient with history of CF with multiple hospital admissions for unexplained chronic abdominal pain found to be caused by microgallbladder, which was managed conservatively.
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Fawcett LK, Widger J, Henry GM, Ooi CY. Case report: Cholecystoduodenostomy for cholestatic liver disease in a premature infant with cystic fibrosis and short gut syndrome. BMC Pediatr 2019; 19:78. [PMID: 30857526 PMCID: PMC6410495 DOI: 10.1186/s12887-019-1443-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 02/26/2019] [Indexed: 12/03/2022] Open
Abstract
Background Cholecystoduodenostomy is a surgical procedure that bypasses the extrahepatic biliary tree and connects the gallbladder directly to the duodenum. This case describes the successful use of this procedure in a novel situation. Case presentation A premature (34 weeks gestation) female infant with cystic fibrosis required a laparotomy on day 1 of life due to an intrauterine small bowel perforation. Resection of small bowel and ileostomy formation resulted in short gut syndrome, with 82 cm residual small bowel and intact ileocaecal valve. Post-ileostomy reversal at 2 months old, she developed conjugated hyperbilirubinaemia. Despite conservative management including increased enteral feeding, ursodeoxycholic acid, cholecystostomy drain insertion and flushes, her cholestatic jaundice persisted. A liver biopsy revealed an “obstructive/cholestatic” picture with fibrosis. To avoid further shortening her gut with an hepatoportoenterostomy, cholecystoduodenostomy was performed at 3 months of age with subsequent post-operative improvement and eventual normalisation of her clinical jaundice and liver biochemistry. Conclusions This is the first reported case of a cholecystoduodenostomy being used successfully to treat an infant with persistent conjugated hyperbilirubinemia, cystic fibrosis and short gut syndrome. Cholecystoduodenostomy is a treatment option that with further study, may be considered for obstruction of the common bile duct in patients with short gut and/or where a shorter operating time with minimal intervention is preferred.
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Affiliation(s)
- Laura K Fawcett
- Department of Respiratory Medicine, Sydney Children's Hospital, level 0 South West Wing, High St, Randwick, NSW, 2031, Australia. .,Discipline of Paediatrics, School of Women's and Children's Health, Medicine, University of New South Wales, Sydney, NSW, Australia. .,Molecular and Integrative Cystic Fibrosis (miCF) Research Centre, Sydney Children's Hospital, High Street, Randwick, NSW, Australia.
| | - John Widger
- Department of Respiratory Medicine, Sydney Children's Hospital, level 0 South West Wing, High St, Randwick, NSW, 2031, Australia.,Discipline of Paediatrics, School of Women's and Children's Health, Medicine, University of New South Wales, Sydney, NSW, Australia.,Molecular and Integrative Cystic Fibrosis (miCF) Research Centre, Sydney Children's Hospital, High Street, Randwick, NSW, Australia
| | - Guy M Henry
- Department of General Surgery, Sydney Children's Hospital, High Street, Randwick, NSW, Australia
| | - Chee Y Ooi
- Discipline of Paediatrics, School of Women's and Children's Health, Medicine, University of New South Wales, Sydney, NSW, Australia.,Molecular and Integrative Cystic Fibrosis (miCF) Research Centre, Sydney Children's Hospital, High Street, Randwick, NSW, Australia.,Department of Gastroenterology, Sydney Children's Hospital, High Street, Randwick, NSW, Australia
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6
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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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Hipoplasia de vesícula biliar con cuadro colestásico como primera manifestación clínica. Cir Esp 2016; 94:242-3. [DOI: 10.1016/j.ciresp.2015.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 02/08/2015] [Accepted: 02/15/2015] [Indexed: 11/21/2022]
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