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Wang J, Qian T, Jiang J, Yang Y, Shen Z, Huang Y, Chen G, Zheng S, Dong R. Gut microbial profile in biliary atresia: a case-control study. J Gastroenterol Hepatol 2020; 35:334-342. [PMID: 31271681 DOI: 10.1111/jgh.14777] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 06/04/2019] [Accepted: 07/01/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND AND AIM Biliary atresia (BA) is a progressive fibro-inflammatory cholangiopathy with an unclear etiology. Various liver disorders are associated with an altered microbiome. However, gut microbiome in BA remains unknown. Here, we performed a case-control study to investigate the gut microbiota in BA. METHODS A cross-sectional analysis was first conducted for 34 BA patients and 34 healthy controls. Then we investigated the shift in gut microbiota 2 weeks after the Kasai procedure in 16 BA patients. Gut microbiome was initially analyzed using 16S ribosome RNA gene sequencing and further validated by metagenomic sequencing. Fecal bile acids were determined using ultra-high performance liquid chromatography. RESULTS Compared with healthy controls, BA showed lower diversity and significant structural segregation in the microbiome. At phylum level, Proteobacteria numbers increased, whereas those of Bacteroidetes decreased in BA. At genus level, several potential pathogens such as Streptococcus and Klebsiella thrived in BA, while numbers for Bifidobacterium and several butyrate-producing bacteria declined. The microbiome was also disturbed after the Kasai procedure. Operational taxonomic units responding to BA showed significant correlation with liver function. Furthermore, the abundance ratio of Streptococcus/Bacteroides showed great promise in distinguishing BA from healthy controls. Intestinal bile acids were dramatically decreased in BA, and Clostridium XIVa positively correlated with the ratio of primary/secondary bile acids. CONCLUSIONS Gut microbial dysbiosis, may be caused by decreased bile acids, was associated with liver function and had a good diagnostic potential for BA. Therefore, further exploration of gut microbiota may provide important insights into their potential diagnostic and therapeutic benefits.
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Affiliation(s)
- Junfeng Wang
- Department of Pediatric Surgery, Children's Hospital of Fudan University and Shanghai Key Laboratory of Birth Defect, Shanghai, China
| | - Tian Qian
- Nutrition Department, Children's Hospital of Fudan University and Shanghai Key Laboratory of Birth Defect, Shanghai, China
| | - Jingying Jiang
- Department of Pediatric Surgery, Children's Hospital of Fudan University and Shanghai Key Laboratory of Birth Defect, Shanghai, China
| | - Yifan Yang
- Department of Pediatric Surgery, Children's Hospital of Fudan University and Shanghai Key Laboratory of Birth Defect, Shanghai, China
| | - Zhen Shen
- Department of Pediatric Surgery, Children's Hospital of Fudan University and Shanghai Key Laboratory of Birth Defect, Shanghai, China
| | - Yanlei Huang
- Department of Pediatric Surgery, Children's Hospital of Fudan University and Shanghai Key Laboratory of Birth Defect, Shanghai, China
| | - Gong Chen
- Department of Pediatric Surgery, Children's Hospital of Fudan University and Shanghai Key Laboratory of Birth Defect, Shanghai, China
| | - Shan Zheng
- Department of Pediatric Surgery, Children's Hospital of Fudan University and Shanghai Key Laboratory of Birth Defect, Shanghai, China
| | - Rui Dong
- Department of Pediatric Surgery, Children's Hospital of Fudan University and Shanghai Key Laboratory of Birth Defect, Shanghai, China
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Borgeat M, Korff S, Wildhaber BE. Newborn biliary atresia screening with the stool colour card: a questionnaire survey of parents. BMJ Paediatr Open 2018; 2:e000269. [PMID: 29862332 PMCID: PMC5976097 DOI: 10.1136/bmjpo-2018-000269] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Revised: 04/17/2018] [Accepted: 04/19/2018] [Indexed: 11/05/2022] Open
Abstract
PURPOSE Biliary atresia can easily be screened using a stool colour card (SCC) and has shown to significantly reduce time to diagnosis, improving children's outcome. Despite the general approval of the clinical usefulness of the SCC, physicians remain reluctant: it might unnecessarily worry parents. This study aimed to analyse the parental reaction to this screening method and if it evokes parental stress. METHODS A semistructured questionnaire was sent to parents with one or more healthy child to inquire about reactions on receipt and use of the SCC. RESULTS 109/256 questionnaires were returned and evaluated (43%). 107/107 parents considered the SCC as helpful, a simple screening method and easy to use (100%). 26/43 were reassured when receiving the SCC (60%), 2 were worried (5%) and 9 had no particular feelings (21%). In 41/49, emotions experienced during its use were positive or neutral (84%), and 3 were worried (6%). In 41/50, the discussion with the paediatrician about stool colour-linked pathologies was neutral (82%), and 9 felt uneasy (18%). CONCLUSION A vast majority of parents appreciate the SCC. It creates uneasiness in a minority of parents. Our results are encouraging and argue in favour of implementing the regular distribution of the SCC in antenatal, postnatal and newborn infant clinics.
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Affiliation(s)
- Morgane Borgeat
- Department of Pediatrics, University Hospitals of Geneva, Geneva, Switzerland
| | - Simona Korff
- Department of Pediatrics, University Hospitals of Geneva, Geneva, Switzerland
| | - Barbara E Wildhaber
- Division of Paediatric Surgery, University Center of Paediatric Surgery of Western Switzerland, University Hospitals of Geneva, Geneva, Switzerland
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Abstract
Early diagnosis followed by proper KP is essential for the improvement of long-term prognosis for patients with BA. It is increasingly accepted that KP at ≤ 30 days of age significantly improves native liver survival rate. Published analyses in English and Japanese indicate that screening by SCC and DB/CB is potentially feasible. Screening with SCC has been implemented in Tochigi Prefecture, Japan, since 1994. The concept of SCC was introduced from Japan to Taiwan and resulted in nationwide screening with SCC for the first time in Taiwan in 2004, followed by Japan in 2012. Home-based screening using SCC is easy and cost-effective; however, it may cause some difficulties for families in case of stools with intermediate colors. Laboratory-based screening using DB/CB may detect the suspected cases earlier, resulting in an increase in the number of patients with BA who undergo KP at ≤ 30 days of age; however, the recall rate is 1% and may be beyond an acceptable range. Further studies are needed to assess the feasibility and cost-effectiveness of both home-based (SCC) and laboratory-based (DB/CB) screening for BA.
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Affiliation(s)
- Akira Matsui
- Graduate School of Nursing Science, St. Luke's International University, 3-8-5 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan.
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Mathiyazhagan G, Jagadisan B. Referral Patterns and Factors Influencing Age at Admission of Infants with Cholestasis in India. Indian J Pediatr 2017; 84:591-596. [PMID: 28397065 DOI: 10.1007/s12098-017-2342-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 03/20/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVES To define the recognition, age at admission, referral time and referral pattern of neonatal cholestasis in India. METHODS This prospective, observational study was conducted from February 2015 through March 2016 in the Pediatric gastroenterology unit of JIPMER, Pondicherry in infants with cholestasis < 6 mo of age. RESULTS Among 64 infants, median age of admission was 52 d (IQR 28-63 d). Fifty of sixty four infants (78.1%) came with parent-reported cholestasis-related symptoms of either jaundice alone (57.8%) or bleeding manifestations (20.3%). In 21.9% infants, jaundice was detected by physicians at a median age of 45 d (IQR 38.5-53.2 d). Two infants had intracranial bleed. Only 34% infants with pale stools were identified by the mother. The median healthcare-seeking time was 5.5 d (IQR 2.5-12 d). Among infants presenting to primary healthcare physicians (PHPs) with cholestasis-related symptoms, median time to referral was 5 d (IQR 2.5-12 d). The first point of healthcare contact in 54.7% was a PHP; 17.1% PHPs had reassured the parents. Herbal preparations were prescribed by 14.3%. Only 11.8% of those with jaundice as the only problem were given vitamin K before referral. Biliary atresia (BA) was missed in neonatal intensive care units in 9 cases. CONCLUSIONS The above issues need to be accounted for before evaluating or implementing screening strategies in India.
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Affiliation(s)
- Gopinathan Mathiyazhagan
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantri Nagar, Pondicherry, 605006, India
| | - Barath Jagadisan
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantri Nagar, Pondicherry, 605006, India.
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Bathena SPR, Thakare R, Gautam N, Mukherjee S, Olivera M, Meza J, Alnouti Y. Urinary bile acids as biomarkers for liver diseases II. Signature profiles in patients. Toxicol Sci 2014; 143:308-18. [PMID: 25344563 DOI: 10.1093/toxsci/kfu228] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Hepatobiliary diseases result in the accumulation of bile acids (BAs) in the liver, systemic blood, and other tissues leading to an unfavorable prognosis. The BA profile was characterized by the calculation of indices that describe the composition, sulfation, and amidation of total and individual BAs. Comparison of the urinary BA profiles between healthy subjects and patients with hepatobiliary diseases demonstrated significantly higher absolute concentrations of individual and total BAs in patients. The percentage sulfation of some individual BAs were different between the two groups. The percentage amidation of overall and most individual BAs was higher in patients than controls. The percentage of primary BAs (CDCA and CA) was higher in patients, whereas the percentage of secondary BAs (DCA and LCA) was lower in patients. BA indices belonging to percentage amidation and percentage composition were better associated with the severity of the liver disease as determined by the model for end-stage liver disease (MELD) score and disease compensation status compared with the absolute concentrations of individual and total BAs. In addition, BA indices corresponding to percentage amidation and percentage composition of certain BAs demonstrated the highest area under the receiver operating characteristic (ROC) curve suggesting their utility as diagnostic biomarkers in clinic. Furthermore, significant increase in the risk of having liver diseases was associated with changes in BA indices.
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Affiliation(s)
- Sai Praneeth R Bathena
- *Department of Pharmaceutical Sciences, College of Pharmacy, Department of Internal Medicine, College of Medicine and Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska 68198
| | - Rhishikesh Thakare
- *Department of Pharmaceutical Sciences, College of Pharmacy, Department of Internal Medicine, College of Medicine and Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska 68198
| | - Nagsen Gautam
- *Department of Pharmaceutical Sciences, College of Pharmacy, Department of Internal Medicine, College of Medicine and Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska 68198
| | - Sandeep Mukherjee
- *Department of Pharmaceutical Sciences, College of Pharmacy, Department of Internal Medicine, College of Medicine and Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska 68198
| | - Marco Olivera
- *Department of Pharmaceutical Sciences, College of Pharmacy, Department of Internal Medicine, College of Medicine and Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska 68198
| | - Jane Meza
- *Department of Pharmaceutical Sciences, College of Pharmacy, Department of Internal Medicine, College of Medicine and Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska 68198
| | - Yazen Alnouti
- *Department of Pharmaceutical Sciences, College of Pharmacy, Department of Internal Medicine, College of Medicine and Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska 68198
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Abstract
OBJECTIVES International trends in incidence and outcomes of biliary atresia (BA) are controversial and a wide range of estimates have been reported worldwide. We reviewed the population-based literature to assess international variation of BA incidence and outcomes, and to assess the evidence for seasonal variation in incidence, centralization of Kasai hepatoportoenterostomy, and newborn screening. METHODS We conducted a systematic review (registration number CRD42011001441) of observational or interventional research within MEDLINE, EMBASE, and the Cochrane Database, which reported incidence, prevalence, or outcomes of infants with BA. Population-based studies, defined by inclusion of an entire population or representative sample, were included. Outcomes included overall survival, native liver survival (NLS), and time to Kasai hepatoportoenterostomy. Single- or multicenter studies were excluded unless those centers captured all potential patients within a jurisdiction. Two independent data extractors reviewed the abstracts and articles. RESULTS A total of 40 studies were included following review of 3128 references. A wide range of incidence was reported internationally. Ten-year overall survival ranged from 66.7% to 89%. NLS ranged from 20.3% to 75.8% at 1 to 3 years and 24% to 52.8% at 10 years. Earlier age at Kasai was a predictor of improved NLS. Seasonality was reported in 11 studies, and 3 reported an increased incidence during the months of August to March. The evidence for centralization of Kasai to high-volume centers is promising but does not account for all case-mix, provider, or health system factors involved in volume-outcome relations. Stool color card screening resulted in earlier Kasai and improved NLS in Taiwan. CONCLUSIONS Large, international studies could help fill the gaps in knowledge identified by this review.
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Wildhaber BE. Biliary atresia: 50 years after the first kasai. ISRN SURGERY 2012; 2012:132089. [PMID: 23304557 PMCID: PMC3523408 DOI: 10.5402/2012/132089] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/23/2012] [Accepted: 10/30/2012] [Indexed: 12/20/2022]
Abstract
Biliary atresia is a rare neonatal disease of unknown etiology, where obstruction of the biliary tree causes severe cholestasis, leading to biliary cirrhosis and death in the first years of life, if the condition is left untreated. Biliary atresia is the most frequent surgical cause of cholestatic jaundice in neonates and should be evoked whenever this clinical sign is associated with pale stools and hepatomegaly. The treatment of biliary atresia is surgical and currently recommended as a sequence of, eventually, two interventions. During the first months of life a hepatoportoenterostomy (a "Kasai," modifications of which are discussed in this paper) should be performed, in order to restore the biliary flow to the intestine and lessen further damage to the liver. If this fails and/or the disease progresses towards biliary cirrhosis and life-threatening complications, then liver transplantation is indicated, for which biliary atresia represents the most frequent pediatric indication. Of importance, the earlier the Kasai is performed, the later a liver transplantation is usually needed. This warrants a great degree of awareness of biliary atresia, and the implementation of systematic screening for this life-threatening pathology.
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Affiliation(s)
- Barbara E Wildhaber
- Division of Pediatric Surgery, Department of Pediatrics, University Hospital of Geneva, 1211 Geneva, Switzerland
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Abstract
The age threshold at the time of Kasai hepatic portoenterostomy associated with a prognosis of biliary atresia (BA) is becoming clearer as 10-year native liver survival data become more frequent in the recent literature, whereas the age at diagnosis has not dramatically decreased during the last 3 decades. A stool color card screening implemented in 1994 in Japan is now expanding worldwide. However, the contribution of this modality will probably be limited because of the nature of this disease, for example, 'progressive obliterative cholangiopathy'. A cholic stool was actually observed only in 50% before diagnosis according to the Japanese BA Registry data. Thus, color card screening does not appear to be instrumental in detecting patients with BA early enough before 1 month of age. A highly sensitive, adequately specific, noninvasive and quantitative method may be expensive, but the overall cost would be lower than that of liver transplant.
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Affiliation(s)
- Toshihiro Muraji
- Department of Pediatric Surgery, Ibaraki Children's Hospital, 3-3-1 Futabadai, Mito, Ibaraki 311-4145, Japan.
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Palermo JJ, Joerger S, Turmelle Y, Putnam P, Garbutt J. Neonatal cholestasis: opportunities to increase early detection. Acad Pediatr 2012; 12:283-7. [PMID: 22634076 PMCID: PMC3398230 DOI: 10.1016/j.acap.2012.03.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2011] [Revised: 03/23/2012] [Accepted: 03/28/2012] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To describe primary care management of early and prolonged jaundice in otherwise-healthy term infants to identify opportunities to increase early diagnosis of cholestasis. METHODS Community-based pediatricians in St Louis, Missouri completed a mailed, anonymous, 29-item survey to assess practice demographics, timing of routine newborn office visits, and the management of early and prolonged neonatal jaundice. RESULTS A total of 108 of 230 (47%) of eligible physicians responded (mean years in practice, 15.3, SD, 9.4). More respondents were very familiar with national guidelines for management of early (49%) than prolonged (16%) neonatal jaundice. Eighty-six percent reported all newborns were checked with transcutaneous bilirubin before hospital discharge. For transcutaneous bilirubin results at 48 hours of 7, 10, 12 and 15 mg/dL, 1%, 26%, 70%, and 74% of respondents, respectively, would order a fractionated bilirubin. Although the first routine visit usually occurred in the first week after discharge, 25% of physicians reported the 2nd visit was routinely scheduled after 4 weeks of age. Ninety-four percent reported they would obtain a fractionated bilirubin for infants jaundiced beyond 4 weeks of age. If cholestasis was identified at 6 weeks of age, 32% would obtain additional testing without referral to a subspecialist. CONCLUSIONS Management of early and prolonged neonatal jaundice is variable. Current practices appear to miss opportunities for early diagnosis of cholestasis and referral that are unlikely to be addressed without redesigning systems of care.
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Affiliation(s)
- Joseph J. Palermo
- Department of Pediatrics, Washington University, St. Louis, MO, United States
| | - Shannon Joerger
- Department of Pediatrics, Washington University, St. Louis, MO, United States
| | - Yumirle Turmelle
- Department of Pediatrics, Washington University, St. Louis, MO, United States
| | - Peter Putnam
- Department of Pediatrics, Washington University, St. Louis, MO, United States
| | - Jane Garbutt
- Department of Pediatrics, Washington University, St. Louis, MO, United States
- Department of Medicine, Washington University, St. Louis, MO, United States
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Suzuki M, Muraji T, Obatake M, Nio M, Ito K, Suzuki K, Ota K, Maisawa S, Yamashiro Y, Shimizu T. Urinary sulfated bile acid analysis for the early detection of biliary atresia in infants. Pediatr Int 2011; 53:497-500. [PMID: 21040191 DOI: 10.1111/j.1442-200x.2010.03268.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Measurement of urinary sulfated bile acid (USBA) is a non-invasive method to detect bile congestion. Our aim was to evaluate the feasibility of USBA analysis for the early detection of biliary atresia (BA). METHODS We determined the USBA-to-creatinine ratio (USBA/cr) in 1148 infants at 10-40 days after birth. All infants were followed until the 3- to 4-month postnatal routine health check. The cutoff value for USBA/cr was 55.0 µmol/g creatinine. RESULTS Among the infants tested, 47 (4.10%) had USBA/cr ratios that exceeded the cutoff value. Two of these 47 infants had liver disease; one was diagnosed with neonatal hepatitis syndrome, and the other was diagnosed with BA. The BA patient underwent USBA analysis for the first time on day 18 after birth and hepatoportoenterostomy on day 49. No other infants were diagnosed with hepatobiliary disease during the follow-up period. CONCLUSION This USBA analysis provided the correct assessment without fail and identified a case of BA. This approach could be used for the screening and early detection of BA when the false-positive rate is decreased by improving the methods for sample collection and urine storage.
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Affiliation(s)
- Mitsuyoshi Suzuki
- Department of Pediatrics, Juntendo University School of Medicine, Tokyo, Japan.
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Negoro S, Tanaka A, Takikawa H. Urinary bile acid sulfate levels in patients with hepatitis C virus-related chronic liver diseases. Hepatol Res 2009; 39:760-5. [PMID: 19473428 DOI: 10.1111/j.1872-034x.2009.00516.x] [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] [Indexed: 02/08/2023]
Abstract
AIM Urinary bile acids are mainly conjugated with sulfuric acid, and urinary sulfated bile acid (USBA) levels in hepatobiliary diseases have been reported. However, the relationship between USBA and fasting serum total bile acid (TBA) has not been studied in hepatobiliary diseases. In the present study, we measured USBA levels in patients with hepatitis C virus-related chronic liver diseases, and the relationship between TBA and various laboratory tests was studied. METHODS USBA was measured using an automatic assay kit in 66 patients with chronic hepatitis and 28 patients with liver cirrhosis, and its relationship between TBA and various laboratory tests was studied. RESULTS The median USBA level was 10.7 micromol/g creatinine in patients with chronic hepatitis and 41.1 micromol/g creatinine in liver cirrhosis (P = 0.000). More patients with chronic hepatitis had elevated USBA levels (61%) compared to TBA level (39%) (P = 0.002). USBA level was well correlated with TBA (r(s) = 0.680), and negatively correlated with albumin (r(s) = -0.488), prothrombin time (r(s) = -0.385) and platelet counts (r(s) = -0.394). In patients with liver cirrhosis, USBA was significantly elevated in Child-Pugh class B compared to Child-Pugh class A (P = 0.036). CONCLUSION Although the metabolic pathways of USBA and TBA are different, these levels correlated very well, and USBA is considered to be a useful indicator of hepatic function like TBA in patients with chronic hepatitis C.
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Affiliation(s)
- Shinichiro Negoro
- Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan
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Kawai H, Kudo N, Kawashima Y, Mitsumoto A. Efficacy of urine bile acid as a non-invasive indicator of liver damage in rats. J Toxicol Sci 2009; 34:27-38. [PMID: 19182433 DOI: 10.2131/jts.34.27] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Estimation of liver damage is important in the pathophysiological and toxicological study of liver disease. As a novel, non-invasive marker of liver damage, we studied the efficacy of urine bile acids (UBA) in a rat model of liver disease. Thioacetamide (TAA)-treated rats were used in this study. Single intraperitoneal administration of high-dose TAA induces severe damage to the liver, and thus is used as a model of acute hepatitis. Continuous administration of low-dose TAA yields mild damage to the liver, and induces cirrhosis and hepatic tumors. In this study, it was found that both acute and chronic administration of TAA was associated with a dose-dependent elevation of UBA. The elevation of UBA content correlated with the alteration of blood biochemical indicators, and UBA screening showed a remarkable ability to distinguish liver-damaged rats from healthy rats. In particular, UBA analysis was found to have high sensitivity, specificity, and positive predictive value for the screening of rats with abnormal serum alkaline phosphatase (ALP) activity due to chronic liver damage, which was confirmed to include cholestasis and subsequent cirrhosis by liver histological analysis. In conclusion, we demonstrated that measurement of UBA is a simple, non-invasive and effective method for the screening of cholestasis in TAA-treated rats. We suggest that UBA analysis may have potent applicability for monitoring the progress of liver damage in animal models of chronic liver disease, such as cirrhosis and hepatic encephalopathy.
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Affiliation(s)
- Hiroshi Kawai
- Faculty of Pharmaceutical Sciences, Josai International University, 1 Gumyo, Togane, Chiba 283-8555, Japan.
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Hsiao CH, Chang MH, Chen HL, Lee HC, Wu TC, Lin CC, Yang YJ, Chen AC, Tiao MM, Lau BH, Chu CH, Lai MW. Universal screening for biliary atresia using an infant stool color card in Taiwan. Hepatology 2008; 47:1233-40. [PMID: 18306391 DOI: 10.1002/hep.22182] [Citation(s) in RCA: 176] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
UNLABELLED Biliary atresia is the most common cause of death from liver disease in children. Although the Kasai operation before 60 days of age can significantly improve prognosis, delay in referral and surgery remains a formidable problem worldwide because of difficulties in differentiating it from benign prolonged neonatal jaundice. We established a universal screening system using an infant stool color card to promote the early diagnosis and treatment of biliary atresia. After a pilot regional study in 2002-2003, a national stool color screening system was established by integrating the infant stool color card into the child health booklet given to every neonate in Taiwan since 2004. Within 24 hours of the discovery of an abnormal stool color, this event is reported to the registry center. The annual incidence of biliary atresia per 10,000 live births in 2004 and 2005 was 1.85 (40/216,419) and 1.70 (35/205,854), respectively. The sensitivity of detecting biliary atresia using stool cards before 60 days of age was 72.5% in 2004, which improved to 97.1% in 2005. The national rate of the Kasai operation before 60 days of age increased from 60% in 2004 to 74.3% in 2005. The jaundice-free rate (<2 mg/dL) at 3 months after the Kasai operation among infants with biliary atresia in 2004-2005 was 59.5% (44 of 74), significantly higher than the historical data of 37.0% in 1976-2000 before the stool card screening program (P = 0.002). CONCLUSION Universal screening using the stool color cards can enhance earlier referral, which may ultimately lead to timely performance of the Kasai operation and better postoperative outcome in infants with biliary atresia.
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Affiliation(s)
- Cheng-Hui Hsiao
- Department of Pediatrics, Cardinal Tien Hospital Yung Ho Branch, Taipei, Taiwan
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Sokol RJ, Shepherd RW, Superina R, Bezerra JA, Robuck P, Hoofnagle JH. Screening and outcomes in biliary atresia: summary of a National Institutes of Health workshop. Hepatology 2007; 46:566-81. [PMID: 17661405 PMCID: PMC3888317 DOI: 10.1002/hep.21790] [Citation(s) in RCA: 171] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Biliary atresia is the most common cause of end-stage liver disease in the infant and is the leading pediatric indication for liver transplantation in the United States. Earlier diagnosis (<30-45 days of life) is associated with improved outcomes following the Kasai portoenterostomy and longer survival with the native liver. However, establishing this diagnosis is problematic because of its rarity, the much more common indirect hyperbilirubinemia that occurs in the newborn period, and the schedule for routine infant health care visits in the United States. The pathogenesis of biliary atresia appears to involve immune-mediated fibro-obliteration of the extrahepatic and intrahepatic biliary tree in most patients and defective morphogenesis of the biliary system in the remainder. The determinants of the outcome of portoenterostomy include the age at surgery, the center's experience, the presence of associated congenital anomalies, and the postoperative occurrence of cholangitis. A number of screening strategies in infants have been studied. The most promising are early measurements of serum conjugated bilirubin and a stool color card given to new parents that alerts them and their primary care provider to alcholic stools. This report summarizes a National Institutes of Health workshop held on September 12 and 13, 2006, in Bethesda, MD, that addressed the issues of outcomes, screening, and pathogenesis of biliary atresia.
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Affiliation(s)
- Ronald J Sokol
- Department of Pediatrics, University of Colorado School of Medicine, The Children's Hospital, Denver, CO, USA.
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Shinka T, Inoue Y, Ohse M, Kuhara T. Simple and quantitative analysis of urinary sulfated tauro- and glycodihydroxycholic acids in infant with cholestasis by electrospray ionization mass spectrometry. J Chromatogr B Analyt Technol Biomed Life Sci 2007; 855:104-8. [PMID: 17466603 DOI: 10.1016/j.jchromb.2007.04.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2006] [Revised: 03/29/2007] [Accepted: 04/03/2007] [Indexed: 11/22/2022]
Abstract
Here we report a simple, sensitive, and accurate method for detecting urinary sulfated tauro- and glyco-bile acids that uses electrospray ionization mass spectrometry. The sulfated tauro- and glycodihydroxycholic acids mainly generated [M-2H](2-) negative ions at m/z 288.6 and m/z 263.6, respectively. These doubly charged ions appeared primarily in samples prepared from the urine of patients with cholestasis and were detected quantitatively. Cholestatic jaundice is the primary clinical sign of biliary atresia. The measurement of doubly charged negative ions, especially of sulfated taurodihydroxycholic acid (principally taurochenodeoxycholate-3-sulfate), is a useful screening modality for biliary atresia in neonates.
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Affiliation(s)
- Toshihiro Shinka
- Division of Human Genetics, Medical Research Institute, Kanazawa Medical University, Uchinada, Kahoku-gun, Ishikawa, Japan.
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Higuchi A, Hasegawa Y. Dose Adjustments of Hydrocortisone and L-thyroxine in Hypopituitarism Associated with Cholestasis. Clin Pediatr Endocrinol 2006; 15:93-6. [PMID: 24790327 PMCID: PMC4004839 DOI: 10.1297/cpe.15.93] [Citation(s) in RCA: 5] [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: 11/25/2005] [Accepted: 04/11/2006] [Indexed: 11/22/2022] Open
Abstract
A patient with congenital hypopituitarism associated with cholestasis is reported here.
Large doses of fat-soluble hormones (hydrocortisone (20 mg/m2/day) and
L-thyroxine (14 μg/kg/day)) were needed to resolve hypoglycemia and hypothyroidism during
cholestasis. The doses could be reduced to 10 mg/m2/day and 3.5 μg/kg/day,
respectively, after improvement of cholestasis. Sodium valproate, which is a water-soluble
drug, did not need any dose adjustments during cholestasis. Adjustment of fat-soluble
hormone doses during cholestasis should be considered in patients with cholestasis.
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Affiliation(s)
- Asako Higuchi
- Division of Endocrinology and Metabolism, Tokyo Metropolitan Kiyose Children's Hospital, Tokyo, Japan
| | - Yukihiro Hasegawa
- Division of Endocrinology and Metabolism, Tokyo Metropolitan Kiyose Children's Hospital, Tokyo, Japan
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18
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Chen SM, Chang MH, Du JC, Lin CC, Chen AC, Lee HC, Lau BH, Yang YJ, Wu TC, Chu CH, Lai MW, Chen HL. Screening for biliary atresia by infant stool color card in Taiwan. Pediatrics 2006; 117:1147-54. [PMID: 16585309 DOI: 10.1542/peds.2005-1267] [Citation(s) in RCA: 112] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE We aimed to detect biliary atresia (BA) in early infancy to prevent additional liver damage because of the delay of referral and surgical treatment and to investigate the incidence rate of BA in Taiwan. METHODS A pilot study to screen the stool color in infants for the early diagnosis of BA was undertaken from March 2002 to December 2003. We had designed an "infant stool color card" with 7 numbers of different color pictures and attached it to the child health booklet. Parents were then asked to observe their infant's stool color by using this card. The medical staff would check the number that the parents chose according to their infant's stool color at 1 month of age during the health checkup and then send the card back to the stool color card registry center. RESULTS The average return rate was approximately 65.2% (78,184 infants). A total of 29 infants were diagnosed as having BA, and 26 were screened out by stool color card before 60 days of age. The sensitivity, specificity, and positive predictive value were 89.7%, 99.9%, and 28.6%, respectively. Seventeen (58.6%) infants with BA received a Kasai operation within 60-day age period. The estimated incidence of BA in screened newborns was 3.7 of 10,000. CONCLUSIONS The stool color card was a simple, efficient, and applicable mass screening method for early diagnosis and management of BA. The program can also help in estimating the incidence and creating a registry of these patients.
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Affiliation(s)
- Shan-Ming Chen
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
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Moyer V, Freese DK, Whitington PF, Olson AD, Brewer F, Colletti RB, Heyman MB. Guideline for the evaluation of cholestatic jaundice in infants: recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr 2004; 39:115-28. [PMID: 15269615 DOI: 10.1097/00005176-200408000-00001] [Citation(s) in RCA: 215] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
For the primary care provider, cholestatic jaundice in infancy, defined as jaundice caused by an elevated conjugated bilirubin, is an uncommon but potentially serious problem that indicates hepatobiliary dysfunction. Early detection of cholestatic jaundice by the primary care physician and timely, accurate diagnosis by the pediatric gastroenterologist are important for successful treatment and a favorable prognosis. The Cholestasis Guideline Committee of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition has formulated a clinical practice guideline for the diagnostic evaluation of cholestatic jaundice in the infant. The Cholestasis Guideline Committee, consisting of a primary care pediatrician, a clinical epidemiologist (who also practices primary care pediatrics), and five pediatric gastroenterologists, based its recommendations on a comprehensive and systematic review of the medical literature integrated with expert opinion. Consensus was achieved through the Nominal Group Technique, a structured quantitative method. The Committee examined the value of diagnostic tests commonly used for the evaluation of cholestatic jaundice and how those interventions can be applied to clinical situations in the infant. The guideline provides recommendations for management by the primary care provider, indications for consultation by a pediatric gastroenterologist, and recommendations for management by the pediatric gastroenterologist. The Cholestasis Guideline Committee recommends that any infant noted to be jaundiced at 2 weeks of age be evaluated for cholestasis with measurement of total and direct serum bilirubin. However, breast-fed infants who can be reliably monitored and who have an otherwise normal history (no dark urine or light stools) and physical examination may be asked to return at 3 weeks of age and, if jaundice persists, have measurement of total and direct serum bilirubin at that time. This document represents the official recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition on the evaluation of cholestatic jaundice in infants. The American Academy of Pediatrics has also endorsed these recommendations. These recommendations are a general guideline and are not intended as a substitute for clinical judgment or as a protocol for the care of all patients with this problem.
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Muraji T, Harada T, Miki K, Moriuchi T, Obatake M, Tsugawa C. Urinary sulfated bile acid concentrations in infants with biliary atresia and breast-feeding jaundice. Pediatr Int 2003; 45:281-3. [PMID: 12828581 DOI: 10.1046/j.1442-200x.2003.01710.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Toshihiro Muraji
- Department of Surgery, Kobe Children's Hospital, Kobe, School of Allied Health Sciences, Osaka University, Osaka, Japan.
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21
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Abstract
Intrahepatic cholestasis of pregnancy (ICP) affects about 0.7% of deliveries in Britain. It is regarded as a benign condition for the mother but is associated with increased fetal mortality in late pregnancy and early delivery is advised. Ursodeoxycholic acid (UDCA) treatment is beneficial to the mother and does not appear to harm the fetus. ICP is often regarded as a disease of the maternal liver already made 'cholestatic' by high levels of circulating progesterone. We propose that ICP should be considered as a feto-maternal disease involving complex interactions between maternal and fetal bile acid metabolism across the placenta. During the late stages of gestation, when there is a rise in fetal and maternal bile acid levels, the placenta may fail to render potentially hepatotoxic bile acids water soluble and hence excretable. This might cause a vicious cycle leading to further cholestasis in the maternal liver already challenged by progesterone.
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22
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Obatake M, Muraji T, Satoh S, Nishijima E, Tsugawa C. Urinary sulfated bile acids: a new simple urine test for cholestasis in infants and children. J Pediatr Surg 2002; 37:1707-8. [PMID: 12483636 DOI: 10.1053/jpsu.2002.36701] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND/PURPOSE Measurement of urinary sulfated bile acid (USBA) has been reported as a simple urine test that reflects the degree of cholestasis. The authors report the diagnostic value of this new laboratory test in various cholestatic conditions affecting infants and children. METHODS A urine sample was collected from 4 surgical neonates with parenteral nutrition-induced cholestasis and 48 patients with biliary atresia (BA). USBA was measured by direct enzymatic assay. RESULTS In 3 patients receiving parenteral nutrition, USBA increased with caloric gains. For one surgical patient, a decrease in calories because of liver dysfunction resulted in a decrease of USBA, closely reflecting the fluctuations of caloric intake. In patients with BA, a significant positive correlation was noted between serum bile acid and USBA (r = 0.85; P <.01). Ten of 14 febrile episodes in 6 patients with liver dysfunction and increased C-reactive protein showed elevated USBA, thus diagnosed as cholangitis. Four febrile episodes caused by viral infection showed no elevation of USBA. CONCLUSIONS USBA is a simple and sensitive noninvasive test reflecting the degree of cholestasis in infants and children. USBA correlated highly with serum bile acid levels and may be helpful in diagnosis of cholestasis caused by cholangitis without blood sampling.
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Abstract
Biliary atresia is the leading cause of cholestasis in infants younger than 3 months. It is also the leading indication for liver transplantation in children. This review focuses on recent advances in the etiology, diagnosis, and management of biliary atresia.
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Affiliation(s)
- M R Narkewicz
- Pediatric Liver Disease Section, Pediatric Gastroenterology, Hepatology and Nutrition, Pediatric Liver Center, University of Colorado School of Medicine, Children's Hospital, Denver, Colorado 80218, USA.
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Abstract
Although the prognosis of biliary atresia has been improved in recent years, particularly in the era of liver transplantation, hepatic portoenterostomy, e.g., the Kasai operation, is still the first line of surgical treatment. Successful hepatic portoenterostomy depends on early diagnosis and operation, adequate operative technique, prevention of postoperative cholangitis, and precise postoperative management. The pathophysiology of the liver and of the intrahepatic bile ducts in this disease is still controversial.
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Affiliation(s)
- R Ohi
- Department of Pediatric Surgery, Tohoku University School of Medicine, Sendai, Japan.
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25
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Abstract
Although the prognosis of biliary atresia has been dramatically improved in the era of liver transplantation, the Kasai operation is still the first line of surgical treatment. Successful hepatic portoenterostomy depends on early diagnosis and surgery, adequate surgical technique, prevention of cholangitis, and precise postoperative management.
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Affiliation(s)
- M Nio
- Department of Pediatric Surgery, Tohoku University School of Medicine, Sendai, Japan
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