Neonatal cholestasis. New approaches to diagnostic evaluation and therapy

Evaluation of the use of laparoscopic-guided cholecystocholangiography and liver biopsy in definitive diagnosis of neonatal cholestatic jaundice

BACKGROUND

Once it is established that a jaundiced infant has direct hyperbilirubinemia, the principal diagnostic concern is to differentiate hepatocellular from obstructive cholestasis. Traditional tests such as ultrasonography, percutaneous liver biopsy and technetium 99 m hepatobiliary iminodiacetic acid (HIDA) scan are often not sufficiently discriminating. Definitive exclusion of biliary atresia (BA) in the infant with cholestatic jaundice usually requires mini-laparotomy and intra-operative cholangiography. This approach has many drawbacks because those sick infants are subjected to a time-consuming procedure with the probability of negative surgical exploration.

AIM OF THE STUDY

The aim of this study was to determine the feasibility of laparoscopic-guided cholecystocholangiography (LGCC) and its accuracy and safety in the diagnosis of BA and thus preventing unnecessary laparotomy in infants whose cholestasis is caused by diseases other than BA.

PATIENTS AND METHODS

Twelve cholestatic infants with direct hyperbilirubinemia subjected to LGCC (age, 7-98 days; mean, 56 days) after ultrasound scan and (99 mTc) HIDA scan and percutaneous liver biopsy failed to provide the definitive diagnosis.

RESULTS

One patient had completely absent gall bladder (GB) so the laparoscopic procedure was terminated and laparotomy was done (Kasai operation). Four patients had small size GB; they underwent LGCC that showed patent common bile duct with atresia of common hepatic duct, so laparotomy and Kasai operation was performed. Seven patients had well-developed GB, LGCC revealed patent biliary tree, so laparoscopic liver biopsies were taken for histopathology. Five of those patients had neonatal hepatitis, and two had cholestasis as a complication of prolonged TPN. No perioperative complications or mortalities were recorded.

CONCLUSION

When the diagnosis neonatal cholestasis remains elusive after traditional investigations, LGCC is an accurate and simple method for differentiating BA from hepatocellular causes.

Comparison of phenobarbitone and ursodeoxycholic acid in drug-augmented hepatobiliary scintigraphy for excluding the diagnosis of obstructive cholestasis in neonatal cholestasis syndrome

OBJECTIVES

Neonatal cholestasis is a common cause of jaundice among newborns. Hepatobiliary scintigraphy plays an important role in the diagnosis of neonatal cholestasis by ruling out extrahepatic biliary atresia, which is one of the common causes. Phenobarbitone and ursodeoxycholic acid (UDCA) have been used to improve the specificity of hepatobiliary scintigraphy in ruling out obstructive causes of neonatal cholestasis syndrome (NCS). The present study was undertaken to compare the utility of phenobarbitone and UDCA in augmenting hepatobiliary scintigraphy in the evaluation of NCS.

MATERIALS AND METHODS

Seventy-four consecutive patients with NCS referred for hepatobiliary scintigraphy were initially subjected to a baseline scan. Twenty patients showed tracer activity in the intestine within 24 h after injection, thus ruling out obstructive cholestasis. Fifty-four patients who did not show any tracer activity in the intestine were categorized as nonexcretors. Four nonexcretors were lost to follow-up and were excluded from the study. Fifty nonexcretors showing scan features suggestive of obstructive cholestasis were further randomized into those receiving phenobarbitone (n=20), UDCA (n=20), or placebo (n=10). These groups were further evaluated with drug-augmented hepatobiliary scintigraphy, after premedication, for any excretory activity in the intestine.

RESULTS AND CONCLUSION

Out of 50 patients who were evaluated with drug-augmented hepatobiliary scintigraphy two patients from the phenobarbitone group and one patient each from UDCA and placebo groups showed a change in excretory pattern from the baseline scan. However, these results were statistically nonsignificant (P=1.00). In the present study, drug-augmented (phenobarbitone or UDCA) hepatobiliary scintigraphy did not seem to improve the results (negative predictive value) for ruling out an obstructive cause of neonatal cholestasis.

Early laparoscopic Kasai's procedure in a low weight newborn

The authors present an early laparoscopic treatment in a newborn with biliary atresia. They describe the technical details of the Kasai laparoscopic procedure. A 10-day-old girl, weight 2.4 kg, was admitted with a history of jaundice and fecal acholia since birth, with elevated total bilirubin and abnormal hepatic test. Abdominal ultrasound showed a small gallbladder with hyperechogenicity in porta hepatis and absence of biliary principal duct. Other metabolic and hematological tests were normal. The procedure was performed at 20-day-old by laparoscopy. The cholangiography confirmed the biliary atresia and Kasai's procedure was continued by laparoscopy and transumbilical extracorporeal Roux-Y approach. The duration of the procedure was 220 min, with good tolerance of pneumoperitoneum due to the laparoscopy. Feedings of breast milk began on the third day postoperative, presenting normal colored stools, with normalization of the hepatic test. A 20 months follow-up was without complications.

Neonatal cholestasis: an uncommon presentation of hyperargininemia

Hyperargininemia is a rare inborn error of metabolism due to arginase deficiency, which is inherited in an autossomal recessive manner. Arginase is the final enzyme of the urea cycle and catalyzes the conversion of arginine to urea and ornithine. This condition typically presents in early childhood (between 2 and 4 years of age) with developmental delay associated with progressive spastic paraparesis. Neonatal presentation is very uncommon with a poorly described outcome. Here, we discuss two cases of neonatal cholestasis as initial clinical presentation of hyperargininemia. In case 1, diagnosis was established at 2 months of age upon investigation of the etiology of cholestatic injury pattern and hepatosplenomegaly, and treatment was then initiated at when the patient was 3 months old. Unfortunately, the patient had progressive biliary cirrhosis to end-stage liver disease complicated with portal hypertension for which she underwent successful orthotopic liver transplant at 7 years of age. In case 2, hyperargininemia was identified through newborn screening and treatment was started when patient was 21 days old. Cholestasis was only identified in the patient's further evaluation and it resolved 2 weeks into treatment. The patient is currently 18 months old and her development and neurological examination remain unremarkable. Neonatal cholestasis as first presentation of hyperargininemia is rare, but this disorder should be included in the differential diagnosis of unexplained cholestasis in the neonate. In fact, these two cases suggest that arginase deficiency may be the cause of cholestatic liver disease.

Perinatal cytomegalovirus hepatitis: to treat or not to treat with ganciclovir

OBJECTIVE

The use on ganciclovir for perinatal cytomegalovirus (CMV) infection is controversial. We aim to evaluate the use of ganciclovir treatment for neonatal CMV hepatitis.

METHODS

We present five infants with perinatally-acquired CMV hepatitis as a single organ manifestation of CMV infection. The three more severely affected children, i.e. those with cholestasis and elevation of serum hepatic enzymes to more than twice the normal values, were treated for 15 days with intravenous ganciclovir.

RESULTS

The three treated infants improved clinically and CMV DNA in the blood disappeared during treatment. After cessation of ganciclovir treatment all of the patients had a relapse of the infection. The two untreated patients recovered completely.

CONCLUSION

The long-term outcome of infants with CMV hepatitis is unpredictable. Some patients have persistent liver injury despite ganciclovir therapy. Ganciclovir therapy did not prevent chronic liver disease in any of the patients in our study. Owing to the possible serious side-effects the cost-benefit of ganciclovir treatment should be carefully evaluated.

Triangular cord sign and ultrasound features of the gall bladder in infants with biliary atresia

The aim of this study was to reassess the accuracy of the triangular cord sign, the triangular cord sign coupled with abnormal gall-bladder length, and an irregular gall-bladder wall in the diagnosis of biliary atresia. The ultrasonograms of 46 infants with cholestatic jaundice were reviewed for the triangular cord sign, gall-bladder length and gall-bladder wall without knowledge of the clinical data. Of the 23 infants with biliary atresia, 22 had the triangular cord sign whereas 17 infants with other causes of cholestatic jaundice did not have the triangular cord sign. The sensitivity, specificity, accuracy and positive predictive value of the triangular cord sign in the diagnosis of biliary atresia were 95.7, 73.9, 84.8 and 78.6%, respectively. The sensitivity, specificity, accuracy and positive predictive value of the triangular cord sign coupled with abnormal gall-bladder length in the diagnosis of biliary atresia were all 95.7%. Gall-bladder wall irregularity was seen in seven of 14 infants (50%) with biliary atresia whose gall bladders contained bile on ultrasound and in two of 22 infants (9.1%) without biliary atresia whose gall bladders contained bile on ultrasound. At the medical centre where this study was performed and where infants present with cholestatic jaundice at an advanced stage, the ultrasonographic triangular cord sign coupled with abnormal gall-bladder length is more reliable than the ultrasonographic triangular cord sign alone or gall-bladder wall irregularity in the diagnosis of biliary atresia.

A novel inborn error of metabolism detected by elevated methionine and/or galactose in newborn screening: neonatal intrahepatic cholestasis caused by citrin deficiency

Adult-onset type II citrullinaemia, caused by deficiency of the citrin protein encoded by the SLC25A13 gene, is characterised by a liver-specific argininosuccinate synthetase deficiency. DNA analysis for citrin deficiency revealed that SLC25A13 mutations are the cause of a particular type of neonatal intrahepatic cholestasis. We retrospectively investigated nine infants with cholestatic jaundice of unknown origin, detected by newborn screening over a period of 17 years, to determine the role of SLC25A13 defects in children. The results of the newborn screening were varied; four neonates were positive for hypermethioninaemia, two for hyperphenylalaninaemia, one for hypergalactosaemia and two for both hypermethioninaemia and hypergalactosaemia. Clinical characteristics of the patients were severe intrahepatic cholestasis, hypercitrullinaemia, and fatty liver. The symptoms resolved in all patients by 12 months of age without special treatment other than nutritional management. Although five patients were lost to follow-up, we detected SLC25A13 mutations in the remaining four patients examined.

CONCLUSION

the differential diagnosis of cholestatic jaundice of unknown origin in infants should therefore include citrin deficiency. In this paper, we stress the importance of newborn screening to detect infants with neonatal intrahepatic cholestasis caused by citrin deficiency.

Diagnostic laparoscopy in prolonged jaundice

BACKGROUND

The early diagnosis of surgical jaundice in a neonate is an important step for the surgical success in extrahepatic biliary atresia. Diagnostic laparoscopy, as in many areas in surgery, is included in the conventional diagnostic methods of extrahepatic biliary atresia.

METHODS

Since 1992, 24 infants with prolonged jaundice, in whom extrahepatic biliary atresia and neonatal hepatitis could not be differentiated with conventional diagnostic interventions, have been evaluated laparoscopically.

RESULTS

A coarse, irregular, greenish-brown liver with some degree of fine angiomatous development and an atretic gallbladder are the findings of laparoscopic evaluation in an infant with extrahepatic biliary atresia. However, in neonatal hepatitis, the liver is smooth, sharp-edged, and chocolate brown in color, and simultaneously performed cholangiography should show the passage of the contrast material both into the proximal biliary tracts and the intestinal system. In this series, 10 of 24 cases were proved to be neonatal hepatitis diagnosed by laparoscopy, so unnecessary laparotomy was avoided in 42% of the cases.

CONCLUSION

When the diagnostic laparoscopy, in which the liver and the gallbladder are directly visualized, is combined with the cholangiographic examination, the most accurate and earlier diagnosis in an infant with prolonged jaundice can be achieved, and the important period of time for the surgical success in extrahepatic biliary atresia will be minimally wasted.

Anaesthesia, perioperative management and outcome of correction of extrahepatic biliary atresia in the infant: a review of 50 cases in the King's College Hospital series

Extrahepatic biliary atresia (EHBA) is an uncommon condition presenting in the first few weeks of life. It has an incidence of 0. 5-1 per 10 000 live births and is the end result of a destructive inflammatory process involving the extrahepatic biliary system of unknown aetiology occurring in utero. The net result is neonatal jaundice due to bile stasis, with subsequent hepatocellular damage and cirrhosis. In the untreated, patient death is inevitable within 2 years. Precise diagnosis (or exclusion) of EHBA in the persistently jaundiced infant must be made urgently and major surgery (hepatic portoenterostomy: Kasai procedure) carried out as soon as possible, preferably before 6-8 weeks of age. This review is concerned with anaesthesia for correction of EHBA in 50 consecutive patients and also outlines the experience gained in the largest European centre for correction of EHBA where the number of cases now approaches 500.

Neonatal jaundice: the role of laparoscopy

BACKGROUND

When managing neonatal jaundice, despite continual improvement of diagnostic tests and increasing knowledge regarding its pathogenesis, there is no single test or imaging modality that can reliably define biliary atresia. Early diagnosis is essential for a better surgical outcome. In many situations, mini-laparotomy and operative cholangiography may be needed to settle the definitive diagnosis, with the risk of having negative exploration in those high-risk patients with medical etiology. The use of laparoscopy may help in avoiding unnecessary exploration for such group of patients.

METHODS

Thirty-three patients aged between 1 and 4 months with conjugated hyperbilirubinemia were the subject for this study. All had a HIDA scan result suggestive of biliary atresia. They underwent a diagnostic laparoscopy before surgical exploration. When the gallbladder was not visualized we proceeded to laparotomy. In patients with a good size gallbladder visualized at laparoscopy, a laparoscopic-guided cholangiogram was then performed, and laparoscopic liver biopsy done for those who had patent biliary tree.

RESULTS

Two groups of patients were identified: the first group (21 patients) showed small atretic gallbladder; 18 patients had biliary atresia with complete intra- and extrahepatic atresia; these patients underwent a Kasai hepatic-portoenterostomy. Two patients showed a patent gallbladder and common bile duct with atresia of the common hepatic and intrahepatic ducts, and they underwent a portocholecystostomy. The last patient showed left-sided gallbladder arising from the left lobe of the liver that was missed during laparoscopy, and operative cholangiogram showed hypoplastic biliary ducts. The second group included 12 patients with good-sized gallbladder, and laparoscopic-guided percutaneous cholangiogram showed normal communicating patent biliary system, hypoplastic in 2, and they underwent laparoscopic liver biopsy. No mortality related to the laparoscopic procedure was encountered in this series, and one patient with hypoplastic gallbladder had adhesive intestinal obstruction on the fifth day after laparoscopy necessitating exploration.

CONCLUSION

Laparoscopy with laparoscopic-guided cholangiography may be a very useful tool used in accurately diagnosing infants with conjugated hyperbilirubinemia, and in avoiding unnecessary laparotomies performed on these critical babies.

Demonstration of McCune-Albright mutations in the liver of children with high gammaGT progressive cholestasis

Two patients presented with neonatal cholestasis and acholic stools as first manifestations of McCune-Albright syndrome. Both went through an extensive evaluation including an exploratory laparotomy with peroperative cholangiography which ruled out biliary atresia. One patient presented from the fourth month of life with the classical café-au-lait spots following Blaschko's lines, while less classical café-au-lait spots were seen in the second patient at the age of 4 years. Bone lesions were seen in one patient at the age of 2.5 years and in the other at the age of 4 years. Despite the severity of presentation, both patients cleared their jaundice within 6 months, but still had mild abnormalities of liver function tests. Both patients showed an activating mutation of codon 201 in the gene encoding the alpha-subunit of the G-protein that stimulates adenylcyclase in liver tissue, suggesting that this metabolic defect could be responsible for the cholestatic syndrome. Similar mutations have been found in other affected tissues in patients with the McCune-Albright syndrome. We propose that McCune-Albright syndrome be included in the list for differential diagnosis of neonatal cholestasis and chronic cholestasis of infancy, as a rare cause.

A new diagnostic approach to biliary atresia with emphasis on the ultrasonographic triangular cord sign: comparison of ultrasonography, hepatobiliary scintigraphy, and liver needle biopsy in the evaluation of infantile cholestasis

BACKGROUND/PURPOSE

The authors evaluated prospectively the utility of ultrasonography, Tc-99m-DISIDA hepatobiliary scintigraphy, and liver needle biopsy in differentiating biliary atresia (BA) from intrahepatic cholestasis in 73 consecutive infants who had cholestasis.

METHODS

Sixty three ultrasonographic examinations of 61 infants with 7.0-MHz transducer were carried out, focusing on the fibrous tissue at the porta hepatis. The authors defined the triangular cord (TC) as visualization of a triangular or tubular shaped echogenic density just cranial to the portal vein bifurcation on a transverse or longitudinal scan.

RESULTS

Although 17 of 20 ultrasonographic examinations from infants who had BA denoted TC, 43 ultrasonographic examinations from infants with either neonatal hepatitis (NH) or other causes of cholestasis denoted no TC, showing a diagnostic accuracy of 95% with 85% sensitivity and 100% specificity. Investigation with Tc-99m-DISIDA hepatobiliary scintigraphy showed that 24 of 25 infants who had BA had no gut excretion, and 16 of 46 infants who had either NH or other causes of cholestasis had gut excretion, showing a diagnostic accuracy of 56% with 96% sensitivity and 35% specificity. Therefore, gut excretion of tracer excluded BA, but no gut excretion of tracer needed further investigations as liver needle biopsy. Forty-four liver needle biopsies were carried out in 19 infants who had BA and 24 infants who had either NH or other causes of cholestasis. Although 18 of 20 biopsy findings in infants who had BA were correctly interpreted as having BA, 23 of 24 biopsy results in infants who had either NH or other causes of cholestasis were correctly diagnosed, showing a diagnostic accuracy of 93% with 90% sensitivity and 96% specificity.

CONCLUSIONS

Since the introduction of ultrasonographic TC sign in the diagnosis of BA by our institution, we have found that it seemed to be a simple, time-saving, highly reliable, and non-invasive tool in the diagnosis of BA from other causes of cholestasis. The authors propose a new diagnostic strategy in the evaluation of infantile cholestasis with emphasis on ultrasonographic TC sign as first priority of investigations. When the TC is visualized, prompt exploratory laparotomy is mandatory without further investigations. When the TC is not visualized, hepatobiliary scintigraphy is the next step. Excretion of tracer into the small bowel actually rules out BA. Liver needle biopsy is reserved only for the infants with no excretion of tracer. The authors believe that a correct decision regarding the need for surgery can be made in almost all cases with infantile cholestasis by this multidisciplinary approach.