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Ramaswamy PK, Jana M, Sharma R, Kandasamy D, Gupta AK, Bhatnagar V, Agarwala S, Malik R, Das P, Gupta SD. Novel Scoring Systems and Age-Based Hepatic Shear Wave Stiffness Cut-Offs for Improving Sonographic Diagnosis of Biliary Atresia. Indian J Pediatr 2024; 91:667-674. [PMID: 37380918 DOI: 10.1007/s12098-023-04607-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 03/17/2023] [Indexed: 06/30/2023]
Abstract
OBJECTIVES To make sonographic evaluation for biliary atresia (BA) more objective and reproducible using scoring systems, and evaluate hepatic shear wave elastography (SWE) as an adjunct in sonographic diagnosis of BA. METHODS Sixty-four infants with cholestatic jaundice were enrolled between June 2016 and March 2018 in this prospective observational cohort study. Sonography and SWE was performed with SuperSonic Aixplorer system. Novel scoring systems were developed incorporating established sonographic parameters and hepatic stiffness values and analysed using SPSS software. RESULTS Of the 18 patients confirmed as BA, 3 were misdiagnosed on conventional sonography (16.7%) as non-BA. Gall bladder (GB) wall irregularity and fasting GB length were the most accurate (93.8%) and most specific (97.8%) individual parameters, respectively. A significant difference was noted in the triangular cord (TC) thickness of BA and non-BA infants (p <0.001), with a high specificity of 95.6% for a 4 mm cut-off value for a positive TC sign. Comparison of hepatic SWE stiffness among age-matched groups of BA and non-BA showed significant differences (≤60 d: p = 0.003; >60 d: p <0.001) but with a reduced accuracy (93.8%). Diagnostic accuracy of greyscale scoring system (96.9%), greyscale + elastography scoring system in ≤60 d (94.4%) and >60 d (97.8%) were better than that of conventional sonographic diagnosis (93.8%). CONCLUSIONS Grey scale scoring system improves the accuracy of sonographic diagnosis of BA without any additional cost or time penalty along with making it universally reproducible. SWE has only an adjunctive role, if any, in the sonographic diagnosis of BA.
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Affiliation(s)
- Praveen Kesav Ramaswamy
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Manisha Jana
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India.
| | - Raju Sharma
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Devasenathipathy Kandasamy
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Arun Kumar Gupta
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Veereshwar Bhatnagar
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Sandeep Agarwala
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Rohan Malik
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Prasenjit Das
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
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Menon J, Shanmugam NP. Nutrition in Pediatric Liver Disease. Indian J Pediatr 2024; 91:366-373. [PMID: 38324201 DOI: 10.1007/s12098-024-05036-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 01/11/2024] [Indexed: 02/08/2024]
Abstract
In liver disease, there is derangement of appetite, digestion, absorption, assimilation, storage and metabolism of both macro and micronutrients. These derangements have an impact on mortality and morbidity associated with liver diseases. In infants, breast feeds should not be stopped unless there are compelling reasons such as underlying metabolic problem. Parenteral nutrition should be considered only if, oral or nasogastric feeding is not possible. The effect of malnutrition on liver disease and impact of liver failure on nutrition is vicious and nutritional intervention has to be done at the earliest to break that vicious cycle. This chapter gives an overview of nutritional management in acute and chronic liver diseases in children and also its impact on specific clinical scenarios including liver transplantation.
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Affiliation(s)
- Jagadeesh Menon
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Dr Rela Institute & Medical Centre, Bharath Institute of Higher Education and Research, Chennai, India
| | - Naresh P Shanmugam
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Dr Rela Institute & Medical Centre, Bharath Institute of Higher Education and Research, Chennai, India.
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Chen F, Huang Y, Huang Z, Fang F, Zhou H, Shu S. The epidemiological characteristics of liver disease in hospitalized children: a 10-year single-center retrospective study. Front Pediatr 2024; 12:1344714. [PMID: 38510075 PMCID: PMC10950907 DOI: 10.3389/fped.2024.1344714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 02/26/2024] [Indexed: 03/22/2024] Open
Abstract
Background This investigation aimed to examine the epidemiological characteristics of children with liver disease hospitalized for the first time between June 2012 and May 2022 in a tertiary hospital. Methods The study retrospectively recruited children aged between 29 days and 18 years who had been hospitalized for liver disease. Clinical characteristics were categorized by age and etiology, and time trends were assessed using linear regression analysis. Results A total of 4,313 children were recruited, with a median age of 0.7 (0.2-4.5) years, and 54.5% of the cases were in the 0-1 years age group. Infection was the primary cause of liver disease (30.0%), followed by undiagnosed cases (25.8%), biliary obstructive disease (15.9%), inherited metabolic liver disease (13.9%), and non-alcoholic fatty liver disease (NAFLD) (3.2%). Genetic diagnoses were established in 43.9% (478/1,088) of patients. The percentage of NAFLD demonstrated an upward trend from 1.2% in 2012 to 12.6% in 2022 (p = 0.006). In contrast, the percentage of cytomegalovirus hepatitis decreased from 13.3% in 2012 to 3.4% in 2022 (p = 0.002). Conclusions Liver disease in infancy makes up the largest group in pediatric liver disease. Infection remains the leading cause of pediatric liver disease. Hospital admissions for NAFLD in children have increased rapidly over the past decade, while cytomegalovirus hepatitis has declined markedly.
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Affiliation(s)
| | | | | | | | | | - Sainan Shu
- Department of Pediatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Beati F, Mosca A, Pietrobattista A, Liccardo D, Ronci S, Monti L, Francalanci P, Spada M, Maggiore G, Bagolan P, Fusaro F. Biliary atresia in preterm infants: a single center experience and review of literature. Front Surg 2024; 11:1353424. [PMID: 38496210 PMCID: PMC10940420 DOI: 10.3389/fsurg.2024.1353424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 02/19/2024] [Indexed: 03/19/2024] Open
Abstract
Introduction The diagnosis of biliary atresia (BA) remains challenging, and there is still uncertainty regarding the optimal time to perform a Kasai portoenterostomy (KPE). Little is known about the difficulties in the diagnosis and outcomes of BA in preterm infants (PBA). This study, which represents the first Italian report of preterm infants with BA, aims to describe a single-center experience of BA in preterm newborns. Methods We retrospectively reviewed all infants consecutively diagnosed with BA who underwent a Kasai procedure at the Bambino Gesù Children's Hospital between January 1998 and December 2021. Prematurity was defined as a gestational age (GA) of <37 weeks. Demographic, laboratory, and histology data were recorded, and the main outcomes considered were clearance of jaundice (COJ), native liver survival, and mortality. Results A total of 21 PBA were compared with 117 term BA controls (TBA). The median GA of PBA was 35.1 (32-36.1) weeks, with a mean birth weight of 2,100 (1,897-2,800) g. Age at first presentation was significantly lower in PBA patients: 46 (22-68) vs. 61 (44-72) days; p = 0.02. The median age at KPE was similar between the two groups: 70 days (33 corrected) for PBA vs. 67 in TBA; p = 0.8. At the time of surgery, median serum bilirubin was lower in the PBA group (7.7 vs. 8.6 mg/dl, p = 0.04). Similarly, the median APRi at the time of KPE was lower but not significant in the PBA group: 1.09 vs. 1.16; p = 0.8. No differences were found in terms of COJ between the PBA and TBA groups: n = 9 (43%) vs. 34 (35%); p = 0.2. Overall native liver survival was similar between the two groups: 8.6 (4.8-12.2) for the PBA group vs. 7.6 (5.6-9.5) years for the TBA group with no significant differences; p = 0.45. Post-KPE native liver survival was similar between the two groups: 38% vs. 52% at 5 years for the TBA and PBA groups, respectively; p = 0.54. Conclusion The PBA and TBA groups appear to have similar outcomes in terms of COJ, overall native liver survival, and 5-year liver survival. Considering the corrected GA, early KPE is related to lower cholestatic damage. Further multicenter studies are required.
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Affiliation(s)
- Federico Beati
- Neonatal Surgery Unit, Area of Fetal, Neonatal and Cardiological Sciences, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Antonella Mosca
- Hepatogastroenterology and Liver Transplant Unit and Medical Genetics Laboratory, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Andrea Pietrobattista
- Hepatogastroenterology and Liver Transplant Unit and Medical Genetics Laboratory, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Daniela Liccardo
- Hepatogastroenterology and Liver Transplant Unit and Medical Genetics Laboratory, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Sara Ronci
- Neonatal Surgery Unit, Area of Fetal, Neonatal and Cardiological Sciences, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Lidia Monti
- Department of Radiology, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Paola Francalanci
- Pathology Unit, Department of Diagnostic and Laboratory Medicine, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Marco Spada
- Division of Abdominal Transplantation and Hepato-Bilio-Pancreatic Surgery Unit, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Giuseppe Maggiore
- Hepatogastroenterology and Liver Transplant Unit and Medical Genetics Laboratory, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Pietro Bagolan
- Neonatal Surgery Unit, Area of Fetal, Neonatal and Cardiological Sciences, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
- Department of Systems Medicine, University of Tor Vergata, Rome, Italy
| | - Fabio Fusaro
- Neonatal Surgery Unit, Area of Fetal, Neonatal and Cardiological Sciences, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
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El Raichani N, Thibault M, Alvarez F, Lavoie JC, Mohamed I. The effects of gestational age on neonatal cholestasis: A retrospective cohort study. J Neonatal Perinatal Med 2024; 17:101-110. [PMID: 38251066 DOI: 10.3233/npm-230034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
BACKGROUND Reference guidelines for neonatal conjugated hyperbilirubinemia (cholestasis) management use a uniform approach regardless of gestational age (GA). We hypothesize that the clinical pattern of neonatal cholestasis is tightly related to GA. The aim of this study was to describe the effects of GA on neonatal cholestasis. METHODS A retrospective 4-year cohort study in a 70-bed neonatal care unit. Neonates with conjugated bilirubin≥34.2μmol/L (2 mg/dL) were identified. The incidence, clinical characteristics, etiology, treatment, and prognosis were compared between infants <32 and≥32 weeks GA. RESULTS Overall incidence of cholestasis was 4% (125/3402). It was >5 times higher and the mean duration was >1.5 times longer in neonates <32 weeks GA (10% versus 1.8%, p <0.01 and 49 versus 31 days, p <0.01, respectively). The onset of cholestasis was later in neonates <32 weeks (22 versus 10 days of life, p <0.001). This later onset of cholestasis was associated with parenteral nutrition, whereas the earlier onset was associated with other causes. Treatment using fish oil lipids was more frequently administrated to infants <32 weeks GA, whereas Ursodeoxycholic acid was administrated more frequently in≥32 weeks GA. Cholestasis resolved during hospitalization in 73% of <32 versus 38% in≥32 weeks GA infants (p <0.01). CONCLUSIONS The incidence, clinical presentation, etiology, treatment, and clinical evolution of neonatal cholestasis were all significantly affected by GA. Our results support the use of a GA-oriented approach for the management of neonatal cholestasis.
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Affiliation(s)
- N El Raichani
- Department of Nutrition, University of Montreal, Montreal, QC, Canada
| | - M Thibault
- Department of Pharmacy, CHU Sainte-Justine, Montreal, QC, Canada
| | - F Alvarez
- Department of Pediatrics-Gastroenterology, Hepatology and Nutrition, CHU Sainte-Justine, University of Montreal, Montreal, QC, Canada
| | - J-C Lavoie
- Department of Nutrition, University of Montreal, Montreal, QC, Canada
- Departments of Pediatrics-Neonatology, CHU Sainte-Justine, University of Montreal, Montreal, QC, Canada
| | - I Mohamed
- Department of Nutrition, University of Montreal, Montreal, QC, Canada
- Departments of Pediatrics-Neonatology, CHU Sainte-Justine, University of Montreal, Montreal, QC, Canada
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Gong Z, Lin L, Lu G, Wan C. Development and validation of a model for early diagnosis of biliary atresia. BMC Pediatr 2023; 23:549. [PMID: 37907911 PMCID: PMC10617173 DOI: 10.1186/s12887-023-04370-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 10/06/2023] [Indexed: 11/02/2023] Open
Abstract
BACKGROUND AND AIMS Early diagnosis of biliary atresia (BA), particularly distinguishing it from other causes of neonatal cholestasis (NC), is challenging. This study aimed to design and validate a predictive model for BA by using the data available at the initial presentation. METHODS Infants presenting with NC were retrospectively identified from tertiary referral hospitals and constituted the model design cohort (n = 148); others were enrolled in a prospective observational study and constituted the validation cohort (n = 21). Clinical, laboratory, and abdominal ultrasonographic features associated with BA were assessed. A prediction model was developed using logistic regression and decision tree (DT) analyses. RESULTS Three predictors, namely, gamma glutamyl transpeptidase (γGT) level, triangular cord sign (TC sign), and gallbladder abnormalities, were identified as factors for diagnosing BA in multivariate logistic regression, which was used to develop the DT model. The area under the receiver operating characteristic (ROC) curve (AUC) value for the model was 0.905, which was greater than those for γGT level, TC sign, or gallbladder abnormalities alone in the prediction of BA. CONCLUSION A simple prediction model combining liver function and abdominal ultrasonography findings can provide a moderate and early estimate of the risk of BA in patients with NC.
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Affiliation(s)
- Zongrong Gong
- Department of Pediatrics, West China Second Hospital, Sichuan University and Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, No 20, 3rd Section of Renmin South Road, Chengdu, 610041, People's Republic of China
- Department of Respiration, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510623, China
| | - Lin Lin
- Department of Respiration, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510623, China
| | - Gen Lu
- Department of Respiration, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510623, China
| | - Chaomin Wan
- Department of Pediatrics, West China Second Hospital, Sichuan University and Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, No 20, 3rd Section of Renmin South Road, Chengdu, 610041, People's Republic of China.
- Department of Pediatric Infectious Disease, West China Women's and Children's Hospital, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Second University Hospital, Sichuan University, Ministry of Education, No 20, 3rd section of Renmin South Road, 610041, Chengdu, P.R. China.
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Sun W, Zhang X, Su H, Wang X, Qin F, Gong X, Wang B, Yu F. Genetic and clinical features of patients with intrahepatic cholestasis caused by citrin deficiency. J Pediatr Endocrinol Metab 2023:jpem-2022-0616. [PMID: 37146272 DOI: 10.1515/jpem-2022-0616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 04/17/2023] [Indexed: 05/07/2023]
Abstract
OBJECTIVES Citrin deficiency (CD) is an autosomal recessive disease caused by mutations of the SLC25A13 gene, plasma bile acid profiles detected by liquid chromatography-tandem mass spectrometry (LC-MS/MS) could be an efficient approach for early diagnosis of intrahepatic cholestasis. The aim of this study was to investigate the genetic testing and clinical characteristics of a series of patients with CD, and to analyse plasma bile acid profiles in CD patients. METHODS We retrospectively analysed data from 14 patients (12 males and 2 females, age 1-18 months, mean 3.6 months) with CD between 2015 and 2021, including demographics, biochemical parameters, genetic test results, treatment, and clinical outcomes. In addition, 30 cases (15 males and 15 females, age 1-20 months, mean 3.8 months) with idiopathic cholestasis (IC) served as a control group. Plasma 15 bile acid profiles were compared between the CD and IC groups. RESULTS Eight different mutations of the SLC25A13 gene were detected in the 14 patients diagnosed with CD, of which three novel variants of the SLC25A13 gene were investigated, the c.1043C>T (p.P348L) in exon11, the c.1216dupG (p.A406 Gfs*13) in exon12 and the c.135G>C (p.L45F) in exon3. More than half of the patients with CD had prolonged neonatal jaundice, which was associated with significantly higher alpha-fetoprotein (AFP) levels, hyperlactatemia and hypoglycemia. The majority of patients were ultimately self-limited. Only one patient developed liver failure and died at the age of 1 year due to abnormal coagulation function. In addition, the levels of glycochenodeoxycholic acid (GCDCA), taurocholate (TCA), and taurochenodeoxycholic acid (TCDCA) were significantly increased in the CD group compared with those in the IC group. CONCLUSIONS Three novel variants of the SLC25A13 gene were identified for the first time, providing a reliable molecular reference and expanding the SLC25A13 gene spectrum in patients with CD. Plasma bile acid profiles could be a potential biomarker for non-invasive early diagnosis of patients with intrahepatic cholestasis caused by CD.
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Affiliation(s)
- Wenjun Sun
- Department of Endocrine Genetic Metabolism in Children, Maternal and Child Health Hospital of Hubei Province, Wuhan, China
| | - Xiaoxi Zhang
- Department of Urology, Tian You Hospital Affiliated to Wuhan University of Science & Technology, Wuhan, China
| | - Hang Su
- Department of Endocrine Genetic Metabolism in Children, Maternal and Child Health Hospital of Hubei Province, Wuhan, China
| | - Xiaoxia Wang
- Department of Endocrine Genetic Metabolism in Children, Maternal and Child Health Hospital of Hubei Province, Wuhan, China
| | - Fang Qin
- Department of Endocrine Genetic Metabolism in Children, Maternal and Child Health Hospital of Hubei Province, Wuhan, China
| | - Xiangling Gong
- Department of Endocrine Genetic Metabolism in Children, Maternal and Child Health Hospital of Hubei Province, Wuhan, China
| | - Bo Wang
- Medical Genetics Center, Maternal and Child Health Hospital of Hubei Province, Wuhan, China
| | - Fei Yu
- Department of Endocrine Genetic Metabolism in Children, Maternal and Child Health Hospital of Hubei Province, Wuhan, China
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He Y, Gao W, Li Y, Xu C, Wang Q. A single-center, retrospective analysis of 17 cases of hemolytic disease of the fetus and newborn caused by anti-M antibodies. Transfusion 2023; 63:494-506. [PMID: 36727659 DOI: 10.1111/trf.17249] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 12/27/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE We aimed to summarize the laboratory findings and clinical features of hemolytic disease of the fetus and newborn (HDFN). METHODS We retrospectively analyzed the data for 17 infants with anti-M-induced HDFN (anti-M-HDFN) diagnosed between June 2013 and May 2019. Their maternal history, neonatal diagnosis on admission, and laboratory test results were compared with those of 15 infants with HDFN involving the ABO blood group system, 15 infants with HDFN involving the Rh system, and 15 premature infants. RESULTS In the anti-M-HDFN group, 94.12% (16/17), 35.29% (6/17), and 17.65% (3/17) had free antibodies in plasma, a positive direct antiglobulin test, and a positive elution test, respectively. In 12 infants, free antibody reactions were stronger at 4°C than at 37°C, and the antibody titer at 4°C ranged from 1 to 512. All 17 infants with anti-M-HDFN developed anemia: 14 were treated with blood transfusion and 1 with neonatal exchange transfusion. Sixteen infants improved, and one died. Anti-M-HDFN had a higher rate of maternal stillbirth, lower gestational age, lower birthweight, and higher incidence of respiratory distress than other HDFN types. CONCLUSION Anti-M may cause HDFN. It may present with varying degrees of anemia, low regenerative anemia, and low bilirubin levels. In addition, infants with anti-M-HDFN may have a negative elution test and direct antiglobulin test. These tests are helpful in examining antibody responses at a low temperature of 4°C.
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Affiliation(s)
- Yanjing He
- Department of Blood Transfusion, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Wa Gao
- Department of Blood Transfusion, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Yang Li
- Department of Blood Transfusion, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Chang Xu
- Department of Blood Transfusion, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Qiushi Wang
- Department of Blood Transfusion, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
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Ye ZT, Kuo HC, Tseng SF, Chung SR, Tsou SX. Using Blue Mini-LEDs as a Light Source Designed a Miniaturized Optomechanical Device for the Detection of Direct Bilirubin. NANOSCALE RESEARCH LETTERS 2022; 17:111. [PMID: 36417033 PMCID: PMC9684399 DOI: 10.1186/s11671-022-03750-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 11/15/2022] [Indexed: 05/30/2023]
Abstract
This study developed a miniaturized optomechanical device (MOD) for the feasibility study of direct bilirubin in urine using high-collimation blue mini-light-emitting diodes (Mini-LEDs) as the light source. The constructed MOD used optical spectroscopy to analyze different concentrations of direct bilirubin using the absorbance spectrum to achieve a noninvasive method for detection. The experimental results showed that between the absorbance and different concentrations of direct bilirubin at the blue Mini-LEDs central wavelength (462 nm) was the optimum fitting wavelength; in the direct bilirubin concentration range from 0.855 to 17.1 μmol/L, the coefficient of determination (R2) was 0.9999, the limit of detection (LOD) of 0.171 μmol/L, and the limit of quantitation (LOQ) of 0.570 μmol/L. Therefore, we propose using blue Mini-LEDs as a light source to design a MOD to replace the invasive blood sampling method with a spectroscopic detection of direct bilirubin concentration corresponding to absorbance.
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Affiliation(s)
- Zhi Ting Ye
- Department of Mechanical Engineering, Advanced Institute of Manufacturing with High-Tech Innovations, National Chung Cheng University, 168, University Rd., Min-Hsiung, Chia-Yi, 62102 Taiwan, ROC
| | - Hsin-Ching Kuo
- Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chia-Yi, Taiwan, ROC
| | - Shen Fu Tseng
- Department of Mechanical Engineering, Advanced Institute of Manufacturing with High-Tech Innovations, National Chung Cheng University, 168, University Rd., Min-Hsiung, Chia-Yi, 62102 Taiwan, ROC
| | - Shu-Ru Chung
- Department of Materials Science and Engineering, National Formosa University, No. 64, Wunhua Rd., Huwei Township, 632 Yunlin County Taiwan, ROC
| | - Shang-Xuan Tsou
- Department of Mechanical Engineering, Advanced Institute of Manufacturing with High-Tech Innovations, National Chung Cheng University, 168, University Rd., Min-Hsiung, Chia-Yi, 62102 Taiwan, ROC
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Dong B, Weng Z, Lyu G, Yang X, Wang H. The diagnostic performance of ultrasound elastography for biliary atresia: A meta-analysis. Front Public Health 2022; 10:973125. [PMID: 36388297 PMCID: PMC9643747 DOI: 10.3389/fpubh.2022.973125] [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: 06/19/2022] [Accepted: 10/07/2022] [Indexed: 01/25/2023] Open
Abstract
Background Biliary atresia (BA) is a severe inflammatory obliterative cholangiopathy of infancy that requires early diagnosis and prompt surgical intervention. In this study, we aimed to obtain comprehensive evidence on the diagnostic performance of liver stiffness measurement by ultrasound elastography in the detection of BA through a meta-analysis. Methods The PubMed, EMBASE, Cochrane Library, and Web of Science databases were searched for studies that investigated the diagnostic performance of ultrasound elastography in the detection of BA up to January 10, 2022. In this study, in order to summarize the diagnostic performance of ultrasound elastography, the summary receiver operating characteristic (SROC) modeling was constructed. Heterogeneity was estimated with the I 2 statistic. Multiple subgroup analyses were also performed. Results Fourteen studies from eleven articles, including 774 BA patients, 850 non-BA patients, and 173 controls were included in the present meta-analysis. The summary sensitivity and specificity of ultrasound elastography for liver stiffness were 85% [95% confidence interval (CI): 79-89%] and 82% (95% CI: 73-88%) with the I 2 value of 82.90 and 84.33%, respectively. The area under the SROC curve (AUROC) using ultrasound elastography for diagnosing BA was 0.90 (95% CI: 0.87-0.92). In addition, a subgroup analysis of 9 two-dimensional shear wave elastography studies was also performed. Subgroup analysis revealed that the summary sensitivity and specificity were 85% (95% CI: 77-91%) and 79% (95% CI: 71-86%), respectively, and the summary AUROC was 0.89 (95% CI: 0.86-0.92). Conclusions Ultrasound elastography exhibits good diagnostic accuracy for BA and can be served as a non-invasive tool to facilitate the differential diagnosis of BA.
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Affiliation(s)
- Bingtian Dong
- Department of Ultrasound, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Zongjie Weng
- Department of Medical Ultrasonics, Fujian Provincial Maternity and Children's Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Guorong Lyu
- Department of Ultrasound, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China,Collaborative Innovation Center for Maternal and Infant Health Service Application Technology, Quanzhou Medical College, Quanzhou, China,*Correspondence: Guorong Lyu
| | - Xiaocen Yang
- Department of Ultrasound, Chenggong Hospital, Xiamen University, Xiamen, China
| | - Huaming Wang
- Department of Ultrasound, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
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Liao FM, Chang KC, Wu JF, Chen HL, Ni YH, Chang MH. Direct Bilirubin and Risk of Biliary Atresia. Pediatrics 2022; 149:186994. [PMID: 35506333 DOI: 10.1542/peds.2021-053073] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/14/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Early detection of biliary atresia (BA) is important for optimal treatment. Direct bilirubin (D-bil) levels are used for BA screening. In this study, we aimed to determine the sensitivity and specificity of elevated D-bil and the direct-to-total bilirubin (D/T) ratio for BA detection in high-risk infants. METHODS This retrospective, cross-sectional study was conducted in a tertiary medical center in Taiwan. Infants indicated for total bilirubin and D-bil measurements before age 60 days were included. The first bilirubin assessment was considered the test point. BA diagnosis was based on International Classification of Diseases, Ninth and Tenth Revision, codes 751.61 and Q44.0 to Q44.3, respectively. RESULTS Between January 2009 and December 2016, 4468 infants were enrolled, including 38 with BA. Among infants aged 3 to 60 days, a sensitivity of 100% (95% confidence interval, 90.3-100.0) was found for D-bil ≥1.0 mg/dL and either D-bil ≥1.0 mg/dL or D/T ratio ≥20%. However, D-bil ≥1.0 mg/dL had higher specificity (77.3% [76.0-78.5] vs 68.3% [66.8-69.7], respectively). In newborns aged <3 days, D-bil ≥0.5 mg/dL was considered a positive result, with a sensitivity of 50%. D-bil >0.45 mg/dL was a better cutoff point in receiver operating characteristic analysis, with a sensitivity and specificity of 100% (95% CI: 15.8-100) and 15.4% (95% CI, 11.8-19.7), respectively. CONCLUSIONS D-bil ≥1.0 mg/dL was better for BA detection than the D/T ratio in infants aged 3 to 60 days. For newborns aged <3 days, a more definitive cutoff point is required.
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Affiliation(s)
- Fang-Min Liao
- Department of Pediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan.,Department of Pediatrics, Saint Paul's Hospital, Taoyuan, Taiwan
| | - Kai-Chi Chang
- Department of Pediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan
| | - Jia-Feng Wu
- Department of Pediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan
| | - Huey-Ling Chen
- Department of Pediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan.,Department of Medical Education and Bioethics, National Taiwan University College of Medicine, Taipei, Taiwan.,Hepatitis Research Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Yen-Hsuan Ni
- Department of Pediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan.,Hepatitis Research Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Mei-Hwei Chang
- Department of Pediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan.,Hepatitis Research Center, National Taiwan University Hospital, Taipei, Taiwan
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12
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Mittal A, Kahlam A, Le A, Ahlawat S, Monteiro IM. Hospital Utilization, Treatment Modalities, and Mortality Using Different Biopsy Methods in Infants With Biliary Atresia. Cureus 2022; 14:e24726. [PMID: 35676980 PMCID: PMC9166456 DOI: 10.7759/cureus.24726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2022] [Indexed: 11/24/2022] Open
Abstract
Objectives To present a nationwide retrospective analysis of the sequelae and aftereffects of different liver biopsy methods in the care of pediatric patients with biliary atresia. Methods The National Inpatient Sample 2001-2013 database was queried for a primary diagnosis of biliary atresia and stratified based on biopsy type including percutaneous, surgical, laparoscopic, and transjugular. Patient demographics, length of stay, hospital costs, type of treatment, and mortality were compared by biopsy type. One-way analysis of variance test and multivariable logistic regression were used for analysis with α < 0.05. Results A total of 4,306 patients with biliary atresia were identified, of whom 2,293 underwent no biopsy, and 723 and 1,080 underwent a percutaneous or surgical biopsy, respectively. Significant differences in socio-demographics were demonstrated between the biopsy types. The length of stay and hospital charges were statistically significantly different between the biopsy types where patients without biopsies had the smallest length compared to percutaneous, surgical, and combination of biopsies. Overall, the Kasai procedure was done more frequently compared to direct liver transplantation, and compared to other biopsy types, undergoing a combination of biopsies had the highest odds of undergoing either procedure. Conclusions When comparing different biopsy methods, surgical biopsies of the liver outperformed percutaneous biopsies in hospital utilization and progression to definitive treatments with the Kasai procedure. Our research indicated that vulnerable populations such as minorities or the indigent may undergo inferior treatments or infrequently undergo definitive treatment. The need for definitive diagnostic guidelines is understated in patients with biliary atresia.
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13
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Fu H, Zhao R, Jia X, Li X, Li G, Yin C. Neonatal Dubin-Johnson syndrome: biochemical parameters, characteristics, and genetic variants study. Pediatr Res 2022; 91:1571-1578. [PMID: 34050268 DOI: 10.1038/s41390-021-01583-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 03/18/2021] [Accepted: 04/16/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND The clinical characteristics and gene mutation characteristics of children with Dubin-Johnson syndrome (DJS) need in-depth study. METHODS The clinical and genomic data of neonatal Dubin-Johnson syndrome (NDJS) and 155 cases with idiopathic cholestasis (IC) were analyzed from June 2016 to August 2020 RESULTS: ABCC2 gene variants were identified in eight patients, including one patient with homozygous variants and seven patients with compound heterozygous variants. A total of 13 different ABCC variants were detected in the NDJS patients, including three nonsense variants, six missense variants, three frameshift variants, and a splice site variant. The variant c.2443C > T (p.R815X), c.4237_4238insCT (p.H1414Lfs*17), c.960_961insGT (p.L322Cfs*3), c.4250delC (p.S1417Ffs*14), c.2224G > A (p.D742N), c.4020G > C (p.K1340N), and c.2439 + 5G > A were not reported in the Human Gene Variant Database. There was no significance in the sex, birth weight, and onset age between the NDJS and IC groups. Compared with the IC group, the NDJS group had significantly higher levels of total bilirubin (TB), but a significantly lower level of alanine transaminase and a ratio of direct bilirubin (DB) to TB. There is no significance in total bile acid, gamma-glutamyl-transpeptidase, albumin, or international normalized ratio between the two groups. CONCLUSIONS NDJS should be considered in prolonged neonatal intrahepatic cholestasis, especially in infants with normal or slightly elevated transaminase levels. IMPACT Explore the biochemical parameters, characteristics, and genetic profile of NDJS. By summarizing the characteristics of biochemical indicators, seven new mutation types of the ABCC2 gene were detected, which expanded the mutation spectrum of the ABCC2 gene. NDJS should be considered in prolonged neonatal intrahepatic cholestasis, especially in infants with normal or slightly elevated transaminase levels.
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Affiliation(s)
- Haiyan Fu
- Digestive Department, Children' Hospital of Hebei Province, Shijiazhuang, Hebei, China
| | - Ruiqin Zhao
- Digestive Department, Children' Hospital of Hebei Province, Shijiazhuang, Hebei, China.
| | - Xiaoyun Jia
- Digestive Department, Children' Hospital of Hebei Province, Shijiazhuang, Hebei, China
| | - Xiaolei Li
- Digestive Department, Children' Hospital of Hebei Province, Shijiazhuang, Hebei, China
| | - Guigui Li
- Digestive Department, Children' Hospital of Hebei Province, Shijiazhuang, Hebei, China
| | - Chunlan Yin
- Digestive Department, Children' Hospital of Hebei Province, Shijiazhuang, Hebei, China
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14
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Chen LJ, Chen PJ, Yang SF, Chen JY. Causative organisms and antimicrobial susceptibility in jaundiced infants with significant bacteriuria. J Chin Med Assoc 2022; 85:514-518. [PMID: 35120356 DOI: 10.1097/jcma.0000000000000698] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Jaundice may be one of the first signs of urinary tract infection (UTI) in infants. The most common pathogen is Escherichia coli. Currently recommended antibiotic treatment for neonatal UTI is ampicillin and an aminoglycoside. Recently, increasing ampicillin and gentamicin resistance in strains of E. coli has been isolated. The aim of this study was to determine causative organisms and antimicrobial susceptibility in jaundiced infants with significant bacteriuria (SB). METHODS We evaluated admitted afebrile, asymptomatic infants younger than 1-month old with hyperbilirubinemia (total bilirubin >15 mg/dl) requiring phototherapy between January 2011 and December 2015. A total of 615 asymptomatic jaundiced infants were enrolled. Urinalysis and urine cultures were performed on all jaundiced infants. A urine culture was defined as SB if a single pathogen with more than 105-colony forming units per milliliter (CFU/ml) by sterile urinary collection bag or 104 CFU/ml by catheterization was isolated. RESULTS A total of 88 (14.3%) of 615 asymptomatic jaundiced infants had positive urinary culture. E coli was the most common cultured bacteria (40 cases, [45.5%]). Enterococcus faecalis was the second most common bacteria (17 cases, [19.3%]). Seven cases (8.0%) of Streptococcus agalactiae and six cases (6.8%) of Klebsiella pneumoniae were also identified. Ampicillin sensitivity was found in 22.5% of E. coli infections, gentamicin sensitivity was found in 84.2%, and extended-spectrum β-lactamases were found in 7.5%. CONCLUSION E. coli was the most common causative organism for infants with SB. We suggest modifying current empiric antibiotics by changing gentamicin to amikacin for neonatal Gram-negative bacterial infections.
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Affiliation(s)
- Lih-Ju Chen
- Division of Neonatology, Changhua Christian Children's Hospital, Changhua City, Taiwan, ROC
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan, ROC
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan, ROC
| | - Ping-Ju Chen
- Department of Dentistry, Changhua Christian Hospital, Changhua City, Taiwan, ROC
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan, ROC
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan, ROC
| | - Shun-Fa Yang
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan, ROC
| | - Jia-Yuh Chen
- Division of Neonatology, Changhua Christian Children's Hospital, Changhua City, Taiwan, ROC
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan, ROC
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan, ROC
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15
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Arboleda-Bustan JE, Ribalta T, Albert A, Cuadras D, Martín-Solé O. Expression of Protein SOX9 in Biliary Atresia. J Pediatr Gastroenterol Nutr 2022; 74:e21-e26. [PMID: 34789667 DOI: 10.1097/mpg.0000000000003356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Biliary atresia (BA) is still an enigmatic disease. Deeper knowledge of its pathophysiology could help develop better treatments. SOX9 regulates bile duct development, liver regeneration and fibrosis; therefore, it could be determinant in characterizing BA liver damage. Aim: To study if there is a SOX9 expression pattern in liver biopsies from BA patients. METHODS Liver biopsies from BA patients (group BA), from age-matched infants without primary hepatic disease (group Control), and from patients with other liver conditions (group OLC) were compared. Expression of SOX9 was checked for: amount, intensity of immunoreaction, localization within ductular structures, perifibrotic epithelial cells, and lobular cells. The scores were added to create a scale from 0 to 11 that allowed group comparison. SOX9 Scale and liver survival were also looked for a correlation. RESULTS All BA cases had a score >4, while all controls scored <4. OLC livers scored 1 to 8 (3.5 ± 2.0) (P < 0.001 between all groups). A cut-off at 4 had 100% sensitivity and 88.24% specificity to differentiate BA from Controls and from OLC (area under receiver operating characteristic curve: 0.9989 (95% confidence interval: 0.9964-1.000). Strong expression of SOX9 was observed mainly in the nuclei of proliferated ductules of portal spaces and fibrotic bridges. SOX9 Scale score could not be related to liver survival in this study. CONCLUSION In BA livers, SOX9 is mainly expressed in reactive ductular epithelium, following a pattern significantly different from that seen in non-BA patients; thus, SOX9 Scale may have a role in the diagnosis of BA.
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Affiliation(s)
| | - Teresa Ribalta
- Department of Pathology, Hospital Sant Joan de Déu, Hospital Clínic, Universitat de Barcelona, and Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Asteria Albert
- Department of Pediatric Surgery, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Daniel Cuadras
- Department of Statistics, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Oriol Martín-Solé
- Department of Pediatric Surgery, Hospital Sant Joan de Déu, Barcelona, Spain
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16
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Mahmud S, Gulshan J, Parvez M, Tasneem F, Ahmed SS. Etiology and outcome of neonatal cholestasis: an experience in a tertiary center of Bangladesh. EGYPTIAN LIVER JOURNAL 2022. [DOI: 10.1186/s43066-021-00168-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Neonatal cholestasis (NC) is a major cause of morbidity and mortality in young infants. This study examines the etiology of NC and its outcome during 2 years of follow-up at a tertiary referral center in Bangladesh.
Results
Out of 80 cholestatic infants, 60% had intrahepatic cholestasis with a mean age of onset of 12.4±2.8 days and a mean age of admission of 82.4±29.0 days. The remaining 40% were extrahepatic with a mean age of onset of 6.7±2.3 days and a mean age of admission of 94.6±50.4 days. Biliary atresia (BA), idiopathic neonatal hepatitis (INH), and TORCH (Toxoplasma, rubella, cytomegalovirus, and herpes simplex) infection except rubella were the most common causes. After receiving treatment, 46.2% of the cases improved, 23.8% deteriorated with morbidity, and 30% died. The majority of the children with INH, TORCH, choledochal cyst, hypothyroidism, galactosemia, and urinary tract infection (UTI) with sepsis were improved. Significant mortality was found in BA (56.6%), intrahepatic bile duct paucity (PIBD) (100%), and progressive familial intrahepatic cholestasis (PFIC) (100%) whereas the rest of BA (43.4%) live with persistent morbidity. Significant clinical improvement was observed in 37 (46.2%) cases of cholestasis evidenced by decreasing jaundice, change of color of urine from dark to normal color, change of stool color from pale to yellow, and gradual decrease in liver size from hepatomegaly state. In addition, decreasing median total bilirubin, direct bilirubin, alanine transaminase, gamma-glutamyl transferase, and alkaline phosphatase showed biochemical improvement at 2 years follow-up. The age of admission, etiology, and presence of ascites are the predictors of outcomes.
Conclusion
BA was the most common cause of extrahepatic while INH and TORCH infection were the most common cause of intrahepatic cholestasis. Majority of children with intrahepatic cholestasis improved but deteriorated with BA and genetic causes. Prompt referral and early diagnosis as well as the etiology of NC were the main determinants of the favorable outcome.
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17
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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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18
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Ranucci G, Della Corte C, Alberti D, Bondioni MP, Boroni G, Calvo PL, Cananzi M, Candusso M, Clemente MG, D'Antiga L, Degrassi I, De Ville De Goyet J, Di Dato F, Di Giorgio A, Vici CD, Ferrari F, Francalanci P, Fuoti M, Fusaro F, Gaio P, Grimaldi C, Iascone M, Indolfi G, Iorio R, Maggiore G, Mandato C, Matarazzo L, Monti L, Mosca F, Nebbia G, Nuti F, Paolella G, Pinon M, Roggero P, Sciveres M, Serranti D, Spada M, Vajro P, Nicastro E. Diagnostic approach to neonatal and infantile cholestasis: A position paper by the SIGENP liver disease working group. Dig Liver Dis 2022; 54:40-53. [PMID: 34688573 DOI: 10.1016/j.dld.2021.09.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 08/23/2021] [Accepted: 09/12/2021] [Indexed: 12/11/2022]
Abstract
Neonatal and infantile cholestasis (NIC) can represent the onset of a surgically correctable disease and of a genetic or metabolic disorder worthy of medical treatment. Timely recognition of NIC and identification of the underlying etiology are paramount to improve outcomes. Upon invitation by the Italian National Institute of Health (ISS), an expert working grouped was formed to formulate evidence-based positions on current knowledge about the diagnosis of NIC. A systematic literature search was conducted to collect evidence about epidemiology, etiology, clinical aspects and accuracy of available diagnostic tests in NIC. Evidence was scored using the GRADE system. All recommendations were approved by a panel of experts upon agreement of at least 75% of the members. The final document was approved by all the panel components. This position document summarizes the collected statements and defines the best-evidence diagnostic approach to cholestasis in the first year of life.
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Affiliation(s)
- Giusy Ranucci
- Department of Pediatrics, Santobono-Pausilipon Children's Hospital AORN, Naples, Italy
| | - Claudia Della Corte
- Hepatology, Gastroenterology, Nutrition and Liver transplantation Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | | | - Maria Pia Bondioni
- Pediatric Radiology, University of Brescia, ASST Spedali Civili di Brescia, Brescia, Italy
| | | | - Pier Luigi Calvo
- Pediatric Gastroenterology Unit, Regina Margherita Children's Hospital, Azienda Ospedaliera-Universitaria Città della Salute e della Scienza, Turin, Italy
| | - Mara Cananzi
- Unit of Gastroenterology, Digestive Endoscopy, Hepatology and Care of Children with Liver Transplantation, University Hospital of Padova, Padova, Italy
| | - Manila Candusso
- Hepatology, Gastroenterology, Nutrition and Liver transplantation Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Maria Grazia Clemente
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Lorenzo D'Antiga
- Hepatology, Gastroenterology and Transplantation Unit, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Irene Degrassi
- Service of Paediatric Hepatology, Department of Paediatrics, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Jean De Ville De Goyet
- Pediatric Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, ISMETT UPMC, Palermo, Italy
| | - Fabiola Di Dato
- Department di Translational Medical Science, School of Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Angelo Di Giorgio
- Hepatology, Gastroenterology and Transplantation Unit, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Carlo Dionisi Vici
- Division of Metabolism and Metabolic Diseases Research Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | | | - Paola Francalanci
- Department of Pathology, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Maurizio Fuoti
- Pediatric Gastroenterology and Endoscopy Unit Children's Hospital, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Fabio Fusaro
- Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Paola Gaio
- Unit of Gastroenterology, Digestive Endoscopy, Hepatology and Care of Children with Liver Transplantation, University Hospital of Padova, Padova, Italy
| | - Chiara Grimaldi
- Division of Abdominal Transplantation and Hepatobiliopancreatic Surgery, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Maria Iascone
- Medical Genetics Laboratory, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Giuseppe Indolfi
- Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Raffaele Iorio
- Department di Translational Medical Science, School of Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Giuseppe Maggiore
- Hepatology, Gastroenterology, Nutrition and Liver transplantation Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Claudia Mandato
- Department of Pediatrics, Santobono-Pausilipon Children's Hospital AORN, Naples, Italy
| | | | - Lidia Monti
- Department of Radiology, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Fabio Mosca
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Gabriella Nebbia
- Service of Paediatric Hepatology, Department of Paediatrics, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Federica Nuti
- Service of Paediatric Hepatology, Department of Paediatrics, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giulia Paolella
- Service of Paediatric Hepatology, Department of Paediatrics, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Michele Pinon
- Pediatric Gastroenterology Unit, Regina Margherita Children's Hospital, Azienda Ospedaliera-Universitaria Città della Salute e della Scienza, Turin, Italy
| | - Paola Roggero
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marco Sciveres
- Pediatric Hepatology and Liver Transplantation, ISMETT UPMC, Palermo, Italy
| | - Daniele Serranti
- Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Marco Spada
- Division of Abdominal Transplantation and Hepatobiliopancreatic Surgery, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Pietro Vajro
- Department of Medicine, Surgery and Dentistry, "Scuola Medica Salernitana" University of Salerno, Baronissi, Italy
| | - Emanuele Nicastro
- Hepatology, Gastroenterology and Transplantation Unit, Hospital Papa Giovanni XXIII, Bergamo, Italy
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19
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Filippi L, Tamagnini S, Lorenzoni F, Caciotti A, Morrone A, Scaramuzzo R. Case Report: Dramatic Cholestasis Responsive to Steroids in a Newborn Homozygous for H63D HFE Variant. Front Pediatr 2022; 10:930775. [PMID: 35874562 PMCID: PMC9304806 DOI: 10.3389/fped.2022.930775] [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: 04/28/2022] [Accepted: 06/20/2022] [Indexed: 12/19/2022] Open
Abstract
In a newborn with very precocious liver failure, cholestatic jaundice, and low γ-glutamyl transpeptidase, progressive hepatosplenomegaly induced a progressively worsening respiratory distress, that was successfully treated with steroids. Laboratory and genetic tests did not find any disease usually associated with neonatal cholestasis. However, the patient was positive for a homozygous mutation of the HFE gene, which is associated with hereditary hemochromatosis, a disease with typical onset in adulthood. Although no firm conclusions can be drawn from a single clinical case, this experience suggests that hereditary hemochromatosis could have played a role in the induction of this serious cholestasis, probably already arisen in the uterus. We suggest that hereditary hemochromatosis ought to be included in the panel of the possible causes of neonatal cholestasis and that steroids ought to be added to the pharmacological armamentarium for treating specific conditions which cause cholestasis in newborns.
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Affiliation(s)
- Luca Filippi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.,Neonatology Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Sara Tamagnini
- Neonatology Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | | | - Anna Caciotti
- Laboratory of Molecular Biology of Neurometabolic Diseases, Department of Neuroscience, Meyer Children's Hospital, Florence, Italy
| | - Amelia Morrone
- Laboratory of Molecular Biology of Neurometabolic Diseases, Department of Neuroscience, Meyer Children's Hospital, Florence, Italy.,Department of NEUROFARBA, University of Florence, Florence, Italy
| | - Rosa Scaramuzzo
- Neonatology Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
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20
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Abstract
Cholestatic jaundice is a common presenting feature of hepatobiliary and/or metabolic dysfunction in the newborn and young infant. Timely detection of cholestasis, followed by rapid step-wise evaluation to determine the etiology, is crucial to identify those causes that are amenable to medical or surgical intervention and to optimize outcomes for all infants. In the past 2 decades, genetic etiologies have been elucidated for many cholestatic diseases, and next-generation sequencing, whole-exome sequencing, and whole-genome sequencing now allow for relatively rapid and cost-effective diagnosis of conditions not previously identifiable via standard blood tests and/or liver biopsy. Advances have also been made in our understanding of risk factors for parenteral nutrition-associated cholestasis/liver disease. New lipid emulsion formulations, coupled with preventive measures to decrease central line-associated bloodstream infections, have resulted in lower rates of cholestasis and liver disease in infants and children receiving long-term parental nutrition. Unfortunately, little progress has been made in determining the exact cause of biliary atresia. The median age at the time of the hepatoportoenterostomy procedure is still greater than 60 days; consequently, biliary atresia remains the primary indication for pediatric liver transplantation. Several emerging therapies may reduce the bile acid load to the liver and improve outcomes in some neonatal cholestatic disorders. The goal of this article is to review the etiologies, diagnostic algorithms, and current and future management strategies for infants with cholestasis.
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Affiliation(s)
- Amy G Feldman
- Digestive Health Institute, Children's Hospital Colorado, Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine, Aurora, CO
| | - Ronald J Sokol
- Digestive Health Institute, Children's Hospital Colorado, Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine, Aurora, CO
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21
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Mancell S, Islam M, Dhawan A, Whelan K. Fat-soluble vitamin assessment, deficiency and supplementation in infants with cholestasis. J Hum Nutr Diet 2021; 35:273-279. [PMID: 34679231 DOI: 10.1111/jhn.12957] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 10/07/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Infants with cholestasis are at risk of fat-soluble vitamin deficiency. The present study amied to review practice relating to the assessment, deficiency and supplementation of fat-soluble vitamins in infants with cholestasis. METHODS The medical records of all newly diagnosed infants with cholestasis (conjugated bilirubin >17 mmol L-1 />20% total bilirubin) at King's College Hospital between 2017 and 2019 were reviewed. Data extracted included bilirubin, serum vitamin concentrations (A, D, E), international normalised ratio and evidence of supplementation at initial assessment, as well as at 3 and 6 months. Rates of vitamin assessment, deficiency and supplementation were compared using chi-squared or Fisher's exact test. RESULTS In total, 136 infants (87 male) with idiopathic neonatal cholestasis (n = 62), biliary atresia (n = 40) and other aetiology (n = 34) were included. Assessment of serum vitamins (A, D, E) was low (33.3%-52.2%) and deficiency was initially high for vitamin D (60.6%) and vitamin E (70.9%). Supplementation prevalence at initial assessment was high (A, E, K), but dropped significantly at 3 and 6 months for vitamin E (p = 0.003) and vitamin K (p = 0.001), whereas vitamin D supplementation was consistently low throughout (25%-33.3%). Infants with biliary atresia were more likely to have vitamins assessed (3 months), be deficient initially (D, E) and supplemented (E, K) throughout. Supplementation continued in up to 80% of infants despite cholestasis resolving. CONCLUSIONS Supplementation was generally high and continued in many despite cholestasis resolving. Deficiency of vitamin D and vitamin E was high at initial assessment, although lower at follow-up. Actual prevalence of deficiency of all vitamins is unknown because monitoring was not consistently performed.
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Affiliation(s)
- Sara Mancell
- Department of Nutrition and Dietetics, King's College Hospital NHS Foundation Trust, London, UK
| | - Maeisha Islam
- Department of Nutrition and Dietetics, King's College Hospital NHS Foundation Trust, London, UK.,Department of Nutritional Sciences, King's College London, London, UK
| | - Anil Dhawan
- Paediatric Liver, GI & Nutrition Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Kevin Whelan
- Department of Nutritional Sciences, King's College London, London, UK
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22
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Garegrat R, Pareek P, Pandey S, Suryawanshi P. Unusual case of immune haemolytic disease causing severe neonatal cholestasis in a newborn. BMJ Case Rep 2021; 14:e243991. [PMID: 34521738 PMCID: PMC8442038 DOI: 10.1136/bcr-2021-243991] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2021] [Indexed: 11/04/2022] Open
Abstract
Neonatal hyperbilirubinaemia is a very common entity witnessed in most of the newborns. Rarely are there events where the bilirubin levels reach extreme values mandating invasive therapy. Unconjugated hyperbilirubinaemia when solely present is easy to manage and diagnose the common aetiological factors associated with it. The issue arises when we come across a mixed picture of conjugated with unconjugated hyperbilirubinaemia and puts us in a dilemma as to what are we treating. Our case highlights a similar picture where we witnessed the highest documented levels of total bilirubin but to our surprise the major component of which was direct bilirubin. This report takes us through the differentials which were ruled out and our management strategies for solving this rare mystery.
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Affiliation(s)
- Reema Garegrat
- Neonatology, Bharati Vidyapeeth University, Pune, Maharashtra, India
| | - Prince Pareek
- Neonatology, Bharati Vidyapeeth University, Pune, Maharashtra, India
| | - Snehavardhan Pandey
- Pediatric Hepatology and Liver Transplant, Sahyadri Hospital, Pune, Maharashtra, India
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23
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Hartmann P, Carter R, Keller B, Saenz NC, Schwarz KB. Complete Absence of the Extrahepatic Biliary Tree in a Newborn With Pigmented Stools. Pediatrics 2021; 148:peds.2020-038596. [PMID: 34398808 DOI: 10.1542/peds.2020-038596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/18/2021] [Indexed: 11/24/2022] Open
Abstract
"Yellow stools in neonatal cholestasis exclude biliary atresia." This conventional wisdom led to the development of the infant stool color card, which alerts parents to seek medical referral when pale stools are observed, a strategy that has been shown to improve survival in infants with biliary atresia (BA). Here, we present a case of a newborn with significant direct hyperbilirubinemia (direct bilirubin level of up to 9.2 mg/dL on day of life 10) who continued to produce colored stools. Whole-genome sequencing results were negative for genetic causes of cholestasis. Hepatobiliary scintigraphy findings were nonexcretory. A liver biopsy specimen revealed cholestasis, ductular hyperplasia, giant cell formation, minimal inflammation, minimal portal or periportal fibrosis, and no evidence of viral changes. On day of life 38, during the exploratory laparotomy, the patient was found to have complete absence of the extrahepatic biliary tree, or biliary aplasia, possibly a rare, severe form of BA. This report aims to increase our vigilance and help prevent diagnostic error in patients with signs and symptoms of BA who may produce pigmented stools. Primary care physicians should hence refer an infant (early and urgently) to a pediatric gastroenterologist for further workup for a direct bilirubin level >1.0 mg/dL with any total bilirubin level, irrespective of the color of the infant's stools.
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Affiliation(s)
- Phillipp Hartmann
- Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics
| | | | - Benjamin Keller
- Division of Pediatric Surgery, Department of Surgery, University of California, San Diego, La Jolla, California
| | - Nicholas C Saenz
- Division of Pediatric Surgery, Department of Surgery, University of California, San Diego, La Jolla, California
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24
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Conjugated Hyperbilirubinemia in Infants: Is There Still a Role for ERCP? Can J Gastroenterol Hepatol 2021; 2021:9969825. [PMID: 34258256 PMCID: PMC8249117 DOI: 10.1155/2021/9969825] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 06/17/2021] [Indexed: 11/17/2022] Open
Abstract
Over a twenty-year period, we performed 255 ERCP procedures in infants aged up to 1 year. ERCP was indicated in cholestatic infants with suspicion of biliary obstruction. The most common diagnosis was biliary atresia (48%), choledochal cysts (13%), and choledocholithiasis (4%). The procedure complication rate was 13.7%. Hyperamylasemia occurred in 12.9%. More severe complications were rare-0.8% of ERCP procedure. There were no cases of postprocedural pancreatitis or death. Our study has proved that ERCP is a safe and reliable method in this age group. Its high specificity and negative predictive value for extrahepatic biliary atresia can prevent unnecessary surgeries in patients with normal bile ducts or endoscopically treatable pathologies.
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25
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Boo YA, Chang MH, Jeng YM, Peng SF, Hsu WM, Lin WH, Chen HL, Ni YH, Hsu HY, Wu JF. Diagnostic Performance of Transient Elastography in Biliary Atresia Among Infants With Cholestasis. Hepatol Commun 2021; 5:882-890. [PMID: 34027275 PMCID: PMC8122382 DOI: 10.1002/hep4.1672] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 12/10/2020] [Accepted: 12/18/2020] [Indexed: 12/20/2022] Open
Abstract
Biliary atresia (BA) is a challenging liver disease in infancy. Early diagnosis of BA is important for timely hepatoportoenterostomy. We evaluated the age-specific diagnostic performance of transient elastography (TE) with a liver stiffness measurement (LSM) greater than 7.7 kPa in BA among infants with cholestasis. A total of 61 infants with cholestasis (5-121 days of age) were enrolled in this prospective follow-up study; 15 infants were BA. Four age groups were defined (≤30, 31-60, 61-90, and 91-180 days). Picrosirius red staining was performed to quantify the percentage of collagen fibers in liver specimens. The utility of an LSM greater than 7.7 kPa for diagnosis of BA among infants with cholestasis was compared among age groups. In all four groups, TE showed high diagnostic power for BA using the criterion of an LSM greater than 7.7 kPa. Positive predictive values were 100%, 100%, and 100% in the groups aged 30 days or younger, 31 to 60 days, and 61 to 90 days, respectively. Respective negative predictive values were 90.9%, 94.7%, and 100%, and respective diagnostic accuracies were 92.9%, 95.2%, and 100%. The positive predictive value, negative predictive value, and diagnostic accuracy were 100%, 100%, and 100%, respectively, for LSM greater than 8.8 kPa in the group aged 91 to 180 days. The LSM was positively correlated with the percentage of collagen fibers stained by picrosirius red (P = 0.03). Conclusion: In this prospective follow-up study, TE had good diagnostic accuracy for differentiation of BA from non-BA cholestasis in infants with cholestasis who were 90 days of age or younger. The LSM was significantly positive correlated with the liver fibrosis status stained by picrosirius red in infants with cholestasis.
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Affiliation(s)
- Yin-Ann Boo
- Department of PediatricsNational Taiwan University HospitalTaipeiTaiwan
| | - Mei-Hwei Chang
- Department of PediatricsNational Taiwan University HospitalTaipeiTaiwan.,The Hepatitis Research CenterNational Taiwan University HospitalTaipeiTaiwan
| | - Yung-Ming Jeng
- Department of PathologyNational Taiwan University HospitalTaipeiTaiwan
| | - Shinn-Forng Peng
- Department of RadiologyNational Taiwan University HospitalTaipeiTaiwan
| | - Wen-Ming Hsu
- Department of SurgeryNational Taiwan University HospitalTaipeiTaiwan
| | - Wen-Hsi Lin
- Department of SurgeryNational Taiwan University HospitalTaipeiTaiwan
| | - Huey-Ling Chen
- Department of PediatricsNational Taiwan University HospitalTaipeiTaiwan.,The Hepatitis Research CenterNational Taiwan University HospitalTaipeiTaiwan
| | - Yen-Hsuan Ni
- Department of PediatricsNational Taiwan University HospitalTaipeiTaiwan.,The Hepatitis Research CenterNational Taiwan University HospitalTaipeiTaiwan
| | - Hong-Yuan Hsu
- Department of PediatricsNational Taiwan University HospitalTaipeiTaiwan
| | - Jia-Feng Wu
- Department of PediatricsNational Taiwan University HospitalTaipeiTaiwan
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26
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Santos Silva E, Moreira Silva H, Catarino C, Dias CC, Santos-Silva A, Lopes AI. Neonatal cholestasis: development of a diagnostic decision algorithm from multivariate predictive models. Eur J Pediatr 2021; 180:1477-1486. [PMID: 33410939 DOI: 10.1007/s00431-020-03886-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 11/06/2020] [Accepted: 11/20/2020] [Indexed: 11/28/2022]
Abstract
Despite the recent advances involving molecular studies, the neonatal cholestasis (NC) diagnosis still relays on the expertise of medical teams. Our aim was to develop models of etiological diagnosis and unfavourable prognosis which may support a rationale diagnostic approach. We retrospectively analysed 154 patients born between January 1985 and October 2019. The cohort was divided into two main groups: (A) transient cholestasis and (B) other diagnosis (with subgroups) and also in two groups of outcomes: (I) unfavourable and (II) favourable. Multivariate logistic regression analysis identified the lower gestational age as the only variable independently associated with an increased risk of transient cholestasis and signs and/or symptoms of sepsis with infectious or metabolic diseases. Gamma-glutamyl transferase serum levels > 300 IU/L had a positive predictive value for both diagnosis of biliary atresia and for alpha-1-antitrypsin deficiency (A1ATD) and for unfavourable prognosis. A model of diagnosis for A1ATD (n = 34) showed an area under the ROC curve = 0.843 [confidence interval (CI): 0.773-0.912].Conclusion: This study identified some predictors of diagnosis and prognosis which helped to build a diagnostic decision algorithm. The unusually large subgroup of patients with A1ATD in this cohort emphasizes its predictive diagnostic model. What Is Known • The etiological diagnosis of neonatal cholestasis (NC) requires a step-by-step guided approach, and diagnostic models have been developed only for biliary atresia. • Current algorithms neither address the epidemiology changes nor the application of the new molecular diagnostic tools. What Is New • This study provides diagnostic predictive models for patients with A1ATD, metabolic/infectious diseases, and transient cholestasis, and two models of unfavourable prognosis for NC. • A diagnostic decision algorithm is proposed based on this study, authors expertise and the literature.
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Affiliation(s)
- Ermelinda Santos Silva
- Gastroenterology Unit, Paediatrics Division, Child and Adolescent Department, Centro Materno-Infantil do Norte, Centro Hospitalar Universitário do Porto, Largo da Maternidade, n° 45, 4050-651, Porto, Portugal. .,Integrated Master in Medicine, Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Rua Jorge Viterbo Ferreira, n° 228, 4050-313, Porto, Portugal. .,UCIBIO, REQUIMTE, Laboratory of Biochemistry, Department of Biological Sciences, Faculdade de Farmácia, Universidade do Porto, Rua Jorge Viterbo Ferreira, n° 228, 4050-313, Porto, Portugal.
| | - Helena Moreira Silva
- Gastroenterology Unit, Paediatrics Division, Child and Adolescent Department, Centro Materno-Infantil do Norte, Centro Hospitalar Universitário do Porto, Largo da Maternidade, n° 45, 4050-651, Porto, Portugal
| | - Cristina Catarino
- UCIBIO, REQUIMTE, Laboratory of Biochemistry, Department of Biological Sciences, Faculdade de Farmácia, Universidade do Porto, Rua Jorge Viterbo Ferreira, n° 228, 4050-313, Porto, Portugal
| | - Cláudia Camila Dias
- MEDCIDS (Departamento de Medicina da Comunidade, Informação e Decisão em Saúde) and CINTESIS (Centro de Investigação em Tecnologias e em Serviços de Saúde), Faculdade de Medicina da Universidade do Porto, Rua Dr Plácido da Costa, s/n, 4200-450, Porto, Portugal
| | - Alice Santos-Silva
- UCIBIO, REQUIMTE, Laboratory of Biochemistry, Department of Biological Sciences, Faculdade de Farmácia, Universidade do Porto, Rua Jorge Viterbo Ferreira, n° 228, 4050-313, Porto, Portugal
| | - Ana-Isabel Lopes
- Paediatric Gastroenterology Unit, Paediatrics Department, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Av. Prof. Egas Moniz, 1600-190, Lisboa, Portugal.,Faculdade de Medicina, Universidade de Lisboa, Av. Prof. Egas Moniz, 1649-028, Lisboa, Portugal
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27
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Role of percutaneous liver biopsy in infantile cholestasis: cohort from Arabs. BMC Gastroenterol 2021; 21:118. [PMID: 33711954 PMCID: PMC7953702 DOI: 10.1186/s12876-021-01699-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 02/18/2021] [Indexed: 11/11/2022] Open
Abstract
Background Investigators from different parts of the world are calling for a re-evaluation of the role of liver biopsy (LB) in the evaluation of infantile cholestasis (IC), especially in the light of emerging non-invasive diagnostic technologies. Therefore, this retrospective single-center study was conducted to determine the impact of LB on the diagnosis and management of IC in a cohort from Arabs. Methods From 2007 until 2019, 533 cases of IC were referred for evaluation. All infants who underwent LB were included in the study. We categorized the yield of LB into: (1) defined specific diagnosis; (2) excluded an important diagnosis. A single pathologist reviewed and made the histology report. Results 122 LB specimens met the inclusion criteria. The main indication for LB was a high suspicion of biliary atresia (BA) [high gamma-glutamyl transferase (GGT) cholestasis and pale stool] in 46 cases (37.8%). Liver biopsy had sensitivity of 86.4%, specificity (66.7%), PPV (70.4%), NPV (84.2%) in diagnosing BA. LB had a direct impact on clinical management in 52 cases (42.6%): (1) The true diagnosis was suggested by LB in 36 cases; (2) LB excluded BA and avoided intraoperative cholangiogram in 16 cases with high suspicion of BA. Among the 76 cases with low suspicion of BA, LB suggested the true diagnosis or helped to initiate specific management in 8 cases only (10.5%). In contrast, molecular testing confirmed the diagnosis in 48 (63%). Conclusion LB continues to be an important tool in the workup of cases with a high suspicion of BA. The low yield of LB in cases with low suspicion of BA calls for a re-evaluation of its role in these cases in whom early incorporation of cholestasis sequencing gene panels can have a better diagnostic yield.
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28
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Misra S, Majumdar K, Sakhuja P, Jain P, Singh L, Kumar P, Dubey AP. Differentiating Biliary Atresia From Idiopathic Neonatal Hepatitis: A Novel Keratin 7 Based Mathematical Approach on Liver Biopsies. Pediatr Dev Pathol 2021; 24:103-115. [PMID: 33439108 DOI: 10.1177/1093526620983730] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND AIMS Differentiating biliary atresia (BA) from idiopathic neonatal hepatitis (INH) is vital in routine pediatric practice. However, on liver biopsy, few cases offer a diagnostic challenge to discriminate these entities with certainty. Bile ductular reaction (DR), intermediate hepatobiliary cells (IHBC) and extra-portal ductules (EPD) indicate progenitor cell activation, as a response to various hepatic insults. The present study aims to quantify DR, IHBC and EPD by Keratin 7 (CK7) immunohistochemistry (IHC) in BA and INH and to devise a mathematical approach to better differentiate the two, especially in histologically equivocal cases. METHODS A total of 98 cases were categorized on biopsy as BA, INH or equivocal histology, favoring BA or INH. CK7 DR mean, IHBC mean and EPD mean values were compared between BA and INH. A formula was derived to help distinguish these two entities, the cut-off value, sensitivity and specificity of which were determined by receiver operating characteristic (ROC) curve. This formula was applied and validated on histologically equivocal cases. RESULTS Univariate logistic regression revealed significant difference between BA and INH with respect to CK7 DR and CK7 EPD mean (p < 0.001 in both); however, CK7 IHBC mean was not significant (p = 0.08). On multivariate logistic regression, only CK7 DR had significant impact on diagnosis (p < 0.001). A formula: (CK7 DR)2 + (CK7 EPD)/(CK7 IHBC) was derived to help distinguish BA from INH. Cut off value of 10.5 and above, determined by ROC curve, favored a diagnosis of BA (sensitivity= 93.4%, specificity= 94.6%). Histologically equivocal and discrepant cases could be correctly categorized using this formula. CONCLUSIONS Formula using CK7 IHC parameters may aid pathologists better distinguish BA from INH, especially in histologically equivocal cases.
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Affiliation(s)
- Sunayana Misra
- Department of Pathology, GB Pant Institute of Post Graduate Medical Education and Research, New Delhi, India
| | - Kaushik Majumdar
- Department of Pathology, GB Pant Institute of Post Graduate Medical Education and Research, New Delhi, India
| | - Puja Sakhuja
- Department of Pathology, GB Pant Institute of Post Graduate Medical Education and Research, New Delhi, India
| | - Priyanka Jain
- Department of Clinical Research, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Lavleen Singh
- Department of Pathology, Chacha Nehru Bal Chikitsalaya, New Delhi, India
| | - Praveen Kumar
- Department of Pediatrics, Lady Hardinge Medical College, Kalawati Saran Children's Hospital, New Delhi, India
| | - A P Dubey
- Department of Pediatrics, Maulana Azad Medical College, Lok Nayak Hospital, New Delhi, India
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29
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[Clinical characteristics and gene variants of patients with infantile intrahepatic cholestasis]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2021; 23. [PMID: 33476544 PMCID: PMC7818162 DOI: 10.7499/j.issn.1008-8830.2009079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To explore the clinical characteristics and genetic findings of patients with infantile intrahepatic cholestasis. METHODS The clinical data were collected in children who were admitted to the Department of Gastroenterology in Children's Hospital, Capital Institute of Pediatrics from June 2017 to June 2019 and were suspected of inherited metabolic diseases. Next generation sequencing based on target gene panel was used for gene analysis in these children. Sanger sequencing technology was used to verify the genes of the members in this family. RESULTS Forty patients were enrolled. Pathogenic gene variants were identified in 13 patients (32%), including SLC25A13 gene variation in 3 patients who were diagnosed with citrin deficiency, JAG1 gene variation in 3 patients who were diagnosed with Alagille syndrome, ABCB11 gene variation in 3 patients who were diagnosed with progressive familial intrahepatic cholestasis type 2, HSD3B7 gene variation in 1 patient who was diagnosed with congenital bile acid synthesis defect type 1, AKR1D1 gene variation in 1 patient who was diagnosed with congenital bile acid synthesis defect type 1, NPC1 gene variation in 1 patient who was diagnosed with Niemann-Pick disease, and CFTR gene variation in 1 patient who was diagnosed with cystic fibrosis. CONCLUSIONS The etiology of infantile intrahepatic cholestasis is complex. Next generation sequencing is helpful in the diagnosis of infantile intrahepatic cholestasis.
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30
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Ali A, Ong EY, Sadu Singh BK, Cheah FC. Comparison Between Sodium Acetate and Sodium Chloride in Parenteral Nutrition for Very Preterm Infants on the Acid-Base Status and Neonatal Outcomes. Pediatr Gastroenterol Hepatol Nutr 2020; 23:377-387. [PMID: 32704498 PMCID: PMC7354868 DOI: 10.5223/pghn.2020.23.4.377] [Citation(s) in RCA: 2] [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: 09/24/2019] [Revised: 03/02/2020] [Accepted: 05/01/2020] [Indexed: 12/29/2022] Open
Abstract
PURPOSE To compare between sodium acetate (SA) and sodium chloride (SC) in parenteral nutrition (PN) with associated metabolic acidosis and neonatal morbidities in preterm infants. METHODS Preterm infants below 33 weeks gestational age, and with a birth weight under 1,301 g were enrolled and further stratified into two groups: i) <1,000 g, or ii) ≥1,000 g in birth weight. The subjects were randomized to receive PN containing SA or SC within the first day of life. The results of routine blood investigations for the first 6 days of PN were collated, and the neonatal outcomes were recorded upon discharge or demise. RESULTS Fifty-two infants entered the study, with 26 in each group: 29 infants had extremely low birth weight (ELBW). There were no significant differences in birth weight, gestation, sex, exposure to chorioamnionitis and antenatal steroids, surfactant doses and duration of mechanical ventilation between groups. The SA group had significantly higher mean pH and base excess (BE) from days 4 to 6 than the SC (mean pH, 7.36 vs. 7.34; mean BE -1.6 vs. -3.5 [p<0.01]), with a two-fold increase in the mean BE among ELBW infants. Significantly fewer on SA required additional bicarbonate (n=4 vs. 13, p=0.01). The rate of bronchopulmonary dysplasia (BPD) was approximately four-fold lower in SA than SC (n=3 vs. 11, p<0.01). No significant differences were observed in necrotizing enterocolitis, patent ductus arteriosus, retinopathy of prematurity, cholestatic jaundice, and mortality between groups. CONCLUSION The use of SA in PN was associated with reduced metabolic acidosis and fewer BPD.
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Affiliation(s)
- Adli Ali
- Department of Paediatrics, Faculty of Medicine, University Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Ee-Yan Ong
- Department of Pharmacy, University Kebangsaan Malaysia Medical Center, Kuala Lumpur, Malaysia
| | | | - Fook-Choe Cheah
- Department of Paediatrics, Faculty of Medicine, University Kebangsaan Malaysia, Kuala Lumpur, Malaysia
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31
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Li M, Liu S, Wang M, Hu H, Yin J, Liu C, Huang Y. Gut Microbiota Dysbiosis Associated with Bile Acid Metabolism in Neonatal Cholestasis Disease. Sci Rep 2020; 10:7686. [PMID: 32377002 PMCID: PMC7203226 DOI: 10.1038/s41598-020-64728-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 04/20/2020] [Indexed: 01/04/2023] Open
Abstract
Neonatal cholestasis disease (NCD) is a complex and easily mis-diagnosed condition. We analyzed microbiota community structure in feces and measured short-chain fatty acids, bile acids (BAs) and liver function of 12 healthy, 13 NCD, and 13 treated infants after diagnosis. Based on 16S rRNA gene amplicon sequencing and gas-chromatographic-mass-spectrometric analysis of secondary BAs, we identified microbial genera and metabolites that associate with abnormal bile secretion. Streptococcus gallolyticus and Parabacteroides distasonis, and Lactobacillus gasseri had higher relative abundance in healthy and NCD infants respectively. Compared to NCD patients, healthy infants had higher LCA, CDCA and GCDCA fecal concentrations. The three microbial species and three secondary bile acids were selected as potential non-invasive combined biomarkers to diagnose NCD. We propose that microbiota-metabolite combined biomarkers could be used for diagnosis of NCD, and this may contribute to improved early clinical diagnosis of NCD in the future.
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Affiliation(s)
- Meng Li
- Department of Pediatrics, the First Affiliated Hospital of Kunming Medical University and Yunnan Key Laboratory of Laboratory Medicine, 650032, Kunming, China
| | - Sixiang Liu
- Department of Gastroenterology, Children's Hospital of Kunming Medical University, 650034, Kunming, China
| | - Mingying Wang
- Department of Gastroenterology, Children's Hospital of Kunming Medical University, 650034, Kunming, China
| | - Hongwei Hu
- Department of Pediatrics, the First Affiliated Hospital of Kunming Medical University and Yunnan Key Laboratory of Laboratory Medicine, 650032, Kunming, China
| | - Jianwen Yin
- Yunnan Center for Disease Control and Prevention, 650100, Kunming, China
| | - Chuanfa Liu
- Kunming Institute of Zoology, Chinese Academy of Sciences, 650000, Kunming, China.
- University of Chinese Academy of Sciences, 100049, Beijing, China.
| | - Yongkun Huang
- Department of Pediatrics, the First Affiliated Hospital of Kunming Medical University and Yunnan Key Laboratory of Laboratory Medicine, 650032, Kunming, China.
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32
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Lemoine C, Melin-Aldana H, Brandt K, Mohammad S, Superina R. The evolution of early liver biopsy findings in babies with jaundice may delay the diagnosis and treatment of biliary atresia. J Pediatr Surg 2020; 55:866-872. [PMID: 32216969 DOI: 10.1016/j.jpedsurg.2020.01.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 01/25/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND The early diagnosis of biliary atresia (BA) is associated with a better outcome after portoenterostomy. However, very early liver biopsy findings may appear atypical for BA and delay diagnosis. Repeat biopsy histology may change rapidly to show more typical features. METHODS Between 1997 and 2018, 6 babies with jaundice had more than one biopsy to establish diagnosis. Clinical and histologic data were collected. chi-Square was used for analysis (p < 0.05 significant). RESULTS Five patients had two biopsies, and one had three. Median age at first, second, and third biopsy was 40 (13-57), 68.5 (35-78), and 133 days, respectively. Biopsy readings showed no portal edema initially (0/6), but in all 6 on repeat biopsy (p = 0.001). Bile duct proliferation was seen in 6/6 final biopsies, but in only 1/6 initially (p = 0.003). All patients underwent a portoenterostomy (median age 75 days (43-113)). Median delay between initial biopsy and Kasai was 29 days (14-67). Transplant free survival (n = 5 patients) ranged from 184 to 716 days (median 309 days). One patient died before being transplanted. CONCLUSION Early biopsies may not display characteristic findings of BA, but these can appear quickly on subsequent evaluation. The interval needed to repeat a biopsy may have an adverse effect on bile drainage. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Caroline Lemoine
- Division of Transplant Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Hector Melin-Aldana
- Department of Pathology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Katherine Brandt
- Division of Transplant Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Saeed Mohammad
- Division of Gastroenterology, Hepatology, and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Riccardo Superina
- Division of Transplant Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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Preventive Effect of Bifidobacterium Supplementation on Neonatal Cholestasis in Preterm Neonates with Very Low Birth Weight. Gastroenterol Res Pract 2020; 2020:4625315. [PMID: 32211042 PMCID: PMC7085826 DOI: 10.1155/2020/4625315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 02/03/2020] [Accepted: 02/15/2020] [Indexed: 01/30/2023] Open
Abstract
Background Cholestasis is a common but serious clinical condition in preterm neonates. The current management for preterm neonatal cholestasis has limitations. The aim of this study was to determine effects of Bifidobacterium supplementation on the prevention and alleviation of cholestasis in preterm infants with very low birth weight. Methods Preterm neonates with very low birth weight were enrolled in the Children's Hospital of Soochow University between December 2012 and December 2017. The patients were randomly assigned into Bifidobacterium and control groups, and effects of Bifidobacterium supplementation on the outcomes were compared between the two groups. Results There was no significant difference in the baseline characteristics in the two groups. Notably, the proportion of cases with neonatal cholestasis was significantly lower, with fewer neonatal cholestasis-associated complications in the Bifidobacterium group compared with the control group (6% versus 22%, P < 0.01). Furthermore, the Bifidobacterium group exhibited less severe cholestasis and better improvement of the liver function than the control group as evidenced by the biochemical tests (P < 0.01). Furthermore, the Bifidobacterium group exhibited less severe cholestasis and better improvement of the liver function than the control group as evidenced by the biochemical tests (P < 0.01). Furthermore, the Bifidobacterium group exhibited less severe cholestasis and better improvement of the liver function than the control group as evidenced by the biochemical tests (days, P < 0.01). Furthermore, the Bifidobacterium group exhibited less severe cholestasis and better improvement of the liver function than the control group as evidenced by the biochemical tests (P < 0.01). Furthermore, the Bifidobacterium group exhibited less severe cholestasis and better improvement of the liver function than the control group as evidenced by the biochemical tests (P < 0.01). Furthermore, the Bifidobacterium group exhibited less severe cholestasis and better improvement of the liver function than the control group as evidenced by the biochemical tests (P < 0.01). Furthermore, the Bifidobacterium group exhibited less severe cholestasis and better improvement of the liver function than the control group as evidenced by the biochemical tests (P < 0.01). Furthermore, the Bifidobacterium group exhibited less severe cholestasis and better improvement of the liver function than the control group as evidenced by the biochemical tests ( Conclusions Bifidobacterium supplementation has significantly preventive and other beneficial effects on the management of cholestasis in preterm infants with very low birth weight. Its long-term safety and effectiveness will need further investigation. This trial is registered with the Chinese Clinical Trial Registry (Registration No. ChiCTR1900022296).
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Tessier MEM, Shneider BL. 60 Days in Biliary Atresia: A Historical Dogma Challenged. Clin Liver Dis (Hoboken) 2020; 15:S3-S7. [PMID: 32140208 PMCID: PMC7050960 DOI: 10.1002/cld.843] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 05/16/2019] [Indexed: 02/04/2023] Open
Affiliation(s)
- Mary Elizabeth M. Tessier
- Department of Pediatrics, Section of Pediatric Gastroenterology, Hepatology and NutritionBaylor College of MedicineHoustonTX
| | - Benjamin L. Shneider
- Department of Pediatrics, Section of Pediatric Gastroenterology, Hepatology and NutritionBaylor College of MedicineHoustonTX
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Abstract
OBJECTIVES The present study aimed to estimate the value of serum interleukin-33 (IL-33) levels in infants with cholestasis, correlate serum IL-33 levels with the clinicopathological profile of infants with cholestasis, and compare its level with that of healthy infants who served as control. METHODS Sixty infants with cholestasis were enrolled in the present study and divided into biliary atresia (BA) group and non-BA group, in addition to 30 healthy infants as a control group. All infants were analyzed for their clinical and biochemical features, histopathological profile, and serum level of IL-33 by enzyme-linked immune sorbent assay. RESULTS Serum level of IL-33 in BA group (median 48.0, interquartile range: 28.9-106.2) was significantly higher than that of the non-BA group (median 17.3, interquartile range: 13.7-18.8 pg/mL) and both were higher than that of the control group. There was a positive correlation between serum IL-33 and aspartate aminotransferase, alanine aminotransferase, bilirubin (total and direct) levels, and fibrosis stage among the BA group. Serum IL-33 at a cut-off value of 20.8 pg/mL can detect BA with a specificity of 95% and a sensitivity of 96.7%. CONCLUSION The significantly higher production of IL-33 in patients with BA compared to non-BA suggests a potential role of IL-33 for initiation and progression of the disease process, also, IL-33 may have a diagnostic role in infants with BA.
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Santos Silva E, Almeida A, Frutuoso S, Martins E, Valente MJ, Santos-Silva A, Lopes AI. Neonatal Cholestasis Over Time: Changes in Epidemiology and Outcome in a Cohort of 154 Patients From a Portuguese Tertiary Center. Front Pediatr 2020; 8:351. [PMID: 32695736 PMCID: PMC7338938 DOI: 10.3389/fped.2020.00351] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 05/27/2020] [Indexed: 01/23/2023] Open
Abstract
Introduction: In the last two decades there have been advances in the diagnosis and management of neonatal cholestasis, which may have changed its epidemiology, diagnostic accuracy, outcomes, and survival. Our goal was to characterize these changes over time in our setting. Methods: Retrospective cohort study in a tertiary center, enrolling patients born between January 1985 and October 2019. The cohort was divided into two periods, before (A; n = 67) and after (B; n = 87) the year 2000; and in two groups, according to patient's outcome (favorable, unfavorable). Overall survival and survival with and without orthotopic liver transplant (OLT) were evaluated in the two periods (A and B) and in different subgroups of underlying entities. Results: We found that the age of cholestasis recognition decreased significantly from period A to period B [median 43 days and 22 days, respectively, (p < 0.001)]; the changes in epidemiology were relevant, with a significant decrease in alpha-1-antitrypsin deficiency (p < 0.001) and an increase in transient cholestasis (p = 0.004). A next-generation sequencing (NGS) panel available since mid-2017 was applied to 13 patients with contributory results in 7, but, so far, only in 2 patients led to conclusive diagnosis of underlying entities. The number of cases of idiopathic cholestasis did not vary significantly. Over time there was no significant change in the outcome (p = 0.116). Overall survival and survival without OLT had no significant improvement during the period of observation (in periods A and B, 86 vs. 88%, and 85 vs. 87%, respectively). However, in period B, with OLT we achieved the goal of 100% of survival rate. Conclusions: Our data suggest that transient cholestasis became a very important subset of neonatal cholestasis, requiring specific guidance. The NGS panels can provide important inputs on disease diagnosis but, if applied without strict criteria and expertise, they can open a Pandora's box due to misinterpretation. Despite all the advances in accurate diagnosis and timely management-including early recognition of cholestasis-the improvement in patient outcomes and survival were still not significant.
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Affiliation(s)
- Ermelinda Santos Silva
- Paediatric Gastroenterology Unit, Centro Materno-Infantil do Norte, Centro Hospitalar Universitário do Porto, Porto, Portugal.,Integrated Master in Medicine, Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal.,UCIBIO-REQUIMTE, Laboratory of Biochemistry, Faculdade de Farmácia, Universidade do Porto, Porto, Portugal
| | - Alexandra Almeida
- Neonatology Unit, Centro Materno-Infantil do Norte, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Simão Frutuoso
- Neonatology Unit, Centro Materno-Infantil do Norte, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Esmeralda Martins
- Integrated Master in Medicine, Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal.,Metabolic Diseases Reference Center, Centro Materno-Infantil do Norte, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Maria João Valente
- UCIBIO-REQUIMTE, Laboratory of Biochemistry, Faculdade de Farmácia, Universidade do Porto, Porto, Portugal
| | - Alice Santos-Silva
- UCIBIO-REQUIMTE, Laboratory of Biochemistry, Faculdade de Farmácia, Universidade do Porto, Porto, Portugal
| | - Ana Isabel Lopes
- Paediatric Gastroenterology Unit, Hospital Universitário de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal.,Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
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Wang Y, Pan W, Zhao D, Chen Y, Chen X, Xia H. Diagnostic Value of Serum Procollagen III N-Terminal Peptide for Liver Fibrosis in Infantile Cholestasis. Front Pediatr 2020; 8:131. [PMID: 32296668 PMCID: PMC7136468 DOI: 10.3389/fped.2020.00131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 03/10/2020] [Indexed: 01/29/2023] Open
Abstract
Background: Several non-invasive markers have been reported as being effective for the assessment of fibrosis in adults with chronic viral hepatitis. The infantile liver is more susceptible to cholestasis, and it is important to promptly evaluate liver fibrosis to guide the clinical treatment. However, the clinical value of these markers in infants with cholestasis remains unknown. Aim: To investigate the correlation between serum laminin (LN), hyaluronic acid (HA), procollagen III N-terminal peptide (PIIINP) level, and liver fibrosis stage in infants with cholestasis. Methods: One hundred and thirty-seven term infants with cholestasis were included. Laparoscopic exploration and cholangiography were performed to diagnose or rule out biliary atresia. Serum LN, HA, and PIIINP were measured prior to laparoscopic exploration. Liver biopsy was performed for all patients. Liver fibrosis was staged on a five-point scale (F0-F4) according to the METAVIR scoring system. The correlation between serum markers and liver fibrosis stage was assessed. A receiver operator characteristic analysis was performed to determine the accuracy of serum markers for predicting the liver fibrosis stage. Results: Serum PIIINP and HA were positively correlated with liver fibrosis stage (r = 0.622, P < 0.001, and r = 0.41, P < 0.001, respectively). There was no significant correlation between serum LN and liver fibrosis stage (P > 0.05). Serum aspartate aminotransferase, total bilirubin, direct bilirubin, and PIIINP were independently correlated with the fibrosis stage on multivariate ordinal regression analysis. Receiver operating curve (ROC) analysis showed that serum PIIINP was the most effective for the diagnosis of fibrosis grade. The area under the ROC curves (AUROCs) for serum PIIINP for diagnosing fibrosis stages ≥F1, ≥F2, ≥F3, and F4 (cirrhosis) were 0.843, 0.789, 0.82, and 0.891, respectively. The cut-off serum PIIINP value for predicting fibrosis stage ≥F1 was 242.3 ng/mL, with 73.8% sensitivity and 90% specificity. The cut-off value for predicting cirrhosis was 698.7 ng/mL, with 75% sensitivity and 96% specificity. Conclusion: Serum PIIINP is a promising biomarker for predicting liver fibrosis stage, especially cirrhosis. Its assessment is a simple and non-invasive diagnostic method for liver fibrosis in infants with cholestasis.
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Affiliation(s)
- Yingcan Wang
- Department of Neonatology, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Weihua Pan
- Department of Pediatric Surgery, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Dongying Zhao
- Department of Neonatology, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yan Chen
- Department of Neonatology, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xuting Chen
- Department of Neonatology, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hongping Xia
- Department of Neonatology, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Fu HY, Zhao RQ, Bai GL, Yin CL, Yin RK, Li HH, Shi WN, Liu YL, Cheng LJ, Jia XY, Li GG, Zhao SG. [Value of serum gamma-glutamyl transpeptidase combined with direct bilirubin in the diagnosis of biliary atresia in infants]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2019; 21. [PMID: 31874659 PMCID: PMC7389014 DOI: 10.7499/j.issn.1008-8830.2019.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To study the value of serum gamma-glutamyl transpeptidase (GGT) combined with direct bilirubin (DB) in the diagnosis of biliary atresia. METHODS A total of 667 infants with cholestasis who were hospitalized and treated from July 2010 to December 2018 were enrolled as subjects. According to the results of intraoperative cholangiography and follow-up, they were divided into biliary atresia group with 234 infants and cholestasis group with 433 infants. The two groups were compared in terms of age of onset, sex, and serum levels of total bilirubin (TB), DB, alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bile acid (TBA), and GGT. A receiver operating characteristic (ROC) curve analysis was performed for indices with statistical significance, and the area under the ROC curve (AUC) and the optimal cut-off value for diagnosis were calculated. RESULTS The biliary atresia group had a significantly younger age of onset than the cholestasis group (P<0.001). There were no significant differences in sex, ALT, and AST between the two groups (P>0.05), while the biliary atresia group had significantly higher serum levels of TB, DB, TBA, and GGT than the cholestasis group (P<0.05). GGT combined with DB had the highest AUC of 0.892 (95% confidence interval: 0.868-0.916) in the diagnosis of biliary atresia. At the optimal cut-off values of 324.0 U/L for GGT and 115.1 μmmol/L for DB, GGT combined with DB had a sensitivity of 79.8% and a specificity of 83.2% in the diagnosis of biliary atresia. CONCLUSIONS GGT combined with DB has high sensitivity and specificity in the diagnosis of biliary atresia and can be used as an effective indicator for diagnosis of biliary atresia in infants.
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Affiliation(s)
- Hai-Yan Fu
- Department of Infectious and Digestive Diseases, Hebei Children's Hospital, Shijiazhuang 050031, China.
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Abstract
The co-occurrence of gut microbiota dysbiosis and bile acid (BA) metabolism alteration has been reported in several human liver diseases. However, the gut microbiota dysbiosis in infantile cholestatic jaundice (CJ) and the linkage between gut bacterial changes and alterations of BA metabolism have not been determined. To address this question, we performed 16S rRNA gene sequencing to determine the alterations in the gut microbiota of infants with CJ, and assessed their association with the fecal levels of primary and secondary BAs. Our data reveal that CJ infants show marked declines in the fecal levels of primary BAs and most secondary BAs. A decreased ratio of cholic acid (CA)/chenodeoxycholic acid (CDCA) in infants with CJ indicated a shift in BA synthesis from the primary pathway to the alternative BA synthesis pathway. The bacterial taxa enriched in infants with CJ corresponded to the genera Clostridium, Gemella, Streptococcus, and Veillonella and the family Enterobacteriaceae and were negatively correlated with the fecal BA level and the CDCA/CA ratio but positively correlated with the serological indexes of impaired liver function. An increased ratio of deoxycholic acid (DCA)/CA was observed in a proportion of infants with CJ. The bacteria depleted in infants with CJ, including Bifidobacterium and Faecalibacterium prausnitzii, were positively and negatively correlated with the fecal levels of BAs and the serological markers of impaired liver function, respectively. In conclusion, the reduced concentration of BAs in the gut of infants with CJ is correlated with gut microbiota dysbiosis. The altered gut microbiota of infants with CJ likely upregulates the conversion from primary to secondary BAs.IMPORTANCE Liver health, fecal bile acid (BA) concentrations, and gut microbiota composition are closely connected. BAs and the microbiome influence each other in the gut, where bacteria modify the BA profile, while intestinal BAs regulate the growth of commensal bacteria, maintain the barrier integrity, and modulate the immune system. Previous studies have found that the co-occurrence of gut microbiota dysbiosis and BA metabolism alteration is present in many human liver diseases. Our study is the first to assess the gut microbiota composition in infantile cholestatic jaundice (CJ) and elucidate the linkage between gut bacterial changes and alterations of BA metabolism. We observed reduced levels of primary BAs and most secondary BAs in infants with CJ. The reduced concentration of fecal BAs in infantile CJ was associated with the overgrowth of gut bacteria with a pathogenic potential and the depletion of those with a potential benefit. The altered gut microbiota of infants with CJ likely upregulates the conversion from primary to secondary BAs. Our study provides a new perspective on potential targets for gut microbiota intervention directed at the management of infantile CJ.
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Okazaki T, Ochi T, Nakamura H, Tsukui T, Koga H, Urao M, Lane GJ, Yamataka A. Needle liver biopsy has potential for delaying Kasai portoenterostomy and Is obsolete for diagnosing biliary atresia in the laparoscopic era. J Pediatr Surg 2019; 54:2570-2573. [PMID: 31522798 DOI: 10.1016/j.jpedsurg.2019.08.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Accepted: 08/24/2019] [Indexed: 01/11/2023]
Abstract
AIM Early diagnosis is essential for the successful management of biliary atresia (BA). We assessed the efficacy of our diagnostic strategies for BA in the laparoscopic era. METHODS A retrospective review of the medical records of 132 infants presenting with suspected BA between 1998 and 2018 was performed to assess the efficacy of "basic" tests (blood biochemistry, abdominal ultrasound, and Tc-99m N-pyrydoxyl-5-methyltriptophane liver scintigraphy) and the value of laparoscopic assessment of the porta hepatis and/or cholangiography for choosing between Kasai portoenterostomy (PE) or cholangiodrainage (CD) for treatment. RESULTS BA was excluded on "basic" tests in 7 cases: 109/125 had BA diagnosed laparoscopically and proceeded immediately to PE. Nonatrophic gallbladder cases (n = 10) had CD and other morbidity diagnosed on liver biopsy (Bx; n = 6). Sensitivity, specificity, and accuracy of diagnosis using "basic" tests were 100%, 30.4%, and 87.9%, respectively. Accuracy of laparoscopy without Bx was 100%, allowing immediate progression to PE without waiting for Bx results or trauma from Bx to heal. "Basic" tests and laparoscopy can be completed within one week. CONCLUSIONS A combination of "basic" tests and laparoscopy can diagnose BA promptly and accurately without Bx. Bx is essentially unnecessary for diagnosing BA if laparoscopy is performed. TYPE OF STUDY Study of diagnostic test. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Tadaharu Okazaki
- Department of Pediatric Surgery, Juntendo University Urayasu Hospital, Urayasu-shi, Chiba, Japan.
| | - Takanori Ochi
- Department of Pediatric General and Urogenital Surgery, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Hiroki Nakamura
- Department of Pediatric General and Urogenital Surgery, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Takafumi Tsukui
- Department of Pediatric General and Urogenital Surgery, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Hiroyuki Koga
- Department of Pediatric General and Urogenital Surgery, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Masahiko Urao
- Department of Pediatric Surgery, Juntendo University Nerima Hospital, Tokyo, Japan
| | - Geoffrey J Lane
- Department of Pediatric General and Urogenital Surgery, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Atsuyuki Yamataka
- Department of Pediatric General and Urogenital Surgery, Juntendo University Graduate School of Medicine, Tokyo, Japan
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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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Tsuda N, Shiraishi S, Sakamoto F, Ogasawara K, Tomiguchi S, Yamashita Y. Tc-99m PMT scintigraphy in the diagnosis of pediatric biliary atresia. Jpn J Radiol 2019; 37:841-849. [PMID: 31571132 DOI: 10.1007/s11604-019-00882-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Accepted: 09/17/2019] [Indexed: 02/04/2023]
Abstract
PURPOSE Hepatobiliary scintigraphy plays an important role in the differentiation of biliary atresia (BA) and non-BA. The usefulness of 99mTc-iminodiacetic acid (IDA) derivatives in BA diagnosis is reported in several papers. In contrast, there are no comprehensive data on differentiating BA from non-BA using 99mTc-N-pyridoxyl-5-methyl-tryptophan (PMT). Our objective was to evaluate the usefulness of 99mTc-PMT scintigraphy in the diagnosis of BA. MATERIALS AND METHODS 52 infants who received 99mTc-PMT scintigraphy for suspected BA were retrospectively evaluated. Preoperative cholangiograms or follow-ups were used as the gold standard for diagnosis of BA. We analyzed the utility of 99mTc-PMT scintigraphy, various clinical and investigational parameters in the diagnosis of BA. RESULTS The final diagnoses in this group were BA (67.3%) and non-BA (32.7%). 99mTc-PMT scintigraphy, stool color change, total bilirubin, direct bilirubin, aspartate aminotransferase (AST) and γ-glutamyl transferase (γ-GTP) led to distinguishing between BA and non-BA in univariate analysis. Subsequent multivariate logistic regression analysis indicated that 99mTc-PMT scintigraphy and γ-GTP were independent predictors of BA. The diagnostic accuracy of 99mTc-PMT scintigraphy was 94.2%. CONCLUSIONS 99mTc-PMT scintigraphy is more accurate in the diagnosis of BA than other conventional examinations. In addition, false positives of 99mTc-PMT scintigraphy could be reduced by combining γ-GTP level monitoring.
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Affiliation(s)
- Noriko Tsuda
- Department of Diagnostic Radiology, Faculty of Life Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan.
| | - Shinya Shiraishi
- Department of Diagnostic Radiology, Faculty of Life Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan
| | - Fumi Sakamoto
- Department of Diagnostic Radiology, Faculty of Life Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan
| | - Koji Ogasawara
- Department of Diagnostic Radiology, Faculty of Life Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan
| | - Seiji Tomiguchi
- Department of Diagnostic Medical Imaging, School of Health Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Yasuyuki Yamashita
- Department of Diagnostic Radiology, Faculty of Life Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan
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Nicastro E, Di Giorgio A, Marchetti D, Barboni C, Cereda A, Iascone M, D'Antiga L. Diagnostic Yield of an Algorithm for Neonatal and Infantile Cholestasis Integrating Next-Generation Sequencing. J Pediatr 2019; 211:54-62.e4. [PMID: 31160058 DOI: 10.1016/j.jpeds.2019.04.016] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 03/15/2019] [Accepted: 04/09/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To evaluate the performance of a diagnostic protocol for neonatal/infantile cholestasis in which the main clinical patterns steered the early use of different genetic testing strategies. STUDY DESIGN An observational study was conducted between 2012 and 2017 in a tertiary care setting on a prospective cohort of children with cholestasis occurring at ≤1 year of age and persisting ≥6 weeks, to measure the detection rate of underlying monogenic diseases. After the exclusion of biliary atresia, a clinically driven genetic testing was performed, entailing 3 different approaches with different wideness: confirmatory single-gene testing; focused virtual panels; and wide search through trio whole-exome sequencing. RESULTS We enrolled 125 children (66 female, median age 2 months); 96 (77%) patients had hypocholic stools and were evaluated rapidly to exclude biliary atresia, which was the final diagnosis in 74 (59%). Overall, 50 patients underwent genetic testing, 6 with single confirmatory gene testing, 38 through panels, and 6 with trio whole-exome sequencing because of complex phenotype. The genetic testing detection rate was 60%: the final diagnosis was Alagille syndrome in 11, progressive familial intrahepatic cholestasis type 2 in 6, alpha-1-antitrypsin deficiency in 3, and progressive familial intrahepatic cholestasis type 3 in 2; a further 7 genetic conditions were identified in 1 child each. Overall, only 18 of 125 (14%) remained with an indeterminate etiology. CONCLUSIONS This protocol combining clinical and genetic assessment proved to be an effective diagnostic tool for neonatal/infantile cholestasis, identifying inherited disorders with a high detection rate. It also could allow a noninvasive diagnosis in children presenting with colored stools.
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Affiliation(s)
- Emanuele Nicastro
- Pediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII, Bergamo, Italy.
| | - Angelo Di Giorgio
- Pediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Daniela Marchetti
- Medical Genetics Laboratory, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Chiara Barboni
- Pediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Anna Cereda
- Clinical Genetics, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Maria Iascone
- Medical Genetics Laboratory, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Lorenzo D'Antiga
- Pediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII, Bergamo, Italy
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Aspelund G, Mahdi EM, Rothstein DH, Wakeman DS. Transitional care for patients with surgical pediatric hepatobiliary disease: Choledochal cysts and biliary atresia. J Gastroenterol Hepatol 2019; 34:966-974. [PMID: 30552863 DOI: 10.1111/jgh.14575] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 11/13/2018] [Accepted: 12/09/2018] [Indexed: 12/14/2022]
Abstract
Choledochal cysts (CDCs) and biliary atresia (BA) are rare pediatric hepatobiliary anomalies that require surgical intervention due to increased risk of malignancy and liver failure, respectively. The underlying disease and operative procedures place patients at risk for long-term complications, which may continue to affect them into adulthood. Lack of a transitional care model in the health-care system potentiates the challenges they will face following aging out of their pediatric providers' care. We sought to elucidate the long-term complications and challenges patients with CDCs and BA face, review the current literature regarding transitioning care, and propose guidelines aiding adult providers in continued care and surveillance of these patients. A literature review was performed to assess short-term and long-term complications after surgery and the current standards for transitioning care in patients with a history of CDCs and BA. While transitional programs exist for patients with other gastrointestinal diseases, there are few that focus on CDCs or BA. Generally, authors encourage medical record transmission from pediatric to adult providers, ensuring accuracy of information and compliance with treatment plans. Patients with CDCs are at risk for developing biliary malignancies, cholangitis, and anastomotic strictures after resection. Patients with BA develop progressive liver failure, necessitating transplantation. There are no consensus guidelines regarding timing of follow up for these patients. Based on the best available evidence, we propose a schema for long-term surveillance.
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Affiliation(s)
- Gudrun Aspelund
- Department of Pediatric Surgery, Maria Fareri Children's Hospital, Valhalla, New York, USA
| | - Elaa M Mahdi
- Department of Surgery, School of Medicine and Dentistry, University of Rochester, Rochester, New York, USA
| | - David H Rothstein
- Department of Pediatric Surgery, School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA
| | - Derek S Wakeman
- Department of Surgery, School of Medicine and Dentistry, University of Rochester, Rochester, New York, USA
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Moreira-Silva H, Maio I, Bandeira A, Gomes-Martins E, Santos-Silva E. Metabolic liver diseases presenting with neonatal cholestasis: at the crossroad between old and new paradigms. Eur J Pediatr 2019; 178:515-523. [PMID: 30693370 DOI: 10.1007/s00431-019-03328-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 01/15/2019] [Accepted: 01/17/2019] [Indexed: 12/18/2022]
Abstract
Metabolic liver diseases (MLD) are an important group of disorders presenting with neonatal cholestasis (NC). The spectrum of liver involvement is wide and the presumptive diagnosis is traditionally based on clinical and laboratory findings. Recently, next-generation sequencing (NGS) panels have emerged as an appealing tool to diagnose neonatal/infantile cholestatic disorders. The aim of this study was to identify clinical phenotypes of liver injury and contribute to find a diagnostic methodology that integrates new molecular diagnostic tools. We retrospectively analyzed the clinical and biochemical features of 16 patients with MLD and NC. Patients were categorized into three groups: A-NC with liver failure (N = 8): tyrosinemia type I (n = 2), classic galactosemia (n = 5), mitochondrial DNA depletion syndrome (n = 1); B-NC evolving with chronic liver disease (N = 5): argininemia (n = 2); mitochondrial cytopathy (n = 1); congenital disorders of glycosylation type Ia (n = 1); Zellweger syndrome (n = 1); and C-transient NC (N = 3): Niemann-Pick type C (n = 2), citrullinemia type II (n = 1).Conclusion: MLD presenting with NC can be categorized into three main clinical phenotypes of liver injury. We highlight transient NC as a clue for MLD that must be pursued. New molecular diagnostic tools can play a key role, but application criteria must be established to make them cost-effective. What is Known: • Metabolic liver diseases are an important group of disorders presenting with neonatal cholestasis. • The diagnostic approach is challenging and traditionally based on clinical and laboratory findings. Next-generation sequencing is a recent and rapidly developing tool in pediatric hepatology. What is New: • We provide a liver-targeted characterization of metabolic liver diseases presenting with neonatal cholestasis, categorizing them into three clinical phenotypes that may narrow the diagnostic possibilities. • A clinical decision-making algorithm is proposed, in which the NGS technology is integrated.
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Affiliation(s)
- Helena Moreira-Silva
- Pediatric Gastroenterology Unit, Centro Materno Infantil do Norte - CMIN, Centro Hospitalar Universitário do Porto, Largo da Maternidade de Júlio Dinis, 4050-651, Porto, Portugal
| | - Inês Maio
- Pediatric Gastroenterology Unit, Centro Materno Infantil do Norte - CMIN, Centro Hospitalar Universitário do Porto, Largo da Maternidade de Júlio Dinis, 4050-651, Porto, Portugal
| | - Anabela Bandeira
- Pediatric Metabolic Unit, Centro Materno Infantil do Norte - CMIN, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Esmeralda Gomes-Martins
- Pediatric Metabolic Unit, Centro Materno Infantil do Norte - CMIN, Centro Hospitalar Universitário do Porto, Porto, Portugal.,Instituto de Ciências Biomédicas Abel Salazar, Porto, Portugal
| | - Ermelinda Santos-Silva
- Pediatric Gastroenterology Unit, Centro Materno Infantil do Norte - CMIN, Centro Hospitalar Universitário do Porto, Largo da Maternidade de Júlio Dinis, 4050-651, Porto, Portugal. .,Instituto de Ciências Biomédicas Abel Salazar, Porto, Portugal.
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Abstract
BACKGROUND Patients with gastroschisis and prolonged total (or partial) parenteral nutrition (PN) commonly develop direct hyperbilirubinemia (DH). OBJECTIVE To quantify the prevalence and severity of DH in newborns with gastroschisis and characterize the diagnostic work-up for DH in this patient population. DESIGN/METHODS Retrospective chart review of patients born with gastroschisis between 2005 and 2015 for the first 6 months of life. RESULTS 29 patients were identified with gastroschisis. Mean gestational age and birthweight were 36.4 (± 1.8) weeks and 2.5 (± 0.6) kg. 41% were treated with primary reduction versus staged closure. Peak total and direct bilirubin (DB) levels were 10.17 ± 6.21 mg/dL and 5.58 ± 3.94 mg/dL, respectively. 23 patients (79.3%) were diagnosed with DH and 78.2% underwent additional work-up for hyperbilirubinemia consisting of imaging and laboratory studies, none of which revealed a cause for DH other than the presumed PN-associated cholestasis. In all patients, DB began to decline within 1-10 days of initiation of enteral feeds. CONCLUSION(S) DH is common in patients with gastroschisis and is unlikely to be associated with pathology aside from PN. Additional work-up may lead to unnecessary resource utilization. LEVELS OF EVIDENCE Case series with no comparison group, Level IV.
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Lin HC, Kasi N, Quiros JA. Alpha1-Antitrypsin Deficiency: Transition of Care for the Child With AAT Deficiency into Adulthood. Curr Pediatr Rev 2019; 15:53-61. [PMID: 30421678 PMCID: PMC6696823 DOI: 10.2174/1573396314666181113094517] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 10/02/2018] [Accepted: 11/06/2018] [Indexed: 11/22/2022]
Abstract
IMPORTANCE Alpha1-antitrypsin (AAT) deficiency is a common, but an underdiagnosed genetic condition, affecting 1 in 1500 individuals. It can present insidiously with liver disease in children. Although clinical practice guidelines exist for the management of AAT deficiency, especially with regards to pulmonary involvement, there are no published recommendations that specifically relate to the management of the liver disease and monitoring for lung disease associated with this condition, particularly in children. OBJECTIVE To review the literature on the management of AAT deficiency-associated liver disease in adults and children. EVIDENCE REVIEW A systematic search for articles indexed in PubMed and published was undertaken. Some earlier selected landmark references were included in the review. Search terms included: "alpha1-antitrypsin deficiency"; "liver disease"; "end-stage liver disease"; "liver transplantation" and "preventative management". Recommendations for the management of children with suspected or confirmed AAT deficiency were made according to the Strength of Recommendation Taxonomy scale. FINDINGS Liver complications arising from AAT deficiency result from the accumulation of mutated AAT protein within hepatocytes. Liver disease occurs in 10% of children, manifested by cholestasis, pruritus, poor feeding, hepatomegaly, and splenomegaly, but the presentation is highly variable. A diagnostic test for AAT deficiency is recommended for these children. Baseline liver function tests should be obtained to assess for liver involvement; however, the only curative treatment for AAT deficiency-associated liver disease is organ transplantation. Conclusion and Relevance: There should be a greater vigilance for AAT deficiency testing among pediatricians. Diagnosis should prompt assessment of liver involvement. Children with AATdeficiency- associated liver disease should be referred to a liver specialist and monitored throughout their lifetimes for the symptoms of AAT-deficiency-related pulmonary involvement.
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Affiliation(s)
- Henry C Lin
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, United States
| | - Nagraj Kasi
- Division of Pediatric Gastroenterology, Hepatology and Nutrition MUSC Children's Hospital, South Carolina, SC, United States
| | - J Antonio Quiros
- Division of Pediatric Gastroenterology, Hepatology and Nutrition MUSC Children's Hospital, South Carolina, SC, United States
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Pandita A, Gupta V, Gupta G. Neonatal Cholestasis: A Pandora's Box. CLINICAL MEDICINE INSIGHTS-PEDIATRICS 2018; 12:1179556518805412. [PMID: 30574003 PMCID: PMC6295748 DOI: 10.1177/1179556518805412] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 08/29/2018] [Indexed: 12/15/2022]
Abstract
Neonatal cholestasis (NC) is a diagnostic dilemma frequently countered in a neonatal care unit. Early diagnosis is vital for achieving an optimal patient outcome as many causes of cholestasis such as biliary atresia are time-sensitive and amenable to treatment if analyzed and treated early. Nonetheless, it is not generally simple to analyze these cases right on time as some of them are regularly missed due to the presence of pigmented stools, lack of newborn metabolic screening, and named as instances of prolonged jaundice. In this manner, we prescribe to explore all reasons for prolonged jaundice stretching out past 14 days in neonates. Besides, we suggest that stool card ought to be a piece of release rundown for all newborn children being released from the nursery. This is of most extreme significance in the nation like India where guaranteeing customary follow-up is as yet a tough assignment. These stool cards will help in the early determination of patients with NC particularly biliary atresia and guarantee their auspicious cure. Another reason which needs exceptional say is parenteral nutrition–associated liver illness, as the proportion of preterm babies is getting greater and greater with better neonatal care. These extreme preterm infants are in the requirement for prolonged (>14 days) total parenteral nourishment because of which they are at high hazard for NC contrasted with their more developed peers. In this survey, we will give an understanding of clinical approach, differential diagnosis, and clinical review of NC.
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Affiliation(s)
- Aakash Pandita
- Department of Neonatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Vishal Gupta
- Department of Neonatology, Max Hospital, New Delhi, India
| | - Girish Gupta
- Department of Neonatology, Max Hospital, New Delhi, India
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Zhan J, Chen Y, Wong KKY. How to evaluate diagnosis and management of biliary atresia in the era of liver Transplantation in China. WORLD JOURNAL OF PEDIATRIC SURGERY 2018. [DOI: 10.1136/wjps-2018-000002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BackgroundBiliary atresia (BA) is one of the most challenging hepatobiliary diseases in children. Notwithstanding the reasonable outcome of liver transplantation (LT), portoenteral anastomosis (Kasai operation) is still the first choice of treatment for patients with BA. How to improve the survival rate of the patients with BA in the era of LT is a new challenge.Data sourcesBased on recent original publications and the experience with the BA in China, we review many factors that influence BA survival situation, including early diagnosis and screen plan, defects of early treatment, Kasai operation, and LT and indicate present questions about BA diagnosis and treatment in China.ResultsBA diagnosis may also be delayed due to insufficient understanding of BA and lack of jaundice monitoring methods at different levels of the hospitals in China. Further education of the physicians at smaller city hospitals about BA, neonatal jaundice and cholestasis would be helpful in improving early diagnosis of BA. Early surgical intervention is still the only guarantee to improve the survival rate of BA with native liver.ConclusionsIn the era of LT, especially in China, Kasai operation can provide waiting time for living donor LT and improve the success rate of LT and minimize the rapid deterioration of liver function of the children with BA and decrease the mortality in patients with BA.
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Timmons Z, Timmons J, Conrad C, Miloh T. Epidemiology of Hyperbilirubinemia in a Quaternary Pediatric Emergency Department over a Three-Year Period. Pediatr Gastroenterol Hepatol Nutr 2018; 21:297-305. [PMID: 30345243 PMCID: PMC6182479 DOI: 10.5223/pghn.2018.21.4.297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 03/25/2018] [Accepted: 05/16/2018] [Indexed: 11/14/2022] Open
Abstract
PURPOSE There is a lack of scholarly reports on pediatric emergency department (PED) exposure to hyperbilirubinemia. We aimed to describe the epidemiology of hyperbilirubinemia in patients presenting to a PED over a three-year period. METHODS This was a retrospective cohort study, completed at an urban quaternary academic PED. Patients were included if they presented to the PED from 2010 to 2012, were 0 to 18 years in age, and had an elevated serum bilirubin for age. A chart review was completed to determine the incidence of hyperbilirubinemia, etiology, diagnostic work up and prognosis. The data set was stratified into four age ranges. RESULTS We identified 1,534 visits where a patient was found to have hyperbilirubinemia (0.8% of all visits). In 47.7% of patients hyperbilirubinemia was determined to have arisen from an identifiable pathologic etiology (0.38% of all visits). First-time diagnosis of pathologic hyperbilirubinemia occurred in 14% of hyperbilirubinemia visits (0.11% of all visits). There were varying etiologies of hyperbilirubinemia across age groups but a male predominance in all (55.0%). 15 patients went on to have a liver transplant and 20 patients died. First-time pathologic hyperbilirubinemia patients had a mortality rate of 0.95% for their initial hospitalization. CONCLUSION Hyperbilirubinemia was not a common presentation to the PED and a minority of cases were pathologic in etiology. The etiologies of hyperbilirubinemia varied across each of our study age groups. A new discovery of pathologic hyperbilirubinemia and progression to liver transplant or death during the initial presentation was extremely rare.
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Affiliation(s)
- Zebulon Timmons
- Division of Emergency Medicine, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Jaci Timmons
- Division of Pediatrics, Cardon Children's Medical Center, Mesa, AZ, United States
| | - Christina Conrad
- Division of Emergency Medicine, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Tamir Miloh
- Division of Gastroenterology, Texas Children's Hospital, Houston, TX, United States
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