The liver in pediatric gastrointestinal disease

Incidental hypertransaminasemia in children-a stepwise approach in primary care

Children with elevated liver enzymes are occasionally discovered through laboratory work-up from different clinical scenarios. Although the majority will have transient and/or benign conditions, a subgroup will have underlying liver disorders. The differential diagnosis is broad and therefore, a systematic approach is of utmost importance. In this article, we reviewed the most recent and relevant literature to provide a comprehensive overview of the main disease processes that cause hypertransaminasemia in children. Ultimately, we propose a practical stepwise approach to guide primary care physicians in the evaluation of abnormal liver enzymes in asymptomatic children. The first step is to obtain a complete history along with a thorough physical examination to exclude red flags, which should dictate urgent consultation with a paediatric gastroenterologist or hepatologist.  Conclusion: Hypertransaminasemia is a challenging scenario in the primary care setting. The aetiology can be broad, ranging from hepatic and extrahepatic to transient versus chronic liver disease. Timely referral to a specialised centre is of paramount importance for conducting targeted research and to not miss the chance of identifying a progressive, but still asymptomatic, treatable liver disease. What is Known: • Elevated liver enzyme is a challenging scenario in the primary care setting. • There are few studies guiding the evaluation of asymptomatic hypertransaminasemia in the paediatric population and a standardised approach is lacking. What is New: • We propose a practical stepwise approach to guide primary care physicians in the evaluation of abnormal liver enzymes.

Autoimmune liver disease in gastrointestinal conditions

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Liver Involvement in Children during the Diagnosis of Celiac Disease: A Single-Center Experience from Turkey

BACKGROUND: Liver abnormalities in Celiac disease (CD) are common. The aim of this study was to investigate the children with CD who were followed up in our clinic presenting with elevated aminotransferase levels. METHODS: In this study, the data of 419 pediatric patients with CD were retrospectively analyzed, and those with elevated aminotransferase levels during the diagnosis of CD were assessed. RESULTS: Elevation of aminotransferase levels was found in 66 (15.7%) patients among the 419 patients during the diagnosis of CD. The mean age of these patients was 7.33±3.96 years. Liver enzymes were mildly elevated in 63 (95.4%) patients. However, half of the patients with elevated liver enzymes had a 1.25-fold increase in aminotransferase levels. Patients with hypertransaminasemia had higher weight loss and lower folic acid values compared with patients with normal liver enzymes. Patients' liver tests were reverted to normal, except for two patients with chronic liver disease, after 9.27±3.16 months of administering a gluten-free diet. CONCLUSION: Patients with liver involvement should be investigated for CD. Especially, mildly elevation of aminotransferase levels should be taken into account by pediatricians for Celiac hepatitis.

Cystic Fibrosis Liver Disease: Know More

Cystic fibrosis (CF) is a multisystem disease caused by mutations in the CF transmembrane conductance regulator (CFTR) gene. CFTR is expressed in the apical surface of cholangiocytes. Homozygous CFTR gene mutation results in viscous and acidic bile secretions secondary to deficient surface fluid and bicarbonate efflux. Viscous, inspissated bile causes ductular obstruction and hepatotoxicity from retained bile components, leading to fibrosis and ultimately cirrhosis, known as CF liver disease (CFLD). CFLD is the third leading cause of death in CF patients. CFLD manifestations can take many forms. They range from asymptomatic elevation of transaminases to cirrhosis and end-stage liver disease. CFLD is diagnosed after excluding other causes of chronic liver disease. To date, there is no effective therapy to prevent or treat CFLD. Management of CFLD emphasizes on optimizing nutritional status. Ursodeoxycholic acid is the only available treatment that may prevent progression of CFLD at present. All CF patients with CFLD need annual investigations and follow-up for early detection of the disease. Liver transplantation should be considered in patients with decompensated cirrhosis and portal hypertension, with acceptable long-term outcomes. Novel therapies of CFLD are promising. This review article aims to summarize the published literature on CFLD, its pathophysiology, clinical features and complications, and management including new therapeutic options.

Paediatric fatty liver disease (PeFLD): All is not NAFLD - Pathophysiological insights and approach to management

The recognition of a pattern of steatotic liver injury where histology mimicked alcoholic liver disease, but alcohol consumption was denied, led to the identification of non-alcoholic fatty liver disease (NAFLD). Non-alcoholic fatty liver disease has since become the most common chronic liver disease in adults owing to the global epidemic of obesity. However, in paediatrics, the term NAFLD seems incongruous: alcohol consumption is largely not a factor and inherited metabolic disorders can mimic or co-exist with a diagnosis of NAFLD. The term paediatric fatty liver disease may be more appropriate. In this article, we summarise the known causes of steatosis in children according to their typical, clinical presentation: i) acute liver failure; ii) neonatal or infantile jaundice; iii) hepatomegaly, splenomegaly or hepatosplenomegaly; iv) developmental delay/psychomotor retardation and perhaps most commonly; v) the asymptomatic child with incidental discovery of abnormal liver enzymes. We offer this model as a means to provide pathophysiological insights and an approach to management of the ever more complex subject of fatty liver.

Relationship between Nonalcoholic Fatty Liver Disease and Vitamin D Nutritional Status in Extreme Obesity

AIM

To evaluate the relationship of nonalcoholic fatty liver disease (NAFLD) with nutritional status of vitamin D in extreme obesity.

METHODS

Descriptive cross-sectional study in individuals with class III obesity (BMI ≥ 40 kg/m2), aged ≥ 20 years to < 60 years. Data were obtained for weight, height, waist circumference (WC), and serum 25-hydroxyvitamin D (25(OH)D) levels. Vitamin D analysis was performed by high performance liquid chromatography (HPLC) and the cutoff points used for its classification were < 20 ng/mL for deficiency and 20-29.9 ng/ml for insufficiency. NAFLD gradation was conducted through histological evaluation by liver biopsy.

RESULTS

The sample is comprised of 50 individuals (86% female). BMI and average weight were 44.1 ± 3.8 kg/m2 and 121.4 ± 21.4 kg, respectively. Sample distribution according to serum 25(OH)D levels showed 42% of deficiency and 48% of insufficiency. The diagnosis of NAFLD was confirmed in 100% of the individuals, of which 70% had steatosis and 30% had steatohepatitis. The highest percentage of 25(OH)D insufficiency was seen in individuals with steatosis (66%/n = 21) and steatohepatitis (93%/n = 16). All individuals with steatohepatitis presented VDD (p < 0.01).

CONCLUSION

The results of this study showed high prevalence of serum 25(OH)D inadequacy in individuals with class III obesity, which worsens as the stage of liver disease progresses.

Hypertransaminasemia in Newly Diagnosed Pediatric Patients With Celiac Disease

OBJECTIVES

The aim of the present study was to determine the proportion of pediatric patients with celiac disease (CD) who had transaminases obtained at diagnosis and to determine the proportion with hypertransaminasemia.

METHODS

Data from newly diagnosed patients with CD at Nationwide Children's Hospital from February 2007 to March 2014 were retrospectively reviewed. Alanine transaminase (ALT) and aspartate transaminase (AST) values at diagnosis and after initiation of a gluten-free diet (GFD) were assessed.

RESULTS

Of 388 patients (mean age 10.1 ± 4.4 years, 235 girls), 185 (47.7%) had transaminases obtained at the time of diagnosis. Twenty-eight of one hundred eighty-five (15.1%) had an elevated ALT and/or AST level with an average ALT 2.52 × upper limit of normal (ULN) and AST 1.87 × ULN. Those with hypertransaminasemia were younger than those with normal levels (6.31 ± 4.75 vs 11.00 ± 4.28 years, P < 0.0001). Sex, symptoms at diagnosis, and weight, height, and body mass index z scores were not predictive of elevated transaminases. Of the 21 patients with hypertransaminasemia at diagnosis who had repeat laboratory test results after starting the GFD, 15 (71.4%) normalized whereas 6 (28.6%) remained elevated.

CONCLUSIONS

There is variation in practice among pediatric gastroenterologists in the assessment of transaminases in children with CD. Hypertransaminasemia is present at diagnosis in a significant proportion of children with CD although at a lower frequency than previously reported. Younger patients are more likely to have an elevation in transaminases. Abnormal transaminases normalize in the majority of patients within 1 year after initiation of a GFD.

PNPLA3 148M Carriers with Inflammatory Bowel Diseases Have Higher Susceptibility to Hepatic Steatosis and Higher Liver Enzymes

BACKGROUND

Inflammatory bowel diseases (IBD) are characterized by chronic relapsing inflammation of the gastrointestinal tract and encompass Crohn's disease and ulcerative colitis. IBD are often associated with extraintestinal manifestations affecting multiple organs including the liver. Increased levels of serum aminotransferases, possibly related to nonalcoholic fatty liver disease, constitute one of the most frequently described IBD-related liver diseases. The PNPLA3 I148M substitution is a major common genetic determinant of hepatic fat content and progression to chronic liver disease. The aim of this study was to investigate whether carriers of PNPLA3 148M allele with IBD have higher risk of liver steatosis and increase in transaminases levels.

METHODS

The PNPLA3 I148M (rs738409) genotype was performed by Taqman assays in 158 individuals from Southern Italy (namely, Catanzaro cohort) and in 207 individuals from Northern Italy (namely, Milan cohort) with a definite diagnosis of IBD. Demographic and clinical data and also alanine transaminase levels were collected for both cohorts. The Catanzaro cohort underwent liver evaluation by sonography and liver stiffness and controlled attenuation parameter measurements by transient elastography.

RESULTS

Here, we show for the first time that carriers of the PNPLA3 148M allele with IBD have a greater risk of hepatic steatosis (odds ratio, 2.9, and confidence interval, 1.1-7.8), higher controlled attenuation parameter values (P = 0.029), and increased circulating alanine transaminase (P = 0.035) in the Catanzaro cohort. We further confirm the higher alanine transaminase levels in the Milan cohort (P < 0.001).

CONCLUSIONS

Our results show that PNPLA3 148M carriers with IBD have higher susceptibility to hepatic steatosis and liver damage.

Nonalcoholic Fatty Liver Disease Relationship with Metabolic Syndrome in Class III Obesity Individuals

INTRODUCTION

Obesity is represented mainly by abdominal obesity and insulin resistance (IR), both present in most individuals diagnosed with metabolic syndrome (MS). IR is the key risk factor in the pathogenesis of nonalcoholic fatty liver disease (NAFLD). Objective. To relate NAFLD to MS in class III obese individuals.

METHODOLOGY

A descriptive cross-sectional study with class III obese individuals, aged ≥ 20-60 years. Blood pressure measurement, weight, height, body mass index (BMI), waist circumference (WC) and blood glucose, insulin, high-density lipoprotein cholesterol (HDL-c), and triglycerides data were obtained. HOMA-IR (homeostatic model assessment insulin resistance) calculation was carried out with a cutoff value of 2.71 for IR evaluation. The diagnosis of NAFLD was performed by liver biopsy and the diagnosis of MS was performed in accordance with the National Cholesterol Education Program/Adult Treatment Panel III (NCEPATP III).

RESULTS

Of the 50 individuals evaluated, 86% were women and BMI means were 45.4 ± 3.6 Kg/m(2). The overall individuals had NAFLD, 70% steatosis, and 30% steatohepatitis. The diagnosis of MS occurred in 56% but showed no significant association with NAFLD (P = 0.254). Triglycerides (178 ± 65.5 mg/dL) and insulin (28.2 ± 22.6 mcU/mL) mean values were significantly higher in steatohepatitis (P = 0.002 and P = 0.042, resp.) compared to individuals with steatosis. IR was confirmed in 76% and showed a relationship with NAFLD severity.

CONCLUSION

NAFLD was not related to MS; however, MS components, evaluated in isolation, as well as IR, were related to the presence and severity of NAFLD.