Comparison of different diagnostic methods in infants with Cholestasis

INTRODUCTIONCholestatic jaundice in early infancy is an important clinical condition that results from diminished bile flow and/or excretion, and can be caused by a number of disorders. Idiopathic neonatal hepatitis (INH) and biliary atresia (BA) are two …     

Neonatal jaundice

Neonatal jaundice lasting greater than 2 weeks should be investigated. Pale stools and dark or yellow urine are evidence of liver disease, which should be urgently investigated. The neonatal hepatitis syndrome has many causes, and a structured approach to investigation is mandatory. It should be possible to confirm or exclude biliary atresia within one week, so that definitive surgery is not delayed unnecessarily. Babies with the neonatal hepatitis syndrome should have vigorous fat-soluble vitamin supplementation, including parenteral vitamin K if coagulation is abnormal. The prognosis for infants with idiopathic neonatal hepatitis and multifactorial cholestasis is excellent.     

Atypical causes of cholestasis

Cholestatic liver disease consists of a variety of disorders. Primary sclerosing cholangitis and primary biliary cirrhosis are the most commonly recognized cholestatic liver disease in the adult population, while biliary atresia and Alagille syndrome are commonly recognized in the pediatric population. In infants, the causes are usually congenital or inherited. Even though jaundice is a hallmark of cholestasis, it is not always seen in adult patients with chronic liver disease. Patients can have “silent” progressive cholestatic liver disease for years prior to development of symptoms such as jaundice and pruritus. In this review, we will discuss some of the atypical causes of cholestatic liver disease such as benign recurrent intrahepatic cholestasis, progressive familial intrahepatic cholestasis, Alagille Syndrome, biliary atresia, total parenteral nutrition induced cholestasis and cholestasis secondary to drug induced liver injury.     

Variant clinical courses of 2 patients with neonatal intrahepatic cholestasis who have a novel mutation of SLC25A13

Deficiency of citrin due to mutations of the SLC25A13 gene causes not only adult-onset type II citrullinemia, but also neonatal intrahepatic cholestasis. Neonatal intrahepatic cholestasis is a self-limiting condition and spontaneously disappears by 12 months of age without special treatment. The natural history of patients with SLC25A13 mutations is not clear. Two patients with infantile hepatic dysfunction were found to have a novel mutation of the SLC25A13 gene. DNA analyses of SLC25A13 disclosed that the first patient was a compound heterozygote for the Ex16+74_IVS17-32del516 (del516-Ex16/IVS17) and IVS11+1G-->A mutations and the second one a homozygote for the del516-Ex16/IVS17 mutation. It is predicted that the 516-base pair deletion mutation leads to a frameshift from codons 556 to 564, a premature termination at codon 565, and a truncated form of the citrin protein (normal, 675 amino acids). The first patient had disseminated intravascular coagulation associated with hepatic dysfunction in the neonatal period. The other patient had persistent cholestatic jaundice and underwent an operation to rule out bile duct atresia. Without specific treatment, both patients had a favorable clinical course. In conclusion, citrin deficiency resulting from the mutation of SLC25A13 presented variant clinical courses, followed by hypercitrullinemia and intrahepatic cholestasis in infancy. The conditions in the patients were self-limiting and spontaneously disappeared.     

Liver disease in children with PiZZ alpha 1-antitrypsin deficiency

We present our experience with 18 pediatric patients with alpha 1-antitrypsin deficiency of the PiZZ phenotype. Fifteen patients (83%) presented with neonatal cholestatic jaundice at a mean age of 2 +/- 0.6 months (+/- S.D.). The male:female ratio was 15:3, indicating a male predominance. All metabolic, infectious and obstructive causes of jaundice were ruled out by appropriate tests in the patients with neonatal cholestasis. Liver biopsy in 14 patients with neonatal cholestasis showed a histological picture of cholestasis in all biopsies; neonatal giant cell hepatitis appeared in seven, increased fibrosis in appeared five and established liver cirrhosis appeared in two biopsies. Patients were followed for a mean of 3.7 +/- 2.4 years (+/- S.D.). Of the 15 patients with neonatal cholestasis, 3 under went liver transplantation because of decompensated liver cirrhosis at 3, 3 1/2 and 7 years. Two patients died at 4 months and 3 years from complications of liver cirrhosis. Of the remaining 10 patients, 3 had histological evidence of liver cirrhosis, and the remaining 7 patients continue to have enlarged liver and spleen with abnormal liver function tests. Of the three patients without history of neonatal cholestasis, only one had enlarged liver and spleen, and the remaining two are healthy with normal liver function tests. Our experience indicates serious liver disease is highly likely to develop in patients with PiZZ alpha 1-antitrypsin deficiency who present with neonatal cholestatic jaundice. Our experience differs from more recent reports on such patients.     

Prolonged neonatal cholestasis: prospective study

Due to the urgency in choosing either clinical treatment or immediate surgical intervention, the study of the prolonged neonatal cholestasis involves two basic aims: the differential diagnosis between biliary atresia and neonatal hepatitis and the research into the associated etiological agents. So, in a prospective trial carried out in the 70's, 77 children with prolonged neonatal cholestasis were studied in order to establish the differential diagnosis between biliary atresia and neonatal hepatitis, followed by the evaluation of 108 children towards a pathogenesis of the prolonged neonatal cholestasis. The results of the differential diagnosis showed that within 18 items examined only 8 proved to be good biliary atresia indicators. They are as follows (in decreasing order): ductular proliferation (portal tracts), fibrosis (portal tracts), cholestasis (portal tracts), stools colour--acholia, hepatomegaly, canalicular cholestasis (lobule), infiltrate (portal tracts), giant cells (lobule). These eight items were then gathered in a sole indicator of great discriminative power, with a confidence level of 99%. The figures regarding the pathogenesis are: rubella virus 0%, herpes simplex virus 0%, listeriosis 0%, cytomegalovirus 2.2%, hepatitis B virus 2.4%, toxoplasmosis 2.8%, alpha-1-antitrypsin deficiency 13.1%, syphilis 21.1%, autoantibodies against the liver 58.4%. Such work thus revealed that those eight most important factors when differentiating biliary atresia from neonatal hepatitis remain as fundamental indicators and, when employed alongside other diagnostic methods, can help in the assembling of a multifactorial strategy less and less invasive and more precise. The pathogenic study, with its heavy dependency on time and place, has become more complete with the introduction of new diagnostic methods, evolving to the ideal progressive reduction of idiopathic processes.     

Clinical problems with developmental anomalies of the biliary tract

Cholestatic jaundice defined as conjugated hyperbilirubinemia is a typical feature of neonatal liver disease. Biliary atresia is the most common disorder producing cholestasis during the first 2 months of life. Syndromic and non-syndromic paucity of the intralobular bile ducts and choledochal cysts can also present with cholestasis during early life. Liver dysfunction from obstruction of the biliary tree must be differentiated from numerous disorders affecting hepatocytes such as congenital infection and inborn errors of metabolism. Early recognition and a stepwise diagnostic evaluation of the cholestatic infant are essential in successfully treating many metabolic and infectious liver diseases of the infant as well as surgically relieving obstruction in patients with biliary atresia.     

Quantitative analysis of ductus proliferation, proliferative activity, Kupffer cell proliferation and angiogenesis in differential diagnosis of biliary atresia and neonatal hepatitis

BACKGROUND/AIMS: The clinical presentation of cholestasis in infancy caused by neonatal hepatitis and biliary atresia are very similar. Differential diagnosis is sometimes very difficult. The diagnostic accuracy is very important. The surgical treatment of biliary atresia should be performed as early as possible. If cases of biliary atresia are misdiagnosed, they will become progressive cirrhosis and if cases of neonatal hepatitis are misdiagnosed, they will result in unnecessary laparotomy. The aim of this study is to determine the role of quantitative analysis of ductus proliferation, proliferative activity, Kupffer cell proliferation and angiogenesis in the differential diagnosis of biliary atresia and neonatal hepatitis. METHODOLOGY: This study included 60 infants, 30 with neonatal hepatitis and 30 with biliary atresia. Differential diagnosis was done by ultrasonography, cholescintigraphy and liver biopsy. The parafifin-embedded tissue sections of liver biopsies underwent immunohistochemistry with Ki67 to mark proliferation activity, cytokeratin to mark the proliferating ductuli, vimentin to mark Kupffer cells, and CD34 to mark capillary vessels. Number of ductuli per high power field, number of Ki-67 positive cells per ductus, number of Kupffer cells per high power field and number of capillary vessels per high power field were calculated. Independent T test was used for statistical evaluation. RESULTS: Independent sample T test indicated that there is a significant difference for proliferating ductuli and proliferation activity between neonatal hepatitis and biliary atresia. Biliary atresia cases represent more proliferating ductuli and proliferation activity in ductal epithelial cells than neonatal hepatitis cases. There is no statistical significance for Kupffer cell proliferation and vascularization. CONCLUSIONS: Our results indicate that, quantitative analysis of proliferating ductuli and proliferation activity of ductal epithelial cells may be helpful in differential diagnosis of neonatal hepatitis and biliary atresia. Besides neither Kupffer cell proliferation nor vascularization are found to be useful in differential diagnosis.     

Flucloxacillin induced delayed cholestatic hepatitis

We report four cases of severe delayed cholestatic hepatitis induced by flucloxacillin. All patients presented with deep jaundice and pruritus which developed soon after ceasing flucloxacillin. Liver function tests were abnormal in all patients with markedly elevated serum bilirubin concentration, alkaline phosphatase and aspartate transaminase levels. Extrahepatic biliary obstruction and infective hepatitis were excluded in all cases. Liver biopsies showed centrilobular cholestasis with portal and lobular inflammation and eosinophil infiltration. Although symptoms resolved within six weeks in all patients, cholestatic liver function tests have persisted in two patients for more than six months. With the increasing usage of this drug and the delayed presentation of cholestasis, flucloxacillin needs to be considered in the differential diagnosis of all patients presenting with cholestatic jaundice.     

Paraneoplastic cholestasis associated with prostate carcinoma.

Paraneoplastic syndromes associated with prostate carcinoma are very rare. We report a patient with prostate carcinoma and cholestatic jaundice without biliary obstruction, hepatic involvement or infectious etiology. In the literature, only one case of idiopathic cholestatic jaundice with prostate carcinoma has been reported and a paraneoplastic etiology was suggested. In our case, cholestasis rapidly regressed with chemotherapy and the patient is well at six months of follow-up. Paraneoplastic cholestasis should be kept in mind in the absence of biliary tract obstruction, hepatic involvement or infectious etiology.     

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

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

Idiopathic adulthood ductopenia: case report and review of the literature

The clinical and pathological findings of idiopathic ductopenia were studied in a 30-year-old woman who initially manifested jaundice and pruritus. Serum biochemical tests of liver function indicated severe and progressive cholestasis. Viral hepatitis markers and circulating autoantibodies were absent. The patient had a normal cholangiogram and lacked evidence of inflammatory bowel disease. Histological examination of a liver specimen showed severe cholestasis and absence of interlobular bile ducts. Severe jaundice and intractable pruritus developed in the patient and served as the indications for liver transplantation 4 months after initial examination. Transplantation resulted in prompt and complete resolution of the jaundice and pruritus. Two types of idiopathic adulthood ductopenia associated with different prognoses are recognized. Patients with type 1 idiopathic adulthood ductopenia are asymptomatic or manifest symptoms of cholestatic liver disease. They tend to have less destruction of the intrahepatic bile ducts on liver biopsy specimens. Their clinical course ranges from spontaneous improvement to progression to biliary cirrhosis. In contrast, patients with type 2 idiopathic adulthood ductopenia generally manifest initial symptoms of decompensated biliary cirrhosis, have extensive destruction of the intrahepatic bile ducts on liver biopsy, and frequently require orthotopic liver transplantation.     

Polymerase chain reaction to detect human cytomegalovirus in livers of infants with neonatal hepatitis.

Neonatal hepatitis is closely related to human cytomegalovirus infection in Taiwan, a conclusion based on serological and urine culture studies. To obtain more direct evidence further relating cytomegalovirus to the pathogenesis of neonatal hepatitis, the cytomegalovirus genome was studied in the liver tissues of 50 infants with neonatal hepatitis using the polymerase chain reaction (PCR). Liver tissues from 26 infants with biliary atresia and another 30 infants and children with diagnoses other than neonatal hepatitis, cholestasis, or hepatitis were also studied for comparison. Sequences from the immediate early gene 1 and 2 regions were used as primers. The liver tissues from 23 (46%) of the 50 infants with neonatal hepatitis were positive for cytomegalovirus genome, whereas those of 2 of the 26 infants with biliary atresia and none of the liver tissues from 30 infants and children without neonatal hepatitis were positive for cytomegalovirus genome, by PCR. The results of PCR correlated well with that of serology and urine culture. This study provides further evidence of cytomegalovirus in the pathogenesis of neonatal hepatitis.     

Endoscopic cholangiopancreatography in the infant: evaluation of a new prototype pediatric duodenoscope

The usefulness of a new pediatric duodenoscope PJF in the diagnosis of neonatal cholestasis was studied in 23 infants with ages ranging from 19 to 150 days. In 22 of 23 infants the papilla was cannulated. In 13 of 14 neonates (93%) with neonatal hepatitis, the common bile duct was opacified and biliary atresia was excluded. In one of two neonates with choledochal cyst, the common bile duct was demonstrated. In six of seven neonates (86%) with biliary atresia, only the pancreatic duct was demonstrated and the diagnosis was suspected. Although absence of a common bile duct opacification does not rule out biliary atresia, ERCP with the new duodenoscope proved to be most useful in the diagnosis of normal biliary tree and served to avoid unnecessary surgery in most infants with neonatal cholestasis.     

CHOLESTASIS IN ACUTE ALCOHOLIC LIVER DISEASE

10 of a series of 108 patients with alcoholic liver disease presented with cholestasis associated with non-cirrhotic alcoholic liver disease and without evidence of extrahepatic biliary obstruction. In 7 patients liver histology and the associated conditions presenting as cholestasis were heterogeneous. However, in 3 patients who had been drinking excessively before cholestatic jaundice developed, cholestasis was a major feature of liver histology. The term acute alcoholic cholestasis is suggested for this apparently distinct syndrome of cholestatic jaundice in the absence of hepatitis.     

Cholangiography via laparoscopy in the differential diagnosis of neonatal hepatitis and bile duct atresia

Twenty-three infants with neonatal cholestasis were examined laparoscopically. The differential diagnosis between biliary atresia and neonatal hepatitis was not established by-clinical and laboratory investigations. In 10 out of 23 cases the transcutaneous-transhepatic-cholangiography, performed with laparoscopy demonstrated the permeability of the biliary tree in children that are not suffering from the atresia. The hepatic biopsy by laparoscopic view allowed to complete the investigation in these cases, avoiding unnecessary laparotomy. In infants suffering from biliary atresia the surgery indication was early and exact.     

Role of some viral infections in neonatal cholestasis

Viral infection is one of the postulated causes of neonatal cholestasis. In addition to earlier reports on the association of viral infection and intrahepatic cholestasis (IH), recent studies have suggested a similar link to extra hepatic biliary atresia (EHBA). The aim of this work was to evaluate the role of some viral infections in neonates presenting with cholestasis to the Neonatology Ward of Zagazig University Hospitals. Sixty-two neonates were included in the study (44 cholestatic neonates and 18 apparently healthy neonates as the control group). All neonates were subjected to full history taking and complete physical examination. Laboratory investigations included CBC, liver function tests, bleeding profile, blood cultures, abdominal ultrasound and detection of HBsAg and serum IgM antibodies against certain viruses (CMV, Reovirus III, HSV I, HSV II, Rubella virus) using ELISA. Radionuclide cholescintigraphy was performed for patients only. The study revealed that cholestatic neonates were significantly associated with dark urine, pale stool and hepatomegaly compared with the control (P<0.004, P<0.001, P<0.008, respectively). Quantitation of IgM antibody titre using ELISA revealed significantly higher levels of serum anti-CMV IgM and anti-Reovirus III IgM in cholestatic than in the control groups. No significant differences were found in levels of anti-HSV I, anti-HSV II or anti-rubella antibodies between cholestatic and control groups. HBsAg was negative for all neonates; cholestatic and control. Lastly, no significant differences were found between neonates with EHBA (7 cases) and Intrahepatic cholestasis (37 cases) regarding anti -CMV IgM or anti -Reo III IgM. It can be concluded that CMV and Reovirus type 3 infections of the neonates are associated with the development of cholestatic disorder, not only due to IH cholestasis but also due to the production of EHBA.     

LP-X in cholestasis.

Extrahepatic and intrahepatic biliary obstruction of different etiology were studied in 62 patients, who were investigated for the presence of lipoprotein X (Lp-X). It was found present in 19 of 20 cholestasis by lithiasis, in all three primary biliary cirrhosis patients, in 2 of 4 cirrhosis, in 5 of 13 hepatitis, in all three benign recurrent intrahepatic cholestasis and in 1 of 2 recurrent juandice of pregnancy. It was found in a Dubin Johnson. Lp-X disappeared in 4 patients within two weeks after relief of the obstruction. It was found in patients with cholestatic hepatitis during the first week of jaundice. It was found in the first 48 hours in three patients with cholestasis by lithiasis. Lp-X does not help in differential diagnosis between extrahepatic and intrahepatic biliary obstruction, but the time of its appearance could contribute to it in some cases. A word of caution is raised in indicating surgery in a cholestatic patient without the presence of Lp-X.     

Diagnostic and therapeutic approach to cholestatic liver disease.

When cholestatic liver disease is present, liver ultrasound should be performed to ascertain if cholestasis is extrahepatic or intrahepatic. If bile ducts appear dilated and the probability of interventional treatment is high, endoscopic retrograde cholagio-pancreatography (ERCP) or trans-hepatic cholangiography (THC) should be the next step. If the probability of interventional therapeutics is low, cholangio-MRI should be performed. Once bile duct dilation and space occupying lesions are excluded, a work up for intrahepatic cholestasis should be started. Some specific clinical situations may be helpful in the diagnostic strategy. If cholestasis occurs in the elderly, drug-induced cholestatic disease should be suspected, whereas if it occurs in young people with risk factors, cholestatic viral hepatitis is the most likely diagnosis. During the first trimester of pregnancy cholestasis may occur in hyperemesis gravidorum, and in the third trimester of gestation cholestasis of pregnancy should be suspected. A familial history of recurrent cholestasis points to benign recurrent intrahepatic cholestasis. The occurrence of intrahepatic cholestasis in a middle-aged woman is a frequent presentation of primary biliary cirrhosis, whereas primary sclerosing cholangitis should be suspected in young males with inflammatory bowel disease. The presence of vascular spider nevi, ascites, and a history of alcohol abuse should point to alcoholic hepatitis. Neonatal cholestasis syndromes include CMV, toxoplasma and rubinfections or metabolic defects such as cystic fibrosis, alpha1-antitrypsin deficiency, bile acid synthesis defects, or biliary atresia. The treatment of cholestasis should include a management of complications such as pruritus, osteopenia and correction of fat soluble vitamin deficiencies. When hepatocellular failure or portal hypertension-related complications occur, liver transplantation should be considered.     

Fecal elastase 1, serum amylase and lipase levels in children with cholestasis.

BACKGROUND/AIM: The pancreatic functions of children with cholestatic liver diseases were unclear. Due to anatomic vicinity and common ontogenic origin, hepatobiliary disorders of infancy may also affect pancreatic function. The aim of the study was to evaluate the exocrine pancreatic function and common pancreatic function tests in children with cholestatic disorders. METHODS: In 40 children with cholestasis, fecal elastase 1 (FE1) concentrations were measured. Serum amylase and lipase values were tested. The diagnoses included 32 patients with extrahepatic cholestasis (biliary atresia (BA) and choledochal cyst), and 8 patients with intrahepatic cholestasis (progressive familial intrahepatic cholestasis and Alagille syndrome). None had renal insufficiency or clinical symptoms/signs of acute pancreatitis. RESULTS: All the patients had normal FE1 (>200 microg/g). Nineteen percent (7/37) had elevated serum amylase levels (>100 U/l). Thirty-two percent (12/37) had elevated serum lipase levels above the normal (>120 U/l). Seventy-three percent (8/11) of BA patients with bilirubin >2 mg/dl had elevated serum lipase levels compared to 18% (3/17) with bilirubin < or = 2 mg/dl (p = 0.0036). None had detectable pancreatic abnormality on ultrasonography and magnetic resonance images. CONCLUSIONS: None of the cholestatic children in this study had exocrine pancreatic insufficiency as detected by FE1. Hyperamylasemia and/or hyperlipasemia were frequently found. In children with BA, those with impaired biliary excretion tended to have elevated serum pancreatic enzymes as compared with those who had no jaundice. A decreased hepatic metabolism may be the cause.