Screening for biliary atresia: A ray of hope

Increased Serum Levels of Activated Caspases in Murine and Human Biliary Atresia

In biliary atresia (BA), apoptosis is part of the pathomechanism, which results in progressive liver fibrosis. There is increasing evidence suggesting that apoptotic liver injury can be non-invasively detected by measuring the caspase activity in the serum. The purpose of this study was to investigate whether serological detection of caspase activation mirrors apoptotic liver injury in the infective murine BA-model and represents a suitable biomarker for BA in humans. Analysis showed increased caspase-3 activity and apoptosis in the livers of cholestatic BALB/c mice, which correlated significantly with caspase activation in the serum. We then investigated caspase activation and apoptosis in liver tissues and sera from 26 BA patients, 23 age-matched healthy and 11 cholestatic newborns, due to other hepatopathies. Compared to healthy individuals, increased caspase activation in the liver samples of BA patients was present. Moreover, caspase-3 activity was significantly higher in sera from BA infants compared to patients with other cholestatic diseases (sensitivity 85%, specificity 91%). In conclusion, caspase activation and hepatocyte apoptosis play an important role in experimental and human BA. We demonstrated that serological detection of caspase activation represents a reliable non-invasive biomarker for monitoring disease activity in neonatal cholestatic liver diseases including BA.

Stool color card screening for biliary atresia

INTRODUCTION

Biliary atresia is a major cause of extrahepatic obstructive jaundice in neonates. Early Kasai operation is the gold standard of treatment. In this study, we evaluated the effectiveness of stool color card screening by using claims data from the National Health Insurance Research Database.

METHODS

This was a retrospective cohort study. Data from medical charts of all inpatients who were diagnosed with biliary atresia from 1996 to 2008 were collected from Taiwan's National Health Insurance Research Database. Patients who received a Kasai operation or liver transplant were identified by the Operation code. The patients' gender, age at admission, and type of operation were collected and analyzed.

RESULTS

From 1996 to 2008, the overall incidence of biliary atresia was 1.48 per 10,000 live births. The median age at first admission for patients with suspected biliary atresia decreased after the implementation of stool color card screening (47 vs 43 days). The proportion of very late referral decreased from 9.5% to 4.9%. The median age of Kasai operation advanced from 51 to 48 days. The proportions of Kasai operation within 60 days of age were 68.9% before and 73.6% after screening program.

CONCLUSION

Stool color card screening seemed to increase parents' and physicians' awareness of biliary atresia. It also was associated with a decline in the proportion of late referral. Thus, screening might be especially effective in areas with high a proportion of late referral. Improvements in the speed of workup and the operation room should be the focus of education and training in the future.

Biliary atresia: a new immunological insight into etiopathogenesis

Biliary atresia is an idiopathic neonatal cholestatic disease characterized by the destruction of both the intra- and extra-hepatic biliary ducts. There are two clinical manifestations of the disease: an embryonal subtype, which often presents at birth and is associated with congenital malformations, and a 'perinatal' subtype, which is probably an acquired disease due to unknown etiology. Over the last two decades, researchers have focused on activation of the cell-mediated immunity as the mechanism for biliary epithelial cell destruction for the latter subtype. A proposed trigger of this immune response is an initial viral infection, inducing biliary epithelial cells to become antigen-presenting cells and thus instigating immune-mediated destruction of the biliary tract. However, putative viruses have never been confirmed. More recently, a novel hypothesis - that maternal microchimerism may initiate a host immunologic response towards the bile duct epithelia - has been proposed. This paper discusses the etiology of biliary atresia in the context of the current research.