Absent gallbladder on fetal ultrasound: prenatal findings and postnatal outcome

Prenatal genetic detection in foetus with gallbladder size anomalies: cohort study and systematic review of the literature

OBJECTIVES

The aim of the study was to evaluate the detection rate of genetic abnormalities in cases of foetal gallbladder (FGB) size abnormalities to determine whether these abnormalities justify prenatal diagnosis.

METHODS

Two hundred and twenty-seven foetuses with gallbladder (GB) size anomalies who underwent prenatal diagnosis between January 2015 and June 2024 were included in the study. All these patients underwent chromosomal microarray and/or karyotyping, and 37 cases also underwent whole exome sequencing (WES). Two hundred and eight cases were followed up for postnatal outcomes. Then, we reviewed the literature of FGB anomalies cases with confirmed chromosomal results.

RESULTS

The study included 227 foetuses, comprising 60 cases with isolated GB size anomalies and 167 cases with non-isolated GB size anomalies. Non-isolated GB size anomalies were associated with findings such as hyperechogenic bowel, ventriculomegaly, foetal growth restriction (FGR), cardiac anomalies, renal dysplasia and single umbilical artery. The overall diagnostic yield of genetic tests was 10.57% (24/227). Aneuploidies were identified in seven foetuses. Pathogenic/likely pathogenic copy number variations (CNVs) were found in nine foetuses, and α0-thalassemia in five foetuses. Additionally, three pathogenic single-nucleotide variants (SNVs) were detected through WES. Foetuses with non-isolated GB size anomalies showed a higher rate of detecting genetic abnormalities compared to those with isolated GB size anomalies, with a significant difference in statistical analysis (13.2% vs. 3.3%, p = .033, Chi-square test). A total of eight studies, involving 407 cases met the criteria for inclusion in the systematic review. Overall, 28 foetuses were identified to have chromosomal abnormalities (6.9%, 28/407).

CONCLUSIONS

This study indicates that parents of foetuses with GB size anomalies should be informed about the potential for aneuploidy, pathogenic CNVs and SNVs, and genetic testing should be recommended in cases of non-isolated foetal GB size anomalies.

Outcomes of pregnancies diagnosed with absent or abnormal fetal gallbladder in a tertiary center

OBJECTIVE

The objective of this study was to investigate the ultrasonographic characteristics and outcomes of fetuses with atypical and non-visualized fetal gallbladder in our tertiary care hospital.

METHODS

A retrospective analysis was conducted on cases in which the fetal gallbladder was not visualized or exhibited atypical characteristics at our institution over a four-year period. The patients were divided into two groups: absent gallbladder and atypical gallbladder. The groups with isolated and additional anomalies were analyzed according to their ante- and postnatal characteristics.

RESULTS

The study comprised 78 patients (37 absent, 41 atypical gallbladder). In the isolated fetal absence of gallbladder group, the gallbladder was visualized in three of 13 patients during antenatal ultrasonographic follow-up and in half of the remaining 10 patients during postnatal follow-up. In the postnatal period, five newborns with absent isolated gallbladder are being followed up with suspicion of biliary atresia and isolated gallbladder agenesis. In the absence of a gallbladder with an additional anomaly group, 58% of fetuses died during the intrauterine and neonatal period. Fetuses in the isolated atypical gallbladder group are being followed as healthy after birth. Pregnancies with atypical gallbladder appearance and additional anomalies resulted in 33% neonatal death, 12% intrauterine demise, and 25% termination of pregnancy.

CONCLUSION

In instances where the fetal gallbladder is not consistently discernible, it is imperative to exercise caution with regard to the possibility of biliary atresia. In the event that the fetal gallbladder exhibits unusual characteristics, a meticulous examination for the presence of additional anomalies is recommended.

Postnatal Outcome After Ultrasound Findings of an Abnormal Fetal Gallbladder: A Systematic Review and Meta-Analysis

OBJECTIVE

To describe postnatal outcome following the prenatal diagnosis of an abnormal fetal gallbladder.

METHODS

We conducted a systematic review of studies from January 1980 to January 2023 that described FGB abnormalities, which included agenesis or non-visualisation, abnormal content presence of sludge, abnormal shape or size and abnormal position, and postnatal outcome to determine the association with pathology.

RESULTS

In 51 studies, 842 fetuses had abnormal FGB. Non-visualisation of the FGB was the most common diagnosis (521 fetuses, mean gestational age 21.6 weeks, range 14-29). The FGB was subsequently visualised prenatally in 128 out of 521 cases (24.6%; 95% CI, 20.9%-28.3%). Of the 393 cases with persistent FGB non-visualisation (75.4%; 95% CI, 71.7-79.1), 48 cases (12.2%; 95% CI, 9.0-15.5) underwent termination of pregnancy (TOP) with FGB agenesis confirmed in 16 out of 26 fetuses that had a postmortem examination (61.5%; 95% CI, 42.8-80.2). After excluding cases with missing outcomes (n = 121), postnatal ultrasound was performed in 82.4% of cases with persistent non-visualised FGB (224/272; 95% CI, 77.8%-86.9%). The gallbladder was not visualised in 63.4% (142/224; 95% CI, 57.1-69.7), confirming GB agenesis. This was an isolated finding in 41.1% of cases (92/224; 95% CI, 34.6-47.5). Of 272 known outcomes, biliary atresia, cystic fibrosis, and structural or chromosomal abnormalities were diagnosed in 8.5% (n = 23), 12.5% (n = 34), 18.0% (n = 49) and 6.3% (n = 17) cases, respectively. The sensitivity (true positive rate) of ultrasound for GB agenesis in fetuses with persistently non-visualised FGB was 58.1% (158/272; 95% CI, 52.2%-64.0%). Fetal gallbladder stones/sludge were described in 100 fetuses mainly in the third trimester of pregnancy (mean gestational age 33.8 weeks). Resolution of postnatally followed up cases occurred in around one-third of the cases (37.3%) within 1 month after birth. There was a low reported association with severe conditions (2%).

CONCLUSIONS

This systematic review and meta-analysis found that when the fetal gallbladder was absent in mid-trimester, it was visualised in subsequent fetal ultrasound examinations in around 25% of cases. If persistently absent on prenatal ultrasound, the confirmed rate of GB agenesis was around 50%, with the neonates having biliary atresia, cystic fibrosis, or structural abnormalities. Because of the association with severe conditions, if persistent FGB agenesis is suspected, prenatal diagnosis should be offered. FGB abnormalities such as stones/sludge tended to resolve by 1 year of age with around half of all cases resolving by 1 month postnatal.

Autonomous fetal morphology scan: deep learning + clustering merger - the second pair of eyes behind the doctor

The main cause of fetal death, of infant morbidity or mortality during childhood years is attributed to congenital anomalies. They can be detected through a fetal morphology scan. An experienced sonographer (with more than 2000 performed scans) has the detection rate of congenital anomalies around 52%. The rates go down in the case of a junior sonographer, that has the detection rate of 32.5%. One viable solution to improve these performances is to use Artificial Intelligence. The first step in a fetal morphology scan is represented by the differentiation process between the view planes of the fetus, followed by a segmentation of the internal organs in each view plane. This study presents an Artificial Intelligence empowered decision support system that can label anatomical organs using a merger between deep learning and clustering techniques, followed by an organ segmentation with YOLO8. Our framework was tested on a fetal morphology image dataset that regards the fetal abdomen. The experimental results show that the system can correctly label the view plane and the corresponding organs on real-time ultrasound movies.Trial registrationThe study is registered under the name "Pattern recognition and Anomaly Detection in fetal morphology using Deep Learning and Statistical Learning (PARADISE)", project number 101PCE/2022, project code PN-III-P4-PCE-2021-0057. Trial registration: ClinicalTrials.gov, unique identifying number NCT05738954, date of registration 02.11.2023.

Difficulty in the Diagnosis of Biliary Atresia Splenic Malformation Syndrome In Utero

The fetus of a 30-year-old pregnant Japanese woman was diagnosed with absence of inferior vena cava (IVC) and azygos continuation of interrupted IVC without cardiac anomalies at 34 weeks of gestation, and a healthy male neonate weighing 2,910 g was delivered at 37 weeks of gestation. On day 42 after birth, direct bilirubin predominant hyperbilirubinemia and high serum gamma-GTP levels were detected. Computed tomography revealed the presence of a lobulated and accessory spleen, and laparotomy demonstrated type III biliary atresia (BA), confirming the final diagnosis of BA splenic malformation (BASM) syndrome. In retrospect, non-visualization of the gallbladder was missed in utero. The combination of the absence of IVC and BA without cardiac anomalies is far less likely to occur in left isomerism. Although BA remains difficult to detect in utero, special attention should be paid to cases of BA associated with findings of left isomerism, including the absence of IVC, to enable early diagnosis and treatment of BASM.

Dysmorphic Gallbladder Found on Prenatal Ultrasound as a Hint for Biliary Atresia

Biliary atresia (BA) is a rare but devastating cholangiopathy. We report a case series of dysmorphic gallbladders detected during prenatal ultrasound, which were confirmed as BA after birth. We present the prenatal ultrasound findings as well as integral follow-up, with an aim to raise awareness regarding the association between BA and dysmorphic gallbladder. Although this dysmorphic gallbladder is a strong hint for BA, it is also important to search for other related sonographic features, such as the presence of microcysts at the hepatic hilum, dilated right hepatic artery, and seroperitoneum, which may provide more evidence for the diagnosis of BA.

Anomalies of the fetal gallbladder: pre-and postnatal correlations

The gallbladder is not part of the standard survey of a fetus during obstetrical ultrasound. Yet, some anomalies can be detected. Most are clinically benign, but some are features of or associated with more serious complications. Biliary atresia constitutes the diagnosis with the worst prognosis. Its in utero diagnosis is difficult. Still, markers do exist and should be searched for. Knowledge of the normal appearances, variants and abnormalities of the gallbladder contributes to proper management. Any suspicion should lead to meticulous postnatal workup. Pre- or postnatal magnetic resonance imaging can provide additional information in select cases.

Improving prenatal detection of abdominal supraumbilical anomalies: The sonographic examination of fetal anechoic spaces of upper abdomen revisited

Visualization of the axial plane of the fetal abdomen is mandatory to obtain abdominal biometry in the assessment of fetal growth in the second and third trimesters. The main anatomic landmarks that must be identified in this view include the fetal stomach and the intrahepatic portion of the umbilical vein, which are easily identifiable as they appear anechoic on ultrasound. The gallbladder is the other prominent anechoic structure in this plane. Focused study of the morphological characteristics of, and spatial relationship among, these three anechoic spaces is a simple technique to detect anomalies involving fetal upper abdominal organs. In this review, the sonographic features of those conditions that can be detected using this technique, which was termed the Fetal Examination of the Anechoic Spaces of upper abdomen Technique (FEAST), are classified and illustrated.

[Overview of Biliary Atresia]

Biliary atresia is a progressive, idiopathic, obliterative disease of the extrahepatic biliary tree that presents with biliary obstruction in the neonatal period. It is the most common indication for liver transplantation in children. If untreated, progressive liver cirrhosis leads to death by two years of age. Nowadays, more than 90% of biliary atresia patients survive into adulthood with the development of Kasai portoenterostomy and liver transplantation technology. Early diagnosis is critical since the success rate of the Kasai portoenterostomy decreases with time. This study comprehensively reviews the recent advances in the etiology, classification, prevalence, clinical manifestations, treatment, and prognosis of biliary atresia.

Pregnancy Outcomes of Non-Visualization of the Fetal Gallbladder from a Chinese Tertiary Single Centre and Literature Review

Objection: To explore the clinical features and prognosis of non-visualization of the fetal gallbladder (NVFGB). Methods: Sixty-five cases diagnosed with NVFGB in the Peking University First Hospital were collected retrospectively from January 2019 to December 2020. Results: Forty-nine cases were successfully followed up. Among them, the gallbladder of 21 fetuses (42.9%) was present in the later pregnancy. In the rest 28 cases (57.1%), the gallbladders were absent during the whole pregnancy. Eleven of twenty-eight fetuses (39.3%) with NVFGB were complicated with other structural anomalies. In the remaining 17 cases of isolated NVFGB (60.7%) during the whole pregnancy, there was one case of congenital biliary atresia, three cases of a small gallbladder, one case of gallstone and one case of the gallbladder with several septa inside. A total of nine cases (18.4%) underwent prenatal diagnosis, four of which revealed abnormal copy number variant (CNV) results. Conclusion: Nearly half of NVFGB could be noted during the later pregnancy. The persistent NVFGB during the pregnancy has a higher risk to complicate gallbladder abnormality, other structural anomalies and abnormal CNV results. Other structures, especially the heart, gastrointestinal and urinary system, should be carefully examined when NVFGB is suspected.

Echogenicities in the fetal gallbladder: Prevalence, sonographic findings, and postnatal outcomes

PURPOSE

To investigate the prevalence of echogenicity in the fetal gallbladder (EFG) and to present prenatal sonographic findings and their postnatal outcomes.

MATERIALS AND METHODS

We performed a retrospective study within 17420 pregnant women during a 66-month period. Fetuses with an incidental finding of EFG in their 2nd or 3rd trimester of pregnancy were followed until birth per two weeks with sonographic examinations.

RESULTS

Out of 5977 fetuses, 44 fetuses were found to have EFG with a prevalence of 0.74%. Nine (20%) of 44 fetuses had single echogenicity, 25 (56%) had multiple echogenicities, 10 (22%) had sludge-like echogenicities. In Doppler sonography, 28 fetuses with EFG exhibited twinkling artifacts; however, none of the echogenicities had obvious acoustic shadowing. All of the cases were resolved either in utero or after birth before 10 months of age.

CONCLUSION

EFG is a late third-trimester phenomenon with a prevalence of 0.74%. Most EFGs presented as twinkling artifacts, suggesting they had a cholesterol component.

Postnatal outcomes of fetuses with isolated gallbladder anomalies: be aware of biliary atresia

OBJECTIVES

To analyze the normal development of fetal gallbladder (GB) and evaluate the postnatal outcomes of fetuses with isolated GB anomalies without other structural abnormalities by ultrasound.

METHODS

This was a retrospective study. We collected normal cases during 2016 between 15 and 40 gestational weeks and measured the length and width of GB to establish a normal reference range of GB. Using the 10th and 90th percentiles of the normal reference range, isolated cases of enlarged or small GB without other structural anomalies were selected between January 2017 and December 2019. Simultaneously, cases of echogenic material in the GB were included. Fetuses with non-visualization of the fetal gallbladder (NVFGB) were collected between January 2010 and December 2019. Postnatal outcomes of these cases were followed up and analyzed.

RESULTS

There were 670 cases in the normal group and a linear correlation was found between the dimensions of GB and the gestational age, including the length (r = 0.69; p < .05; y = 0.97 + 0.70 × gestational age) and width (r = 0.48; p < .05; y = 1.65 + 0.12 × gestational age). Sixty-two cases with isolated GB anomalies were collected, including nine cases of enlarged GB, four cases of small GB, three cases of echogenic material in the GB, and 46 cases of NVFGB. Sixty fetuses (96.8%, 60/62) had good outcomes, except that two neonates (4%, 2/50) in small GB and NVFGB groups were both born with BA. In the NVFGB group, 97.8% (45/46) were with good outcomes, in which gallbladders were finally visualized in 37 (80.4%, 37/46) cases and GB agenesis was postnatally diagnosed in eight (17.4%, 8/46) patients by ultrasound.

CONCLUSION

The postnatal outcomes of most fetuses (96.8%) with isolated GB anomalies such as enlarged GB, echogenic material in the GB were favorable. When it comes to cases of small GB or NVFGB in prenatal ultrasound diagnosis, we should alert biliary atresia in prenatal counseling.

Fetal Hepatomegaly: Causes and Associations

Fetal hepatomegaly is associated with significant fetal morbidity and mortality. However, hepatomegaly might be overlooked when numerous other fetal anomalies are present, or it might not be noticed when it is an isolated entity. As the largest solid organ in the abdomen, the liver can be seen well with US or MRI, and the normal imaging characteristics are well described. The length of the fetal liver, which can be used to identify hepatomegaly, can be determined by measuring the liver from the diaphragm to the tip of the right lobe in the sagittal plane. Fetal hepatomegaly is seen with infection, transient abnormal myelopoiesis, liver storage and deposition diseases, some syndromes, large liver tumors, biliary atresia, and anemia. Some of these diagnoses are treatable during the fetal period. Attention to the associated findings and specific hepatic and nonhepatic imaging characteristics can help facilitate more accurate diagnoses and appropriate patient counseling.^©RSNA, 2020.

Practical approach to imaging diagnosis of biliary atresia, Part 1: prenatal ultrasound and magnetic resonance imaging, and postnatal ultrasound

We present a practical approach to imaging in suspected biliary atresia, an inflammatory cholangiopathy of infancy resulting in progressive fibrosis and obliteration of extrahepatic and intrahepatic bile ducts. Left untreated or with failure of the Kasai procedure, biliary atresia progresses towards biliary cirrhosis, end-stage liver failure and death by age 3. Differentiation of biliary atresia from other nonsurgical causes of neonatal cholestasis is challenging because there is no single method for diagnosing biliary atresia, and clinical, laboratory and imaging features of this disease overlap with those of other causes of neonatal cholestasis. Concerning imaging, our systematic literature review shows that ultrasonography is the main tool for pre- and neonatal diagnosis. Key prenatal features, when present, are non-visualisation of the gallbladder, cyst in the liver hilum, heterotaxy syndrome and irregular gallbladder walls. Postnatal imaging features have a very high specificity when present, but a variable sensitivity. Triangular cord sign and abnormal gallbladder have the highest sensitivity and specificity. The presence of macro- or microcyst or polysplenia syndrome is highly specific but less sensitive. The diameter of the hepatic artery and hepatic subcapsular flow are less reliable. When present in the context of acholic stools, dilated intrahepatic bile ducts rule out biliary atresia. Importantly, a normal US exam does not rule out biliary atresia. Signs of chronic hepatopathy and portal hypertension (portosystemic derivations such as patent ductus venosus, recanalised umbilical vein, splenomegaly and ascites) should be actively identified for - but are not specific for - biliary atresia.

Utility of Magnetic Resonance Imaging in Diagnosis of Prenatal Non-Visualization of the Fetal Gallbladder: A Case-Series Study

BACKGROUND This study aimed to assess the utility of magnetic resonance imaging (MRI) in the diagnosis of prenatal non-visualization of the fetal gallbladder (PNVGB). MATERIAL AND METHODS The clinical data of 32 pregnant women with PNVGB who underwent MRI examination during the second and third trimester of pregnancy were collected and their outcomes were analyzed. RESULTS MRI showed that 26 patients (81.3%) had isolated PNVGB and 6 (18.8%) had additional malformations. In 26 patients with isolated PNVGB, 7 were found in the gallbladder on MRI and 4 were found on subsequent ultrasonography. One patient had termination of pregnancy (TOP) and 1 patient was lost to follow-up; the remaining 24 patients were known to deliver a healthy child. Among the 6 patients with additional malformations, 3 terminated their pregnancies due to combined severe abnormalities: 1 patient with horseshoe kidney and 1 with fetal echogenic bowel both had a healthy child, while 1 with fetal growth restriction (FGR) delivered a child who walked on tiptoe. CONCLUSIONS MRI contributes to identifying PNVGB detected or suspected by ultrasonography.

Outcome of non-visualization of fetal gallbladder on second-trimester ultrasound: cohort study and systematic review of literature

OBJECTIVES

To investigate the ultrasound characteristics and outcome of fetuses with non-visualization of the fetal gallbladder (NVFGB) followed in our tertiary university hospital, and to provide a comprehensive review of the literature on prenatal findings and outcome of NVFGB.

METHODS

NVFGB was defined as non-visualization of the gallbladder on two targeted ultrasound examinations performed within a 1-week period. First, we reviewed the medical records of NVFGB cases managed in our center over a 9-year period. Then, we performed a systematic review of the literature to identify studies on NVFGB. The incidence of chromosomal anomalies, later visualization of the gallbladder, gallbladder agenesis, cystic fibrosis and biliary atresia was assessed in fetuses with isolated and non-isolated NVFGB. The role of hepatic enzyme measurements in the diagnosis of cystic fibrosis and biliary atresia in fetuses with NVFGB was also reviewed.

RESULTS

Sixteen cases of NVFGB were followed in our center, in 10 (62.5%) of which it was an isolated finding. The incidence of biliary atresia was 12.5% and that of gallbladder agenesis was 12.5%, while no case of cystic fibrosis was reported. The gallbladder was visualized later in pregnancy or postnatally in 43.8% and 25.0% of cases, respectively. A total of seven studies, including our cohort, involving a total of 280 NVFGB cases, met the inclusion criteria for the systematic review. Overall, 20.5% of fetuses had an associated ultrasound anomaly, and the incidence of chromosomal anomaly in this group was 20.4%. In cases with isolated NVFGB, the incidence of chromosomal anomaly was 1.9%. In fetuses with normal karyotype and isolated NVFGB, the gallbladder was later visualized in 70.4% of cases, while the incidence of gallbladder agenesis, cystic fibrosis and biliary atresia was 25.2%, 3.1% and 4.8%, respectively. In fetuses with non-isolated NVFGB, the incidence of cystic fibrosis and biliary atresia was 23.1% and 18.2%, respectively. The negative predictive value of amniotic fluid enzyme levels for the prediction of severe disease (including biliary atresia or cystic fibrosis) ranged between 94% and 100% when evaluated before 22 weeks' gestation, and dropped to 88% after 22 weeks.

CONCLUSIONS

In cases with persistent NVFGB, the risk of a severe postnatal condition should be considered. A detailed ultrasound scan should be offered and parents tested for cystic fibrosis gene mutation. An invasive procedure for karyotyping and measurement of liver enzyme concentrations before 22 weeks constitutes a reasonable work-up. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Echogenic material in the fetal gallbladder: prevalence, sonographic spectrum, and perinatal outcome in an unselected third-trimester population

Objective: To determine the prevalence, sonographic spectrum, and clinical significance of echogenic material in the fetal gallbladder in our population.Methods: Sonographic visualization of the fetal gallbladder was attempted in 3894 consecutive third-trimester pregnancies (4026 fetuses). Gallbladder content was classified as clear (anechoic), containing echogenic material that was either diffuse (sludge), or presenting as a single focus or multiple foci (gallstone(s)). Information on the clinical course was obtained by reviewing the medical records or contacting the provider or the parents themselves.Results: During the three and a half-year study period from July 2014 to December 2017, 19 fetuses were identified as having echogenic material in the gallbladder (prevalence 1/211, 0.47%). Among them, echogenic biliary sludge was found in eight fetuses (42%); all eight were asymptomatic and a normal gallbladder was documented postnatally in four of them. Single (n = 3) or multiple (n = 8) echogenic foci were found in 58% of cases, which was associated with a good prognosis and subsequent resolution between 1 and 10 months of life in all cases.Conclusions: The prevalence of echogenic material in the fetal gallbladder in our population was similar to that previously reported in the literature. The prognosis appears to be favorable, with resolution and without subsequent postnatal hepatic or gastrointestinal complications in all cases.

Outcome of prenatally diagnosed fetal heterotaxy: systematic review and meta-analysis

OBJECTIVES

The main aim of this systematic review was to evaluate the prevalence and type of associated anomalies in fetuses with heterotaxy diagnosed prenatally on ultrasound; the perinatal outcome of these fetuses was also studied.

METHODS

An electronic search of MEDLINE, EMBASE and CINAHL databases was performed. Only studies reporting the prenatal diagnosis of isomerism were included. Outcomes observed included associated cardiac and extracardiac anomalies, fetal arrhythmia, abnormal karyotype, type of surgical repair and perinatal mortality. The analysis was stratified according to the type of heterotaxy syndrome (left (LAI) or right (RAI) atrial isomerism). Meta-analyses of proportions were used to combine data. Quality assessment of the included studies was performed using the Newcastle-Ottawa Scale for cohort studies.

RESULTS

Sixteen studies (647 fetuses) were included in the analysis. Atrioventricular septal defect was the most common associated major cardiac anomaly found both in fetuses with LAI (pooled proportion (PP), 59.3% (95% CI, 44.0-73.7%)), with obstructive lesions of the right outflow tract occurring in 35.5% of these cases, and in fetuses with RAI (PP, 72.9% (95% CI, 60.4-83.7%)). Fetal arrhythmias occurred in 36.7% (95% CI, 26.9-47.2%) of cases with LAI and were mainly represented by complete atrioventricular block, while this finding was uncommon in cases with RAI (PP, 1.3% (95% CI, 0.2-3.2%)). Abnormal stomach and liver position were found, respectively, in 59.4% (95% CI, 38.1-79.0%) and 32.5% (95% CI, 11.9-57.6%) of cases with LAI, and in 54.5% (95% CI, 38.5-70.1%) and 45.9% (95% CI, 11.3-83.0%) of cases with RAI, while intestinal malrotation was detected in 14.2% (95% CI, 2.5-33.1%) of LAI and 27.1% (95% CI, 7.9-52.0%) of RAI cases. Hydrops developed in 11.8% (95% CI, 2.9-25.6%) of fetuses diagnosed prenatally with LAI. Biventricular repair was accomplished in 78.2% (95% CI, 64.3-89.4%) of cases with LAI, while univentricular repair or palliation was needed in 17.0% (95% CI, 9.7-25.9%); death during or after surgery occurred in 26.8% (95% CI, 4.6-58.7%) of LAI cases. Most children with RAI had univentricular repair and 27.8% (95% CI, 15.5-42.1%) died during or after surgery.

CONCLUSIONS

Fetal heterotaxy is associated with a high prevalence of cardiac and extracardiac anomalies. Approximately one quarter of fetuses with heterotaxy died during or after surgery. Abnormal heart rhythm, especially heart block, is common in fetuses with LAI, while this finding is uncommon in RAI. Biventricular repair was common in LAI while univentricular repair was required in the majority of children affected by RAI. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Non-visualization of fetal gallbladder in microarray era - a retrospective cohort study and review of the literature

OBJECTIVE

The objective of this study is to examine the frequency of abnormal Chromosomal Microarray (CMA) analyses among fetuses with isolated non-visualization of fetal gallbladder.

METHODS

Data from CMA analyses performed due to isolated non-visualization of fetal gallbladder between January 2013 and September 2016 were retrospectively acquired from a computerized database of the Israeli Ministry of Health. The results were compared with the rate for clinically significant CMA findings in general population, based on a large cohort of 5541 pregnancies undergoing CMA due to maternal request, and a systematic review of 9272 cases with normal ultrasound.

RESULTS

Of 45 pregnancies with isolated non-visualization of fetal gallbladder, CMA testing yielded one (2.22%) gain-of-copy-number variant at 16p11.2, categorized as "pathogenic". In addition, one finding of unknown significance was demonstrated. The risk for clinically meaningful CMA findings among pregnancies with isolated absent gallbladder was not significantly increased compared to control population.

CONCLUSIONS

To the best of our knowledge, this study is the first report describing the rate of pathogenic CMA results in fetuses with isolated non-visualization of fetal gallbladder. The results, in conjunction with previous studies, show that the risk for abnormal CMA results in pregnancies diagnosed with non-visualized gallbladder is not significantly different from pregnancies with normal ultrasound.

Prenatal diagnosis of biliary atresia: A case series

BACKGROUND

Biliary atresia is a progressive disease presenting with jaundice, and is the most common indication for liver transplantation in the pediatric population. Prenatal series have yielded conflicting results concerning a possible association between BA and prenatal nonvisualization of the gallbladder.

AIMS

This retrospective case series was performed to assess the association between biliary atresia, prenatal nonvisualization of the gallbladder and other sonographic signs.

STUDY DESIGN/SUBJECTS

We identified biliary atresia patients who underwent a Kasai procedure by a single pediatric surgeon and/or follow up by a single pediatric gastroenterologist. Axial plane images and/or video recordings were scrutinized for sonographic signs of biliary atresia on the second trimester anomaly scan.

OUTCOME MEASURES

Proportion of biliary atresia cases with prenatal sonographic signs.

RESULTS

Twenty five charts of children with biliary and high quality prenatal images were retrieved. 6/25 (24%) of cases analyzed had prenatal nonvisualization of the gallbladder or a small gallbladder on the prenatal scan. Two cases had biliary atresia splenic malformation syndrome. None of the cases had additional sonographic markers of biliary atresia.

CONCLUSIONS

Our study suggests that in addition to the well-established embryonic and cystic forms, an additional type can be suspected prenatally, which is characterized by prenatal nonvisualization of the gallbladder in the second trimester. This provides additional evidence that some cases of BA are of fetal rather than perinatal onset and may have important implications for prenatal diagnosis, for counseling and for research of the disease's etiology and pathophysiology.

[Isolated gallbladder agenesis mimicking biliary colic: A difficult preoperative diagnosis]

Isolated gallbladder agenesis is a very rare and unrecognized congenital anomaly. Patients are usually asymptomatic, but 23% present with symptoms suggestive of biliary colic. Ultrasound investigation often fails to diagnose this malformation, misinterpreted as scleroatrophic gallbladder, leading to unnecessary and potentially dangerous surgery. We report on a case of a 9-year-old child who complained of biliary colic. Ultrasound showed a possible scleroatrophic gallbladder. This diagnosis was in doubt, however, because the patient had no previous history of cholecystitis. Finally, magnetic resonance cholangiopancreatography failed to show any gallbladder. The absence of the visualization of the gallbladder in a context of right upper quadrant pain should suggest gallbladder agenesis. Pain can be explained by the so-called postcholecystectomy syndrome.

Beyond pancreatic insufficiency and liver disease in cystic fibrosis

Cystic fibrosis is a life shortening hereditary disease, primarily leading to progressive pulmonary infection and exocrine pancreatic dysfunction. Several gastrointestinal complications other than malabsorption can arise during the disease course and with the progressively increasing life span of patients with CF; new and more rare complications are being recognized. We review the literature on gastrointestinal manifestations in CF, excluding the liver and pancreas.

CONCLUSION

We describe the clinical presentation and treatment of more common conditions like gastroesophageal reflux, small intestinal bacterial overgrowth, intussusception, meconium ileus, distal intestinal obstruction syndrome, and constipation, and we also discuss what is known on celiac disease, appendicitis, fibrosing colonopathy, inflammation and inflammatory bowel disease and gastrointestinal cancer.

WHAT IS KNOWN

• Gastrointestinal complications arise early in the course of the disease and have a severe impact on the quality of life of the patients. What is New: • This review is a concise summary of the current literature on gastrointestinal complications of cystic fibrosis. • We focused on clinical presentation and diagnostic investigations and provide a comprehensive resume of the current treatment options.

Extracardiac anomalies in prenatally diagnosed heterotaxy syndrome

OBJECTIVE

To assess the incidence and impact of extracardiac anomalies on the prognosis of fetuses with heterotaxy syndrome.

METHODS

All fetuses diagnosed with heterotaxy syndrome by three experienced examiners over a period of 14 years (1999-2013) were reviewed retrospectively.

RESULTS

In total, 165 fetuses with heterotaxy syndrome were diagnosed in the study period. One hundred and fifty (90.9%) had cardiac defects; extracardiac anomalies that did not involve the spleen were present in 26/165 (15.8%) cases. Of the total study cohort, termination of pregnancy was performed in 49 (29.7%) cases, intrauterine death occurred in 11 (6.7%), postnatal death occurred in 38 (23.0%) and 67 (40.6%) were alive at the latest follow-up, resulting in a total perinatal and pediatric mortality of 59.4%. Among the 105 liveborn neonates, 15 (14.3%) had extracardiac anomalies with significant impact on the postnatal course: one neonate died following repair of an encephalocele, six had successful treatment for various types of intestinal malrotation and/or atresia and one underwent hiatal hernia repair; the remaining seven had biliary atresia, of which five died and the two survivors are awaiting liver transplantation. The status of the spleen was assessed in 93/105 liveborn children and was found to be abnormal in 84/93 (90.3%). There were three cases of lethal sepsis, all associated with asplenia. Of the 38 postnatal deaths, 29 (76.3%) had a cardiac cause, seven (18.4%) had an extracardiac cause and in two (5.2%) the reason was uncertain.

CONCLUSIONS

Although the leading causes of death in fetuses and children with heterotaxy syndrome are cardiac, a small subset of fetuses have extracardiac anomalies with significant impact on outcome. These anomalies often escape prenatal detection, and therefore neonates at risk should be monitored for bowel obstruction, biliary atresia and immune dysfunction in order to allow timely intervention through a multidisciplinary approach. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Prenatal ultrasound diagnosis of cystic biliary atresia

Nonvisualization of the gallbladder during the second trimester of pregnancy should prompt concern for biliary atresia. A normal‐sized gallbladder with irregular and crenelated wall associated with a cyst of the extrahepatic tract should raise concern for cystic biliary atresia.

Nonvisualization of the Fetal Gallbladder: Can Levels of γ-Glutamyl Transpeptidase in Amniotic Fluid Predict Fetal Prognosisγ

Objective: In cases of nonvisualization of the fetal gallbladder (NVFGB), we investigated whether amniotic fluid levels of γ-glutamyl transpeptidase (GGTP) can distinguish normal development or benign gallbladder agenesis from severe anomaly such as biliary atresia. Methods: This is a retrospective cohort study of pregnancies in which the gallbladder was not visualized in the second-trimester fetal anatomy scan. Levels of GGTP in amniotic fluid were analyzed prior to 22 weeks of gestation by amniocentesis. Data were collected regarding other fetal malformations, fetal karyotype, and screening results for cystic fibrosis transmembrane conductance regulator (CFTR) gene mutations. Results: Of 32 cases of NVFGB, 27 (84%) had normal GGTP levels and a normal CFTR gene screening, and 1 of them had an abnormal karyotype. Three of the 5 cases with low GGTP were diagnosed with extrahepatic biliary atresia, proven by histopathological examination following termination of pregnancy. The fourth case had hepatic vasculature abnormality and the fifth isolated gallbladder agenesis. In 22 of 32 cases (68.7%), the gallbladder was detected either later in pregnancy or after delivery. Conclusion: The findings support low levels of GGTP in amniotic fluid, combined with NVFGB, as a sign of severe disease, mainly biliary atresia. Normal GGTP levels, concomitant with isolated NVFGB, carry a good prognosis.

Coexistence of gallbladder agenesis and cholangiocarcinoma: report of a case

Gallbladder agenesis (GA) is a rare condition and was first described by Lemary in 1701. Nearly 400 cases of GA is described in the literature and it is associated with various congenital abnormalities and malformations in some cases. Cholangiocarcinoma (CCA) is the malignant tumor arising from bile ducts. A wide range of risk factors have been identified for cholangiocarcinoma. A case of cholangiocarcinoma in which gallbladder agenesis was found incidentally was described in this study.

[Prenatal diagnosis of gallbladder abnormalities: a review]

OBJECTIVES

Our objective was to review the possible consequences and management possibilities of fetal gallbladder abnormalities.

MEANS AND METHODS

A search through publications was conducted using the Pubmed database.

RESULT

The majority of fetal gallbladder abnormalities are benign (absence, malformation, cholelithiasis, sludge...). When the absence of gallbladder is isolated, biliary tract atresia, that is a rare but severe disease, must be evoked.

CONCLUSION

An extensive morphological analysis of the fetus is required in cases with gallbladder abnormalities. An amniocentesis for caryotype analysis must be proposed when an absent gallbladder is associated with other fetal abnormalities and in all cases of absent gallbladder for digestive enzymes evaluation to rule out a biliary atresia.

Biliary atresia: clinical aspects

Biliary atresia (BA) remains an enigmatic disease with a degree of etiologic heterogeneity. A number of variants can be defined clinically, and these include the syndromic group (typically BA splenic malformation), cystic BA, and cytomegalovirus (CMV) IgM +ve associated BA. The remainder, and still the largest group, may be termed isolated BA(.) There is a wide variation in incidence across the globe from 1 in 5000 in Taiwan to 1 in 20,000 live births in Northern Europe, although the reasons for such a disparity remain obscure. Management remains primarily surgical with an attempt to restore bile flow by resection of extrahepatic biliary remnants and a reconstruction portoenterostomy (the Kasai procedure), reserving liver transplantation for those where this fails or complications of chronic liver disease supervene. Clearance of jaundice to normal values has been achieved in 40%-55% of cases in large series from around the world, with an expectation of 5-year native liver survival of similar proportions.

A review of pathophysiology and management of fetuses and neonates with meconium ileus for the pediatric surgeon

PURPOSE

Meconium ileus (MI) is the earliest clinical manifestation of cystic fibrosis (CF), occurring in up to 20% of patients with CF. Our aim was to review and integrate current knowledge about the diagnosis and management of fetuses and neonates with MI that may aid the pediatric surgeon in caring for these patients.

METHODS

We identified areas of interest including pathophysiology, prenatal diagnosis, nonoperative and operative management, postoperative management, and prognosis. We performed a Medline search using the search term meconium ileus for English language articles published in the last 20 years. We reviewed reference lists to identify other articles of historical significance.

RESULTS

Meconium ileus is primarily associated with CF transmembrane (conductance) regulator mutations F508del, G542X, W1282X, R553X, and G551D, and modifier genes have been found to explain approximately 17% of the phenotypic variability. Mouse, pig, and ferret models for CF demonstrate neonatal bowel obstruction mimicking MI. Sonographic findings of hyperechoic masses and dilated bowel in a high-risk fetus are suggestive of MI. Less than 7% of low-risk fetuses with hyperechoic bowel will have MI. Contemporary series of noninvasive management with Gastrografin enema report success rates of 36% to 39%, significantly lower than historical values. The optimal surgical technique remains controversial, although primary anastomosis results in surgical complication rates between 21% and 31%, higher than those noted with delayed anastomosis. Pulmonary function for patients with CF and MI at 15 and 25 years old is similar to those without MI, although height and weight percentiles may be lower.

CONCLUSIONS

This review for pediatric surgeons presents an examination of the literature and synthesizes current information about the pathophysiology, prenatal diagnosis, nonoperative and operative management, postoperative management, and prognosis of the patient with CF and MI.