Resolution of nonsyndromic paucity of intrahepatic bile ducts in infancy

An unusual case of trisomy 18 associated with paucity of bile ducts

A case of neonatal cholestasis associated with Trisomy 18 (Edward's syndrome) is presented. A 3-day-old boy was referred to our clinic due to respiratory distress, elevated serum direct bilirubin levels, a systolic heart murmur, growth restriction and micrognathia. Liver biopsy and chromosomal analysis revealed paucity of intrahepatic bile ducts and Trisomy 18. Extrahepatic biliary atresia was reported in only a few patients with Trisomy 18. To our knowledge, we described for the first time a patient with Trisomy 18 and neonatal cholestasis associated with paucity of interlobular bile ducts.

Paucity of intrahepatic bile ducts in infancy: experience of a tertiary center

BACKGROUND: Intrahepatic cholestasis secondary to paucity of bile duct is an alteration of the anatomic integrity of the biliary tract. Can be defined only histologically and, clinically, two categories are recognized: syndromic and non-syndromic, where the prognosis is generally more severe. AIM: To evaluate the history, clinical and biochemical characteristics, etiology and improvement of children who have paucity of intrahepatic bile duct followed at tertiary center. PATIENTS AND METHODS: Eleven children with paucity of intrahepatic bile duct, followed at the Pediatric Hepatology Service of the University Hospital, Campinas, SP, Brazil, were evaluated in the period from 1986 to 2001. RESULTS: Among the patients, three presented the syndromic and eight the non-syndromic form (two with alpha-1-antitrypsin deficiency, one with lues, one secondary to sepsis, three with probable etiology by cytomegalovirus and one without a definite etiology). Referral ranged from 31 to 1185 days. Birth weights ranged from 1920 g to 3590 g. Most of the patients presented pale stools. The median bile duct/portal tract ratio was 0.14. The majority of the children presented a favorable follow-up, regardless of the form of presentation. CONCLUSION: Paucity of intrahepatic bile ducts should be considered in children with cholestasis and its differentiation from extrahepatic causes of neonatal cholestasis is important in order to avoid surgery. Diagnosis of non-syndromic form should not be regarded as unfavorable prognosis, as the evolution is probably related to the etiology in this form of presentation.

Update on the etiologies and management of neonatal cholestasis

The early detection of cholestatic liver disease is one of the major challenges facing pediatricians when evaluating the jaundiced infant. Early recognition of liver disease greatly facilitates the care and outcome of infants, because several serious life-threatening disorders may have cholestasis as a major presenting sign of underlying neonatal liver disease. A key component of the work-up is measurement of serum conjugated bilirubin levels, which if elevated should prompt the clinician to initiate a work-up to determine the cause of neonatal cholestasis. In general, if a patient is developing progressive jaundice soon after birth, is still jaundiced at 2 weeks of life, or develops jaundice within the first month of life, a work-up for neonatal cholestasis should begin. A number of previously undiagnosed causes of neonatal cholestasis are beginning to be assigned genetic and infectious etiologies, with significant implications for the work-up and management of cholestatic infants.

Bile acid transport

Bile acids undergo a unique enterohepatic circulation, which allows them to be efficiently reused with minimal loss. With the cloning of key bile acid transporter genes in the liver and intestine, clinicians now have a detailed understanding of how the different components in the enterohepatic circulation operate. These advances in basic knowledge of this process have directly led to a rapid and highly detailed understanding of rare genetic disorders of bile acid transport, which usually present as pediatric cholestatic disorders. Mutations in specific bile acid or lipid transporters have been identified within specific cholestatic disorders, which allows for genetic tests to be established for specific diseases and provides a unique opportunity to understand how these genes operate together. These same transporters may also prove useful for development of novel drug delivery systems, which can either enhance intestinal absorption of drugs or be used to target delivery to the liver or biliary system. Knowledge gained from these transporters will provide new therapeutic modalities to treat cholestatic disorders caused by common diseases.

Nonsyndromic paucity of interlobular bile ducts: clinical and laboratory findings of 10 cases

BACKGROUND

Reports concerning nonsyndromic paucity of the interlobular bile ducts are not common.

METHODS

The clinical, biochemical, and histological features of ten such children were described.

RESULTS

All presented with jaundice, starting in the first month in seven and in the fourth, seventeenth, and thirtieth month in the others. Alcoholic stools were present intermittently in seven and persistently in three patients. Pruritus was a prominent symptom in five. Liver function tests were abnormal in all but one. Liver biopsies were performed at ages of 20 days to 3 years (median 5 months). In addition to a paucity of interlobular bile ducts, histology revealed intracellular cholestasis in all, portal fibrosis in four, and regenerative nodules in two patients. Complications of fat-soluble vitamin deficiency occurred in seven. Therapy consisted of supplementation of those vitamins and administration of cholestyramine, phenobarbital, prednisolone, or ursodeoxycholic acid. While one child had a successful orthotopic liver transplantation, three died. Consanguinity rate was 80% among the parents, and five of the patients had siblings with similar symptoms.

CONCLUSIONS

Prognosis of these patients is variable. Differentiation from other forms of cholestasis is important especially to avoid surgery.