Intrahepatic bile ducts in biliary atresia--a possible factor determining the prognosis

The extent of biliary proliferation in liver biopsies from patients with biliary atresia at portoenterostomy is associated with the postoperative prognosis

BACKGROUND/PURPOSE

In biliary atresia (BA), a derangement in the biliary system remains, despite portoenterostomy performance. Many factors can influence the disease progression rate. This study aimed to analyze the association between biliary proliferation extent in biopsies from BA patients and postoperative prognosis.

METHODS

Biliary proliferation was evaluated by a morphometric analysis of the cytokeratin 7 positivity percentage (PCK7) in wedge liver biopsies from 47 BA patients. The extent of fibrosis was evaluated by a fibrosis score (FS). The outcome 1-year native liver survival was correlated, using a multivariable regression analysis, with PCK7, FS, and age at portoenterostomy.

RESULTS

The PCK7 ranged between 0.80% and 14.79% (M +/- SD = 7.36% +/- 4.15%). Patients who died or underwent transplantation had higher PCK7 than survivors with their native livers (P < .001). The area under the receiver operating characteristic curve for PCK7 in relation to the outcome was 0.845 (P < .001). The cutoff point of PCK7 for the maximal effect on postoperative prognosis was 10.18% (sensitivity = 0.71, specificity = 0.88). The PCK7 was the only studied variable associated with 1-year native liver survival, independently of age and FS (P = .002).

CONCLUSION

The extent of biliary proliferation at portoenterostomy, evaluated by PCK7, was associated with 1-year native liver survival of BA patients.

Time-course changes in the liver of biliary atresia patients on magnetic resonance imaging

BACKGROUND

Using magnetic resonance imaging (MRI), changes in the livers of postoperative biliary atresia (BA) patients were investigated.

METHODS

Periodic MRI was performed in 32 postoperative BA patients. The findings were evaluated by calculating the near-normal liver tissue area that corresponded with normal- or high-signal regions on T1-weighted imaging. The patients were divided into three groups based on the extent of near-normal liver tissue on the final MRI: group A, n = 14; group B, n = 13; and group C, n = 5, included patients with >40%, 20-40%, and <20% area of near-normal liver tissue, respectively. The relationship among the macroscopic and histological findings in the liver at orthotopic living donor liver transplantation (OLDLT), patient outcomes, and MRI findings were investigated.

RESULTS

In group A, 11 patients had no evidence of liver dysfunction. In group B, six patients either had undergone or were awaiting OLDLT. In group C, all patients had undergone OLDLT. All patients had either adequate or impaired bile drainage in each liver segment. The segmental changes corresponded with the liver architecture at OLDLT. The changes could be evaluated on MRI at 1-2 years after surgery.

CONCLUSIONS

Adequate and restricted areas of liver tissue with near-normal structure were indicative of good and poor prognoses, respectively. Shortly after portoenterostomy, these segmental changes occurred and/or developed in each liver segment and could be detected on MRI. It is emphasized that patients with >40% area of near-normal liver architecture at the initial stages did not require OLDLT, while those with <20% area did require OLDLT.

Biliary atresia: recent progress

Extrahepatic biliary atresia (EHBA), an inflammatory sclerosing cholangiopathy, is the leading indication for liver transplantation in children. The cause is still unknown, although possible infectious, genetic, and immunologic etiologies have received much recent focus. These theories are often dependent on each other for secondary or coexisting mechanisms. Concern for EHBA is raised by a cholestatic infant, but the differential diagnosis is large and the path to diagnosis remains varied. Current treatment is surgical with an overall survival rate of approximately 90%. The goals of this article are to review the important clinical aspects of EHBA and to highlight some of the more recent scientific and clinical developments contributing to our understanding of this condition.

Histological assessment of bile lake formation after hepatic portoenterostomy for biliary atresia

Bile lakes develop after hepatic portoenterostomy in some patients with biliary atresia, and have been regarded as an indication of poor prognosis. We reported that bile lakes have no epithelium of the bile duct on their wall, and are surrounded by bile ducts; however, the mechanism of bile lake formation is little known. We investigated histologically how bile ducts are formed using whole removed liver, and the characteristics of bile ducts around bile lakes. From April 1980 to July 2006, we encountered 84 patients with biliary atresia. Bile lakes were analyzed histologically in 11 patients who underwent liver transplantation in our hospital. Bile lakes had a fibrotic cyst wall and lacked epithelia. In most cases, bile stasis, calculi formation, damaged bile ducts, and invasion of inflammatory cells were observed around the bile lakes. Bile ducts around bile lakes were not stained by CD56, but bile ducts around liver lobuli were stained by CD56. The present study speculates that bile lakes would arise from original bile ducts, which are damaged, and fuse together after calculi are formed in bile ducts.

Intrahepatic cystic lesions after hepatic portoenterostomy for biliary atresia with bile lake and dilated bile ducts

BACKGROUND

Intrahepatic cystic lesions develop after hepatic portoenterostomy in some patients with biliary atresia and have been regarded as an indication of poor prognosis; however, there is confusion about the terminology and concepts of the lesions. We investigated whether the cystic lesions constituted a single entity.

PATIENTS AND METHODS

From 1980 to 2005, we encountered 80 patients with biliary atresia. Abdominal ultrasonography disclosed intrahepatic cystic lesions in 20 (25%) patients after hepatic portoenterostomy. The cystic lesions were analyzed morphologically with radiologic imaging studies and histologically in 13 patients who underwent liver transplantation.

RESULTS

Fifteen patients had solitary simple cystic lesions, and 5 patients had multiple continuous oval or beaded lesions. Solitary lesions had a fibrotic cyst wall and lacked epithelia. Continuous lesions had a cyst wall covered with biliary epithelia. Thirteen patients with solitary cysts died or required liver transplantation. In 2 patients with continuous lesions, surgical reboring of the porta hepatis could eliminate cystic lesions and jaundice.

CONCLUSIONS

Intrahepatic cystic lesions include 2 different conditions. Solitary cysts are retention pseudocysts, which should be referred to as a bile lake, and are associated with poor prognosis. Continuous beaded cysts are dilated bile ducts, which may be reversed. This distinction is important when considering the treatment strategy.

Long-term outcome in type I biliary atresia

PURPOSE

This retrospective study reviews the long-term outcome of type I biliary atresia (BA).

METHODS

Three hundred twenty-three patients with BA, including 50 with type I, underwent corrective surgery. The surgical results, role of cholangiograms during the corrective surgery, late complications, and current statuses were evaluated.

RESULTS

The overall survival rate of the nontransplant type I patients was better than that of the type II/III patients (52% vs 33%, P = .0009). Cholangiograms of 32 patients were classified into 3 types: cloudy (48%), treelike (13%), and mixed (39%). Of 26 patients who underwent corrective surgery in 1972 or later, 7 (50%), 7 (78%), and 3 (100%) patients of the cloudy type, mixed type, and treelike type, respectively, have survived without liver transplantation (LTx). Of 18 type I patients who survived more than 20 years without LTx, 7 developed severe late complications. Two of them eventually required LTx after 20 years old.

CONCLUSIONS

Use of cholangiograms during corrective surgery might have a long-term prognostic value. The overall survival rate of type I BA was better than that of type II/III. The incidence of late complications was, however, considerably high in the type I survivors. All patients required careful long-term follow-up.

The perinatal transition of the hepatobiliary cyst size provides information about the condition of bile flow in biliary cystic malformation cases

PURPOSE

The aim of this study was to understand the level of bile flow by perinatal transitions of the hepatobiliary cyst size in biliary cystic malformation (BCM) cases and to examine the association between the transitions of the cyst size, cholangiographic images of the intrahepatic bile ducts (IHBDs), and histological features of the liver specimens in BCM.

METHODS

We measured perinatal size of the hepatobiliary cyst in 7 BCM cases, composed of 1 case with choledochal cyst and 6 cases with biliary atresia (BA). Bile excretion was inferred from the transition of cyst size and the postoperative course. The IHBD cholangiographic images were also examined. In addition, histology of liver specimens obtained at the time of initial surgery was evaluated for IHBD maturity and fibrosis.

RESULTS

The size of the small cyst in 2 BA cases remained almost unchanged throughout gestation. These cases required longer postoperative period for the clearance of jaundice. Their IHBD images were indistinct, and histology showed severe fibrosis. The ratio of bile ducts to portal tracts was 0.5 in 1 of the cases. However, in other BCM cases where the cysts grew large perinatally, bile excretion was good postoperatively, and their jaundice cleared in shorter period. Their cholangiographic images demonstrated clearer periphery of the IHBDs, and their histology showed mild or moderate fibrosis, if any.

CONCLUSIONS

The perinatal transition of the cyst size in BCM cases can be helpful in assessing the level of bile flow. BCM with a small cyst during gestation can include some BAs with poorer bile flow, vaguer IHBD images, and prominent liver fibrosis. For the treatment of BCM cases, especially patients with a small biliary cyst, prompt response may be required after birth.

The aberrant expression of HLA-DR in intrahepatic bile ducts in patients with biliary atresia: an immunohistochemistry and immune electron microscopy study

BACKGROUND/PURPOSE

Although the precise pathogenesis for the destruction of the intrahepatic biliary tract in a patient with biliary atresia (BA) is still unclear, it is known that progressive destruction of the intrahepatic biliary tract is responsible for poor long-term outcome after surgical treatment. In this study, the authors evaluated the expression of HLA-DR in liver tissue of patients with BA to explore its role in the pathogenesis of this disease.

METHODS

Liver biopsy specimens from patients with BA (n = 14) and normal liver biopsies (n = 12) were studied immunohistochemically and were assessed immune electron microscopically to detect the expression of HLA-DR. All patients underwent follow-up for at least 3 months after surgery evaluating the short-term postoperative outcome by monitoring the serum bilirubin level during jaundice persistency.

RESULTS

The immunohistochemical examinations showed in 10 of 14 liver specimens in the BA group a positive expression of HLA-DR. This expression was mainly detected in bile ducts of the central portal area rather than in proliferated ones in more peripheral areas. None of the specimens from the control group showed positive expression. Eight of 14 specimens in the BA group showed immunoelectron microscopic depositions of colloidal gold in dull and swollen ductules microvilli. This was not observed in the control group. In patients with BA there was an inverse relationship between short-term postoperative outcome and expression of HLA-DR in intrahepatic ductules.

CONCLUSIONS

Our findings show that there is an aberrant expression of HLA-DR in microvilli of the ductules in patients with BA, and this abnormal expression is inversely related to the short-term postoperative outcome. It is suggested that aberrant HLA-DR expression in bile ductules may play a pathogenic role in progressive damage to the intrahepatic bile ducts in BA.

Evidence for segmental bile drainage by hepatic portoenterostomy for biliary atresia: Cholangiographic, hepatic venographic, and histologic evaluation of the liver taken at liver transplantation

BACKGROUND

The result of hepatic portoenterostomy for biliary atresia (BA) has improved, but there are some patients who experience worsened liver function in the long term after one decrease in jaundice owing to portoenterostomy. However, the cause of the liver dysfunction in the long term has not been clearly ascertained.

METHODS

Five patients (5 to 28 years of age) with BA underwent liver transplantation (LT) because of liver dysfunction after successful portoenterostomy. To clarify the cause of liver dysfunction occurring in the long term, the authors performed a cholangiogram, hepatic venogram, and macroscopic/microscopic examination of the liver just after LT.

RESULTS

(1) Macroscopically, the liver could be divided into 3 areas, the hypertrophic, atrophic, and intermediate, with findings between those of the hypertrophic and atrophic areas. (2) The divided areas clearly corresponded to the liver segments. Segment IV was the hypertrophic area in all patients, but segments VI and VII were the atrophic areas in 4 of the 5 patients. (3) Based on the cholangiographic and microscopic findings, the hypertrophic area had near-normal structure with bile ducts. The atrophic area had severe fibrosis and contained only a few bile ducts in the intralobular spaces of liver.

CONCLUSIONS

It seems that segmental bile drainage must have been established by hepatic portoenterostomy in some patients and that some postoperative patients might have worsened liver function in the long-term follow-up period accompanied with progression of fibrosis and impaired bile drainage. These pathologic changes occur in each liver segment.

Atypical morphologic presentation of biliary atresia and value of serial liver biopsies

BACKGROUND

Liver biopsy findings are important in diagnosing extrahepatic biliary atresia. Diffuse ductular proliferation is a characteristic finding. We describe four patients with conjugated hyperbilirubinemia in whom the initial liver biopsy findings showed a lack of ductular proliferation, despite subsequent development of biliary atresia.

RESULTS

On initial biopsy, paucity of intrahepatic bile ducts was present in three of four patients, with a bile duct to portal space ratio of 0.3 to 0.4 (normal, 0.9-1.8). A normal bile duct to portal space ratio of 1.0 was observed in the fourth patient. Ductular proliferation became apparent in three subjects between 9 and 12 weeks of age, and biliary atresia was noted at the time of a Kasai portoenterostomy. The fourth child had well-developed biliary cirrhosis at liver transplantation.

CONCLUSIONS

Changes characteristic of biliary atresia may appear even after 9 weeks of age. Bile duct paucity and normal bile duct to portal space ratio do not preclude the subsequent development of biliary atresia. Infants with unexplained conjugated hyperbilirubinemia and acholic stools should undergo sequential liver biopsies until clinical improvement occurs or until biliary atresia can be excluded from the differential diagnosis.

Biliary atresia with extrahepatic biliary cysts--cholangiographic patterns influencing the prognosis

PURPOSE

Biliary atresia (BA) with extrahepatic biliary cysts (EHBC) has been recognized generally as "correctable" BA, which indicates a good prognosis. The variants of BA with EHBC according to cholangiographic findings and their outcomes were reviewed.

METHODS

An EHBC was observed in 8 (20%) of 40 patients with BA who underwent operation at our institute. Intraoperative cholangiographic patterns included visualization of the intrahepatic bile ducts (type I BA with EHBC) in 6 patients and no visualization (type III BA with EHBC) in 2. Intrahepatic biliary cysts (IHBC) and EHBC were observed simultaneously in 2 patients diagnosed at older age. The follow-up periods ranged between 4 months and 20 years.

RESULTS

Good bile drainage after a hepaticoenterostomy or portoenterostomy was obtained in all 6 patients with type I BA with EHBC. Two who showed IHBC on intraoperative cholangiography had complications caused by postoperative recurrent cholangitis, which led to a liver transplantation in 1. Revision after the portoenterostomy was required in 2 patients with type III BA with EHBC. One became jaundice free after revision, whereas the other died of hepatic failure without bile drainage.

CONCLUSION

Intraoperative cholangiographic findings showing IHBC and type III BA are poor prognostic factors in patients with BA with EHBC.

Computer-generated three-dimensional morphology of the hepatic hilar bile ducts in biliary atresia

BACKGROUND/PURPOSE

In biliary atresia (BA), although the intrahepatic bile ducts are reported to appear in the fetal configuration in about 20% to 60% of cases, information about the 3-dimensional (3-D) morphology of the hilar biliary structures is limited. The authors, therefore, have applied the technique of computer-generated 3-D reconstruction, to study the morphology of the hilar biliary structures in patients who have undergone biliary decompression.

METHODS

Computer-generated 3-D reconstructions were performed from serial sections of the hepatic hilum of 4 BA patients and compared with those obtained from a 3-day old infant who had no apparent biliary disease but died of congenital diaphragmatic hernia (CDH) and with normal human fetal ductal plate at 11 weeks of gestation.

RESULTS

In all 4 BA patients, the hilar bile ducts strongly resembled the ductal plate structures of the fetus rather than the bile ducts of the CDH infant. This leads the authors to suggest that these abnormal biliary structures are the result of improper ductal plate remodeling at the hepatic hilum. In 3 of the BA patients there were some tubular bile ducts that probably are the result of delayed and abnormal attempt at ductal plate remodeling.

Bile ductular proliferation as a prognostic factor in biliary atresia: an immunohistochemical assessment

PURPOSE

The correlation between the histological findings of the intrahepatic biliary epithelium and postoperative bile drainage in biliary atresia (BA) was investigated.

METHODS

The patients with BA were classified into 2 groups, consisting of a good bile drainage group (GBD, n = 14, mean age at initial operation, 57.6+/-18.0 days) and a poor bile drainage group (PBD, n = 11, mean age at initial operation, 86.9+/-42.7 days). Liver specimens from an initial Kasai's operation were examined by immunostaining using anticytokeratin 7 (CK7) antibody and anti-MIB-1 antibody. The number of CK7-positive cells in the bile ductules was microscopically calculated within the 40-microm-thick interstitium along the limiting plate (LP), and the CK7-positive cell number per unit length of the LP was estimated. In addition, the MIB-1 index in bile ductules also was determined.

RESULTS

The number of CK7-positive cells in PBD was significantly higher than that in GBD (167.6+/-45.6 v 117.8+/-32.4/ mm, P<.05). However, the MIB-1 index in biliary cells did not differ between the 2 groups.

CONCLUSION

An increased number of intrahepatic bile duct epithelial cells in liver specimens at the initial operation may be a poor prognostic factor in BA and appears to depend on the duration of bile stasis rather than the degree of bile stasis.

Incidence of intrahepatic biliary cysts in biliary atresia after hepatic portoenterostomy and associated histopathologic findings in the liver and porta hepatis at diagnosis

BACKGROUND/PURPOSE

The association of intrahepatic biliary cysts in biliary atresia (BA) after hepatic portoenterostomy has drawn the attention of many pediatric surgeons and has become an important subject in clinical management, but the incidence and causes of this association are not well known.

METHODS

During the last 14 years, we operated on 33 BA patients by hepatic portoenterostomy. Five patients could not be followed up over a 1-year period, so the remaining 28 patients had their intrahepatic structure investigated by periodic magnetic resonance imaging (MRI), and were confirmed at autopsy. The authors also reviewed the preoperative conditions of these patients and the histopathologic changes in the liver biopsy and the porta hepatis specimens taken at portoenterostomy.

RESULTS

(1) Intrahepatic biliary cysts were found in 6 of the 28 patients studied (21%). Of 16 patients who were operated on after 1989 and are undergoing follow-up by MRI, 4 (25%) had cysts. (2) Five of the 6 patients with cysts had episodes of cholangitis before or at the time of discovery of the cysts, and 4 of them have had their jaundice reappear since the discovery of the cysts. (3) The intralobular spaces (ILS) with fibrosis and the number of bile ducts had increased in the group with cysts compared with those in the group without cysts. (4) The bile duct maximum size in the porta hepatis (PH) was similar in the groups with and without cysts, but a denudation of the mucosal lining cells in the duct, and a fibrosis and inflammation around the duct had increased in the group with cysts compared with those in the group without cysts. (5) Statistically, the fibrosis found in the ILS and the inflammation around the bile duct found in the PH were induced as a correlative factor affecting cyst formation.

CONCLUSIONS

The association of intrahepatic biliary cysts in BA after portoenterostomy is frequent. The fibrous change in the ILS and the inflammatory process around the bile ducts might be potential causes of cyst formation.

Further observations on cystic dilatation of the intrahepatic biliary system in biliary atresia after hepatic portoenterostomy: report on 10 cases

This is a report on ten patients with cystic dilatation of the intrahepatic biliary system (CDIB) after hepatic portoenterostomy. They were five girls and five boys and the diagnosis of CDIB was made at ages 6 months to 11 years (mean age: 2.8 +/- 3.3 years). Follow-up ranged from one month to 15 years (mean: 5.5 +/- 4.9 years). In order to elucidate the factors which affect the clinical outcome of such patients, the types of CDIB (Type A: noncommunicating solitary cyst, Type B: communicating solitary cyst, Type C: multi-cystic dilatation), clinical symptoms at onset of CDIB and the method for the treatment were reviewed in relation to the outcome. For the purpose of understanding pathogenesis of CDIB, immunohistochemical study on hepatobiliary system was done with monoclonal antibody for cytokeratin. Outcome of the patients of Type C was poor, whereas the outcome of patients with type A and B was good. The outcome of preoperatively jaundiced patients was poor, but jaundice-free patients showed good outcome. Method of treatment was not related to the outcome. As epithelium of CDIB was positive for monoclonal antibody of cytokeratin, it was suspected that pathogenesis of CDIB might be related to peribiliary gland which originated from ductal plate.

Proliferation of intrahepatic bile-duct epithelium in biliary atresia : A useful predictor of clinical outcome

Proliferating cell nuclear antigen (PCNA) and transforming growth factor α (TGFα) are considered as markers of cell proliferation. The expression of PCNA and TGFα was evaluated immunohistochemically using anti-PCNA antibody and TGFα in 31 patients with biliary atresia (BA) (15 jaundice-free and 16 with persistent jaundice) and 6 control infants. The labeling indices (LI) for PCNA- and TGFα-positive bile-duct epithelium in BA were 14.1±14.0% and 51.4±33.7%, respectively, which was significantly higher than in the controls (P <0.01). In BA, the number of PCNA-immunoreactive cells was higher in the peripheral bile ductules than in the central bile ducts of the portal tract (P <0.01). LI was not related to patient age at the time of hepatic portoenterostomy in two groups divided at the age of 60 days. Patients in the persistent jaundice group had greater expression of PCNA and TGFα (21.7±16.0% and 76.9±20.7%, respectively) compared to those in the jaundice-free group (6.0±2.7% and 24.3±20.9%, P <0.001). PCNA and TGFα expression in the bile-duct epithelium of the portal tract was closely related to prognosis in BA patients, and thus could be useful as a prognostic marker.

Electron microscopic study of the liver with biliary atresia and neonatal hepatitis

Eleven cases of biliary atresia (BA) and eight of neonatal hepatitis (NH) were studied, using transmission electron microscopy, to document their different ultrastructural characteristics and to elucidate the possible pathogenesis of biliary atresia. Among 30 consecutive liver biopsies obtained from 19 infants with BA or NH, 21 specimens composed (13 BA, 8 NH) were examined ultrastructurally. The electron microscopic features of NH (patients' age range, 35 to 60 days) were (1) giant hepatocytic transformation with scattered areas of dilated endoplasmic reticulum, indicative of intracytoplasmic degeneration, (2) frequent cytoplasmic biliary necrosis, and (3) relatively intact microvilli in most bile canaliculi, which contained some hepatocytic cytoplasmic fragments. These features strongly suggest that the main pathological process in NH is hepatocellular injury rather than bile duct damage. In contrast, all cases with BA (age range, 27 to 130 days) demonstrated (1) marked hepatocellular cholestasis associated with many lysosomes and myelin figures, (2) marked loss of bile canalicular microvilli, (3) degenerated bile ductular cells containing bile pigments, and (4) periductal inflammatory fibrosis. These features suggest that the main pathological process in BA involves the biliary system. A few viral inclusions were observed in two cases with BA, which suggests that viral infection is a potential cause. In two BA cases (aged 40 and 43 days at the time of first biopsy), the ultrastructural findings essentially were the same as those of NH, and follow-up biopsy specimens (at 48 and 94 days) showed findings consistent with BA. Such results support Landing's hypothesis that BA and NH are different manifestations of a single pathological process.

Immunohistochemical study of proliferating cell nuclear antigen in hepatocytes of biliary atresia: a parameter to predict clinical outcome

The hepatic lobulus was studied histologically and immunohistochemically using the monoclonal antibody for proliferating cell nuclear antigen (PCNA/Cyclin, a cell-cycle-related nuclear protein) in 27 patients with biliary atresia (BA) and six normal infants. The study showed that the labeling index (LI) for PCNA-positive hepatocytes was 37.21 +/- 17.75% in the patients with BA and 3.14 +/- 1.5% in the normal infants (P < .0001). LI for PCNA-positive cells was higher in the periportal area than the pericentral area (P < .01). LI was not related to the patients' age at the time of hepatic portoenterostomy. LI was 20.80 +/- 7.03% for patients whose jaundice cleared postoperatively and 48.49 +/- 13.43% for patients who had persistent jaundice (P < .001). Conventional histological studies of the same specimens showed common findings of BA, such as hepatocellular degeneration, necrosis, inflammatory cell infiltration, and giant cell transformation. Most patients with BA had 8.94 +/- 13.55% giant cell transformation among 1,000 hepatocytes. Patients who exhibited high giant cell transformation had an unfavorable outcome. Only 0.42% of giant cells were immunoreactive for PCNA. In conclusion, the PCNA expression of hepatocytes is closely related to the prognosis of patients with BA, and thus could be used as a prognostic indicator.

Serum bilirubin fractions in cholestatic pediatric patients: determination with Micronex high-performance liquid chromatography

Bilirubin conjugates in the serum of cholestatic pediatric patients were investigated with Micronex high-performance liquid chromatography. Serum bilirubin was resolved into four fractions: delta bilirubin (Bd), bilirubin diglucuronide (BDG), bilirubin monoglucuronide (BMG), and unconjugated bilirubin (Bu). The conjugated bilirubin (BDG+BMG) fraction in preoperative patients with biliary atresia (BA) was 48.8 +/- 5.1%, which was significantly higher than that in patients with infantile hepatitis (P < .01). Among postoperative BA patients who recovered from jaundice, the Bd fraction increased during the first month, remained elevated (60% to 80%) for a while, and then gradually decreased. After 6 months, the Bd fraction decreased to 30% in the jaundice-free survivors, but was still higher than that in controls (7%). Even after the total serum bilirubin had normalized (< or = 1.0 mg/dL), distribution of bilirubin fractions remained abnormal, possibly reflecting impaired hepatic excretion of bilirubin. In conclusion, measurement of the conjugated bilirubin fraction enabled BA to be differentiated from infantile hepatitis, and the delta bilirubin fraction proved to be an important indicator of cholestasis in postoperative BA patients with normal serum bilirubin.

Does the morphology of the extrahepatic biliary remnants in biliary atresia influence survival? A review of 205 cases

Resected extrahepatic remnants taken at the time of portoenterostomy were examined in a single-center review of 205 cases of biliary atresia. The morphological features of the size and number of residual ducts at the porta hepatis and the degree of inflammation at the porta hepatis were analyzed using a semiquantitative scoring system. The morphology of the common hepatic and common bile duct was classified into seven types. These features were then related to age at time of initial surgery and to survival. This showed that few or absent ductal remnants at the porta hepatis and absence of portal inflammation were predictors of poor prognosis. These histological features may represent the "burnt out" end result of the disease process. There was no correlation between age at time of portoenterostomy and either portal duct patency or portal inflammation. The common hepatic and common bile duct were variably involved in the sclerosing process, but the patterns of obliteration were not indicative of prognosis. The severity of intrahepatic biliary cholangiopathy and the extent of liver damage may ultimately be more important to survival in the long term.

A new clinical prognostic predictor for patients with biliary atresia

The excretion of D-glucaric acid (DGA), a metabolite of the cytochrome P-450 pathway, is considered a marker of the viability of hepatocytes. Twelve cases of biliary atresia (BA) have been investigated, correlating the level of DGA, degree of histological alteration of liver parenchyma, and clinical outcome. Urine was collected in the preoperative period. Five patients had good bile flow after the Kasai operation and demonstrated mild liver fibrosis. The urine excretion level of DGA in this group was 17.2 +/- 3.1 mumol/d (control, 15.2 + 2.2 [67od] mmol/d). Seven patients had partial bile drainage or prolonged jaundice. They also had altered liver parenchyma and a very low level of DGA in the urine preoperatively (4.2 + 2.2 mumol/d). Urine excretion of DGA reflected the degree of alteration of liver parenchyma and closely correlated with clinical outcome. Measurement of DGA before the Kasai operation provides information concerning the present hepatic function and the postoperative prognosis. Once the activity of hepatocytes deteriorates, this test is quicker than the other liver function tests. It is noninvasive and is a useful clinical prognostic predictor in BA.

Immunohistochemical demonstration of collagen types III and IV and myofibroblasts in the liver of patients with biliary atresia

To clarify the pathogenesis of pericholangitis in biliary atresia, immunohistochemical and ultrastructural methods were used to quantify the amount of collagen types III and IV, and alpha-smooth muscle actin-positive myofibroblast present in the pericholangial tissue. Patients were divided into two groups: the early-stage group (n = 7; 15 to 30 days old at the time of the Kasai operation), and the advanced-stage group (n = 14; 8 months to 6 years old at the time of liver transplantation). The liver specimen was harvested at the time of the Kasai operation in the early-stage group, and during liver transplantation in the advanced-stage group. Liver tissue from the donor was used as the control. The specimen was visually inspected and classified into three grades to express the extent of proliferation. An increase of collagen types III and IV, and myofibroblast in the pericholangial area was seen even in 2- to 4-week-old patients, which became marked with the progression of the fibrotic disease process. This suggests that pericholangitis occurs in the very early stage of biliary atresia, perhaps before the development of bile duct obstruction.

Cystic dilatation of the intrahepatic biliary system in biliary atresia after hepatic portoenterostomy

Five cases of intrahepatic biliary cyst or cystic dilatation and one suspicious case were found (6.4%) among 93 survivors of biliary atresia. The age at manifestation of such cysts ranged from 6 months to 12 years. These cysts or cystic dilatations were treated surgically in two cases, by percutaneous transhepatic cholangiodrainage (PTCD) in two, and not treated in one. Four patients are alive; one died of biliary atresia. Twenty-nine well-documented cases of intrahepatic biliary cyst were found in the literature, including five treated by the authors. The modes of dilatation were as follows: type A, noncommunicating cyst; type B, cyst with tiny communication with the intestinal loop; and type C, cystic dilatation. Clinical symptoms were fever, jaundice, acholic stool, and "cholangitis." Nineteen patients (66%) had symptoms within 4 years after the Kasai operation (first group); the modes of dilatation were mostly types A and B. However, in five of six patients with type C dilatation, symptoms developed after 10 years of age (second group). The prognosis for the second group appears poor because the condition of the liver worsens once cystic dilatation develops.

Hepatic histology and the development of esophageal varices in biliary atresia

Histological features in liver biopsy specimens taken from 71 infants at the time of surgery for biliary atresia (portoenterostomy) were analyzed using a scoring system and compared with an endoscopic grading of esophageal varices performed at a mean age of 3.4 years. The analysis showed no correlation between a "global" score, which represented the severity of all histological changes in the original biopsy specimen, and the severity of esophageal varices. Further analysis also showed no correlation with any individual histological feature (eg, fibrosis). These findings failed to confirm a previous study, which suggested a relationship between liver changes at surgery and the later development of esophageal varices in children with biliary atresia.

Intrahepatic biliary stones in children

Intrahepatic biliary stones in seven non-Oriental patients were studied in all by sonography, in four patients by computed tomography and in four patients by percutaneous transhepatic cholangiography. For patients had extrahepatic biliary atresia treated with portoenterostomies, one patient had undergone partial liver transplantation and of the remaining two, one had cystic fibrosis and the other immunodeficiency syndrome. All sonograms were abnormal and showed echogenic foci within the liver, with or without associated signs of biliary tract dilatation. CT confirmed the biliary tract dilatation yet calculi were identified in one patient only. PTC was particularly helpful in the patient with immunodeficiency in whom features typical of sclerosing cholangitis were found. This report emphasizes the variable radiological appearance of bile stones which to our knowledge have rarely been described in children with entities other than Oriental cholangitis.

A long-term experience with biliary atresia. Reassessment of prognostic factors

Thirty-four infants with biliary atresia were primarily treated at our institution between 1974 and 1987. The mean age at diagnosis was 8.8 weeks. The Kasai portoenterostomy was used in 11 patients (32%) and the Sawaguchi modification in 23 infants (68%). Overall survival was 47% (16/34), with a mean follow-up of 45 months. Fifteen survivors (94%) are jaundice free, with two having undergone liver transplantation. Survival was not influenced by earlier age at operation, size of ductal remnants, or the use of an external biliary vent. Good bile flow was predictive of a favorable outcome. The incidence of cholangitis was increased in the Kasai (87%) versus the Sawaguchi groups (45%) (p less than 0.05), but 1-year survival rates were similar (55% vs 64%). The authors conclude that portoenterostomy offers a reasonable chance for success and should be the initial procedure for biliary atresia.

Ultrasonographic findings and management of intrahepatic biliary tract abnormalities after portoenterostomy

Ultrasonographic examinations was made in 24 children who had undergone a portenterostomy to correct extrahepatic biliary atresia. Abnormalities were observed in six patients. These were the result of ongoing inflammatory reactions because all had been suffering from cholangitis after surgery, and the size of the biliary tract structure changed in accordance with the occurrence and subsidence of the cholangitis. Ultrasonographic examination showed dilation of the intrahepatic bile duct in one patient and cystic lesions in five patients. Treatment included percutaneous transhepatic bile drainage for dilated bile ducts, alcohol injections for intrahepatic cysts, and reoperation for cysts in the porta hepatis. Treatment was not required for cysts in controllable cholangitis. The results of these approaches were excellent, indicating that they were of benefit in treatment intrahepatic abnormalities occurring after portoenterostomy.

Abnormalities of intrahepatic bile ducts in extrahepatic biliary atresia

The infantile cholangiopathies are a group of conditions associated with neonatal jaundice, which include extrahepatic biliary atresia, paucity of intra-hepatic bile ducts and disorders associated with persistence of fetal biliary structures, the so-called ductal plate malformations. Although previously regarded as distinct entities, it has recently been suggested that they may represent parts of a disease spectrum in which the principal process is one of bile duct destruction, the morphological manifestations in individual cases being influenced by the stage of intra-uterine development at which such injury occurs and by the site within the biliary system at which there is maximum damage. To further examine this concept, we have studied liver biopsy specimens from 37 neonates with extrahepatic biliary atresia, with particular reference to abnormalities of the intrahepatic bile ducts. Paucity of intrahepatic ducts, defined as a bile duct: portal tract ratio of less than 0.9, was identified in six cases (16.2%). In eight cases (21.6%) we found concentric tubular ductal structures similar to those observed in ductal plate malformations. In one case, both abnormalities could be demonstrated. Our findings support the concept that there is overlap between the various types of infantile cholangiopathy.

Intrahepatic biliary cysts after hepatic portoenterostomy in four children with biliary atresia

We report our experience with 4 cases of cystic dilatation of intrahepatic bile ducts following hepatic portoenterostomy for biliary atresia. Two of the cases did not achieve satisfactory bile excretion and all four cases developed recurrent cholangitis after hepatic portoenterostomy. The attacks of cholangitis seemed to be associated with the presence of intrahepatic cysts. Although one case resulted in death from hepatic failure, three other cases are now outpatients. Patients who develop recurrent cholangitis following hepatic portoenterostomy, should be examined to exclude the presence of intrahepatic biliary cysts. Ultrasonography, computed tomography and percutaneous transhepatic cholangiography were all effective in detecting cysts and provided valuable information for planning treatment. Percutaneous transhepatic or surgical drainage of the bile ducts was effective in reducing jaundice, and recurrent cholangitis.

The surgery of "correctable" biliary atresia

Seven of 114 (6%) patients treated in Denver for biliary atresia had a variant of the disease in which only microscopic bile ducts or ductules were identified at the porta hepatis, hepatic lesions were present, even in the neonatal example, and intrahepatic biliary hypoplasia was uniformly present. The excised bile duct cysts consisted of fibrosis or scar tissue and with little or no epithelial lining. Six patients had corrective surgery. The first patient was treated by choledochoenterostomy and became totally obstructed. Definitive operation in this patient and all subsequent patients consisted of excision of all extrahepatic duct structures and Roux-en-Y portoenterostomy. Two patients died, the one who did not have surgical correction and a second who had correction at age 35 weeks. The other five patients have been followed for 18 to 158 months and are anicteric but have some degree of residual liver damage. We conclude that so-called correctable biliary atresia occurs in less than 10% of cases, that because of coincident biliary hypoplasia, "cure" is not a possible outcome, and that the treatment of choice is complete surgical excision of the extrahepatic bile ducts and Roux-en-Y portoenterostomy.

Neonatal cholestasis

The spectrum of diseases causing neonatal cholestasis presents intriguing problems for future investigation. There are many causes, and the eventual outcome of the specific entity has unique individual features, despite the wide areas of overlap. For example, extrahepatic biliary atresia may be the result of the sporadic occurrence of a virus-induced, progressive obliteration of the extrahepatic bile ducts with some degree of intrahepatic bile duct injury. This same sequence of viral infection with persisting injury may account for sporadic (nonfamilial) cases of neonatal hepatitis, as suggested by the Landing hypothesis. Conversely, the familial forms of cholestasis, either neonatal hepatitis or instances of intrahepatic cholestasis, are most likely genetic diseases that represent specific defects in the hepatic excretory process or in the bile secretory apparatus. The persistent nature of these presumed enzymatic or structural defects may explain the less favorable prognosis. Elucidation of the nature of these inborn errors of liver function may allow a better understanding of biliary physiology, and improved therapy.