Intrahepatic bile duct dilatation and cholestasis in autosomal recessive polycystic kidney disease. Demonstration with hepatobiliary scintigraphy

Pregnancy complicated by Caroli's disease with polycystic kidney disease: a case report and following observations

Caroli's disease and Caroli's syndrome are rare congenital disorders characterized by non-obstructive cystic dilatation of the intrahepatic bile ducts. These disorders are often associated with autosomal recessive polycystic kidney disease. A young woman at 11 weeks of gestation was referred to our hospital for proper management of Caroli's disease during pregnancy. Magnetic resonance imaging and laboratory tests revealed Caroli's disease with chronic renal failure caused by polycystic kidney disease. She received diet control, erythropoietin and prophylactic oral antibiotics. Her pregnancy course was uneventful, and she gave birth at 37 weeks of gestation. Thereafter, her renal function gradually worsened. Hemodialysis was begun 5 years after parturition. Though the courses of pregnancies complicated by Caroli's disease or Caroli's syndrome are variable and can include life-threatening conditions, uneventful outcomes can be expected if careful management prevents biliary and renal infection.

Concurrent course of transient neonatal diabetes with cholestasis and paucity of interlobular bile ducts: a case report

We report for the first time a patient with both transient neonatal diabetes mellitus (TNDM) and idiopathic neonatal cholestasis, with both features resolving over a similar time course. Cholestasis was due to paucity of interlobular bile ducts (PILBD). Genetic analysis was consistent with a uniparental disomy of chromosome 6. Paucity of interlobular bile ducts is common in Alagille syndrome but also occurs by unknown mechanisms in a wide spectrum of other diseases. We propose a shared explanation for this patient's TNDM and PILBD mediated by the noted chromosomal abnormality. We suggest that hepatobiliary function be evaluated in patients with TNDM to determine the prevalence and course of cholestasis of the disease.

Hepatectomía parcial curativa en la enfermedad de Caroli del adulto

Caroli's disease consists of a congenital malformation of the intrahepatic bile ducts characterized by saccular, segmental, cystic dilatations giving rise to recurrent cholangitis. The inheritance pattern is unclear and the disease may be associated with other hereditary diseases such as adult polycystic kidney disease. The most effective therapeutic option in symptomatic unilobar Caroli's disease is resection of the affected lobe. In bilobar involvement, liver transplantation should be considered. Due to their rarity, we report three cases of Caroli's disease successfully resolved through lobectomy of the affected lobe: two patients with recurrent cholangitis and one patient with associated adult polycystic kidney disease.

The place of liver transplantation in Caroli's disease and syndrome

Caroli's disease (CD) or syndrome (CS) are rare inherited disorders which may cause severe, life-threatening, cholangitis or which may lead to hepatobiliary degeneration. The typical cystic biliary anomalies are often associated to congenital hepatic fibrosis (CHF) and, less frequently, to cystic renal disease especially autosomic recessive polycystic kidney disease (ARPKD). The place of liver transplantation (LT) in the treatment of CD or CS is evaluated based on our own experience of three successfully transplanted patients, the literature review of 19 patients and the European experience with 110 patients collected in the European Liver Transplant Registry. LT should be proposed as a definitive therapeutic option once severe cholangitis or (suspicion of) malignant transformation is present. The frequently used radiological, endoscopical or surgical biliary drainage procedures carry a high morbidity and mortality rate. In case of concomitant symptomatic CHF and renal failure, combined or sequential hepatorenal transplantation should be carried out, dependent on the evolution of the hepatic and renal disease. In case of associated ARPKD, renal transplantation is often indicated early on because of the more rapid progression of the renal component of the disease.

The value of radionuclide studies in children with autosomal recessive polycystic kidney disease

PURPOSE

To describe and analyze the appearances of autosomal recessive polycystic kidney disease (ARPKD) on Tc-99m DMSA and Tc-99m HIDA scintigraphy.

MATERIALS AND METHODS

The authors evaluated scintigraphic findings for 13 boys and 9 girls (age range, 2 months to 22.75 years; mean, 7.5 years) with ARPKD. Fourteen children underwent Tc-99m DMSA and 20 underwent Tc-99m HIDA scintigraphy according to European guidelines. Kidney outline, internal structure, tracer uptake, and differential function were analyzed on Tc-99m DMSA images, whereas relative liver lobe sizes, hepatocyte tracer uptake, time to peak, and excretion into the biliary tree and gut were evaluated on Tc-99m HIDA scans.

RESULTS

On Tc-99m DMSA images, loss of kidney outline and internal structure was seen in 75% of the scans, and patchy tracer uptake with focal defects throughout the kidneys, particularly at the poles, was evident in 93%. In 85% of the cases, the Tc-99m DMSA changes did not correlate with the ultrasonographic findings where the kidneys are uniformly affected. Characteristic findings on Tc-99m HIDA scans were enlarged left liver lobe in 80%, a delay in maximal hepatocyte uptake in 68%, delayed tracer excretion into the biliary tree in 32% (with stasis in the prominent intrahepatic biliary ducts in 50% or pooling into the segmentally dilated biliary ducts in 25%), and delayed excretion into the gut in 40% of patients.

CONCLUSIONS

In a child with clinically enlarged kidneys that appear diffusely hyperechoic on ultrasound, the appearances on Tc-99m DMSA imaging strongly support the diagnosis of ARPKD. The Tc-99m HIDA findings, especially of an enlarged left lobe of the liver with bile stasis or dilatation, further support the diagnosis.

Caroli's disease: report of 10 cases in children and adolescents in southern Brazil

PURPOSE

The aim of this study was to describe the authors' experience with Caroli's disease in children and adolescents.

METHODS

The authors reviewed the hospital charts of 10 children and adolescents with Caroli's disease diagnosed between 1968 and 1996.

RESULTS

The median age at the onset of symptoms was 5.5 months and the median age at diagnosis was 12 months, both much lower than those reported in the literature. Clinical symptoms were compatible with the classical findings of Caroli's disease, but jaundice and hepatosplenomegaly occurred more frequently. There was an association with congenital renal malformation in eight cases (80%), congenital hepatic fibrosis in five cases, and choledochal cyst in two cases. One case presented the pure form of the disease.