Neonatal cholestasis: a red alert for the jaundiced newborn

Tc-99m PMT scintigraphy in the diagnosis of pediatric biliary atresia

PURPOSE

Hepatobiliary scintigraphy plays an important role in the differentiation of biliary atresia (BA) and non-BA. The usefulness of ^99mTc-iminodiacetic acid (IDA) derivatives in BA diagnosis is reported in several papers. In contrast, there are no comprehensive data on differentiating BA from non-BA using ^99mTc-N-pyridoxyl-5-methyl-tryptophan (PMT). Our objective was to evaluate the usefulness of ^99mTc-PMT scintigraphy in the diagnosis of BA.

MATERIALS AND METHODS

52 infants who received ^99mTc-PMT scintigraphy for suspected BA were retrospectively evaluated. Preoperative cholangiograms or follow-ups were used as the gold standard for diagnosis of BA. We analyzed the utility of ^99mTc-PMT scintigraphy, various clinical and investigational parameters in the diagnosis of BA.

RESULTS

The final diagnoses in this group were BA (67.3%) and non-BA (32.7%). ^99mTc-PMT scintigraphy, stool color change, total bilirubin, direct bilirubin, aspartate aminotransferase (AST) and γ-glutamyl transferase (γ-GTP) led to distinguishing between BA and non-BA in univariate analysis. Subsequent multivariate logistic regression analysis indicated that ^99mTc-PMT scintigraphy and γ-GTP were independent predictors of BA. The diagnostic accuracy of ^99mTc-PMT scintigraphy was 94.2%.

CONCLUSIONS

^99mTc-PMT scintigraphy is more accurate in the diagnosis of BA than other conventional examinations. In addition, false positives of ^99mTc-PMT scintigraphy could be reduced by combining γ-GTP level monitoring.

Phenobarbital-enhanced hepatobiliary scintigraphy in the diagnosis of biliary atresia: two decades of experience at a tertiary center

BACKGROUND

Hepatobiliary scintigraphy is highly sensitive for diagnosing biliary atresia; however, its specificity has varied in the literature from 35% to 97%.

OBJECTIVE

The purpose of this study was to re-evaluate the accuracy of phenobarbital-enhanced hepatobiliary scintigraphy in differentiating biliary atresia from other causes of neonatal cholestasis.

MATERIALS AND METHODS

We retrospectively reviewed all hepatobiliary scans of infants with cholestasis at our institution from December 1990 to May 2011. Per our routine protocol the scans were obtained after pretreatment with phenobarbital (5 mg/kg/day for 5 days) to achieve a serum level of ≥15 mcg/ml. Normal hepatic uptake with no biliary excretion by 24 h was considered consistent with biliary atresia.

RESULTS

One hundred eighty-six infants with 210 hepatobiliary scans composed the study group. Forty-three (23%) infants had the final diagnosis of biliary atresia. Hepatobiliary scintigraphy was 100% sensitive, 93% specific and 94.6% accurate in diagnosing biliary atresia. Of the 186, 39/111 (35.1%) term and 2/68 (2.9%) preterm infants had biliary atresia; two of seven children with unknown gestational age also had biliary atresia. Other diagnoses included neonatal hepatitis, total parenteral nutrition cholestasis, Alagille syndrome, cystic fibrosis, choledochal cyst, hypothyroidism, alpha-1 antitrypsin deficiency and persistent cholestasis of unknown etiology.

CONCLUSION

Phenobarbital-enhanced hepatobiliary scintigraphy is highly accurate in differentiating biliary atresia from other causes of neonatal cholestasis. Biliary atresia is rare in premature infants.

Biochemistry testing associated with pregnancy and the newborn period -- a lot has changed since you were a baby!

Everyone has been a newborn, and everyone's mother has been pregnant. Despite the commonality of these events, medical care and the clinical chemistry laboratory's role in it have changed remarkably over the last 50 years. This review is a historical overview of clinical chemistry testing that is related to pregnancy and the newborn period.

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.