Percutaneous Cholangiography in Prolonged Jaundice of Childhood

Neonatal cholestasis. New approaches to diagnostic evaluation and therapy

Neonatal cholestasis remains a major diagnostic challenge despite increasing knowledge regarding its pathogenesis. The time constraint and urgency in the investigational process is underscored by the age-dependent success rate of the surgical corrective procedures for EHBA. Appropriate interpretation of imaging and pathologic studies requires a pediatric center familiar with the entities causing neonatal cholestasis. When liver failure or progressive hepatic dysfunction is likely to occur, early referral to a liver transplant center is recommended. Despite the increasing experience and excellent results of pediatric liver transplantation, at this point, surgical corrective procedures such as the Kasai procedure remain the first line of treatment for most patients with EHBA.

Bile duct stricture in an infant with gastroschisis treated by percutaneous transhepatic drainage, biliary stenting, and balloon dilation

A newborn twin with an antenatal diagnosis of gastroschisis underwent staged repair of the abdominal wall defect. She developed multiple fistulae due to ischemic bowel and then abdominal wall dehiscence requiring additional surgical interventions. Obstructive jaundice, first evident at 3 weeks of age, became progressively severe. A stricture of the common bile duct was diagnosed by percutaneous transhepatic cholangiography. The stricture was treated by percutaneous biliary drainage, biliary stenting, and balloon dilation of the common bile duct. These procedures, commonly used in adults for biliary decompression, may be useful alternatives to surgical intervention in infants and children with obstructive jaundice due to bile duct stricture.

Extrahepatic biliary atresia: a review of current management

Macroscopic examination of the extrahepatic bile ducts in infants with biliary atresia reveals fibrous occlusion of variable extent from an inflammatory process of unknown aetiology. Histological studies have shown that bile duct remnants at the porta hepatis frequently contain small epithelium-lined channels which communicate with intrahepatic ducts and through which effective bile drainage may be established by the operation of portoenterostomy. The 4-year survival rate in untreated cases is 2 per cent, but surgical treatment can improve the outlook and recent reports suggest that a 5-year survival rate of over 35 per cent can be achieved with portoenterostomies performed before 10 weeks of age. Complications after surgery include progressive liver disease, ascending bacterial cholangitis and portal hypertension.

Results of Surgery in 88 Consecutive Cases of Extrahepatic Biliary Atresia

Of 88 cases of extrahepatic biliary atresia, satisfactory bile flow has been established in 46% of the patients who have undergone portoenterostomies and in 25% of patients with hepaticojejunostomies. Histological analysis of the extrahepatic biliary tissue has not shown a consistent correlation with outcome of operation, except that the patients with one or two large residual ducts lined with columnar epithelium have a better chance of developing bile flow. Cholangitis developed in 43% of the cases, and co-trimoxazole was not shown to have any beneficial effect in a small prospective trial in 18 patients. Severe haemorrhage from oesophageal varices has occurred in 4 jaundice-free survivors. Seventeen patients are now over 3 years of age and thriving but many show persistent elevation of liver enzymes.

Results of surgery in 88 consecutive cases of extrahepatic biliary atresia

Of 88 cases of extrahepatic biliary atresia, satisfactory bile flow has been established in 46% of the patients who have undergone portoenterostomies and in 25% of patients with hepaticojejunostomies. Histological analysis of the extrahepatic biliary tissue has not shown a consistent correlation with outcome of operation, except that the patients with one or two large residual ducts lined with columnar epithelium have a better chance of developing bile flow. Cholangitis developed in 43% of the cases, and co-trimoxazole was not shown to have any beneficial effect in a small prospective trial in 18 patients. Severe haemorrhage from oesophageal varices has occurred in 4 jaundice-free survivors. Seventeen patients are now over 3 years of age and thriving but many show persistent elevation of liver enzymes.

Endoscopic retrograde cholangiopancreatography in children

Gastroduodenoscopy and retrograde cholangiopancreatography has been performed on 25 occasions in 20 children aged between 7 and 16. Radiographs of the clinically relevant duct or ducts were achieved in 96% of attempts, with no complications. The diagnostic information proved useful clinically; in particular it provided a precise map if biliary or pancreatic surgery was being contemplated. Several unexpected congenital duct anomalies were found. This and other recent reports, particularly from Germany, indicate that endoscopic retrograde cholangiopancreatography deserves greater application in children, and can also be used in babies.