Dilatation of the biliary tree in children: sonographic diagnosis and its clinical significance

NCK-associated protein 1 like (nckap1l) minor splice variant regulates intrahepatic biliary network morphogenesis

Impaired formation of the intrahepatic biliary network leads to cholestatic liver diseases, which are frequently associated with autoimmune disorders. Using a chemical mutagenesis strategy in zebrafish combined with computational network analysis, we screened for novel genes involved in intrahepatic biliary network formation. We positionally cloned a mutation in the nckap1l gene, which encodes a cytoplasmic adaptor protein for the WAVE regulatory complex. The mutation is located in the last exon after the stop codon of the primary splice isoform, only disrupting a previously unannotated minor splice isoform, which indicates that the minor splice isoform is responsible for the intrahepatic biliary network phenotype. CRISPR/Cas9-mediated nckap1l deletion, which disrupts both the primary and minor isoforms, showed the same defects. In the liver of nckap1l mutant larvae, WAVE regulatory complex component proteins are degraded specifically in biliary epithelial cells, which line the intrahepatic biliary network, thus disrupting the actin organization of these cells. We further show that nckap1l genetically interacts with the Cdk5 pathway in biliary epithelial cells. These data together indicate that although nckap1l was previously considered to be a hematopoietic cell lineage-specific protein, its minor splice isoform acts in biliary epithelial cells to regulate intrahepatic biliary network formation.

A serious complicatıon of liver hydatid cysts in children: cystobiliary fistulas

AIM

We aimed to determine predictive factors for predicting cystobiliary fistulas (CBF) in children after treatment of liver hydatid cyst (LHD).

METHODS

The records of patients who were treated for LHD between 01.06.2009 and 1.06.2019 were retrospectively reviewed. Age, sex, laboratory test results, size and number of cysts, method of first intervention (percutaneous or surgery), whether or not CBF developed and how it was treated were investigated. Among findings, those could be predictive were investigated. Data were evaluated with SPSS 21.0 program, p < 0.05 was considered significant.

RESULTS

Of the 97 patients, 48 (49.5%) were male, 49 (50.5%) female, the mean age was 11.2 years, Eighty patients had right (82.5%), 13 had left, and 4 had bilobar involvement. As first intervention, surgery was performed in 39 (40.2%); percutaneous treatment was performed in 58 (59.8%) patients. In 8 patients (20.5%) in surgery group and in 6 patients (10.3%) in percutaneous group, totally in 14 patients (14.4%), CBF developed. The mean cyst diameter of CBF-developed group was 114.36 mm, and of CBF-undeveloped group was 74.30 mm. There was no statistically significant differences between groups in terms of age, sex, involved lobe, other organ involvement, and preoperative results (p > 0.5). There was a significant relationship between the cyst diameter and the rate of CBF development in both surgical and percutaneous groups (p < 0.05). ROC analysis was performed, and the cut-off value for the development of CBF detected as 69 mm for children. Since obstructive jaundice seen in adults is not common in children, an increase in liver function tests and bilirubin levels were not seen in our patients.

CONCLUSION

A significant correlation was found only between the size of the cyst and developing CBF. Cysts greater than 69 mm have a higher risk of developing CBF after both percutaneous and surgical treatment and should be closely monitored.

Choledochal cysts in children: How to Diagnose and Operate on

OBJECTIVE

To identify the best mode for diagnosing and treating the patients with choledochal cysts.

METHODS

A retrospective study was performed with medical records of patients diagnosed with choledochal cysts from January 1994 to December 2017. In all cases, the diagnosis was based on ultrasound examination. All the patients underwent cyst resection and were divided in two groups: bile enteric anastomosis in the high portion of the common hepatic duct or in the dilated lower portion.

RESULTS

Eighty-one cases were studied. The age of presentation was 4 y 2 mo ± 4 y 1 mo, and the age for the surgical treatment was 5 y 5 mo ± 4 y 6 mo. In 61 cases, US was the only image examination performed. There were 67 cases of Todani type I (82.7%), 13 cases of type IV (16.0%) and one case of type III (1.2%). Nine patients (29.0%) in the first period and 2 patients (4.0%) in the second period presented with postoperative complications (p=0.016).

CONCLUSION

In patients with choledochal cysts, US is the only necessary diagnostic imaging. Performing the bile enteric anastomosis in the lower portion of the common hepatic duct is safer and has a lower risk of complications.

Management of Pediatric Patients Presenting with Acute Abdomen Accompanying Dilatation of the Common Bile Duct

PURPOSE

The aim of this study was to describe our treatment experiences with patients who had acute abdomen (AA) with common bile duct (CBD) dilatation.

METHODS

The treatment outcomes in children with AA and CBD dilatation were retrospectively reviewed. According to the shape of the intrahepatic bile ducts on ultrasonography (US), the origin of the pain was estimated as choledochal cyst (CC) complication or choledocholithiasis in normal CBD. Patients with complicated CC underwent surgery, and patients with choledocholithiasis in a normal appearing CBD underwent symptomatic treatment initially.

RESULTS

Of the 34 patients, 30 (88.2%) were female. The mean age of the patients was 6.4±4.9 (range, 0.8-17) years. Seventeen (50.0%) patients had CBD stones and 17 (50.0%) did not. Surgical treatment was performed in 20 (58.8%) patients, 2 of whom underwent preoperative stone removal with endoscopic retrograde cholangiopancreatography and an operation. Conservative treatment was applied in 12 (35.3%) patients (8 with and 4 without stones), 1 of whom developed symptom relapse and underwent an operation. Among the 8 patients with CBD stones, 4 (4/17, 23.5%) had complete resolution of the stones and recovery of the CBD diameter after conservative treatment. US findings of patients with stone showed a fusiform or cylindrical shape of the CBD in 14 (82.4%) patients.

CONCLUSION

The presence of stones in the distal CBD and the US features of CBD dilatation may be helpful to diagnose and treat the causes of biliary dilatation. Conservative treatment can be considered as initial therapy in patients with uncomplicated CBD dilatation with stone.

Pediatric choledochal cysts: diagnosis and current management

Choledochal cysts are rare congenital disorders first described by Vater and Ezler in 1723. Their exact etiology remains incompletely understood; however, an anomalous pancreaticobiliary union (APBDU) and subsequent reflux of biliary contents into the biliary tree are thought to play a role. Accordingly, APBDU-associated choledochal cyst patients are significantly more likely to have evidence of hepatitis, cholangitis or pancreatitis and pathologically confirmed inflammation. In 1977, Todani and colleagues modified the original Alonso-Lej classification to include five types of CC. Type I and IV are the most common and most likely to be associated with malignancy. The majority of choledochal cysts are diagnosed in childhood. Clinical presentation varies and most often consists of nonspecific abdominal pain. Diagnosis is typically accomplished using multimodality imaging techniques including computed tomography, magnetic resonance imaging, ultrasound and MRCP. The use of diagnostic PTC and ERCP in CC has been largely replaced by MRCP. Appropriate management consists of prompt, complete cyst excision followed by restoration of biliary enteric continuity when necessary. Minimally invasive CC resection in the pediatric population has demonstrated acceptable outcomes. Prognosis is generally excellent; however, malignancy risk remains higher than the general population even after complete surgical excision.

Asymptomatic Bile Duct Dilatation in Children: Is It a Disease?

PURPOSE

Bile duct dilatation is a relatively common sonographic finding; nevertheless, its clinical significance in children is controversial because little research has been done in the area. Therefore, we investigated the natural course and clinical significance of biliary duct dilatation in children.

METHODS

We performed a retrospective study of 181 children (range, 1-day-old to 17-year-old) in whom dilatation of the intrahepatic duct and/or common hepatic duct and/or common bile duct was detected by abdominal ultrasonography at the Severance Children's Hospital between November 2005 and March 2014. We reviewed and analyzed laboratory test results, clinical manifestations, and clinical course in these patients.

RESULTS

Pediatric patients (n=181) were enrolled in the study and divided into two groups. The first group included 59 subjects, without definitive cause of bile duct dilatation, who did not require treatment; the second group included 122 subjects, with definitive cause of bile duct dilatation or underlying biliary disease, who did require treatment. In the first group, 24 patients (40.7%) showed spontaneous resolution of bile duct dilatation, 20 patients (33.9%) showed no change, and 15 patients (25.4%) were lost to follow-up. In the second group, 31 patients were diagnosed with choledochal cysts, and 91 patients presented with biliary tract dilatations due to secondary causes, such as gallbladder or liver disease, post-operative complications, or malignancy.

CONCLUSION

Biliary dilatation in pediatric patients without symptoms, and without laboratory and other sonographic abnormalities, showed a benign clinical course. No pathologic conditions were noted on follow-up ultrasonography.

Relationship between Anomalous Pancreaticobiliary Ductal Union and Pathologic Inflammation of Bile Duct in Choledochal Cyst

PURPOSE

Choledochal cyst is a cystic dilatation of common bile duct. Although the etiology is presently uncertain, anomalous pancreaticobiliary ductal union (APBDU) is thought to be a major etiology of choledochal cyst. In this study, we analyzed the clinical and anatomical characteristics and pathologies of patients diagnosed with choledochal cyst in a single institute for 25 years.

METHODS

A total of 113 patients, diagnosed with choledochal cyst and who received an operation in Severance Children's Hospital from January 1988 to May 2013, were included. Medical records were reviewed, including clinical and demographic data, surgical procedures. Abdominal ultrasonography, magnetic resonance cholangiopancreatography, and intraoperative cholangiography were used as diagnostic tools for evaluation and classification of choledochal cyst and the presence of anomalous pancreaticobiliary ductal union. Todani's classification, and relationship between APBDU and surgical pathology.

RESULTS

Among 113 patients, 77 patients (68.1%) presented symptoms such as hepatitis, pancreatitis and/or cholecystitis. Eighty three patients (73.5%) had APBDU, and 94 patients (83.2%) showed inflammatory pathologic changes. APBDU, pathologic inflammation, and serological abnormalities such as hepatitis or pancreatitis showed a statistically significant correlation to one another.

CONCLUSION

APBDU is thought to be one of the etiologic factors of choledochal cyst. It is related to the inflammatory changes in bile duct that can lead to the cystic dilatation.

Common bile duct dilatations in asymptomatic neonates: incidence and prognosis

Background. This retrospective study reviewed 213 asymptomatic neonates with common bile duct (CBD) dilatations diagnosed via ultrasound to evaluate their incidence and outcomes. Materials and Methods. From August 2001 to July 2010, 18,230 abdominal ultrasound scans were performed as newborn screening. There were 213 (1.17%) cases of CBD dilatation. Dilatation of neonatal CBD was defined when its diameter was ≥2 mm. The neonates' birth history, CBD size, and follow-up results were analyzed. Results. In the 213 infants, four cystic dilatations (1.88%, 4/213) that were eventually diagnosed as choledochal cysts (CC). Among 209 neonates with fusiform dilatations (size 2.0–6.7 mm), 77 had ultrasound follow-up and 87% of them resolved spontaneously which were diagnosed as transient CBD dilatation (TCBDD). Eighty percent of TCBDDs resolved within 6 months. Patients with initial CBD size ≥3 mm had significantly lower resolution rate and neonates whose mothers are older than 35 years took longer time to resolve. Conclusion. The incidence of CBD dilatation in asymptomatic neonates was 1.17%. Eighty percent of TCBDDs resolved within 6 months. Regular ultrasound follow-up every 6 months may be appropriate for asymptomatic neonates with fusiform CBD dilatations to ensure resolution or progression.

Cystic abdominal masses in children: a pictorial essay

Cystic abdominal masses in children are not an infrequently encountered condition of childhood. These lesions usually present with large size and mimick each other with similar presenting symptoms. Imaging examinations have an important role to determine the type of the cystic abdominal masses, which is crucial for management of patients and presurgical planning. In this pictorial essay, we summarized the imaging features of common cystic abdominal masses of children, including cystic lesions arising from liver, biliary ducts, kidney, pancreas, bowel, ovary, mesentery, and miscellaneous tissues.

Sonographic diagnosis of a common pancreaticobiliary channel in children

BACKGROUND

A common pancreaticobiliary channel is a very rare condition, but its diagnosis is of paramount importance since it can lead to complications that can be prevented.

OBJECTIVE

To illustrate the sonographic diagnosis of a common pancreaticobiliary channel in children referred for abdominal pain or jaundice.

MATERIALS AND METHODS

Four children were diagnosed by ultrasonography and the diagnosis was subsequently confirmed by MRI.

RESULTS

Sonography demonstrated a pancreaticobiliary junction located in the pancreatic head above the sphincter of Oddi. This rare congenital anomaly was confirmed in all patients by MRI.

CONCLUSION

A common pancreaticobiliary channel can be diagnosed by sonography. Nevertheless, our experience is limited, and although sonography can provide an alert and can assist management, it cannot yet replace MRI.

Biliary atresia with choledochal cyst: implications for classification

BACKGROUND & AIMS

To illustrate the limitations of the embryonic and perinatal classification system of biliary atresia (BA), we present a child with an antenatal diagnosis of choledochal cyst (CC) associated with BA and review the published literature.

METHODS

Medline and Pubmed were searched for "BA and CC," "cystic biliary atresia," "BA and cysts," and "biliary cystic malformations."

RESULTS

A 7-week-old with an antenatal diagnosis of CC was found to have BA associated with CC. The literature search identified 88 cases of BA with CC. Sixty-seven cases had type 1 BA (atresia of the common bile duct), 2 had type 2 BA (atresia of the common hepatic duct), and 19 had type 3 BA (atresia of the porta hepatis). Of the 27 cases of antenatal diagnosis of BA with CC only 1 had associated congenital anomalies. Outcome analysis showed poor outcomes were significantly more common (P = .009) and occurred earlier (P = .0249) in patients with type 3 BA. Children with type 3 BA were 5.4 times more likely to develop poor outcomes compared with type 1 (hazard ratio, 5.4; 95% confidence interval, 1.03-27.8).

CONCLUSIONS

BA associated with CC forms a distinct subtype of BA, characterized by a preponderance of type 1 BA, a relatively good clinical outcome after surgery, and an absence of associated congenital anomalies. Antenatal diagnosis of many affected infants supports their inclusion within the embryonic BA group and suggests that a broader interpretation of the embryonic phenotype and further classification of BA based on genetic susceptibility may be required.

Experience with choledochal cysts in infants

The purpose of this analysis is to study the clinical features, liver histology and the outcome after surgery in infants with choledochal cysts (CDCs), and to draw conclusions on the management strategy accordingly. The clinical features, liver histology and the outcome after surgery in 14 cases of CDCs treated before 1 year of age (the "infantile group") were compared with 52 cases that were diagnosed and treated between 1 and 12 years of age (the "classical pediatric group"). The differentiation of the "infantile choledochal cysts" from "biliary atresia with cystic dilatation" was based on the configuration of intrahepatic bile ducts on cholangiogram. Jaundice was the universal presenting feature in 14 patients in the "infantile group", the clinical presentation in 6 infants was indistinguishable from biliary atresia. On the other hand, pancreatitis as a presenting complication was seen exclusively in those presenting later, i.e. the "classical pediatric group". Fibrosis, as early as 4 weeks of age, was seen in all nine (100%) infants in whom a liver histology was available. Seven of these nine infants had bridging fibrosis (n = 4) or cirrhosis (n = 3) on liver histology. The outcome was satisfactory in 9 of the 14 (64.3%) infants despite bridging fibrosis (n = 4) or cirrhosis (n = 1) in 5 of these 9 babies. The CDCs presenting in infancy differ from the classical variety of later presenting pediatric CDCs in terms of their presentation, liver histology and outcome. They merit an emergent surgical treatment following which the outcome is satisfactory. Delay results in progression to end stage liver disease.

Biliary cysts in children--long-term follow-up in Taiwan

BACKGROUND

This study analyzed the clinical presentation, postoperative morbidity and mortality and incidence of associated extrahepatic biliary atresia in children with biliary cysts in Taiwan.

METHODS

We retrospectively reviewed the records of 158 pediatric patients with biliary cysts seen between June 1981 and July 2004, with follow-up ranging from 12 months to 22 years (mean, 11.2 +/- 6.1 years). Patients were divided into three groups: biliary atresia-associated biliary cyst (BABC, 21 patients), non-biliary atresia-associated choledochal cyst (NBACC) in infancy (37 patients), and late NBACC (> 1 year of age, 100 patients).

RESULTS

BABC accounted for 36.2% of the infantile biliary cysts in this study. Extrahepatic cysts in late NBACC had a greater mean diameter than those in infantile NBACC and BABC (21.5 mm vs. 16.0 mm vs. 7.9 mm, p < 0.001). Cholangitis was the most serious complication within 3 months postoperatively in all three groups, resulting in four deaths (two in the infantile NBACC group and one each in the other two groups). Liver cirrhosis developed during long-term follow-up in nine of the 21 patients with BABC, four of whom died. Three of these nine patients underwent liver transplantation and remained well during follow-up. Chronic complications in NBACC occurred mainly in late IVa cases, with persistent intrahepatic dilatation developing in 12 of 35 patients and intrahepatic stones in five. Elevation of serum alanine aminotransferase (ALT) was found preoperatively in 85% of late NBACC and 35% of infantile NBACC cases. Postoperative normalization of ALT occurred after a mean of 152 +/- 23 days and 158 +/- 67 days in late NBACC and infantile NBACC, respectively. Higher ALT levels before operation were associated with a longer period until normalization.

CONCLUSION

The possibility of BABC must be included in the differential diagnosis when a small extrahepatic cyst (< 8 mm in diameter) with prolonged jaundice is found in infancy. Postoperative follow-up is essential for patients with NBACC due to their frequently prolonged elevation of serum ALT and possibility of residual intrahepatic dilatation. Cholangitis was the major cause of death within 3 months postoperatively in this study.

Computerized three-dimensional study of a rotavirus model of biliary atresia: comparison with human biliary atresia

Biliary atresia is a panbiliary disease causing obstructive jaundice in neonates and infants. The clinical spectrum can be broadly categorized into the fetal and perinatal types. A consistent animal model that accurately mimics the whole clinical spectrum of biliary atresia is not yet available. However, rotavirus infection of neonatal mice has been shown to produce atresia in the biliary system. This study investigates the three-dimensional computerized morphology of the murine neonatal model comparing with age-matched control mice. Newborn Balb/c mice were injected intraperitoneally with rhesus rotavirus within 24-48 h after birth. Control mice received 0.9% NaCl. Pups with symptoms of cholestasis were sacrificed from the 5th to the 15th postinjection day, as were age-matched controls. Their hepatobiliary tissues were prepared for three-dimensional computerized image reconstruction. Rotavirus infection caused obliteration of the intrahepatic bile ducts and single to multiple atresias in the extrahepatic bile duct. At 15 days postinjection, intrahepatic ductal proliferation appeared, and the three-dimensional appearances of the intrahepatic biliary structures were similar to the human disease. Cystic duct and gallbladder dilatation was frequently seen in this model, and this feature distinguishes it from the human disease in which the gallbladder is almost always atretic. This rotavirus murine model demonstrates many of the features of human perinatal biliary atresia, and can be used as an investigative tool to further study the pathogenesis of biliary atresia.

Ultrasonography of intra-abdominal cystic lesions in the newborn

Intra-abdominal cystic lesions are increasingly recognized in the newborn because of the advent of routine antenatal ultrasonography. As these lesions are often asymptomatic or non-specific in clinical presentation in the newborn, imaging by ultrasonography has an important role in diagnosis. We present a pictorial review of the commonly encountered intra-abdominal cystic lesions in the newborn, with emphasis on ultrasonographic features that can aid differentiation between the various lesions.