Clinical Characteristics and Long-term Follow-up of Patients with Diabetes Due To PTF1A Enhancer Mutations

CONTEXT

Biallelic mutations in the PTF1A enhancer are the commonest cause of isolated pancreatic agenesis. These patients do not have severe neurological features associated with loss-of-function PTF1A mutations. Their clinical phenotype and disease progression have not been well characterized.

OBJECTIVE

To evaluate phenotype and genotype characteristics and long-term follow-up of patients with PTF1A enhancer mutations.

SETTING

Twelve tertiary pediatric endocrine referral centers.

PATIENTS

Thirty patients with diabetes caused by PTF1A enhancer mutations. Median follow-up duration was 4 years.

MAIN OUTCOME MEASURES

Presenting and follow-up clinical (birthweight, gestational age, symptoms, auxology) and biochemical (pancreatic endocrine and exocrine functions, liver function, glycated hemoglobin) characteristics, pancreas imaging, and genetic analysis.

RESULTS

Five different homozygous mutations affecting conserved nucleotides in the PTF1A distal enhancer were identified. The commonest was the Chr10:g.23508437A>G mutation (n = 18). Two patients were homozygous for the novel Chr10:g.23508336A>G mutation. Birthweight was often low (median SDS = -3.4). The majority of patients presented with diabetes soon after birth (median age of diagnosis: 5 days). Only 2/30 presented after 6 months of age. All patients had exocrine pancreatic insufficiency. Five had developmental delay (4 mild) on long-term follow-up. Previously undescribed common features in our cohort were transiently elevated ferritin level (n = 12/12 tested), anemia (19/25), and cholestasis (14/24). Postnatal growth was impaired (median height SDS: -2.35, median BMI SDS: -0.52 SDS) with 20/29 (69%) cases having growth retardation.

CONCLUSION

We report the largest series of patients with diabetes caused by PTF1A enhancer mutations. Our results expand the disease phenotype, identifying recurrent extrapancreatic features which likely reflect long-term intestinal malabsorption.

[Biliary atresia and congenital cholestatic syndromes : Characteristics before, after and during transition]

BACKGROUND

A growing number of patients with biliary atresia and congenital cholestatic syndromes are reaching adulthood. These patients often have a number of typical medical features, including specific characteristics of liver transplantation medicine.

OBJECTIVE

What are the special features in the care of adults suffering from liver diseases with manifestation in childhood and adolescence, both before and after liver transplantation (LTX). How does the progression of individual diseases differ depending on age at manifestation? What are specific aspects following pediatric LTX?

PATIENTS AND METHODS

Evaluation and discussion of existing guidelines and recommendations of the individual disciplines and professional societies as well as the current literature. Joint discussion of the recommendations between disciplines (gastroenterology, pediatric gastroenterology, surgery). Inclusion of center-specific experiences with transition from existing transition outpatient departments and training.

RESULTS

The recommendations are presented specifically for each disease. Special features in individual diseases after LTX are also discussed. Diagnosis-independent general treatment concepts for cholestasis and chronic liver disease are presented.

CONCLUSION

Patients with biliary atresia and congenital cholestatic syndromes have a life-long chronic liver disease with and without LTX and require specific medical care. The patients benefit from the pooling of expertise in the individual disciplines.

Common misdiagnoses of biliary atresia

OBJECTIVES

Discrimination of biliary atresia (BA) from other causes of neonatal cholestasis (NC) is challenging. We aimed to analyze the clinicopathological findings in cholestatic infants who were provisionally diagnosed with BA and then excluded by intraoperative cholangiography compared with those with a definitive diagnosis of BA and to shed light on common misdiagnoses of BA.

METHODS

We retrospectively analyzed the data of infants diagnosed preoperatively with BA and referred to surgery between the years 2009 and 2013. On the basis of intraoperative cholangiography results, infants were divided into those with a definitive diagnosis of BA and those misdiagnosed with BA.

RESULTS

Out of 147 infants, there was a misdiagnosis of BA in 10 (6.8%) infants. Alanine transaminase was significantly higher in the non-BA group, whereas other clinical and laboratory findings were comparable in both groups. Hepatomegaly and abnormal gallbladder in ultrasound, and ductular proliferation and advanced grades of portal fibrosis in liver biopsy were significantly higher in infants with BA. However, giant cells were more common in the non-BA infants. Nonetheless, the frequency of clay stool, hepatomegaly, abnormal gallbladder, ductular proliferation, and advanced portal fibrosis was remarkable (100, 70, 40, 70, and 50%, respectively) in the misdiagnosed infants. The misdiagnoses were idiopathic neonatal hepatitis, progressive familial intrahepatic cholestasis type 3, cytomegalovirus hepatitis, Alagille syndrome, and a cholangitic form of congenital hepatic fibrosis.

CONCLUSION

A meticulous preoperative workup should be performed to exclude other causes of NC even if signs of BA are present, especially if features such as giant cells in histopathology are present. This involves completing the NC workup in parallel involving all common causes of NC rather than performing them in series to avoid loss of valuable time and efforts.

Evaluation of ultrastructural changes by electron microscopy in neonatal cholestasis

BACKGROUND

Biliary atresia (BA) and idiopathic neonatal hepatitis (NH) account for 50-70% of all cases with neonatal cholestasis. The treatment of the former is early surgical intervention, while the latter requires non-surgical supportive care. Failure to differentiate the two conditions may result in avoidable surgery in NH, which may significantly increase morbidity. The lack of differentiating clinical features, biochemical markers and other specific investigations to distinguish the two is still a major problem.

AIM

This study was thus initiated to evaluate electron microscopic changes in the liver in patients with NH and BA, to correlate these with changes on light microscopy and look for specific differentiating features between the two.

METHODS

Ten patients with neonatal cholestasis whose liver specimens were available for electron microscopic analysis were included in the study. There were 6 patients with BA and 4 patients with NH.

RESULTS

Among the biochemical parameters, serum alkaline phosphatase and gamma glutamyl transpeptidase were significantly higher in BA than in patients with NH. On light microscopy, giant cell transformation was seen in 75% patients with NH and 33.3% of patients with BA. Even in BA, intracellular cholestasis was more prominent than ductular cholestasis (100% vs. 50%). Ductular proliferation was seen in 50% of NH patients and all patients of BA. Electron microscopy revealed prominent endoplasmic changes in all patients with NH and to a milder degree in BA. Changes in mitochondria and glycogen content were similar in both groups.

CONCLUSION

Ultrastructural changes in neonatal cholestasis seen through electron microscopy are largely non-specific and do not differentiate BA from NH.

Wide spectrum of clinical features in a case of arthrogryposis-renal tubular dysfunction-cholestasis syndrome

Arthrogryposis-renal tubular dysfunction-cholestasis syndrome is a rare multisystem disorder, originally described in 1973 and to date only 62 patients have been reported. Herein, we reported on a neonate with arthrogryposis-renal tubular dysfunction-cholestasis syndrome presenting very early after birth. Recurrent febrile illnesses, failure to thrive, ichthyosis, hypothyroidism, and bilateral hearing loss were among other associated findings. Blood films revealed abnormally large platelets. Polyhydramnios, hybrid type of renal tubular acidosis and hypothyroidism found in this case are not usually seen. We propose to expand the acronym of this syndrome and name it as arthrogryposis-renal dysfunction-cholestasis-hypothyroidism-ichthyosis-deafness or dysmorphic features syndrome.

The course of neonatal cholestasis in congenital combined pituitary hormone deficiency

BACKGROUND

Neonatal cholestatic hepatitis is frequently associated with congenital combined pituitary hormone deficiency (CCPHD). Data on the course of this hepatopathy are scarce.

AIM

We retrospectively analyzed the data of all CCPHD infants with cholestasis who presented at the University Children's Hospital, Tuebingen.

RESULTS

All infants (n = 9; 2 females) presented with early and prolonged jaundice, failure to thrive and recurrent hypoglycemia. All males had micropenis and 3/7 cryptorchidism. Median age at diagnosis was 1.4 months. Cholestasis began at a median age of 13 days (range 5-31) and resolved at 88 days (54-174). Maximum direct bilirubin level was 6.9 mg/dl (2.4-11.6). Peaks of ALP (median 721 U/l), ALT (148 U/l) and AST (195 U/l) occurred 2-4 weeks later, while GGT levels were elevated in only two infants (167 U/l). Functional liver parameters were always normal. Liver biopsies (n = 4) showed canalicular cholestasis and mild portal eosinophilic infiltration. TEBIDA radioisotope excretion into the intestinal tract was blocked. Substitution with Lthyroxine, hydrocortisone and growth hormone seemed to accelerate the cure from cholestasis. Liver function at follow-up (median 4 yr) stayed normal.

CONCLUSION

Cholestasis in CCPHD follows the course described here, frequently with normal GGT levels.

Hydranencephaly with cholestasis and giant hepatitis

We present a rare case of hydranencephaly with cholestasis and giant hepatitis. Studies for infectious agents were all negative including for the detection of virus in liver tissue by using polymerase chain reaction. Although the anterior pituitary functions (cortisol, thyroid stimulating hormone, free T4, human growth hormone) were normal, the patient revealed massive cholestasis and giant hepatitis.

Long-term effect of treating pregnant rats with ursodeoxycholic acid on the congenital impairment of bile secretion induced in the pups by maternal cholestasis

Transient latent cholestasis in young rats born from mothers with obstructive cholestasis during pregnancy (OCP) has been reported. The cause of this congenital impairment and the long-term effect on the pups of treating their mothers with ursodeoxycholic acid (UDCA) during pregnancy were investigated. Complete biliary obstruction was imposed on day 14 of pregnancy and UDCA treatment was begun on day 15. Serum bile acids (BAs) concentrations were elevated in 4-week-old pups born from OCP, but not OCP + UDCA, mothers. However, gas chromatographic/mass spectrometric analysis of BA species in basal bile indicated the presence of significant differences among all experimental groups (control, OCP, and OCP + UDCA). Canalicular plasma membrane fluidity was reduced in OCP, but not in OCP + UDCA, pups. Screening by reverse transcription followed by real-time quantitative polymerase chain reaction of the steady-state levels of mRNA of genes related to hepatobiliary function revealed changes (upregulation of Cyp7a1 and Mrp1 and down-regulation of Abcg5 and Abcg8) in OCP group, which were prevented by UDCA treatment. Electron microscopy examination showed multilamellar bodies occupying part of the canalicular lumen in OCP pups. Their number and size were reduced in animals born from OCP + UDCA mothers. In OCP, but not OCP + UDCA, the stimulation of bile flow and BA output induced by taurocholate administration were reduced and cholesterol/BA output ratio was increased, whereas phospholipid/BA output ratio was enhanced in both groups (OCP > OCP + UDCA). In conclusion, UDCA treatment of rats with cholestasis during pregnancy has long-term beneficial effects on their offspring by preventing in part the congenital impairment in hepatobiliary function of the pups that affects their biliary lipid secretion.

Neonatal cholestasis and infantile Gaucher disease: a case report

AIM

To report on clinical complications of liver disease occurring during Gaucher disease.

METHODS

A case of Gaucher disease was revealed by neonatal cholestasis and early onset of portal hypertension.

RESULTS

At 7 d of age, a newborn was admitted for cholestasis associated with hepatosplenomegaly and thrombocytopenia. At that time, bone marrow aspirate and liver biopsy did not reveal any engorged cells. The clinical course was marked by early progressive portal hypertension, and the patient died of uncontrollable upper gastrointestinal bleeding. The histological results of the postmortem showed that Gaucher cells were present in the liver, spleen and bone marrow. The diagnosis was confirmed by enzymatic studies.

CONCLUSION

Isolated neonatal cholestasis could be the first sign of Gaucher disease. Gaucher disease should always be considered in such circumstances, even if, initially, the bone marrow aspirate and liver biopsy do not reveal any engorged cells.

Congenital intrathoracic herniation of the right liver--late presentation as anicteric cholestasis

This report describes an unusual case of right-sided congenital diaphragmatic hernia discovered fortuitously in a 45-year-old woman. Herniation was characterized by intrathoracic protrusion of the right liver and other abdominal viscera, left intrahepatic biliary dilatation, and anicteric cholestasis. Surgical repair was performed.

Evidence for genetic heterogeneity in lymphedema-cholestasis syndrome

Lymphedema-cholestasis syndrome (LCS, Aagenaes syndrome) is the only known form of hereditary lymphedema associated with cholestasis. A locus, LCS1, has recently been mapped to chromosome 15q in a Norwegian kindred. In a consanguine Serbian Romani family with a neonate who had a combination of lymphedema and cholestasis with features atypical for Norwegian LCS, haplotype and linkage analysis of markers spanning the LCS1 region argue that a second LCS locus may exist. The infant may represent an instance of a previously undescribed lymphedema-cholestasis syndrome.

Neonatal cholestasis

Neonatal cholestasis must always be considered in a newborn who is jaundiced for more than 14-21 days and a measurement of the serum total and conjugated bilirubin in these infants is mandatory. Conjugated hyperbilirubinaemia, dark urine and pale stools are pathognomic of the neonatal hepatitis syndrome which should be investigated urgently. The neonatal hepatitis syndrome has many causes and should be investigated using a structured protocol. The most important condition in the differential diagnosis is biliary atresia and affected infants require a Kasai portoenterostomy performed by an experienced surgeon, ideally before the infant is 60 days old. A modified evaluation schedule should be used for preterm infants who have required neonatal intensive care. Genetic causes of the neonatal hepatitis syndrome are increasingly recognized and early diagnosis facilitates genetic counselling and, in some situations, specific treatment. The management of cholestasis is largely supportive, consisting of aggressive nutritional support with particular attention to fat-soluble vitamin status. The use of ursodeoxycholic acid is associated with improvement in biochemical measures of cholestasis and may improve the natural history of cholestasis in some circumstances. Outcome is dependent on aetiology. In idiopathic neonatal hepatitis more than 90% make a complete biochemical and d clinical recovery.

Screening of SLC25A13 mutations in early and late onset patients with citrin deficiency and in the Japanese population: Identification of two novel mutations and establishment of multiple DNA diagnosis methods for nine mutations

We have recently identified SLC25A13 on chromosome 7q21.3 as the gene responsible for adult-onset type II citrullinemia (CTLN2) and found seven mutations in the SLC25A13 gene of CTLN2 patients. Most recently, the SLC25A13 mutations have been detected in neonatal/infantile patients with a type of neonatal hepatitis associated with cholestasis (NICCD). In the present study, we identified a novel mutation, E601X, in the SLC25A13 gene and established multiple DNA diagnosis methods for eight mutations by using a genetic analyzer with GeneScan and the single primer extension procedure (SNaPshot). An additional novel missense mutation (variation), E601K, was detected by SNaPshot analysis and was indistinguishable from the mutation E601X detected by the PCR/RFLP method. Multiple DNA diagnoses for the nine mutations revealed that 100 (male/female: 70/30) out of 115 CTLN2 and 38 (14/24) out of 45 NICCD patients tested were homozygotes or compound heterozygotes. The frequency of homozygotes carrying SLC25A13 mutations in both alleles is estimated to be minimally 1 in 21,000 from carrier detection (18 in 1,315 individuals tested) in the Japanese population. The differences in the gender ratio and in mutation types between CTLN2 and NICCD patients are significant. It is, however, unknown whether all homozygotes with mutated SLC25A13 in both alleles suffer from NICCD, CTLN2, both, or neither.

Advances in familial and congenital cholestatic diseases. Clinical and diagnostic implications

Recent progress in liver cell biology and molecular genetics revealed that a number of familial and congenital cholestatic disorders are caused by mutations in genes coding for hepatobiliary-transporter or for signalling proteins involved in morphogenesis. The status of the field is reviewed in the light of its impact on current diagnostic and clinical practice. The heterogeneous progressive familial intrahepatic cholestasis can now be separated into different genetic diseases. FIC1-defective progressive familial intrahepatic cholestasis (previously Byler disease) is determined by mutations in the FIC1 gene, coding for P-type ATPases of unknown physiological function, while a second form (bile salt export pump defective progressive familial intrahepatic cholestatis) is caused by a defective function of the canalicular bile salt export pump. Furthermore, a group of progressive familial intrahepatic cholestasis patients with high serum gamma glutamyltranspeptidase have mutations in the gene (PGY3) coding for the MDR3 protein, a canalicular ATP-dependent phopshatidylcholine translocator. Recurrent intrahepatic cholestasis (previously benign recurrent cholestasis), is also linked to specific mutations in the FIC1 gene. Finally, in Alagille syndrome, mutations in the JAG1 gene cause deficiency Jagged 1, a ligand for Notch 1, a receptor determining cell fate during early embryogenesis. Diagnosis of Alagille syndrome, a condition that should be suspected in all patients with unexplained cholestasis, will thus be confirmed by genetic analysis for mutations of JAG1. In children with cholestasis and low serum bile acid levels, an inborn error of bile acid synthesis should be excluded by urinary bile acid analysis by means of fast atom bombardment-ionization mass-spectrometry. In contrast, in children with cholestasis and high serum bile acid concentrations, a high serum gamma glutamyltranspeptidase value would indicate MDR3 deficiency, which should be excluded through biliary phospholipid determination and genetic analysis of PGY3 gene. Finally, in those children with cholestasis, high serum bile acids and low gamma glutamyltranspeptidase activity, analysis of mutation in FIC1 and bile salt export pump genes may lead to the diagnosis of progressive familial intrahepatic cholestasis either from bile salt export pump or FIC1 deficiency.

Screening of newborn infants for cholestatic hepatobiliary disease with tandem mass spectrometry

OBJECTIVE

To assess the feasibility of screening for cholestatic hepatobiliary disease and extrahepatic biliary atresia by using tandem mass spectrometry to measure conjugated bile acids in dried blood spots obtained from newborn infants at 7-10 days of age for the Guthrie test.

SETTING

Three tertiary referral clinics and regional neonatal screening laboratories.

DESIGN

Unused blood spots from the Guthrie test were retrieved for infants presenting with cholestatic hepatobiliary disease and from the two cards stored on either side of each card from an index child. Concentrations of conjugated bile acids measured by tandem mass spectrometry in the two groups were compared.

MAIN OUTCOME MEASURES

Concentrations of glycodihydroxycholanoates, glycotrihydroxycholanoates, taurodihydroxycholanoates, and taurotrihydroxycholanoates. Receiver operator curves were plotted to determine which parameter (or combination of parameters) would best predict the cases of cholestatic hepatobiliary disease and extrahepatic biliary atresia. The sensitivity and specificity at a selection of cut off values for each bile acid species and for total bile acid concentrations for the detection of the two conditions were calculated.

RESULTS

218 children with cholestatic hepatobiliary disease were eligible for inclusion in the study. Two children without a final diagnosis and five who presented at <14 days of age were excluded. Usable blood spots were obtained from 177 index children and 708 comparison children. Mean concentrations of all four bile acid species were significantly raised in children with cholestatic hepatobiliary disease and extrahepatic biliary atresia compared with the unaffected children (P<0.0001). Of 177 children with cholestatic hepatobiliary disease, 104 (59%) had a total bile acid concentration >33 micromol/l (97.5th centile value for comparison group). Of the 61 with extrahepatic biliary atresia, 47 (77%) had total bile acid concentrations >33 micromol/l. Taurotrihydroxycholanoate and total bile acid concentrations were the best predictors of both conditions. For all cholestatic hepatobiliary disease, a cut off level of total bile acid concentration of 30 micromol/l gave a sensitivity of 62% and a specificity of 96%, while the corresponding values for extrahepatic biliary atresia were 79% and 96%.

CONCLUSION

Most children who present with extrahepatic biliary atresia and other forms of cholestatic hepatobiliary disease have significantly raised concentrations of conjugated bile acids as measured by tandem mass spectrometry at the time when samples are taken for the Guthrie test. Unfortunately the separation between the concentrations in these infants and those in the general population is not sufficient to make mass screening for cholestatic hepatobiliary disease a feasible option with this method alone.

MR cholangiography in the evaluation of neonatal cholestasis

PURPOSE

To evaluate the usefulness of magnetic resonance (MR) cholangiography in excluding biliary atresia as the cause of neonatal cholestasis.

MATERIALS AND METHODS

MR cholangiography was performed on 10 control and 16 jaundiced neonates and infants aged 3 days to 5 months. Diagnosis of biliary atresia (n = 6) was confirmed with surgery and liver biopsy, with or without surgical cholangiography. Diagnosis of neonatal hepatitis (n = 9) was confirmed with clinical follow-up until jaundice resolved. In one infant, paucity of intrahepatic ducts was diagnosed at liver biopsy. MR cholangiography was performed with respiratory-triggered, heavily T2-weighted turbo spin-echo and optional inversion-recovery turbo spin-echo sequences. Diagnosis of biliary atresia was based on nonvisualization of either the common bile duct or common hepatic duct. Cholescintigraphy with technetium 99m disofenin was performed in all 16 jaundiced patients.

RESULTS

In the 10 controls, the nine patients with neonatal hepatitis, and the one infant with paucity of intrahepatic ducts, MR cholangiography clearly depicted the gallbladder and common hepatic and common bile ducts. MR cholangiography was 100% accurate in excluding biliary atresia as the cause of neonatal cholestasis, while 99mTc disofenin cholescintigraphic findings were false-positive in four of 10 patients with nonobstructive cholestasis.

CONCLUSION

MR cholangiography can be used to depict the major biliary structures of neonates and small infants and to exclude biliary atresia as the cause of neonatal cholestasis by allowing visualization of the biliary tract.

[Early diagnosis of neonatal cholestatic jaundice]

Neonatal cholestasis should be considered in every baby in whom jaundice persists after day 10. Biliary atresia is the main cause of neonatal cholestasis and its prognosis is highly dependent on the early age at which surgery is performed. Finding the cause of cholestasis before day 30 is therefore crucial. This relies, in most instances, on simple clinical, biochemical, radiological and ophthalmologic criteria, the most important of which is a careful study of the degree and duration of stool discoloration.

Neonatal cholestasis and focal medullary dysplasia of the kidneys in a case of microcephalic osteodysplastic primordial dwarfism

We report on a male infant who presented with intrauterine growth retardation, severe postnatal failure to thrive, microcephaly, facial dysmorphism, and skeletal dysplasia. The clinical and radiological findings are consistent with former descriptions of microcephalic osteodysplastic primordial dwarfism (MOPD) type I/III. In addition to previously published features, multiple fractures of the long bones, severe neonatal cholestasis, and histological dysplasia of the kidneys were found. The boy died at the age of 8 months. The new finding of focal renal medullary dysplasia further supports the hypothesis of a basic defect in tissue differentiation in the pathogenesis of this rare condition.

[Obstruction of biliary tracts in infants]

Three cases with the biliary tracts obstruction in infants are reported. Similar early clinical symptoms were subsequently distinguished by the serious of the diagnostic examinations. That allowed for undertaking proper treatment. The prognosis in congenital biliary tract obstruction depends on the child's age time of the operation and in the cases of the inflammatory ethiology depends on the proper antibiotic therapy.

Neonatal hepatobiliary disorders

Neonatal hepatobiliary disorders are now better understood due primarily to new discoveries in molecular genetics, virology, and immunology. Because they are almost always pathologic and require early intervention, the neonatologist must recognize infants with these hepatocellular and ductal cholestatic problems occurring in the first few weeks of life. This article focuses mainly on new developments regarding neonatal metabolic disorders and their potential for gene therapy; perinatal infections, especially those caused by hepatitis B virus, hepatitis C virus, and human immunodeficiency virus; and recent concepts of neonatal hepatitis and biliary atresia, including a review of predictors that influence outcome for infants undergoing Kasai portoenterostomy and liver transplantation.

Delta 4-3-oxosteroid 5 beta-reductase deficiency: failure of ursodeoxycholic acid treatment and response to chenodeoxycholic acid plus cholic acid

BACKGROUND

In some infants with liver disease, 3-oxo-delta 4 bile acids are the major bile acids in urine, a phenomenon attributed to reduced activity of the delta 4-3-oxosteroid 5 beta-reductase required for synthesis of chenodeoxycholic acid and cholic acid. These patients form a heterogeneous group. Many have a known cause of hepatic dysfunction and plasma concentrations of chenodeoxycholic acid and cholic acid that are actually greater than those of the 3-oxo-delta 4 bile acids. It is unlikely that these patients have a primary genetic deficiency of the 5 beta-reductase enzyme.

AIMS

To document the bile acid profile, clinical phenotype, and response to treatment of an infant with cholestasis, increased plasma concentrations of 3-oxo-delta 4 bile acids, low plasma concentrations of chenodeoxycholic acid and cholic acid, and no other identifiable cause of liver disease.

PATIENTS

This infant was compared with normal infants and infants with cholestasis of known cause.

METHODS

Analysis of bile acids by liquid secondary ionisation mass spectrometry and gas chromatography-mass spectrometry.

RESULTS

The plasma bile acid profile of the patient was unique. She had chronic cholestatic liver disease associated with malabsorption of vitamins D and E and a normal gamma-glutamyltranspeptidase when the transaminases were increased. The liver disease failed to improve with ursodeoxycholic acid but responded to a combination of chenodeoxycholic acid and cholic acid.

CONCLUSION

Treatment of primary 5 beta-reductase deficiency requires the use of bile acids that inhibit cholesterol 7 alpha-hydroxylase.

Neonatal cholestasis in two siblings: a variant of Dubin-Johnson syndrome?

OBJECTIVE

Two Japanese brothers with neonatal cholestasis associated with pigment granules in the hepatocytes and hepatosteatosis were evaluated for the possible role of hepatosteatosis in the Dubin-Johnson syndrome.

METHODOLOGY AND RESULTS

The morphology of pigment accumulation and the laboratory data in these cases were examined. The elevation of urinary coproporphrin isomer I to more than 90% and the presence cholestasis resembled that in the Dubin-Johnson syndrome, but the hypertriglyceridaemia ( > 1.13 mmol/L as triolein) and the hepatosteatosis differed. Both infants were thought to have familial hypertriglyceridaemia. However, this diagnosis was difficult to confirm in the absence of data on the normal values of apolipoprotein and lipoprotein isomer for infants.

CONCLUSIONS

A neonatal variant of the Dubin-Johnson syndrome may account for the unusual findings in these infants.

Imaging of neonatal cholestasis

In the neonate with cholestasis, clinical features and standard tests of liver function frequently cannot distinguish between diseases of the hepatocyte and those of the biliary tree. Therefore, a multidisciplinary approach to diagnosis is required. A priority in investigation is the identification of patients requiring surgery. A correct diagnosis regarding the need for surgery can be made in the majority of cases after synthesis of information obtained from abdominal sonography, hepatobiliary scintigraphy, and liver biopsy. Intraoperative cholangiography is performed routinely to precisely delineate the anatomy of the intrahepatic and extrahepatic bile ducts.

Neonatal lupus liver disease

Neonatal lupus erythematosus (NLE) is an autoimmune disease characterized by complete congenital heart block and/or transient skin lesions of subacute cutaneous lupus erythematosus. We report that in approximately 10% of cases of NLE with heart block or skin disease, liver disease also occurs (4 of 35 cases in our series). Cholestasis was the major feature in our cases. Although the cholestasis may be severe, the disease process appears to be transient and surviving babies have been healthy on follow-up. In one liver examined for antibody deposition, IgG antibody deposits, presumably of maternal origin, were present. Three maternal sera were examined for autoantibodies, including liver-specific autoantibodies. No liver-specific autoantibodies were found. Rather, the maternal autoantibodies too were the ubiquitous Ro/SSA-associated autoantigens. The autoantibodies bound the 60 kDa SSA/Ro ribonuclear protein (three of three sera), the 52 kDa SSA/Ro protein (two of three sera) and the SSB/La ribonuclear protein (two of three sera).

[Hypoplasia of the intrahepatic bile ducts. A clinicopathologic study]

Paucity of intrahepatic bile ducts is considered part of the differential diagnosis of cholestatic syndromes in infancy. The purpose of this work is to inform the experience at the Hospital Infantil de Mexico Federico Gómez in the last few years on this entity. We reviewed the clinical charts as well as the biopsies of 31 patients with paucity of intrahepatic bile ducts. We find a slight male preponderance; the vast majority of patients were under three months of age. Cholestasis was the most frequent finding with significant clinicopathologic correlation. The remaining findings were similar to those previously reported, except for a peculiar distortion of the hepatic architecture which may be secondary to the hypoplastic development of the biliary tree. Finally, it is possible that the failure to thrive observed in this patient may commence in utero.

Obstructive jaundice. Causes and surgical interventions

Biliary obstruction can be caused by a number of conditions and can occur in persons of all ages. In every case, prompt diagnosis affords the best opportunity for surgical therapy. Accurate preoperative diagnosis can be difficult because benign and malignant causes may appear similar radiographically. Options in surgical management can be as simple as extraction of a solitary common duct stone or as extensive as pancreaticoduodenectomy or hepatectomy and liver transplantation. Because of the risk of infection with biliary surgery, prophylactic antibiotic treatment should be considered.

Isolation and characterization of an abnormal alpha slow-moving high-density lipoprotein subfraction in serum from children with long-standing cholestasis

An abnormal high-density lipoprotein (HDL) subfraction, detected during periods of mild jaundice in the serum of seven children with chronic cholestasis from birth, was isolated and characterized. This fraction, identified by its slow alpha electrophoretic migration, is present in addition to normal HDL and differs from the abnormal HDL previously described in cholestatic syndromes. It is devoid of apolipoprotein B but is precipitated by phosphotungstate-MgCl2. These properties allowed its isolation by double selective precipitation. This subfraction is undetectable with this procedure in the serum of healthy subjects, is rich in cholesterol, and contains a large amount of apolipoprotein E, which may explain its precipitation by phosphotungstate-MgCl2. These apo E-containing HDL may play a major role in the lipid metabolism of patients with long-standing cholestasis during periods of mild jaundice.

Improved neurologic function after long-term correction of vitamin E deficiency in children with chronic cholestasis

We studied the effect of long-term correction of vitamin E deficiency on neurologic function in 14 children with chronic cholestasis. Vitamin E repletion was achieved in all, either by large oral doses (up to 120 IU per kilogram of body weight per day) or by intramuscular administration of dl-alpha-tocopherol (0.8 to 2.0 IU per kilogram per day). With early institution of therapy, neurologic function remained normal in two asymptomatic children below the age of three years after 15 and 18 months of therapy. Neurologic function became normal in three symptomatic children below age three after 18 to 32 months of therapy. Restitution of neurologic function was more limited in nine symptomatic children 5 to 17 1/2 years old after 18 to 48 months of therapy. We conclude that vitamin E repletion therapy should be initiated at an early age in children with chronic cholestasis complicated by vitamin E deficiency, to prevent irreversible neurologic injury.

[Transfer of antibiotics into the liver tissue of infants with hepatic dysfunction]

Transfer of antibiotic (cefmetazole, CMZ) into the liver tissues of the infant with hepatic dysfunction, 6 cases of congenital biliary atresia, 4 cases of congenital bile duct dilatation, 1 case of congenital biliary hypoplasia, hepatic hemangioma and umbilical hernia with congenital heart disease is reported here. CMZ level in the liver tissues with hepatic dysfunction shows extremely low. Our study revealed that poor transfer of CMZ into the liver tissues might be a main cause of the poor excretion of CMZ into the bile in case of jaundiced infant.

Management of paucity of interlobular bile ducts

Two types of paucity of interlobular bile ducts (PIBD) may be observed in children with chronic cholestasis. The syndromatic type (80 cases) is the most frequent. The non-syndromatic type (32 cases) is the most severe and half of the patients in this group died from liver failure in the first years of life. The main therapeutic point is that patients with PIBD should not be operated on. The only treatment available is symptomatic medical treatment: the main helpful possibilities concern feeding of medium-chain triglycerides, large supplementation of liposoluble vitamins (A, D, E and K) given intramuscularly, phenobarbital and cholestyramine when there is severe pruritus. The place of the liver transplantation will be clarified in the near future.

Urinary excretion of tetrahydroxylated bile acids in children with alpha 1-antitrypsin deficiency and neonatal cholestasis

Urinary excretion of bile acids was investigated in seven infants with alpha 1-antitrypsin deficiency and neonatal cholestasis. The infants were followed prospectively and the bile acid analysis was repeated after 2-8 years in four of the patients. Bile acid excretion during 24 h was quantified by gas-liquid chromatography and the bile acids were identified by gas-liquid chromatography-mass spectrometry. In contrast to healthy controls, all the patients excreted tetrahydroxylated bile acids during cholestasis and in the postcholestatic period. The patients who developed cirrhosis during the observation period had lower concentration of tetrahydroxylated bile acids than those with a more favourable course. Our findings suggest that tetrahydroxylation of bile acids might be an alternative pathway for elimination of bile acids in cholestasis of infancy, and that those infants exhibiting a good capacity of polyhydroxylation might have a better prognosis.

The Rose Bengal test in neonatal cholestasis: diagnostic and prognostic value

131I Rose Bengal(131IRB) studies were performed in 73 infants with extrahepatic biliary atresia (EHBA) and in 37 with intrahepatic cholestasis of various origins. Fecal 131IRB excretion of less than 10% ("complete' cholestasis) was observed in EHBA but also in some patients with either paucity of intrahepatic bile ducts (syndromatic type) or with alpha-1-antitrypsin deficiency. Seventy one 131IRB tests were also performed 3 to 8 weeks postoperatively in children operated on for EHBA. Fecal 131IRB excretion more than 15% was present in 27 out of 34 cases who were later completely jaundice free and in only one out of 37 cases where no bile flow restoration occurred. These results indicate that complete cholestasis in infants can be observed in some types of intrahepatic cholestasis, as well as in EHBA, and show that a post-operative 131IRB test is a reliable means of predicting complete restoration of bile flow in EHBA.

Identification of the jaundiced infant who is likely to recover without surgical intervention

A series of 32 infants with persistant jaundice in whom an unequivocal differentiation between intrahepatic cholestasis and biliary atresia could not be made is reviewed. A protocol including Lipoprotein-X (LP-X) determinations before and after a short course of cholestyramine (CSM) was carried out in all. A fall in serum LP-X after CSM indicates the presence of patent extrahepatic bile ducts (even microscopic) which will function without benefit of hepatic portoenterostomy. A rise in LP-X levels after CSM means an atretic biliary system. The LP-X, CSM protocol was not able to differentiate between the anatomical variants of biliary atresia that may respond to hepatic portoenterostomy and those that will not. Patent bile ducts (even microscopic) in the porta hepatis and/or proximal hepatoduodenal ligament, which are in continuity with intrahepatic ducts, must be present if hepatic portoenterostomy is to be successful. None of our 12 infants undergoing hepatic portoenterostomy showed evidence of bile excretion after the procedure. Microscopic study of serial sections taken through the excised hepatoduodenal ligament tissues of these 12 infants revealed that none had anatomical findings conducive to the success of the operation.