neonatal cholestasis
TRANSCRIPT
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NEONATAL NEONATAL CHOLESTASISCHOLESTASIS
Dr Surya Kumar
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OBJECTIVESOBJECTIVES To know when cholestatic liver disease
should be excluded in the diagnosis of an infant who has jaundice.
How to evaluate a neonate with conjugated hyperbilirubinemia.
Know the therapeutic management of neonates with cholestasis.
Understand the differential diagnosis for neonatal cholestasis.
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DEFINITIONSDEFINITIONS
NASPGHAN Definition : Prolonged conjugated
hyperbilirubinemia that occurs in the newborn period with conjugated bilirubin concentration >1 mg% if the total bilirubin <5.0mg% or >20% of the total bilirubin if the total bilirubin >5.0mg%.
(Moyer et al J PEDIATR GASTROENTEROL NUTR 2004;39:115)
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IAP Definition: Neonatal cholestasis is defined as
conjugated hyperbilirubinemia > 1.5-2 mg% in a newborn/ infant with passage of high coloured urine with or without acholic stools.
(Consensus report on neonatal cholestasis syndrome,INDIAN PEDIATRICS 2000;37:845-
851)
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Incidence:Incidence:
Constitutes 30% of hepatobiliary disorders in india. ( Consensus report on neonatal cholestasis syndrome,INDIAN
PEDIATRICS 2000;37:845-851)
Affects one in 2500 live births.
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ETIOLOGIESETIOLOGIES
Intrahepatic causes
Extrahepatic causes
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INTRAHEPATIC ETIOLOGIESINTRAHEPATIC ETIOLOGIES
Hepatocellular causes Bile duct injury (Neonatal hepatitis) Idiopathic: INH Toxic Intrahepatic bile duct Genetic/Chromosomal hypoplasia or paucity Infectious Metabolic Miscellaneous
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INTRAHEPATIC ETIOLOGIESINTRAHEPATIC ETIOLOGIES
Idiopathic Neonatal HepatitisToxic
◦TPN-associated cholestasis◦Drug-induced cholestasis
Genetic/Chromosomal◦Trisomy 18◦Trisomy 21
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INTRAHEPATIC ETIOLOGIESINTRAHEPATIC ETIOLOGIES
Infectious◦Bacterial sepsis (E. coli, Listeriosis,
Staph. aureus)◦TORCHES◦Hepatitis B and C◦Echo virus
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INTRAHEPATIC ETIOLOGIESINTRAHEPATIC ETIOLOGIESMetabolic
◦Disorders of Carbohydrate Metabolism Galactosemia Fructosemia Glycogen Storage Disease Type IV
◦Disorders of Amino Acid Metabolism Tyrosinemia Hypermethioninemia
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INTRAHEPATIC ETIOLOGIESINTRAHEPATIC ETIOLOGIESMetabolic (cont.)
◦Disorders of Lipid Metabolism Niemann-Pick disease Gaucher disease
◦Disorders of Bile Acid Metabolism 3B-hydroxysteroid
dehydrogenase/isomerase Trihydroxycoprostanic acidemia
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INTRAHEPATIC ETIOLOGIESINTRAHEPATIC ETIOLOGIESMetabolic (cont.)
◦Peroxisomal Disorders Zellweger syndrome
◦Endocrine Disorders Hypothyroidism Idiopathic hypopituitarism
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INTRAHEPATIC ETIOLOGIESINTRAHEPATIC ETIOLOGIES
Metabolic (cont.)◦Miscellaneous Metabolic Disorders Alpha-1-antitrypsin deficiency Cystic fibrosis Neonatal iron storage disease
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INTRAHEPATIC ETIOLOGIESINTRAHEPATIC ETIOLOGIES
Miscellaneous◦Arteriohepatic dysplasia (Alagille syndrome)
◦Nonsyndromic paucity of intrahepatic bile ducts
◦Caroli’s disease◦Byler’s disease◦Congenital hepatic fibrosis
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EXTRAHEPATIC ETIOLOGIESEXTRAHEPATIC ETIOLOGIES Extrahepatic biliary atresia Choledochal cyst Bile duct stenosis Spontaneous perforation of the bile
duct Cholelithiasis Inspissated bile/mucus plug Extrinsic compression of the bile duct
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(Consensus report on neonatal cholestasis syndrome,INDIAN PEDIATRICS 2000;37:845-851)
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CLINICAL PRESENTATIONCLINICAL PRESENTATIONJaundiceScleral icterusHepatomegalyAcholic stoolsDark urineOther signs and symptoms depend on
specific disease process
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GOALS OF TIMELY GOALS OF TIMELY EVALUATIONEVALUATIONDiagnose and treat known medical
and/or life-threatening conditions.
Identify disorders amenable to surgical therapy within an appropriate time-frame.
Avoid surgical intervention in intrahepatic diseases.
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APPRACH TO DIAGNOSIS- IAPAPPRACH TO DIAGNOSIS- IAP
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Approach to diagnosis: Approach to diagnosis: NASPGHANNASPGHAN
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History:History:
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History (contd.)History (contd.)
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Physical examination:Physical examination:
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Physical exam (contd)Physical exam (contd)
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Investigations:Investigations:Urgent investigations:◦CBC with PS, ◦LFT: Total and direct bilirubin, SGOT,
SGPT, alkaline phosphatase, GGT,PT/PTTK.◦Electrolytes.◦Blood culutre.◦Urine culture, routine microscopy.◦RBS (pre-feed).◦Ascitic tap (if ascitis).
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Further tests:Further tests:Ophthalmologic examination.Serum/ urine bile acid levels.DCT and coomb’s test.Cord blood IGM.FTA-ABS, CFT for rubella, CMV, herpes.
Sweat chloride.HBsAG in mother and infant.Liver biopsy:
light microscopy. specific enzyme assay.
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• TORCH, VDRL, Hepatitis B/C, HIV• T4, TSH• Serum cortisol• Alfa -1 AT levels and phenotype• Galactose -1 Phosphate Uridyl transferase(to r/o galactosemia)• Urinary succinyl acetone (to r/otyrosinemia)• Cholesterol, triglycerides• S. iron and ferritin levels (to r/o neonatalhemachromatosis)
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Radiological evaluationRadiological evaluation
Ultrasonography
Excludes choledochal cyst, dilated CBD. Findings s/o BA:1. GB length (<1.5cm long/small lumen)2. GB contraction [CI<86% ± 18% (mean ± SD)
in 6-week-old infants and 67% ± 42% in 4-month-old infants]
3. Triangular cord sign: a triangular- or tubular-shaped echogenic density that was located immediately cranial to the portal vein bifurcation and was 3 mm or more thick (Kanegawa et al. AJR 2003;181:1387)
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Sonogram illustrates method of measuring gallbladder length (long arrow) and width (short arrow). These measurements were obtained using maximal longitudinal image.
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15-day-old female neonate with unknown cause of infantile cholestasis. Sonogram reveals tubular echogenic cord (arrows). "Triangular cord" was 0.3–0.4 cm wide and 1.3–1.6 cm long.
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Hepatobiliary Scintigraphy:Hepatobiliary Scintigraphy:
Tc labelled IDA dyes used.Depends on hepatocellular function &
patency of biliary tract.Neonatal Hepatitis: delayed uptake, n.
excretion.Biliary Atresia: normal uptake, absent
excretion.Sensitive (97%) not specific (80%) for
EHBA.Phenobarbitol priming (5mg/kg x 5d)
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Gayatri devi 2.5 m/F(2000) CHOLEDOCHAL CYST
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Invasive studiesInvasive studies◦Duodenal intubation◦Percutaneous liver biopsy◦Percutaneous transhepatic
cholangiography◦ERCP◦MRCP◦Exploratory laparotomy with
intraoperative cholangiogram
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ERCP imageERCP image
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intra- and extrahepatic (c) biliary dilatation, as well as focal intrahepatic biliary cystic dilatations (arrows). g = gallbladder.
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Percutaneous transhepatic Percutaneous transhepatic cholangiographycholangiography
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LIVER BIOPSY:LIVER BIOPSY:Most imp. Inv in differentiating NH
and BA.Accuracy of 83% to 97%.Prerequisites: Normal PT & platelet
count.Complications: Bleeding Bile peritonitis Pneumothorax
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F/o neonatal hepatitis:F/o neonatal hepatitis:
Marked irregularities in size of hepatocytes.
Bile canaliculi reduced.Kupffer cells swollen.Extramedullary hematopoiesis.Relative absence of bile duct
proliferation.
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f/o biliary atresia:f/o biliary atresia:
Proliferation of proximal ductules.Bile plugs.Portal tract lymphatics and arterioles
dilated.Secondary paucity of portal bile
ducts.Intracellular and canalicular
cholestasis.
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Indications for laparotomy-IAPIndications for laparotomy-IAP
1) Acholic stools & liver bopsy-BA2) Biopsy equivocal but acholic stools,
intrahepatic causes r/o, non excreting HIDA.
3) Biopsy equivocal,acholic stools, baby 7 wks & lap and peroperative cholangiogram.
4) Biopsy equivocal, acholic stools, ERCP atresia.
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EXTRAHEPATIC BILIARY EXTRAHEPATIC BILIARY ATRESIAATRESIA
Generally acholic stools with onset at about 2 weeks-old
Average birth weightHepatomegaly with firm to hard
consistencyFemale predominanceNo well-documented familial cases
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EXTRAHEPATIC BILIARY EXTRAHEPATIC BILIARY ATRESIAATRESIA
Increased incidence of polysplenia syndrome and intra-abdominal vascular anomalies
Normal uptake on radionucleotide scan with absent excretion
Biopsy shows bile duct proliferation, bile plugs, portal or perilobular fibrosis and edema, and intact lobular structure
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IDIOPATHIC NEONATAL IDIOPATHIC NEONATAL HEPATITISHEPATITIS
Generally normal stools or acholic stools with onset at one month-old
Low birth weightNormal liver on exam or
hepatomegaly with normal to firm consistency
Male predominanceFamilial cases (15-20%)
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IDIOPATHIC NEONATAL IDIOPATHIC NEONATAL HEPATITISHEPATITIS
Impaired uptake on radionucleotide scan with normal excretion
Biopsy shows intralobular inflammation with focal hepatocellular necrosis and disruption of the hepatic architecture. No alteration of the bile ducts. Giant cell transformation occurs but is non-specific.
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ALPHA-1-ANTITRYPSIN ALPHA-1-ANTITRYPSIN DEFICIENCYDEFICIENCY
Alpha-1-antitrypsin makes up 90% of alpha-1-globulin fraction
Associated with PiZZ (about 10-20% will have liver disease) and rarely with PiSZ and PiZ-null phenotypes
Biopsy shows hepatocellular edema, giant cell transformation, necrosis, and pseudoacinar transformation.
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ALPHA-1-ANTITRYPSIN ALPHA-1-ANTITRYPSIN DEFICIENCYDEFICIENCY
Biopsy also shows accumulation of PAS-positive, diastase-resistant globules in the cytoplasm of periportal hepatocytes.
Varying degrees of fibrosis correlate with disease prognosis.
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INTRAHEPATIC CHOLESTASIS INTRAHEPATIC CHOLESTASIS SYNDROMESSYNDROMES
Includes several diagnostic entities.Biopsies show cholestasis. May show
paucity of intrahepatic bile ducts, giant cell transformation, and/or fibrosis.
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TREATMENTTREATMENT
Surgical◦Kasai procedure for biliary atresia◦Limited bile duct resection and re-
anastomosis◦Choledochal cyst excision◦Cholecystectomy◦Liver transplantation
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KASAI PROCEDUREKASAI PROCEDUREPerformed for biliary atresia that is
not surgically correctable with excision of a distal atretic segment.
Roux-en-Y portoenterostomyBile flow re-established in 80-90% if
performed prior to 8 weeks-old.Bile flow re-established in less than
20% if performed after 12 weeks-old
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KASAI PROCEDUREKASAI PROCEDURESuccess of the operation is dependent
on the presence and size of ductal remnants, the extent of the intrahepatic disease, and the experience of the surgeon.
Complications are ascending cholangitis and reobstruction as well as failure to re-establish bile flow.
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TREATMENTTREATMENT
Medical management◦Nutritional support◦Treatment of pruritus◦Choleretics and bile acid-binders◦Management of portal hypertension and
its consequences
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IMPAIRMENT MANAGEMENT(NASPGHAN)
MANAGEMENTIAP
Malabsorption Medium chain TGs given Medium chain TGs given,breast feeding cont, 200 Kcal/kg/d,1-2 gm protein/kg/d
Fat soluble vit malabsorption
Vit A deficiency 10,000-15,000 IU/d AQUASOL-A
50,000 IU i.m –diagnosis10,000 IU monthly
Vit E deficiency
50-400 IU/d; oral alfa tocopherol
50-200 mg/d orally
Vit D deficiency 5000 -8000IU/d of D23-5 mcg/kg/d of 25 HCC
30,000 IU i.m –diagnosis& monthly
Vit K deficiency 2.5 -5.0 mg alternate day as water soluble derivative of menadione.
5 mg/d im x3 days,5 mg wkly.Perform PT monthly.
Microutrient deficiency Ca, P, Zn supplementation Ca, P, Zn supplementation
Water soluble Vit def. 2 times RDA supplementation
2-5 times RDA supplementation
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TREATMENTTREATMENT
Treatment of pruritus◦Bile acid-binders: cholestyramine (4-8
g/day)◦Ursodeoxycholic acid (15-20 mg/kg/day)◦Phenobarbital (5mg/kg/day)◦Rifampicin (10 mg/day)◦Terfenadine (1-3 mg/kg/day)◦Photothearpy with UV/ Infrared rays x 3-
10 min/day
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TREATMENTTREATMENTManagement of portal hypertension
and its consequences◦Variceal bleeding
Fluid rescuscitation Blood products Sclerotherapy Balloon tamponade Portovenous shunting Propanolol
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TREATMENTTREATMENTManagement of portal hypertension
and its consequences (cont.)◦Ascites
Sodium restriction Diuretics: spironolactone, furosemide Albumin Paracentesis
◦Thrombocytopenia managed with platelet infusions when clinically indicated
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LIVER TRANSPLANTATIONLIVER TRANSPLANTATIONBiliary atresia is the most common
indication for transplant and may be the initial treatment when detected late or may be used as a salvage procedure for a failed Kasai.
Used early in cases of tyrosinemia.Cost: In excess of 100,000 $Only few centres in india
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Liver transplantationLiver transplantationIndications:1)Decompensated liver disease(ascites
and/or encephelopathy) .2)Failed portoenterostomy.
• 1-year survival rate- 85-90%• 5-8 year survival rate- 75-80%• 1/3 to 1/2patients are of Biliary
Atresia.(Whitington et al SEMIN LIVER DIS1994;14:303-317)
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PrognosisPrognosis Biliary Atresia:• Age(< 8 wks): the single most important
determinant in successful management of BA.
• Of pts. Undergoing Kasai’s procedure,80% jaundice free if done before 60 days, as against 25-35% of infants operated later on.(Mieli –Vergani et al. LANCET 1989;1:421-423)
Neonatal Hepatitis:• No indicators to predict prognosis.
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Long term outcomeLong term outcomeBiliary Atresia: Mean survival in untreated pts. :19 mths (Hays et
al. SURGERY 1963;54:373-375)
3-year survival : <10% (Karrer et al J PEDIATR SURG 1990;25:1076-1080)
Neonatal Hepatitis:Upto 60% of pts.with idiopathis NH recover
completely without any specific therapy.Upto 10% die acutely of bleeding
manifetstations or fulminant hepatic failure. 30 % progress to liver cirrhosis and death
due to CLD.
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Key messagesKey messages
Refer early to specialised centres.Congenital infection is the commonest
cause of cholestatic jaundice in infants.
Percutaneous liver biopsy is safe and most useful for diagnosis.
Surgery for BA and choledochal cyst should be done before 2 months of age.
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Thank You