Efficacy of the seven feature, fifteen point histological scoring system and CD56 in interpretation of liver biopsies in persistent neonatal cholestasis: a five-year study.

CONTEXT: Neonatal cholestasis (NC) lasting more than 2 weeks affects one in 2500 live births. Extrahepatic biliary atresia (EHBA) and idiopathic neonatal hepatitis account for about 70% of all cases of NC. Differentiating these two conditions is important as patient management is very different for both the conditions. AIMS: To assess the usefulness of the seven-feature, 15-point histological scoring system in the interpretation of liver biopsy in NC and usefulness of immunostaining with CD56 (N-CAM) in EHBA. SETTINGS AND DESIGN: Retrospective study of 5 years' duration at a pediatric referral institute, where the case load of NC is high and definitive surgery for EHBA is undertaken after histological confirmation. MATERIALS AND METHODS: The study is of a 5-year duration conducted between June 2007 and May 2012. A total of 210 cases of NC were clinically diagnosed during this period. All the slides were reviewed with reference to a seven-feature, 15-point histological scoring system assessing its usefulness in the interpretation of liver biopsy in NC and utility of the immunohistochemical marker CD56 was also assessed as an aid in the characterization of bile ductular proliferation in EHBA. STATISTICAL ANALYSIS: Statistical analysis was performed and sensitivity and specificity of the histological scoring system for EHBA was analyzed. RESULTS: Of the 210 liver biopsies reviewed using the scoring system, 122 cases were diagnosed as EHBA and 88 cases were diagnosed as other causes of NC. The overall sensitivity of this scoring system was 95.5%, specificity was 93.1% and diagnostic accuracy was 94.6%. CONCLUSIONS: The seven-feature, 15-point histological scoring system has good diagnostic accuracy in the interpretation of liver histology in NC as advanced histopathological findings even at younger age require immediate surgery. CD-56 is a useful marker in the assessment of bile ductular proliferation in EHBA.

Fatal spontaneous subdural bleeding due to neonatal giant cell hepatitis: a rare differential diagnosis of shaken baby syndrome.

A 7-week-old girl showed vomiting after feeding, facial pallor, loss of muscle tone and respiratory depression. An emergency doctor performed successful resuscitation and after arrival in hospital, cranial ultrasound showed left-sided subdural hemorrhage, cerebral edema with a shift of the midline, and a decrease in cerebral perfusion. Ophthalmologic examination showed retinal hemorrhage. In view of this, the doctors suspected shaken baby syndrome and approached the parents with their suspicions, but they denied any shaking or trauma. Despite surgery for the subdural hemorrhage the girl died a few hours later with a severe coagulopathy. Autopsy verified subdural hemorrhage, cerebral edema and retinal hemorrhage, but also revealed intact bridging veins and a lack of optic nerve sheath hemorrhage, therefore shaken baby syndrome could not be proven by autopsy. Histological examination showed severe neonatal giant cell hepatitis as the cause of the severe coagulopathy and the associated spontaneous subdural bleeding. Neonatal giant cell hepatitis may be responsible for unexpected deaths in infancy and, although rarely associated with subdural bleeding, must be considered as a potential differential diagnosis of shaken baby syndrome.

Neonatal giant cell hepatitis: histological and etiological findings.

BACKGROUND: Neonatal giant cell hepatitis (NGCH) is an important diagnostic consideration in infants who present with jaundice. In this study, we examined 2 separate tertiary care center cohorts of individuals with NGCH to better understand the potential etiologies and their histological correlates. METHODS: All liver biopsies (1984 to 2007) with a histological diagnosis of NGCH were reviewed from 2 tertiary care centers. Cases diagnosed at the time of biopsy as biliary atresia, paucity of intrahepatic bile ducts, total parenteral nutrition associated liver injury, or α-1-antitrypsin deficiency were excluded. Liver biopsies were examined for cholestasis, giant cell change, extramedullary hematopoiesis, inflammation, and fibrosis. Follow-up clinical and laboratory findings were reviewed. RESULTS: Sixty-two cases of NGCH were identified (73% male) for analysis. The average age at liver biopsy was 2 months. Giant cell change affected on average 36% of hepatocytes (range, 5%-90%). Extramedullary hematopoiesis was common (74% of cases), often prominent, and included both myelopoiesis and erythropoiesis. Despite the term "hepatitis" in "neonatal giant cell hepatitis," portal and lobular inflammation was mild-to-absent in 95% of cases. Lobular cholestasis ranged from mild-to-moderate and demonstrated predominately a canalicular pattern (84% of cases). Bile ducts appeared hypoplastic (32% of cases) but were not absent or reduced in numbers. In contrast, another 18% of cases showed at least mild focal ductular proliferation. Portal or pericellular fibrosis was present in 30% of cases and was advanced in 8%. Subsequent clinical follow-up identified the following etiologies: Idiopathic (49%), hypopituitarism (16%), biliary atresia (8%), Alagille syndrome (6%), bile salt defects (6%), as well as several other entities present at 5% or less. Of note, the biopsy findings did not readily distinguish between the different etiologies with the exception that bile duct hypoplasia was more common in cases of hypopituitarism. CONCLUSIONS: In this series of cases, pan-hypopituitarism was the most common recognizable clinical association with neonatal giant cell hepatitis. However, most cases of neonatal giant cell hepatitis remain idiopathic and histological features do not readily distinguish among the various etiologies.

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.

Pattern of chronic liver disease in Omani children--a clinicopathological review.

OBJECTIVE: To determine the pattern of chronic liver disease in Omani children. STUDY DESIGN: Seventy six children [43M : 33F] aged 4 days to 10 years, referred to the Paediatric Gastroenterology clinic of the Sultan Qaboos University Hospital, Muscat, Oman, between 1995--2000 for evaluation of liver disease were studied. Liver biopsies were performed in all and tissues obtained processed and examined for histological lesions. RESULT: The main histological diagnoses were neonatal hepatitis (22) biliary atresia (9) biliary hypoplasia (7), cirrhosis (7) and congenital hepatic fibrosis (5). Hepatomegaly with or without jaundice was the indication for liver biopsy in the majority of patients studied. CONCLUSION: The study has provided background information on the occurrence of specific liver diseases in Omani children. Neonatal hepatitis syndrome was the most common diagnosis before the age of 2 years.

Objective criteria of triangular cord sign in biliary atresia on US scans.

PURPOSE: To develop objective criteria for the ultrasonographic (US) appearance of the triangular cord (TC) sign for the diagnosis of biliary atresia. MATERIALS AND METHODS: US was performed in 86 infants with jaundice. Biliary atresia (n = 20) was confirmed with hepatoportoenterostomy. Neonatal hepatitis (n = 66) was diagnosed with needle biopsy (n = 5), cholescintigraphy (n = 19), or clinical findings (n = 42). Thickness of the echogenic anterior wall of the right portal vein (EARPV) was measured. The TC sign was defined as thickness of the EARPV of more than 4 mm on a longitudinal scan. Biliary atresia was diagnosed when the TC sign was present. Statistical analyses were performed to compare the thickness of the EARPV between patients with biliary atresia and those with neonatal hepatitis and to test the significance of a 4-mm thickness as the criterion for the TC sign in the differentiation of biliary atresia from neonatal hepatitis (P <.05). RESULTS: The TC sign was present in 16 (80%) of 20 patients with biliary atresia and in one of 66 patients with neonatal hepatitis. Mean thickness of the EARPV was significantly greater in patients with biliary atresia (5.39 mm) than in patients with neonatal hepatitis (2.17 mm) (P <.05). Use of 4-mm thickness as the criterion for TC sign was statistically significant (P <.05), resulting in a sensitivity of 80%, specificity of 98%, and positive and negative predictive values of 94% for the diagnosis of biliary atresia. CONCLUSION: An objective criterion of the TC sign is an EARPV thicker than 4 mm on a longitudinal scan.

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.

[Congenital hypopituitarism and giant cell hepatitis in a three month old girl]. / Konnataler Panhypopituitarismus und Riesenzellhepatitis bei einem 3 Monate alten Säugling.

CASE REPORT: A three month old girl, with recurrent hypoglycemia and neonatal cholestasis, is reported. A metabolic disease could be excluded. The liver biopsy revealed giant cell hepatitis and intrahepatic bile duct hypoplasia. ACTH, Cortisol and hGH measured during hypoglycemia were low. Magnetic tomography (MR) of the brain showed an "empty sella". After beginning a replacement therapy with hydrocortisone, growth hormone and thyroxine there was no further episode of hypoglycemia. Transaminases and bilirubin levels normalized. The girl is in good condition, growth and development are normal. DISCUSSION: Hypoglycemia is often the first sign in childrens with neonatal hypopituitarism. The association of liver disease and hypopituitarism has been documented in a few reports. The pathophysiological mechanism leading to the liver dysfunction is not well understood. The prognosis of neonatal hypopituitarism as well as the concomitant liver disease is good under sufficient replacement therapy.

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.

[Human papillomavirus, neonatal giant cell hepatitis and biliary duct atresia]. / Virus papiloma humano, hepatitis gigantocelular neonatal y atresia de vías biliares.

We previously recognized the presence of HPV-DNA in cases of idiopathic neonatal giant cell hepatitis (INGCH) and extrahepatic biliary duct atresia (EBDA) in archivated tissue using the PCR technique. In order to investigate a possible vertical transmission we looked for the presence of HPV-DNA in cervical swabs in the mothers along with formalin-fixed paraffin-embedded hepatic tissue from 3 infants with INGCH and 4 patients with EBDA by nested-PCR. Cervical smears showed koilocytosis consistent with HPV infection in 2 cases. Delivery was vaginal except for one that was by cesarean section. All infants were males. Amplification of HPV-DNA was demonstrated in all cases, the types being concordant in infants and mothers. Although this is a small group, the findings appear in line with previous data. The presence of the same type of HPV-DNA in the infants' livers and their mothers' cervical swabs is another argument supporting the possibility of vertical transmission of the virus.

Virus papiloma humano, hepatitis gigantocelular neonatal y atresia de vias biliares / Human papillomavirus, neonatal giant cell hepatitis and biliary duct atresia

En trabajos previos hemos relatado el reconocimiento de la presencia de ADN del HPV en casos de hepatitis gigantocelular neonatal idiopática (HGNI) y atresia de vías biliares (AVB) en material de archivo usando la técnica de PCR. A fin de investigar una posible transmisión vertical estudiamos la presencia de ADN del HPV en hisopados cervicales de madres así como un tejido hepático fijado en formol e incluído en parafina, de 3 lactantes con HGNI y 4 con AVB mediante la técnica de nested-PCR. En dos casos los extendidos cervicales presentaron coilocitos, compatibles con infección por HPV. Excepto en uno el parto fué por vía vaginal en todos. Todos los lactantes eran del sexo masculino. En todos los casos se demostró amplificación del ADN del HPV, siendo concordante los tipos en los lactantes y sus madres. Aunque este es un grupo pequeño los hallazgos están de acuerdo con nuestros datos previos. La presencia del mismo tipo de HPV en el hígado de los lactantes y en hisopados de sus madres es otro argumento que apoya la posibilidad de una transmisión vertical del virus.

Evaluation of mebrofenin hepatoscintigraphy in neonatal-onset jaundice.

BACKGROUND: The prognosis of infants with prolonged neonatal jaundice is dependent on early diagnosis because of the need for prompt surgical management of biliary atresia. OBJECTIVE: To evaluate the usefulness of 99 mTcm-trimethylbromo-iminodiacetic acid (TBIDA, mebrofenin) in the investigation of infantile jaundice. MATERIALS AND METHODS: A retrospective study was undertaken of 58 patients with unexplained prolonged neonatal jaundice. Sixty-eight scans were reviewed. RESULTS: Mebrofenin scintigraphy confirmed the presence of a choledochal cyst in three of the four cases with that diagnosis. There were no false negative results in the nine patients with extrahepatic biliary atresia (EHBA). Three further infants had an incorrect histological diagnosis of EHBA. A gall bladder was identified by US in each case and in one of these, scintigraphy showed gut excretion. In the 16 patients with no gut excretion by 24 h, the final diagnoses were intrahepatic cholestasis (n = 7), Alagille's syndrome (n = 3), neonatal hepatitis (n = 3), alpha-1-antitrypsin deficiency (n = 2) and juvenile xanthogranuloma (n = 1). Seven infants had repeat scintigraphy after the administration of ursodeoxycholic acid (URSO). This changed five non-excretors with hepatitis into excretors. Two infants with hepatitis continued to show non-excretion after URSO, but a gallbladder was identified by US in both. CONCLUSIONS: Mebrofenin scintigraphy is accurate in confirming the presence of a choledochal cyst and in refuting the diagnosis of EHBA. While histology and scintigraphy are each 100 % sensitive for the diagnosis of EHBA, neither, individually, is accurate and the investigation of prolonged neonatal jaundice requires a multi-modality imaging strategy.

Hepatocellular carcinoma following neonatal hepatitis.

Hepatocellular carcinoma is an uncommon malignancy in young children associated with a variety of congenital and acquired conditions. It has been generally held that idiopathic neonatal hepatitis is not an antecedent of hepatocellular neoplasia in childhood. We report a 28-month-old girl in whom a diagnosis of neonatal giant cell hepatitis was confirmed by liver biopsy at 4 months of age who was followed up with serial liver biopsies. Hepatitis B and C virus infection and metabolic abnormalities had been excluded by appropriate testing. There was no history of parenteral nutrition. The morphologic criteria for a diagnosis of cirrhosis were satisfied in a liver biopsy undertaken at 23 months of age. At 28 months a laparotomy was performed because of continuing jaundice and the development of an abdominal mass. Biopsy of the mass revealed a hepatocellular carcinoma. Ploidy studies showed an aneuploid tumor and a hyperdiploid karyotype was confirmed by chromosomal analysis. This case demonstrates by sequential biopsy the progression from neonatal hepatitis to cirrhosis and hepatocellular carcinoma in a young child.

'Triangular cord': a sonographic finding applicable in the diagnosis of biliary atresia.

Biliary atresia (BA) is characterized by luminal obstruction of the extrahepatic bile duct with fibrous remnants. The authors reviewed ultrasonographic examinations of the fibrous tissue in the bifurcation of the portal vein at the porta hepatis and identified the triangular- or tubular-shaped echogenic density, the so-called "triangular cord" (TC), in the vicinity of the portal vein on a transverse or longitudinal scan. In this prospective study, the authors investigated whether TC was useful in the noninvasive diagnosis of biliary atresia in 18 infants who had persistent neonatal jaundice. This was done by comparing the ultrasonographic examination with the histopathologic examination (HPE) of liver specimens obtained from a needle biopsy. The TC was identified in nine patients, all of whom were confirmed to have BA by HPE. The TC was not observed in the other nine patients, who had neonatal hepatitis (NH). The mean size of the TC was 13 mm (wide) x 6 mm (thick) (width range, 5 to 21 mm; thickness range, 4 to 12 mm). The diagnosis of BA was confirmed at the time of Kasai hepatoportojejunostomy in eight of the nine patients whose TC was noted by ultrasonography (US). The other patient was discharged because his parents refused the operation; he died of liver failure at 15 months of age. The nine patients with absent TC were treated medically for NH. Eight of them improved clinically. The other, diagnosed to have NH by needle and wedge liver biopsies, was reexamined 40 days after the initial examination because of worsening jaundice. A 18 x 12-mm TC was visualized ultrasonographically. Additionally, a percutaneous liver biopsy specimen showed BA with severe portal fibrosis and ductal proliferation. The patient underwent a Kasai hepatoportoenterostomy. On the basis of these results, the authors conclude that TC is a very specific ultrasonographic finding, representing the fibrous cone at the porta hepatis, and is a useful tool in the noninvasive diagnosis of BA. However, early exploration or close US follow-up is recommended for any patient suspected of having BA clinically, even if a liver biopsy confirms the NH.

Electron microscopic study of the liver with biliary atresia and neonatal hepatitis.

Eleven cases of biliary atresia (BA) and eight of neonatal hepatitis (NH) were studied, using transmission electron microscopy, to document their different ultrastructural characteristics and to elucidate the possible pathogenesis of biliary atresia. Among 30 consecutive liver biopsies obtained from 19 infants with BA or NH, 21 specimens composed (13 BA, 8 NH) were examined ultrastructurally. The electron microscopic features of NH (patients' age range, 35 to 60 days) were (1) giant hepatocytic transformation with scattered areas of dilated endoplasmic reticulum, indicative of intracytoplasmic degeneration, (2) frequent cytoplasmic biliary necrosis, and (3) relatively intact microvilli in most bile canaliculi, which contained some hepatocytic cytoplasmic fragments. These features strongly suggest that the main pathological process in NH is hepatocellular injury rather than bile duct damage. In contrast, all cases with BA (age range, 27 to 130 days) demonstrated (1) marked hepatocellular cholestasis associated with many lysosomes and myelin figures, (2) marked loss of bile canalicular microvilli, (3) degenerated bile ductular cells containing bile pigments, and (4) periductal inflammatory fibrosis. These features suggest that the main pathological process in BA involves the biliary system. A few viral inclusions were observed in two cases with BA, which suggests that viral infection is a potential cause. In two BA cases (aged 40 and 43 days at the time of first biopsy), the ultrastructural findings essentially were the same as those of NH, and follow-up biopsy specimens (at 48 and 94 days) showed findings consistent with BA. Such results support Landing's hypothesis that BA and NH are different manifestations of a single pathological process.

Fate of infants with neonatal hepatitis: pediatric surgeons' dilemma.

Thirty-five cases of neonatal hepatitis (20 males and 15 females) were reviewed, 3 of whom were lost during the follow-up, leaving 32 patients for review. There were 10 late deaths and 22 patients survived, 18 of whom with a normal bilirubin level and 4 with a bilirubin level of greater than 1.0 mg/dL. In the 18, jaundice disappeared between the ages of 4 and 7 months. The current lifestyles of the patients include 4 adults aged 19 to 21 who are either working or at university, while the other 18 children are all making good progress at school. Except for moderate growth retardation in 3 children, all are growing well. In all 10 patients who died, liver failure persisted until the time of death. Three died of other causes and 7 died of neonatal hepatitis itself between 4 months and 7 years of age. Four patients ran a fulminating course resulting in death between the ages of 4 and 12 months. All 7 had growth and developmental retardation. A histological examination showed that in those who died, there was significantly more periportal fibrosis, inflammation in the periportal area, and diffuse giant cell transformation. These results indicate that some infants with neonatal hepatitis have a poor prognosis and, therefore, the identification of such a condition requires a careful, long-term follow-up.

Neonatal hepatitis syndrome with paucity of interlobular bile ducts in cystic fibrosis.

A male infant presenting with neonatal hepatitis syndrome, characterized by conjugated hyperbilirubinemia and very mild liver function test abnormalities, at 2 weeks of age was found to have no excretion of radioisotope into the intestinal tract on hepatobiliary scan. Liver biopsy revealed severe interlobular bile duct paucity. Other features of Alagille's syndrome were not present; other conditions frequently associated with interlobular bile duct paucity were also excluded. Subsequently, the infant was found to have cystic fibrosis. Cystic fibrosis is thus another disease that may be associated with paucity of interlobular bile ducts presenting as neonatal hepatitis syndrome, and this represents a different pathogenesis of cholestatic jaundice in neonates with cystic fibrosis besides those previously recognized.

[The neonatal hepatitis syndrome]. / Sindromul hepatitei neonatale.

Syndrome of Neonatal hepatitis and atresia of extrahepatic bile ducts are the most frequent causes of jaundice with conjugated bilirubin in the small infant. The neonatal hepatitis is diagnosed by its plurietiologic character, onset in the first 3 months, subacute or chronic, potentially cirrhogenous, evolution, conjugated hyperbilirubinemia and mainly, gigantocellular hepatic transformation--the essential characteristic of the diagnosis. Etiology of neonatal hepatitis has extremely diverse causes: infectious causes, genetic diseases of metabolism, toxic causes, post-hemolytic states, neonatal acute hepatic necroses, parenteral nutrition, chromosomal anomalies, familial syndromes, etc.; there exists also a form with nonspecific cause (idiopathic form). Practically, neonatal hepatitis might often be mistaken for atresia of the extrahepatic bile ducts. In the latter case, the temporization of the surgery (bilidigestive anastomosis) for more than 2 months of cholestasis evolution leads to the appearance of hepatic cirrhosis lesions. The authors analyze various clinical, biological and histopathological elements which permit the differentiation in due time of the two situations that require different therapeutic attitudes. Except for certain situations, which allow an etiologic treatment, the main therapeutic element (pathogenic) is corticotherapy and several additional measures. The paper concludes with appreciations on the evolution, prognosis and prophylaxis possibilities.