Neonatal Cholestasis

Chew Kee Seang

MPaeds (MAL), MRCPCH (UK)
Paediatric Gastroenterology, Hepatology Fellow
University of Malaya
Neonatal Cholestasis: Definition
• Cholestasis – Ancient Greek derived word
• “chole” : bile / gall
• “stasis”: a standing still

“defined as reduced bile formation or flow

resulting in the retention of biliary substances within the liver
normally excreted into bile and destined for elimination into the
intestinal lumen”

Fawaz R, et al. JPGN 2017

Bile acid induced cell injury
• Majority of human bile
acid are hydrophobic
• Cholic acid (CA),
chenodeoxycholic acid
(CDCA)
• Retention and
accumulation → liver
damage

Oxidative stress
Apoptosis
Damage to plasma membrane

Perez MJ, et al. World J Gastroenterol 2009

Definition
• Conjugated hyperbilirubinaemia
• Serum conjugated bilirubin >20% (when total bili > 85 μmol/l )
OR
• > 17μmol/l (when total bilirubin <85 μmol/l )

• Prolonged jaundice defined as persistent jaundice after 14 days of life

(21 days in pre term baby)
Lee WS et al. TEXTBOOK OF PAEDIATRICS AND CHILD HEALTH

• Incidence of neonatal liver disease 1 in 2500 live births

Dick MC, et al. Arch Dis Child 1985
Aetiology
Obstruction Infections Endocrine Genetic Metabolic Toxic
Biliary Atresia Intrauterine Hypothyroidism Alagille Galactosemia Intestinal
infections syndrome failure
Choledochal (TORCHES) Hypopituitarism Citrin deficiency associated liver
cyst Progressive disease (IFALD)
Systemic sepsis familial Fatty-acid
intrahepatic oxidation defects Ischaemia
Urinary tract cholestasis (Perinatal
infection Mitochondrial asyphyxia)
Cystic fibrosis hepatopathies

*Identify treatable causes

Causes of Neonatal Cholestasis - UMMC
Biliary Atresia
10%
Idiopathic neonatal
5% hepatitis syndrome
29%
1% CMV/HSV hepatitis
3%

4% PFIC

Endocrine
10%

Metabolic

TPN cholestasis

Others
38%

Lee WS, et al. SMJ 2010

 (HIDA)

Diseases of Liver and Biliary system. Kelly DA

History
• Jaundice history
• Onset, severity, progression
• Growth
• Stool colour – pale: progressive? Intermittent?
• Prenatal
• History to suggest infection: perinatal risk of sepsis, UTI, TORCHES
• Maternal cholestasis of pregnancy – may be assoc PFIC
• Perinatal
• Prematurity, SGA
• TPN use
• Neonatal infection
• Family history
• Consanguinity
• Neonatal Cholestasis in parent/siblings
Clinical Examination
STOOL INSPECTION
• Dysmorphic features (favouring Alagille syndrome)
• Growth
• Abdomen
• Liver size, consistency
• Any splenomegaly
• Ascites
• Other systemic examination:
• Congenital heart disease
• Spine anomalies, Eye examination
• Features of congenital TORCHES infection
Investigations
1. Establish the presence of cholestasis
• Serum conjugated/direct bilirubin

2. Define severity of liver dysfunction

• Live enzymes: ALT, AST, GGT, ALP
• Liver synthetic function: serum glucose, albumin, and coagulation
• Deranged coagulation despite Vit K indicate neonatal liver failure

3. Establish a cause
• Adequately fasted ultrasound HBS
• Other investigations as indicated
• Bacteriological tests
• TORCHES
• Endocrine function test
• Metabolic disease screen
Case 1
• Day 24 of life, girl
• Admitted for bronchopneumonia
• Incidental finding of conjugated hyperbilirubinemia

Further history:
• Born term, SVD, BW 3.1kg → 3.5kg
• Stool yellowish at home
• Non-consanguineous marriage, first child
• No family history of liver disease
 Stool inspection
Case 1: Examination
• Jaundice
• No dysmorphic features
• CVS: S1 S2 no murmur

• Abd soft, not distended, Liver 3 cm,

soft, no splenomegaly.
• Other systemic examination: NAD

• Any other examination?

Mother: “Stool only turn pale in the ward.”
(D26 OL)
Case 1: Investigations
D27 OL D30 OL D37 OL
Albumin, g/L 31 30 31
Total Bili, µmol/L 125 108 90
Conjugated, µmol/L 89 77 69
ALT 28 37 41
AST 44 60 53
GGT 1055 936 643

PT INR 1.1 0.9

Case 1: D30 OL: Ultrasound abdomen – well fasted
Report:
Intrahepatic ducts and CBD are patent.

Normal gallbladder is visualized measuring 1.9 x 0.8 x 0.4 cm

(volume 0.6 mls).

Gallbladder length 13.6 mm

Post prandial gallbladder (10 minutes post feeding) appears more

contracted measuring 1.8 x 0.4 x 0.6 cm (volume 0.22).

No triangular cord sign.

Impression:
No sonographic evidence of biliary obstruction.
Case 1: summary
• Conjugated hyperbilirubinaemia
• GGT 1055 IU/L
• Stool just turned pale
• Hepatogemaly 3 cm, soft
• Ultrasound: Normal gallbladder, with normal GB contractility

What’s next?
HIDA scan?
Continue monitoring?
 HIDA (hepatobiliary iminodiacetic acid) scan
Principle of HIDA scan (radioisotope scan)
• IDA uptake to liver → excreted in biliary tree → drain to duodenum
• Test dependent on bile flow
Gilmour SM, et al. J Nucl Med. 1997

In other words, pale stool = no bile flow = likely non-excretory HIDA scan

• HIDA scan take a long time: reassessed in 24 hour

• Use of phenobarbitone 5 days prior to HIDA scan
• Phenobarbitone is choleretic
• Increase hepatobiliary clearance
• Unnecessary delay in diagnosis, and hence Kasai Procedure
Fawaz R, et al. JPGN 2017
 1 week later

Serial LFT
D27 OL D30 OL D37 OL
Albumin, g/L 31 30 31
Total Bili, µmol/L 125 108 90
Conjugated, µmol/L 89 77 69
ALT 28 37 41
AST 44 60 53
GGT 1055 936 643

PT INR 1.1 0.9

TSB and GGT reducing trend
What’s next? Check the stool again!!!
Persistent pale and oily
Case 1: Operative cholangiogram

Normal cholangiogram
Green D, et al. J Ultrasound Med
OTC: no flow proximally and 5.323 - 329, June 1986
distally
Atretic gallbladder
Diagnosis: Biliary Atresia (Progressive Obliterative Cholangiopathy)
Case 1: Learning point
1. Stool inspection is mandatory at every visit.

2. A negative ultrasound does NOT rule out biliary atresia

3. Ultrasound: examine gallbladder size well fasted and post feeding

4. If in doubt, refer for OTC (“gold standard”)

Biliary Atresia
Incidence
• Taiwan: 1 in 6,000 live births
Chiu CY, et al. J Pediatr. 2013

• USA: 1 in 12,000 live births

The NS, et al. Am J Med Genet A. 2007

• UK and Ireland: 1 in 16,700 live births

McKiernan PF, et al. The Lancet. 2000
Biliary Atresia (BA) clinical classification
BA with laterality Type of BA, n = 289 Embryonic
Syndromic defect
Splenic anomaly 70% form
10%
Cardiovascular 80%
Gastrointestinal 90%
Genitourinary 10% BA with major
anomalies (no
BA laterality sequence
laterality)
BA splenic malformation
6%

Non-syndromic Perinatal
Cardiovascular 71% Isolated BA (acquired)
Genitourinary 47% 84% form
Gastrointestinal 24%

Schwarz KB, et al. Hepatology. 2013

Biliary Atresia anatomic classification (Ohi)
Type I: Atresia of
Common bile duct

Type II: Atresia of

common hepatic duct

Type III: Atresia of

Porta Hepatis

Ramachandran P, et al. Indian

Pediatr 2015
Diagnosis of Biliary Atresia
• Role of ultrasonography

• Role of HIDA scan

• Liver biopsy

Intraoperative cholangiography
• Gold standard: Operative BA type IIIa
cholangiogram Lee SM, et al. Korean J Radiol. 2015
Gamma Glutamyl transferase (GGT) in diagnosis of biliary atresia

N = 93

Tang KS, et al. Acta Paediatr Taiwan. 2007

Ultrasound examination – adequately fasted

(c) Abnormal gallbladder (arrow)

(a) Normal gallbladder (arrow) (b) Small, abnormal gallbladder subtle irregularity of the wall
normal shape and regular wall. (arrow) (arrow-heads) of this 21-mm-long
Calipers and dotted line indicate irregular wall and abnormal shape gallbladder.
gallbladder lengthmeasurement.
Bowel (arrowhead)
Humphrey and Stringer. Radiology 2007
 Triangular cord (TC) sign

Transverse sonogram Sagittal sonogram Illustration, TC (green)

TC sign (arrow) TC sign (arrow) superior to portal vein Fbrotic remnant of the extrahepatic
Area of increased echogenicity (as (arrowhead) biliary tree
indicated by calipers) is seen anterior to
bifurcation of portal vein (arrowheads Humphrey and Stringer. Radiology 2007
Gallbladder Contractility post feed
3 parameters:

TC Sign ≥3 mm
GB Length < 15 mm
GB Contractility

Takamizawa S, et al. JPedSurg (2007) 42,

2093–2096
Kasai Hepatoportoenterostomy (HPE)
• 1959: Kasai and Suzuki

• Re-establish bile
flow from liver to
intestine via
hepatic porto-
enterostomy

Ohi, R. World J. Surg. 1988

Key point of Kasai Hepatoportoenterostomy
1. Success in obtaining bile flow is better if HPE is done before 60-90
days of age
2. Cholangitis has an adverse effect on bile flow
3. Establishment of bile flow results in better survival
4. Progressive fibrosis and liver dysfunction occur in many children
even jaundice resolves

Sokol RJ, et al. Hepatology 2007

• N=695
• Year 1986 – 2002
• Survival with native
liver (SNL)
• 2-year 57.1%
• 5-year 37.9%
• 10-year 32.4%
• 15-year 28.5%

Serinet MO, et al. Pediatrics 2009

Screening: Stool Colour Card

Early diagnosis
↓
Early surgery
↓
Improved
outcome of BA

https://pediatrics.med.ubc.ca/2013/07/22/blanket-check-car-seat-check-poop-colour-chart-huh/
Biliary Atresia diagnosis: Summary
• Clinical characteristics: Favouring BA
• Pale stool and GGT >200 micromol/l
• Absence of facial dysmorphism, enlarged liver
• Investigation:
• Ultrasound is non-invasive and readily available, operator dependent
• HIDA scan is time consuming, limited availability, may delay diagnosis
• Gold standard: Operative Cholangiogram

**Repeated inspection of stool

Early referral --> improved outcome
Diseases of Liver and Biliary system. Kelly DA
Choledochal cyst
• Extrahepatic biliary obstruction
• Present similar manner with
biliary atresia
• US often can lead diagnosis

• Portoenterostomy has excellent

prognosis
Diseases of Liver and Biliary system. Kelly DA
Aetiology
Obstruction Infections Endocrine Genetic Metabolic Toxic
Biliary Atresia Intrauterine Hypothyroidism Alagille Galactosemia Intestinal
infections syndrome failure
Choledochal (TORCHES) Hypopituitarism Citrin deficiency associated liver
cyst Progressive disease (IFALD)
Systemic sepsis familial Fatty-acid
intrahepatic oxidation defects Ischaemia
Urinary tract cholestasis (Perinatal
infection Mitochondrial asyphyxia)
Cystic fibrosis hepatopathies

*Identify treatable causes

Alagille syndrome (Intrahepatic biliary obstruction)
• AD, JAG1 (95%) or NOTCH-2 (5%) mutation
• Intralobular bile duct paucity on liver biopsy
• Clinical characteristic:
• Cholestasis
• CVS: Peripheral pulmonary stenosis
• Skeletal: Butterfly vertebrae/ hemivertebrae
• Eye: Posterior embryotoxon
• Dysmorphic features
• Prognosis: varies greatly due to variable penetrance
TPN Cholestasis
• PN-related cholestasis is present in up to one-fifth of neonates
receiving PN for >2 weeks

• The incidence directly proportional to the length of PN

• PN ≤1 month : 15.7%
• PN ≥2 months : 60.9%
• P < .0001

• Suggested pathogenesis: Preterm, sepsis, multifactorial

Lauriti G, et al. J Parenter Enteral Nutr 2014

 Low GGT Neonatal Cholestasis

Diseases of Liver and Biliary system.4th edition Kelly DA

Case 2
• Day 58 OL
• Admitted for acute bronchiolitis
• Incidental finding of conjugated hyperbilirubinaemia

• Born FT, SVD, BW 2.9kg, CW 4.4 kg

• Antenatal: no history of fever, rashes
• Non-consanguineous marriage, first child
• Formula fed
• Stool: yellow, pigmented, never had pale stool
Case 2: Examination
• Alert, active
• Tachypnoeic with chest recession

• Abd: Hepatomegaly 3cm, firm; Splenomegaly 3 cm

• Stool inspection: pigmented

• CVS DRNM
• No dysmorphic features
 Plasma Amino acid & Urine Organic
Case 2: Investigations acid:
D58 OL No specific abnormalities detected
Albumin, g/L 32 HIV negative
Total Bili, µmol/L 144 Syphilis total Ab ND
Conjugated, µmol/L 110
ALT 73 Toxoplasma, HSV, Rubella IgM ND
AST 145 CMV IgM detected
GGT 109 CMV IgG 277.3
Corrected
PT INR 3.3 with Vit K
Hemoglobin 7.6 Urine CMV negative
CMV DNA 88600 IU/ml
WBC 13.2
Platelet 165 Is there a need to refer for on
US abdomen: no evidence of BA table cholangiogram (OTC)?
CMV infection and Biliary atresia
• Single centre study, January 2004–December 2011
• N= 210 undergone Kasai operation
• CMV IgM positive = 20/210 (9.5%) Zani A, et al. J Pediatr Surg (2015)

• Review of CMV infection and biliary atresia (n=15 studies)

• Range from 0 – 76.9%
Averbukh LD, Wu GY. 2018;6(4):410–419.

• Possibility of perinatal CMV infection in the pathogenesis of BA

• A positive CMV serology does NOT rule out Biliary Atresia
Case 3: Other examination and progress
• Hearing test: Normal
• Eye: no CMV retinitis
• US brain: no focal lesion no abnormal calcification
• OTC: No evidence of biliary atresia

Diagnosis: CMV hepatitis

Last review at 5 month:

Alb 40 Bili 6 ALT 104 AST 66 GGT 32
Case 3
• D63 OL, boy
• Presented to ED with noisy breathing
• Incidental finding of conjugated hyperbilirubinaemia

• Term 38 week, BW 2.57kg

• Antenatal uneventful. Mixed feeding
• Stool inspection: pigmented
• Non-consanguineous marriage, no history of liver disease or IEM

• O/E: Jaundice, active on handling, not dysmorphic

• Hepatomegaly 4.5cm, soft, no splenomegaly
• Other systemic examination: normal
 Case 3: Investigation
D63 OL D67 OL
Ultrasound abdomen:
Normal gallbladder and
Albumin, g/L 27 32
contractility
Total Bili, µmol/L 176 175
Conjugated, µmol/L 64 65
IEM tests and TORCHES test
ALT 24 36 pending.
AST 61 77
GGT 190 191 IMP: subclinical hypothyroidism
PT INR 1.1 -
Ammonia, µmol/L 57.2 174 Started on thyroxine and
Lactate , mmol/L 4.6 10.5 Ursodeoxycholic acid

Free T4 23.2 Discharge home

TSH 13 ↑ TCA 1 week
 Case 3: Investigation 2 days later, informed by IEM lab on
D63 OL D67 OL abnormal result.
Albumin, g/L 27
Plasma Amino Acid: Citrulline,
Total Bili, µmol/L 176 ornithine, arginine and lysine high.
Conjugated, µmol/L 64
ALT 24 IMP: TRO citrin deficiency. Most
probably NICCD
AST 61
GGT 190
PT INR 1.1
Ammonia, µmol/L 57.2 174 pH 7.27
Lactate , mmol/L 4.6 10.5 PCO2, mmHg 29.5
HOC3, mmol/L 14.7
Free T4 23.2 BE -13.1
TSH 13 ↑
Case 3: Progress
• Started on hyperammonemia cocktail
• Ammonia reduced
• Formula change: lactose free with MCT oil containing formula

• Diagnosis: Citrullinaemia type 2 / Citrin deficiency

• Enzyme study and genetic SLC25A13 gene mutation confirmed
Metabolic liver disorders
• Characterised by raised lactate, ammonia, abnormal plasma amino
acids, urine organic acids and specific tests depends on clinical
presentation
• Examples:
• Citrin Deficiency
• Galactosemia
• Tyrosinaemia Type I
• Long chain fatty acid oxidation disorders
• Mitochondrial hepatopathy
• Niemann Pick type C
• Alpha-1 Anti trypsin deficiency
Transient Neonatal Cholestasis / Idiopathic Neonatal Hepatatis

• N= 460, prospective cohort of neonates requiring admission in 1 year,

single centre
• 32 (7.0%) neonates develop cholestasis
• Risk factors:
• Parenteral nutrition > 7 days
• Prematurity <34 week
• SGA : adjusted OR 4.4 [95% CI: 1.6-12.5]
• History of neonatal surgery adjusted OR 4.6 [95%CI:1.7-12.3]
• Natural history
• 4 weeks old: 41.9% still cholestasis
• 8 weeks old: 12.9% still cholestasis
• 1 year old: all recovered Champion V, et al. J Pediatr Gastroenterol Nutr 2012
Medical management of chronic
cholestasis
Think of function and side effects of bile and chronic liver disease
Nutrition support
• Nutrition support
• 125% of recommended daily calorie requirement
• Protein 2.5-3 g/kg/day
• Fat: medium chain triglyceride predominant formula
• e.g. Alimentum, Pregestimil
• Monitor for steatorrhoea

• Underweight and growth failure: major predictors of waiting list

mortality and posttransplant morbidity and mortality
• Fat soluble vitamin supplementation: Vitamin A, D, E, K
Sokol RJ, et al. Hepatology 2007
Ursodeoxycholic Acid (UDCA)
• Major primary bile acids in bear, hydrophilic
• UDCA is found in human gut after bacterial conversion (in small amount)

Proposed mechanism of UDCA induced cell protection:

• Cholagogues: stimulate bile flow into duodenum
• Mouse model: stimulate BSEP (bile salt export pump) upregulation
• Shift in the composition of the BA pool towards hydrophilicity
• Stabilize hepatocyte membranes
• Antioxidant effect (enhance glutathione level in rat)

Perez MJ, et al. World J Gastroenterol 2009

Summary
• Recognise conjugated hyperbilirubinaemia
• Every case of neonatal cholestasis should be
approached systematically
• Inspect the stool at every visit
• Urgent referral to paediatric surgery when
suspicious of biliary atresia

• Thank you