Prenatal diagnosis and follow up of biliary atresia

British Journal of Obstetrics and Gynaecology 1108 CASE REPORT October 2001, Vol. 108, pp. 1108–1110

CASE REPORT

Prenatal diagnosis and follow up of biliary atresia L. Burc a,*, E. Vuillard b, J. Guibourdenche a, M. Conti d, C. Garel b, D. Porquet a, J. F. Oury c, D. Luton c Case report A twin pregnancy was diagnosed in a woman aged 32 and monitored in the obstetric unit of the Robert Debre´ Hospital. Between 12 and 35 weeks of gestation, eight sonographic examinations were performed by the same senior operator, on a Hitachi Katana ultrasound machine with a 3.5 MHz transducer 1. The gallbladder was not seen in the first twin at 22 weeks of gestation, whereas ultrasonographic examination of the second twin was normal. Karyotyping, screening for cystic fibrosis and gastrointestinal enzyme assays in amniotic fluid were then approved by the local ethics committee 2,3. Written informed consent was obtained from both parents. Amniotic fluid was tested for gamma-glutamyl transpeptidase, 5’ nucleotidase, alkalin phosphatase, amylase and aspartate aminotransferase in a Hitachi 911 analyser. Amniotic fluid was collected from both amniotic sacs. The first twin was treated in specialist gastrointestinal surgical unit from the fifth day after birth. Biochemical and sonographic examinations were performed until his death, 14 days after birth. The second twin was a girl with normal echographic findings throughout the pregnancy. Screening for cystic fibrosis was negative and amniotic fluid enzyme activities were normal. She was born at 36.5 weeks of gestation and was healthy. The first twin was a boy. His gallbladder could not be detected sonographically at 22 weeks of gestation (in full throughout), suggesting biliary atresia. Repeat sonography at 24 weeks of gestation again failed to identify the gallbladder, and a cyst measuring 5mm in diameter was detected immediately below the left portal vein. The cyst gradually enlarged, measuring 10mm at 35 WG. Other possible signs of biliary atresia, such as the presence of an azygos vein and polysplenia, were not found. a

Hormonal Biochemistry Service, Robert Debre´ Hospital, France b Radiology Service, Robert Debre´ Hospital, France c Obstetrics and Gynaecology Service, Robert Debre´ Hospital, France d Biochemistry Service, Biceˆtre Hospital, France * Correspondence: Dr L. Burc, Service de biochimie-hormonologie, Hoˆpital Robert Debre´, 48 Bd Serrurier, 75019-Paris, France. q RCOG 2001 British Journal of Obstetrics and Gynaecology PII: S03 06- 5456(01)0025 5-8

Enzyme assays in the amniotic fluid from 22 to 26 weeks of gestation showed gamma-glutamyl transpeptidase and 5’ nucleotidase activities below the 10 th centile. Other activities were normal and hydramnios was absent (Fig. 1). The boy was born apparently healthy at 36.5 WG, with a birthweight at the 90th centile and an Apgar score of 10/ 10. There was no hepatomegaly or splenomegaly or signs of infection. Hepatomegaly and gradual fading of the stools developed during the first week of life. Postnatal sonographic examination was performed on the second day of life. The gallbladder was not visible and the cyst detected antenatally was unchanged. No other abnormalities were found. At birth, the levels of gamma-glutamyl transpeptidase and 5’ nucleotidase were elevated. Until surgery a reduction by 50% and 75%, respectively, occurred, but their levels remained at the upper normal range (Table 1). The concentrations of conjugated bilirubin and bile salts were elevated. There was no hepatocellular dysfunction and haemostasis was normal. Electrophoresis showed no a 1–antitrypsin deficiency. Phototherapy was started in an attempt to reduce neonatal jaundice. A Kasaii hepatico-jejunal anastomosis was performed to correct the complete gallbladder atresia. After surgery, gamma-glutamyl transpeptidase activity became normal, the bilirubin level decreased and there was moderate hepatocellular dysfunction. The boy died on the second day after surgery of septic shock with multi-organ failure and disseminated intravascular coagulation. A methicillin-sensitive strain of Staphylococcus aureus was identified in the abdominal fluid, liver biopsy and blood culture. Discussion Biliary atresia occurs in 1/8000 to 1/14000 births and explains half of all cases of neonatal cholestasis. Emergency surgery is required to restore liver function and to prevent hepatic fibrosis. Postnatal treatment must be carried out in specialist units 4. Sonographic diagnosis is difficult, as there are no specific signs 5,6. We report the first fully documented case of biliary atresia diagnosed at 22 weeks of gestation, based on fetal echography and amniotic fluid biochemistry. Complete gallbladder atrewww.bjog-elsevier.com

CASE REPORT 1109

Fig. 1. Twin 1 pregnancy survey. GGT ¼ gamma-glutamyl transpeptidase; ASAT ¼ aspartate aminotransferase.

sia was confirmed sonographically at birth. The newborn child was initially healthy, but biochemical analysis showed a large increase in gamma-glutamyl transpeptidase activity, bile acids, total bilirubin and conjugated bilirubin levels. Although these findings are not specific to biliary atresia, as neonatal hepatitis can induce the same pattern 7–10, biochemical diagnosis is essential to establish the diagnosis. Clinical abnormalities and abnormal biochemical investigations are often delayed after birth 8,9, suggesting that antenatal diagnosis may prepare for appropriate treatment in the newborn period. The gallbladder should always be visible at 22 weeks of gestation; if it is not, a second examination must be performed a few days later. However, an ectopic or nonechogenic gallbladder (due to biliary sludge) may be difficult to distinguish from the liver; non-visibility of the gallbladder may also be an early sign of cystic fibrosis 3. Gallbladder agenesis is very rare, and is an indication for termination of pregnancy. The causes of

intrahepatic or subhepatic congenital cysts are numerous, including choledocal cyst, biliary cyst and cystic lymphangioma, but the combination of a non-visible gallbladder and a biliary cyst is strongly suggestive of biliary atresia 11. Postnatally, hyperechogenicity of the portal bifurcation is another reliable sign. Biochemical analysis is required to confirm the echographic findings. Fetal blood sampling can reveal elevated gamma-glutamyl transpeptidase levels resulting from the detergent action of accumulated bile salts on the biliary epithelium 9,12. The value of serum gamma-glutamyl transpeptidase assay is controversial, as it required invasive sampling and lacks specificity 4. Damage to the cells of the bile ducts may occur in many other settings, such as viral infections, genetic diseases, invasive vascular procedures and other abnormalities of the bile ducts, resulting in an increase in gamma-glutamyl transpeptidase activity in the blood 9. If the gallbladder is undetected after two ultrasound

Table 1. Twin 1 neonatal biochemical survey. ASAT ¼ aspartate aminotransferase; ALAT ¼ alanine aminotranfesrase; GGT ¼ gamma-glutamyl transpeptidase; CRP ¼ C-reactive protein. Surgery Varibles

Day 0

Day 1

ASAT (IU/L) ALAT (IU/L) Total bilirubin (mmol/l) Conjugated bilirubin (mmol/l) Alkalin phosphatase (IU/l) GGT (IU/l) 5’nucleotidase (IU/L) Bile acids (mmol/l) CRP (mg/l)

42 8 40 24 156 1200 80 23 ,10

56 15 146 24 237 1210 69 75 ,10

q RCOG 2001 Br J Obstet Gynaecol 108, pp. 1108–1110

Day 2

249 34 950 42 60

Day 4 27 10 348 45 242 814 20 64

Day 5

Day 6

Day 12

Day 14

263 34

31 9 267 43 209 662

173 63 115 36

90 58 90 35 64 78

179

79

1110 CASE REPORT

scans, amniotic fluid sampling may exclude chromosomal abnormalities and cystic fibrosis 13. Gastrointestinal enzyme assays are of value, as they are often diagnostic. Reduced activities have been described in cystic fibrosis, trisomy 21 and trisomy 18 14, whereas increases are observed in oesophageal atresia, duodenal stenosis and gastrointestinal occlusion 15. Digestive enzymes are detectable in amniotic fluid until 20 weeks of gestation, when the anal sphincter closes 4,12,16. Opening of the cloacal membrane and maturation of intestinal villi occur at 14 weeks of gestation, and enzymes are excreted through the anal sphincter into the amniotic cavity. After 20 weeks of gestation the anal sphincter closes under nervous control, gastrointestinal enzymes are no longer excreted into amniotic fluid, but are still detectable in small amounts. We have established reference values for digestive enzymes until 35 weeks of gestation, which allowed us to assess the digestive function of the first twin. Gamma-glutamyl transpeptidase and 5’ nucleotidase arise mainly from bile 12. Few studies have examined the value of amniotic fluid gamma-glutamyl transpeptidase determination in cases of biliary atresia 12, and none have studied 5’ nucleotidase. Any obstruction of the biliary tract will prevent gamma-glutamyl transpeptidase and 5’ nucleotidase from reaching the intestine and the amniotic fluid. This results in an isolated reduction in gamma-glutamyl transpeptidase and 5’ nucleotidase, with no other dysfunction of the gastrointestinal tract 12. Determination of other bile components such as bile acids in amniotic fluid could be of value, but their physiology in the fetus is unknown and no reference values are available 17. The case we report is, to our knowledge, the first to show a marked, isolated decrease in amniotic fluid levels of both gamma-glutamyl transpeptidase and 5’ nucleotidase after 20 weeks of gestation, confirming the echographic signs of biliary atresia. This illustrates the value of combining echography and biochemical analysis of the amniotic fluid to diagnose biliary atresia and to assist with planning appropriate treatment in the newborn period. Acknowledgements The authors would like to thank O. Bernard, departmental

manager of hepatic paediatry unit, Kremlin Biceˆ tre Hospital, for his collaboration.

References 1. Luton D, Fried D, Sibony O, et al. Assessment of fetal thyroid function by colored Doppler echography. Fetal Diagn Ther 1997;12:24–27. 2. Kawasaki ES, Chehab FF. Analysis of gene sequences by hybridization of PCR-amplified DNA to covalently bound oligonucleotide probes. The reverse dot blot method. Methods Mol Biol 1994;28:225–236. 3. Duchatel F, Muller F, Oury JF, Mennesson B, Boue J, Boue A. Prenatal diagnosis of cystic fibrosis; ultrasonography of the gallbladder at 17-19 WG. Fetal Diagn Ther 1993;8:28–36. 4. Bernard O. Diagnostic pre´ coce des icte`res cholestatiques chez le nouveau-ne´ . Arch Pe´ diatr 1998;5:1031–1035. 5. Redkar R, Davenport M, Howard ER. Antenatal diagnosis of congenital anomalies of biliary tract. J Pediatr Surg 1998;33:700–704. 6. Iwai N, Deguchi E, Sasaki Y, Idoguchi K, Yanagihara J. Antanatal diagnosis of biliary atresia (noncorrectable cyst type: a case report). Eur J Pediatr Surg 1999;9:340–342. 7. Liu CS, Chin TW, Wei CF. Value of gamma-glutamyl transpeptidase for early diagnosis of biliary atresia. Chung Hua I Hsueh Tsa Chih 1998;61:716–720. 8. Mushtaq I, Logan S, Morris M, et al. Screening of newborn infants for cholestasis hepatobiliary disease with tandem mass spectrometry. BMJ 1999;319:471–477. 9. Maggiore G, Bernard O, Hadchouel M, Lemonnier A, Alagille D. Diagnostic value of serum g-glutamyl transpeptidase activity in liver diseases in children. J Pediat Gastroenterol Nutr 1991;12:21–26. 10. Broide E, Klinowski E, Koukoulis G, et al. Superoxide dismutase activity in children with chronic liver disease. J Hepatol 2000;32:188–192. 11. Matsubara H, Oya N, Suzuki Y, et al. Is it possible to differentiate between choledocal cyst and congenital biliary atresia (type I cyst) by antenatal ultrasonography? Fetal Diagn Ther 1997;12:306–308. 12. Muller F, Gauthier F, Laurent J, Boue´ J. Amniotic fluid and congenital extrahepatic damage. Lancet 1991;337:232–233. 13. Dechecchi MC, Girella E, Borgo G, Mastella G. Prenatal diagnosis of cystic fibrosis. Enzyme 1989;42:209–218. 14. Giddy MJ, Hay DL, Horacek I. Amniotic fluid enzymes in pregnancies with trisomy 21. Prenat Diagn 1989;9:769–775. 15. Muller F, Dommergues M, Ville Y, et al. Amniotic fluid digestive enzymes: diagnostic value in fetal gastrointestinal obstructions. Prenat Diagn 1994;14:973–979. 16. Hosoda Y, Miyano T, Fujimoto T. Assay of gamma-glutamyl transpeptidase in amniotic fluid offers a possible prenatal diagnosis of biliary atresia in the rat model. Prenat Diagn 1997;17:9–12. 17. Tohma M. Determination of fetal bile acids and related steroidal compounds and their profile in neonatal biological fluids. Yakugaku Zasshi 1996;116:753–775. Accepted 25 May 2001

q RCOG 2001 Br J Obstet Gynaecol 108, pp. 1108–1110