2014 Guideline For The Evaluation of Cholestatic Jaundice in Infants
2014 Guideline For The Evaluation of Cholestatic Jaundice in Infants
2014 Guideline For The Evaluation of Cholestatic Jaundice in Infants
DOI : 10.1097/MPG.0000000000001334
Rima Fawaz1
Ulrich Baumann2
Udeme Ekong3
Björn Fischler4
Nedim Hadzic5
Cara L Mack6
Valérie A. McLin7
Jean P Molleston8
Ezequiel Neimark9
Saul J. Karpen11 , *
Abstract: 276
Figures: 2
Tables: 4
References: 160
Funding support relevant to this manuscript: None reported for any author
Disclosures: CLM, JPM, VLN and SJK are members of the NIH-supported ChiLDReN
network, which focuses upon pediatric cholestatic diseases; NH is a consultant for Alnylam
Boston, MA 02115
Rima.Fawaz@childrens.harvard.edu
Baumann.U@mh-hannover.de
udeme.ekong@yale.edu
bjorn.fischler@karolinska.se
nedim.hadzic@kcl.ac.uk
Aurora, CO 80045
Cara.Mack@childrenscolorado.org
Valérie A. McLin, MD 7
Geneva, Switzerland.
valerie.mclin@hcuge.ch
Indianapolis, IN 46202
jpmolles@iu.edu
Providence, RI
Eneimark@lifespan.org
University of Toronto
Toronto, Canada
vicky.ng@sickkids.ca
Department of Pediatrics
HSRB E204
skarpen@emory.edu
* Corresponding author
printed text, and links to the digital files are provided in the HTML text of this article on the
ABSTRACT
Cholestatic jaundice in infancy affects approximately 1 in every 2500 term infants and is
jaundice is always pathologic and indicates hepatobiliary dysfunction. Early detection by the
primary care physician and timely referrals to the pediatric gastroenterologist/hepatologist are
important contributors to optimal treatment and prognosis. The most common causes of
cholestatic jaundice in the first months of life are biliary atresia (BA, 25- 40%) followed by an
expanding list of monogenic disorders (25%), plus many unknown or multifactorial (e.g.,
parenteral nutrition related) causes, each of which may have time-sensitive and distinct treatment
plans. Thus, these Guidelines can have an essential role for the evaluation of neonatal
cholestasis to optimize care. The recommendations from this clinical practice guideline are
based upon review and analysis of published literature as well as the combined experience of the
authors. The Committee recommends that any infant noted to be jaundiced after 2 weeks of age
be evaluated for cholestasis with measurement of total and direct serum bilirubin, and that an
elevated serum direct bilirubin level (direct bilirubin levels >1.0 mg/dl or >17 μmol/L) warrants
Of note, current differential diagnostic plans now incorporate consideration of modern broad-
based next generation DNA sequencing technologies in the proper clinical context. These
recommendations are a general guideline and are not intended as a substitute for clinical
these recommendations is expected to reduce the time to the diagnosis of pediatric liver diseases,
PREAMBLE
Cholestatic jaundice in infancy is an uncommon but potentially serious problem that indicates
hepatobiliary dysfunction. Early detection of cholestatic jaundice by the primary care physician
and timely, accurate diagnosis by the pediatric gastroenterologist are important for successful
Hepatology and Nutrition, (NASPGHAN) and the European Society for Gastroenterology,
Hepatology and Nutrition (ESPGHAN). This Committee has responded to a need in pediatrics
and developed an updated clinical practice guideline for the diagnostic evaluation of cholestatic
jaundice in the infant. There is an obligate focus upon identifying infants with cholestasis due to
biliary atresia (BA), but also incorporating the recognition that most forms of cholestasis in this
age group are due to non-BA causes. Thus a structured and broad-based diagnostic approach is
required. The recommendations presented in this clinical practice guideline are based on review
and analysis of published literature as well as the experience of the authors and colleagues. The
recommendation is assigned a Class (reflecting benefit versus risk) and Level (assessing strength
approach to diagnose infants with cholestasis. These guidelines are intended to be flexible and
care for all infants. This guideline has been approved both by NASPGHAN and ESPGHAN after
extensive review.
LITERATURE SEARCH
A systematic literature search was performed using accessible databases of relevance: PubMed,
MEDLINE from 2002 until 2014 for targeted topics and keywords (see Supplementary Digital
GRADES OF EVIDENCE
Grades of evidence for each statement were based on the grading of the literature and were
and Evaluation system was classified as outlined in Supplementary Digital Content 2, Table,
http://links.lww.com/MPG/A734.
BACKGROUND
Cholestasis is 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
elevation of serum conjugated (or direct) bilirubin and bile acids as central readily-identified
synonymous, during cholestasis normal bile acid flux and conjugated bilirubin excretion into bile
are both impaired and frequently linked. Hence, a central feature of conjugated (or direct)
of the newborn) is critical because cholestatic jaundice is likely pathological and therefore
patients with cholestatic jaundice will benefit from prompt diagnosis and institution of specific
therapy. Cholestasis can be classified into biliary (obstructive, large extrahepatic or small
Cholestatic jaundice affects approximately 1 in every 2,500 term infants and is thus infrequently
seen by most providers taking care of infants[2]. The most common causes of cholestatic
jaundice in the first months of life are biliary atresia (25- 40%) and an array of individually
uncommon genetic disorders (25%). Often, however, the etiology is unknown. It may be
associated with prematurity or intravenous soy lipid infusions (see below)[3]. The rate of
patients designated by the descriptive term, ―idiopathic neonatal hepatitis‖ as the cause of
discovery of new etiologies, now clinically discoverable with utilization of available next
generation DNA sequencing technologies (see below). Other causes of neonatal cholestasis
include extrahepatic obstruction from common duct gallstones or choledochal cyst; metabolic
disorders such as tyrosinemia type I, galactosemia and inborn errors of bile acid metabolism;
impaired bile flow resulting from either biliary obstruction or hepatocellular metabolic
The incidence of neonatal cholestasis is increased in premature infants, more so in those born at
the limits of viability than those born closer to term. Parenteral nutrition (PN)-related cholestasis
is present in up to one-fifth of neonates receiving PN for more than two weeks[5]. Longer
duration of PN and intestinal failure are independent risk factors for the development of PN
cholestasis in infants and has led to the consideration for reducing exposure to soy lipids where
appropriate[5, 6]. In addition, small for gestational age is a strong independent risk factor for
neonatal cholestasis[7]. This clinical guideline is not meant to address cholestasis in the preterm
infant on parenteral nutrition, but close follow up and serial measurements of fractionated
bilirubin levels early in life are important, alongside monitoring growth and tolerance of enteral
feedings. However persistent cholestasis in any infant should be considered pathological and
identifiable causes of cholestasis, including BA, should be ruled out in a timely fashion, since
another cholestatic condition can certainly be present in an infant who requires PN. It should be
noted the incidence of BA or genetic forms of cholestasis is the same in premature as in term
infants—thus, premature infants warrant consideration for the same evaluation of neonatal
preterm infants compared with term infants, and delayed diagnosis results in poorer outcome[8,
9].
BA is the most frequent identifiable cause of obstructive jaundice in the first 3 months of life.
The prevalence of BA varies according to location around the globe: ~1 in 6,000 live births in
Taiwan, 1 in 12,000 in the United States, 1 in 19,000 in Canada and 1 in 18,000 in Europe[10-
12]. There are three classifications of BA- the nonsyndromic form (84%) which is the most
common, BA with at least one malformation but without laterality (e.g., situs inversus) defects
(6%) and the syndromic BA with laterality defects (10%). The latter two groups have other
systems but the group without laterality defects has more frequent genitourinary anomalies. BA
patients with laterality defects more commonly have splenic anomalies[13]. The etiology of BA
compared with normal (control, non-cholestatic) infants, suggesting that the initiation of the
biliary injury occurs prior to, or very soon after birth (i.e. perhaps due to intrauterine insult or
genetic etiology), thus minimizing the likelihood of biliary tract disease acquired after birth[18].
(HPE) aimed at re-establishing bile flow[19]. If the HPE is performed within the first 60 days of
life, ~70% of patients will establish bile flow; after 90 days of life less than 25% of patients will
have bile flow[3]. Late diagnosis of BA however remains a problem worldwide for a variety of
reasons including the obligate visual overlap with normal physiologic jaundice and the lack of a
readily applicable newborn screening. The average age at HPE in the US is 61 days and 44% of
patients still undergo HPE after 60 days of life[20]. In Europe, late diagnosis is also a challenge
outcome series from Canada, medium age at HPE was 55 days but late referral was still
problematic[11]. Although not systematically evaluated, surgical outcome has been associated
with the expertise in performing HPE in Europe, with improved outcome seen with centralized
care models[11, 24, 25]. In the United States this might be more challenging, but referral to a
Some series report successful HPE drainage beyond 90 days of life reaching 13-35 %[11, 19, 26]
. In a large series that examined outcomes in 743 infants with BA, 2-, 5-, 10-, and 15-year
survival rates with native liver were 57.1%, 37.9%, 32.4%, and 28.5%, survival rates with native
liver decreased when age at surgery increased (< or =30, 31-45, 46-60, 61-75, and 76-90 days).
The investigators in this study estimated that if every patient with BA underwent the Kasai
operation before 46 days of age, 5.7% of all liver transplantations performed annually in France
in patients younger than 16 years could be avoided. These studies highlight the importance of
early detection of cholestasis by providers that can improve outcomes[19]. These also indicate a
need for unbiased screening for cholestasis and BA, perhaps via yet-to-be discovered newborn
Treatable conditions that can present with cholestatic jaundice include bacterial sepsis,
gallstones. These infants often appear acutely ill and early diagnosis will enable timely initiation
normally which might deceive the parent or physician into believing that the jaundice is
specific treatment is not available or curative. The differential diagnoses include a variety of
anatomic, infectious, autoimmune, genetic, metabolic and congenital conditions. This list is not
meant to be exhaustive but rather an overview to help orient the reader (see Table 1).
Jaundice or icterus is clinically evident when the total serum bilirubin level exceeds 2.5-3.0
mg/dL (42- 51 μmol/L). Visual determinations of bilirubin levels are inherently problematic.
Several studies confirm the inability of even experienced caregivers to accurately estimate an
infant’s total serum bilirubin level[28] and this visual assessment cannot determine if the
jaundice is due to indirect, or direct hyperbilirubinemia. The most important initial step in
evaluating a jaundiced infant is measuring serum total and direct (or conjugated) bilirubin.
newborns[29, 30], however it should alert the provider of the possibility of cholestasis, although
testing of all jaundiced newborns at the 2-week visit will detect cholestasis in relatively few[4].
Providers have several options: the most direct is to test serum for total and direct bilirubin at
the 2 week visit (or if concerned at any age), but in the absence of any significant ―red Flags‖,
the infants can follow one of several paths. These ―Flags‖ are detailed in Tables 2 and 3.
acholic stool another option is to see the infant back for follow up in 1 week according to local
practice and caregiver/parental comfort with the plan. If this course is taken, and the jaundice
infant is bottle fed then fractionation of bilirubin is recommended. If the infant’s first visit is at 4
weeks of age as is common practice in many European countries, then any jaundiced infant
should be investigated promptly by measurement of total and direct bilirubin. The actual age of
the infant when measurement of a fractionated bilirubin is performed is dependent upon several
factors and not meant to be proscribed—but practically the measurement should coincide with
the clinical status of the infant in the context of accepted local practice. However, the earlier
measurements of fractionated bilirubin are performed, the earlier a diagnosis of cholestasis can
be made or excluded and thus help direct optimal and timely clinical care plans.
The most commonly used laboratory determination, the diazo or van den Bergh method, does not
specifically measure conjugated bilirubin but reports direct bilirubin which includes both
conjugated bilirubin and delta bilirubin (conjugated bilirubin covalently bound to albumin). For
methodological reasons, the higher the total bilirubin (even if nearly all unconjugated bilirubin)
the higher the reported direct bilirubin, hence specific measurements of conjugated bilirubin are
overall clearance, infants with elevated unconjugated bilirubin may retain some conjugated
bilirubin, but this is variable due to the distinct canalicular transporters for conjugated bilirubin
(Abcc2) and bile acids (Abcb11), and their differential expression in the setting of cholestasis
are considered abnormal when values are greater than 1.0 mg/dL (17 μmol/L) regardless of the
total bilirubin[33]. Thus, for this guideline, an abnormal direct/conjugated bilirubin is defined as
a serum value greater than 1.0 mg/dL (17 μmol/L ), since it is physiologically and clinically
complex to consider incorporating consideration of whether or not the direct fraction exceeds
causes of jaundice are physiologic jaundice and breast milk jaundice. Both are self-limited
Infants who are breast-fed are more susceptible to neonatal jaundice since maternal milk contains
beta-glucuronidase that breaks down conjugated bilirubin to form unconjugated bilirubin and
hence increases the enterohepatic circulation of bilirubin[4, 35, 36]. Expressed breast milk also
contains factors which may inhibit the conjugating enzyme in hepatocytes[37]. Please refer to the
Recommendations:
1. Any formula-fed infant noted to be jaundiced after 2 weeks of age should be evaluated for
cholestasis with measurement of total and conjugated (direct) serum bilirubin (1A).
Depending upon local practice, breast-fed babies that appear otherwise well may be
followed clinically until 3 weeks of age, at which time if they appear icteric should then
HISTORY
Obtaining a detailed prenatal and infant history is fundamental and should include details of the
neonatal screening and any medication including vitamin K supplementation. Details of feeding
history should be noted as well as the timing of the first bowel movement, since delayed passage
of meconium can be seen in patients with cystic fibrosis. The history should systematically
collect information about the onset of jaundice, changes in stool pigmentation and urine color. It
is important to identify history of pale or acholic stools and it is highly recommended to observe
the stool pigment (see below). It is well recognized that parents and health care professionals
assess stool pigmentation subjectively and abnormally pale stools are frequently misinterpreted.
Acholic stools were correctly identified only by 63% of health care providers[39]. Stool color
charts may be helpful in review of history and ascertaining lack of pigmentation of stools in
children with suspected liver disease. In Taiwan, use of a stool color card proved to be effective
with 95.2% sensitivity for pale stools[40]. A large prospective cohort study utilizing home based
screening for BA with a stool card proved cost effective in Canada[41]. Use of the stool card has
been piloted in some European countries, such as Switzerland[42] but has not been
systematically implemented across the US or Europe. Many efforts are being investigated to
use of prolonged soy lipid-based parenteral nutrition leads to cholestasis quite commonly—
in the evaluation of the cholestatic infant, and it is often worthwhile for caregivers to note the
nutrition.
Details in the family history including previous and current pregnancy such as miscarriages,
pruritus or overt liver dysfunction in maternal history should be noted; history of maternal fever,
rash, adenopathy or medication intake can be helpful. The family history should not only focus
on known liver conditions but also on hemolysis and /or cardiac and vascular anomalies. A
PHYSICAL EXAM
The clinician performing a physical exam should not only focus on the abdomen but should also
consider extrahepatic signs, such as: dysmorphic features, poor growth, dermatologic, neurologic
or pulmonary symptoms (Table 3). Palpation of the abdomen may reveal firm hepatomegaly
suspicious for the diagnosis of BA, often with a prominent middle or left lobe. Splenomegaly in
BA appears after the newborn period, and if present at a young age of 2-4 weeks should point
towards other diseases such as storage or hematological disorders. Cardiac examination is key as
impaired hepatic venous outflow, hepatomegaly, and cholestasis. Hypoplastic (male) genitalia
may be a feature of panhypopituitarism but normal genitalia does not exclude this condition.
Confirming whether the infant can visually fix and follow is helpful to rule out septo-optic
dysplasia, but often cross-sectional brain imaging is required for this diagnosis[44, 45]. Direct
observation of urine color, and most importantly stool color, is a necessary component of the
assessment of the jaundiced infant, as acholic stools and dark urine often indicates the presence
findings obtained by a careful history or a detailed physical exam that are unique to BA patients.
Recommendations:
considerations. (1A)
DIAGNOSTIC EVALUATION
This section is devoted to the diagnostic approach to the infant with cholestasis. In addition to
laboratory studies, imaging and liver histopathology are important to evaluate for bile duct
patency since cholestatic infants must be evaluated promptly to exclude treatable surgical
conditions. As noted above, performance of the Kasai HPE for BA is much less likely to benefit
evaluation.
LABORATORY EVALUATION
During the evaluation of the infant with cholestasis, laboratory investigations will help define the
etiology, the severity of the liver disease and detect treatable conditions.
A critical and important initial blood test is the measurement of serum conjugated (direct)
bilirubin (DB), which, if elevated, is a reliable laboratory indicator of cholestasis at this age.
Accompanying evaluation of DB levels are standard biochemical and synthetic liver tests to
assess the severity of the liver disease to include total bilirubin (TB), alanine aminotransferase
transpeptidase (GGTP), prothrombin time (PT) with the International Normalized Ratio (INR),
glucose and albumin. An elevated serum AST without substantial increase in ALT, TB or DB
may point to a hematologic or muscular process, since AST is an enzyme present in red blood
cells and myocytes. GGTP value is typically higher in neonates than older children[47] and is
generally elevated during cholestasis[48]. However, some cholestatic diseases present with
normal or low GGTP, including progressive familial intrahepatic cholestasis (PFIC) type 1
(ATP8B1 deficiency) and 2 (ABCB11 deficiency), bile acid synthesis disorders and TJP2
deficiency[49, 50]. Other conditions including ALGS, PFIC3 (due to ABCB4 deficiency) and
often, but not always, BA frequently present with a high GGTP. Serum AP levels are generally
less helpful than serum GGTP in the evaluation of cholestatic infants since the normal range of
serum AP levels varies greatly in growing infants. Bacterial cultures of blood, urine and other
indicate gestational alloimmune liver disease, metabolic disease or sepsis. When evaluating a
patient with cholestasis it is crucial to review the standard local newborn screening since many
diseases that cause cholestasis are tested such as hypothyroidism, galactosemia, tyrosinemia and
cystic fibrosis. Some countries have extended newborn screens that can be performed upon
request.
The minimum evaluation for any health care professional encountering an infant with jaundice
present after the age of 14 days should include a full history including family history and
gestational history of the mother, physical examination, inspection of stool color, and obtaining a
investigations (Table 4, Tier 1) are recommended. A disciplined and stepwise approach to the
infant with confirmed cholestasis in concert with a pediatric gastroenterologist can then follow in
the ordering of laboratory tests appropriate in each situation, and enabling a targeted work-up
(Table 4, Tier 2). Some local variation is unavoidable due to available expertise (Table 4). ―Red
flags‖ which mandate evaluation for BA include acholic stools, high GGT cholestasis without
alternative etiology and abnormal or absence of gallbladder on ultrasound. Conditions that mimic
BA such as alpha-1-antitrypsin, CF, ALGS and others, should be excluded early on in the
evaluation process.
DIAGNOSTIC IMAGING
investigation to assess for visible obstructing lesions of the biliary tree or identification of
abnormalities[51]. Several hepatic sonographic parameters such as the triangular cord sign,
abnormal gall bladder morphology, lack of gall bladder contraction after oral feeding, non-
visualization of the common bile duct, hepatic artery diameter and hepatic artery diameter to
portal vein diameter ratio, subcapsular blood flow, have been suggested to aid in the diagnosis of
BA[52-56], although none can singularly confirm a diagnosis of BA. It is useful, however, to
know that many, but not all, infants with BA have a small or undetectable gall bladder[57]. In
addition, findings such as abdominal heterotaxy, midline liver, polysplenia, asplenia and pre-
duodenal portal vein increase the concern for BA with malformations. However, it is imperative
Hepatobiliary scintigraphy (HBS) has been used to confirm biliary tract patency, but can be
limited by its low specificity (range 68.5% - 72.2%), and a non-diagnostic result when bile flow
is limited due to a wide variety of etiologies[58]. Patients with interlobular bile duct paucity,
idiopathic neonatal hepatitis, low birth weight and those on parenteral nutrition may have non-
excreting scans[59] This limited accuracy of HBS in differentiating idiopathic neonatal hepatitis
HBS, HBS single photon emission computed tomography (HBS SPECT) and liver biopsy were
compared. The goal of this study of 69 infants with cholestatic jaundice and a final diagnosis of
idiopathic neonatal hepatitis and BA was to determine which modality may help distinguish
between these two diagnoses. All 69 infants underwent MRCP, US, HBS, SPECT and liver
biopsy. HBS had sensitivity and a specificity of 88.24% and 45.71% for detecting BA,
cholestatic infant, but may be of value in determining patency of the biliary tract, thereby
excluding BA. In this study, liver biopsy had the highest sensitivity in detecting BA at 100%, a
A recent meta-analysis addressing the utility of HBS yielded a pooled sensitivity of 98.7%
(range 98-1-99-2%) and a specificity of 70.4%( range 68.5-72.2%) of a non-draining HBS for
excluding BA. This shows that false negative results (excretion of the tracer into the bowel
despite BA) are extremely rare[58]. Limited reports describe infants with apparently initially
excreting HBS and a subsequent diagnosis of BA, although the technical limitations of the study
Many clinicians and radiologists administer phenobarbital for 5-days prior to the study, in an
attempt to enhance biliary excretion of the isotope and increase its discriminatory value[61],
Despite the use of the diagnostic tests described above, it is still not easy to discriminate between
BA and other causes of neonatal cholestasis. As detection of patency of the extrahepatic biliary
tree is the primary goal of diagnostic evaluations in infants with cholestasis, the role of
studied by various groups[64, 65]. While ERCP has proved effective with high positive and
predictive value 88% - 96%, negative predictive value 100%)[64, 66], ERCP requires an
experienced endoscopist, specific infant endoscopy equipment not readily available at many
centers, and a general anesthetic. The superiority of ERCP compared with other types of
well-established non-invasive modality for visualizing the biliary system, including the first
order branches of the intrahepatic bile ducts, extrahepatic bile ducts and gallbladder[68]. The
diagnostic value of three-dimensional MRCP for BA in a large cohort of cholestatic infants and
neonates was therefore recently evaluated, with a reported specificity of 36% and sensitivity of
99%[69].
Recent case series have documented the technique and feasibility of percutaneous transhepatic
PTCC was performed in combination with simultaneous liver biopsy. While this was reported to
effectively exclude BA with a lower negative laparotomy rate, there is a genuine concern that
PTCC may be utilized unnecessarily in infants in whom a liver biopsy alone would have
excluded biliary obstruction. Moreover, a PTCC may not be able to demonstrate retrograde
patency of the biliary tree into the liver and may miss proximal obstruction, thus obviating a
surgical cholangiogram in a patient who may have BA. Importantly, the specificity of liver
biopsy in diagnosing biliary obstruction in this case series was much lower than frequently
HISTOPATHOLOGY
Liver biopsy often remains the cornerstone of the diagnostic work up of infants with cholestatic
90% to 95% of cases and avoid unnecessary surgery in patients with intrahepatic
reporting of liver biopsies from infants with cholestasis. Overall, the pathologists diagnosis of
obstruction in clinically proven cases of BA ranged from 79% to 98%, with a positive predictive
value of 90.7%. The group diagnosed BA with a high level of sensitivity and identified infants
liver disease and all three cases of alpha 1 antitrypsin deficiency. Conversely, a majority of the
intrahepatic cholestasis and one case of bile acid synthetic disorder. In cases of idiopathic
neonatal hepatitis, the percentage of cases read by each pathologist as no obstruction ranged
from 57% – 93%. The classic histologic features of biliary obstruction are bile duct proliferation,
bile plugs, portal or perilobular fibrosis and edema, with preservation of the basic hepatic lobular
architecture (Figure 1). In neonatal hepatitis, lobular disarray and inflammatory cells are seen
within the portal areas, and the bile ductules show little or no alteration (Figure 2). Giant cell
prominent as that seen in neonatal hepatitis[73]. Some disorders that can mimic BA
histologically are parenteral nutrition associated cholestasis, cystic fibrosis and alpha-1-
antitrypsin deficiency. They may show variable ductular reaction and may be impossible to
distinguish from BA without clinical data[72,73]. It is however important to recognize that the
earliest histologic changes of BA may be relatively non-specific, and biopsies performed too
early in the course of the disease may result in a falsely negative diagnosis[72,73,76].
The proper utilization of liver biopsy therefore remains a central component of the diagnostic
evaluation of infants with cholestatic jaundice as the differential diagnosis is perhaps the
broadest of any age group and encompasses obstructive as well as, more commonly, non-
obstructive disorders. In addition to its role in diagnosis, the liver biopsy may also reveal
histological features of significant prognostic value, such as the degree of fibrosis, which may
help predict outcome following HPE and the decision to proceed with HPE[77,78]. Although
procedure in children with a low complication rate of 1.7%[79], the overall complication rate in
infants, even in the hands of an experienced physician, was reported in one small series to be
Recommendations:
8. Limited specificity of MRCP, ERCP, PTCC has a limited role in the general guidance to
duct proliferation, bile plugs and fibrosis in an appropriately timed liver biopsy is the most
supportive test in the evaluation of the infant with protracted conjugated hyperbilirubinemia
(1B). Diseases other than BA that cause cholestasis can be determined via histologic
INTRAOPERATIVE CHOLANGIOGRAM
The intraoperative cholangiogram and histological examination of the duct remnant is considered
the gold standard to diagnose biliary atresia.[51,81,82]. Interestingly, in up to 20% of cases, even
ALGS and cystic fibrosis (CF) being confounding diagnostic conditions[83]. Hence,
preoperative testing for CF and ALGS is very helpful in assisting in the interpretation of the
indications suggest direct referral to the surgeon for the procedure. If BA is confirmed (i.e. non-
immediately, unless there are considerations made by the team that it would be in the best
interest of the infant to proceed to transplant evaluation and not undergo the HPE. No effective
team to the specialists to determine whether the patient would be better served without the HPE.
It is important to note that diagnostic evaluation to rule out BA should be expedited especially
when the infant is above 6 weeks of age. The younger the age at diagnosis of BA, the more
likely that the HPE will be successful (at least in the short term, see above).
Recommendation:
Structural abnormalities:
Choledochal Cyst: Patients with choledochal cysts present with laboratory findings suggestive
of cholestasis. Sometimes patients have cholangitis and present with fever, elevation of the
choledochal cyst and BA as the bile ducts are typically dilated or cystic and the gallbladder is not
prompt careful evaluation for BA (atresia of the distal common bile duct accompanied by cystic
dilation: type 1 BA). In a few studies, cyst size appeared to decrease between prenatal diagnosis
and birth in patients with BA but did not change in patients with choledochal cyst[85,86].
clinical findings, laboratory and diagnostic evaluation, and confirmed by sequencing of JAG1
and NOTCH2 genes, with mutations found in 95% and 5% of patients with ALGS,
respectively[87]. Clinical criteria for the diagnosis of ALGS includes ductopenia on liver biopsy
as well as a characteristic Alagille facies (broad forehead, small pointy chin, but is often difficult
to recognize in the neonatal period), posterior embryotoxon, butterfly vertebrae, renal disease
stenosis)[88] or tetralogy of Fallot. Direct hyperbilirubinemia and occasional acholic stool that
may improve with age can be present[88]. Serum ALT and bile acids are usually elevated. The
GGTP is an important test in orienting the practitioner towards this disorder since it is often
encouraged to evaluate for associated clinical abnormalities found in patients with ALGS when
the diagnosis is suspected either on liver biopsy or by characteristic facies, prior to proceeding
with IOC.
Cystic Fibrosis (CF): Some CF infants present with abnormal liver tests suggestive of biliary
obstruction due to the presence of abnormal bile with plugging of the common bile duct[89].
Checking the newborn screen for immunoreactive trypsinogen is helpful. The gold standard
remains sequencing of the CFTR gene or a positive sweat chloride test, but this is sometimes not
hepatobiliary transport results in progressive cholestasis and liver injury (Table 1). Patients with
PFIC1-3 have a significant elevation of the total serum bile acids. A very important clinical
finding in individuals with PFIC type 1 and 2 (due to ATP8B1 and ABCB11 gene deficiencies,
respectively) is the presence of a normal or low GGTP out of proportion to the degree of
cholestasis[91], associated with normal or low serum cholesterol. Some of the patients with
normal GGTP PFIC were found to have a mutation in the tight junction protein 2 gene (TJP2)
which causes failure of protein localization and disruption of tight-junction structure, leading to
severe cholestatic liver disease that can present very early in life[49]. Patients with PFIC type 3
neonatal cholestasis. Approximately 10-15% of neonates with this condition will present
with cholestasis and a combined picture of hepatocellular injury and obstruction with elevation
of the ALT, AST, GGTP and alkaline phosphatase. The cholestasis is usually severe and the
presence of acholic stools may present a challenge because of the resemblance to BA. Although
some patients may develop cirrhosis early on, jaundice clears in most patients by 4 months of
age[94]. The diagnosis is made based on the phenotype (normal: MM; abnormal: ZZ or SZ;
heterozygous: MZ, MS)[95]. It is important to note that neonates with ZZ phenotype may have
no biliary excretion on scintigraphic studies[96] and liver biopsy may appear obstructive[72].
Hence obtaining the phenotype early in the evaluation of cholestasis could avoid unnecessary
biopsy in this condition. Checking for serum levels of alpha-1-antitrypsin could be helpful if
compound heterozygotes, both of whom may develop liver disease. Patients with MZ, MS, SZ or
homozygous SS A1 phenotypes do not present with neonatal cholestasis unless associated with
another cause[97]. Serum alpha-1-antitrypsin concentrations alone are an insufficient test since
note there have been few case reports of the concurrence of alpha-1-antitrypsin deficiency and
BA[100,101].
Bile Acid Synthesis Disorders (BASD): More than 14 enzymes are involved in the synthesis of
bile acids from cholesterol precursor molecules. BASDs are rare, but in many cases, are
treatable forms of cholestasis. Not all of the infants with the genetic abnormalities leading to
BASD present with cholestasis and jaundice; some may have a more indolent presentation later
during childhood. These conditions often present with normal or low GGTP. Total serum bile
acids are usually low, in contrast to other cholestatic disorders. Fast atom bombardment mass
acid; it is possible to perform rapid diagnosis of potential inborn errors in bile acid synthesis
from urinary bile acid analysis. Molecular techniques then identify the specific mutations in
genes encoding the enzymes responsible for bile acid synthesis[102-104]. Treatment with the
end-products of bile acid synthesis, cholic acid and chenodeoxycholic acid, is often curative for
IEM can present with cholestasis, and as in the other cholestatic disorders, the practitioner has to
picture is compatible with an IEM includes: blood gases, electrolytes, glucose, ammonia, uric
acid, lactic acid, pyruvic acid (L:P ratio), ketone bodies; and in urine, ketone bodies, 2-keto
galactosemia and tyrosinemia are performed in some countries to identify infants before they are
symptomatic. Infants with tyrosinemia can present with mild cholestasis, although more typically
in this treatable but life-threatening condition. With the incorporation of gene panels and exome
sequencing, these disorders may have more precise and timely means of genetic investigations in
Infections:
Cytomegalovirus (CMV): CMV the most common congenital infection, affects 1-2% of
newborns. Most infected newborns are asymptomatic; unfortunately 5-10% of the patients have a
myriad of clinical symptoms that include low birth weight, microcephaly, periventricular
are the most prominent liver-related problems[110,111]. The diagnosis of congenital CMV is
confirmed by culture or PCR from the nasopharynx, saliva, blood or urine soon after birth. Urine
CMV culture or CMV-DNA detection by PCR is presently used for the diagnosis[112,113]. The
IgM CMV-specific antibodies can be monitored but are of limited value, and may be less
multiple investigators, but a role for CMV in the etiology of BA remains unproven[114-116].
Viral hepatitis A, B and C: In general these viruses do not cause neonatal cholestasis. Single
case reports document special circumstances where these infections present with neonatal
cholestasis. Specific studies for these infectious agents in the evaluation of neonatal cholestasis
Other infections: Syphilis, Rubella, Toxoplasmosis and Herpes-virus can present with neonatal
cholestasis, coagulopathy and growth restriction. Obtaining a good maternal history and
discussing with the obstetrician and neonatal intensive care team about placental abnormalities
can help with directing the work up for an infection. Typically infants with these infections
present with jaundice within first 24 hours of life. Congenital syphilis incidence is rising in the
US[117]. Urinary tract infections present with cholestasis in the neonatal period and a urine
Endocrine Disorders:
Thyroid disorders: Few reports in the pediatric literature describe cholestatic liver disease in
infants born to mothers with Graves’ disease[119] The newborn screen is designed to detect high
levels of TSH hence in cases of central hypothyroidism this can be missed and repeating a blood
Panhypopituitarism: The pituitary hormones are involved in the regulation of bile synthesis and
excretion and bile flow. The neonates with this condition present with elevation of the total and
direct bilirubin; they may have hypoglycemia and even shock from adrenal insufficiency. Some
or track. Diagnostic evaluation includes: TSH, total and free T4, early morning cortisol level and
a brain MRI. In these patients a nonfasting ultrasound should be requested as prolonged fasting
can lead to devastating complications related to severe hypoglycemia The cholestasis resolves
The neonatal cholestasis ―black box‖ of unidentified etiologies continues to shrink, but is still a
substantial group of disorders. The identifiable causes of neonatal cholestasis have grown more
numerous largely due to application of modern techniques of clinical genetics. Reducing costs
and easy access to genetic testing, including exome and genome sequencing, and targeted gene
panels, have facilitated diagnosis. Among the most studied causes of neonatal cholestasis in
recent years are metabolic diseases and disorders of bile transport and bile acid synthesis.
dependent on clinical context. Advanced sequencing methods promise to further increase the
diagnostic yield of genetic approaches. Table 1 summarizes known genetic findings presenting
as neonatal cholestasis.
Conclusion
Cholestatic jaundice in an infant is a typical presenting feature of neonatal liver disease and is
hyperbilirubinemia. Identification of infants with cholestasis remains crucial and is in the domain
bilirubin. Hence a careful history, thorough physical exam and fractionation of serum bilirubin
are recommended in any infant with jaundice seen after 2 weeks of life. The relative rarity of
cholestatic jaundice in contrast to unconjugated hyperbilirubinemia in this age range dictates that
many jaundiced infants will be tested to detect those with elevated direct bilirubin levels.
However, investigation for neonatal cholestasis in these settings is highly beneficial, despite its
rarity, because of the gravity of the consequences of missing BA and monogenic diagnoses that
have specific, and often life-saving, interventions. This guideline has been developed to assist in
this process and is not intended as a substitute for clinical judgment or as a protocol for the care
of all infants with cholestasis. Vigilance is crucial in detecting these infants and referring them to
a pediatric gastroenterologist or hepatologist who can provide the essential diagnostic and
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Extrahepatic bile
duct
abnormalities
Biliary atresia LB diagnostic of Situs or
(BA) obstruction with vascular
bile duct anomalies in
proliferation and 5-10%;
bile duct plugs. possible
absence of
Acholic stools gallbladder
Choledochal cyst Abdominal mass Cyst seen by
plus features US
that overlap with
BA (see below)
Choledocholithias Acholic stools US and IOC ABCB4 Multidrug [139]
is diagnostic resistance P-
glycoprotein,
MDR3
Congenital Ascites without Echogenic
perforation of the liver disease ascites
common bile duct
Neonatal GGTP often IOC shows
sclerosing >800 IU/L; LB pruning of
cholangitis shows small small bile
duct destruction ducts
Hepatocellular
diseases
Alpha-1- GGTP often SERPINA1 Anti-protease [144-147]
antitrypsin very high, α-1-
deficiency antitrypsin level
low (neonate
may have false
low), Pi type ZZ
or SZ
Bile acid synthesis GGTP normal, CYP7B1 Oxysterol 7α- [148]
defects FABMS of hydroxylase [103,
urinary bile AKR1D1 Δ4-3-oxosteroid-5β- 104]
acids, may (SRD5B1) reductase deficiency
present with 3β-hydroxy-Δ5-
cirrhosis, fat HSD3B7 C27-
soluble vitamin steroid
deficiencies dehydrogenase
deficiency
Bile acid FABMS of BAAT Absence of [149,
conjugation urinary bile BAL conjugation 150]
defects acids
PFIC1 GGTP low or ATP8B1 FIC1 translocates [140]
normal; diarrhea phospholipids from
Lipid metabolism
When multiple mutations have been identified, the original paper is referenced. This list is not
exhaustive; rather it is an overview of the most characterized genetic diseases and congenital
conditions which may present as neonatal cholestasis. † In clinical practice, protein phenotyping
by electrophoresis is used instead of gene sequencing. US: Ultrasound, IOC: intraoperative
cholangiogram, LB: liver biopsy, GGTP: gamma-glutamyl transferase, MRI: magnetic resonance
imaging, CT: computed tomography, FABMS: fast atom bombardment mass spectroscopy, FTT:
failure to thrive; EM: electron microscopy. NAFLD: non-alcoholic fatty liver disease
Prenatal History
Infant History
Cardiac exam: murmur, signs of heart failure Congenital heart disease: Alagille syndrome,
biliary atresia splenic malformation syndrome
Tier 1: Aim to evaluate after cholestasis has been established in order to both identify treatable disorder
as well as to define the severity of the liver involvement.
• Blood – CBC + differential, INR, AST, ALT, AP, GGTP, TB, DB (or conjugated bilirubin),
albumin and glucose. Check alpha-1-antitryspin phenotype (Pi typing) and level, TSH, T4 if
newborn screen results not readily available.
• Urine – urinalysis, culture, reducing substances (rule out galactosemia)
• Consider bacterial cultures of blood, urine and other fluids especially if infant is clinically ill.
• Verify results of treatable disorders (such as galactosemia and hypothyroidism) from newborn
screen.
• Obtain fasting ultrasound
with BA, highlighting peribiliary fibrosis, ductular proliferation, bile duct plugs. B.) High power
view of A. emphasizing bile duct plugs and damaged cholangioles. C.) Liver biopsy from a 6
week old infant with BA, highlighting peribiliary fibrosis, disordered cholangiocyte profiles and