Michiko Nakagawa

Familial intrahepatic cholestasis associated with progressive neuromuscular disease and vitamin E deficiency.

Three Japanese patients with familial progressive intrahepatic cholestasis developed complications involving neurologic abnormalities characterized by ataxia and pigmentary retinopathy. Serum vitamin E concentrations were extremely low in all patients, suggesting a long-term vitamin E deficiency. High dose oral supplementation of alpha-tocopherol produced normal serum vitamin E levels in two patients. Parenteral administration of vitamin E resulted in no clinical improvement in one patient who first received the treatment at 14 years of age. In the other two patients, the progression of neurological abnormalities was slowed by vitamin E supplementation. Cholestyramine treatment resulted in an apparent decrease in serum vitamin E levels despite oral alpha-tocopherol supplementation.

Significance of serum lipoprotein-X and gammaglutamyltranspeptidase in the diagnosis of biliary atresia. A preliminary study in 27 cholestatic young infants

As simple and nonsurgical means of differentiating biliary atresia (BA) from intrahepatic cholestasis of unknown origin (IC), liver function tests including serum lipoprotein-X (LP-X) and γ-glutamyltranspeptidase (GGTP) were done and evaluated for their usefulness in the diagnosis of 27 cholestatic Japanese young infants. Except for LP-X and GGTP levels (P<0.01, P<0.001), there were no significant differences between the BA (n=11) and IC (n=13) groups. When values of mean plus 4 standard deviations were used to differentiate BA from IC (89 mg/100 ml for LP-X and 194 IU/l for GGTP), all BA patients gave positive results for either the crtical LP-X of GGTP values. On the other hand, all IC patients gave negative results for both levels, although patients with a paucity of intrahepatic biliary ducts (n=3) were also positive for either the critical LP-X or GGTP values. The combination test with serum LP-X and GGTP is recommended for helping to differntiate BA from IC in cholestatic young infants.

Serum bile acid patterns determined by an enzymatic method and high-performance liquid chromatography in young infants with cholestasis.

Serum unconjugated and conjugated bile acids in young infants with intrahepatic cholestasis (idiopathic neonatal hepatitis syndrome, n = 8) or extra-hepatic cholestasis (preoperative extrahepatic biliary atresia, n = 8) were examined by an enzymatic procedure and high-performance liquid chromatography. In comparison with the mean level of total serum bile acid of controls having no liver or gastrointestinal diseases, those of each group markedly increased (15.6 +/- 5.1 vs. 120.9 +/- 64.0 and 161.8 +/- 54.2 nmol/ml), but those of unconjugated bile acid were almost unchanged (1.4 +/- 0.5 vs. 1.0 +/- 0.6 and 0.6 +/- 0.2 nmol/ml). The ratios of cholate to chenodeoxycholate and glycine- to taurine-conjugated bile acids (G/T) were not significantly different between the groups of intrahepatic and extrahepatic cholestasis. However, in the patients with intrahepatic cholestasis, the G/T ratio varied greatly and the quantitative determination of individual conjugated bile acids in serum revealed that a half of the patients examined had very low levels of taurine-conjugated cholate and chenodeoxycholate, suggesting a bile acid metabolism alternation specific for underlying intrahepatic cholestasis.

Cytoplasmic Inclusion Bodies and Minimal Hepatitis: Fibrinogen Storage without Hypofibrinogenemia

A 12-year-old Japanese boy had chronic elevation and fluctuation of serum transaminase levels since infancy, with no signs or symptoms of liver failure. Usual infections or metabolic disorders were eliminated from consideration. No coagulopathy or abnormality in plasma concentrations of clotting factors was found. Light microscopy of liver biopsy specimens obtained at ages 2, 5, and 7 years showed slight hepatocyte disarray and minimal mononuclear-leukocyte lobular inflammation, with eosinophilic inclusion bodies in the cytoplasm of hepatocytes throughout the lobule. These bodies stained with the periodic acid-Schiff (PAS) technique; the PAS-positive material was partly diastase digestible and on immunostaining marked for fibrinogen but not for α1-antitrypsin. On transmission electron microscopy, the bodies were represented by finely granular material contained within membranes and were interpreted as tentatively endoplasmic reticulum. Fibrinogen storage may be manifest as minimal hepatitis without coagulopathy.

Serum bile acids and their conjugates in breast-fed infants with prolonged jaundice

Serum bile acids and their conjugates were analysed in 20 breast-fed infants with prolonged jaundice. The mean total bile acid levels in serum were increased in the breast-fed infants with jaundice, as compared with those in either breastor bottle-fed infants without jaundice. However, there were no significant differences between the groups. All the breast-fed infants examined, regardless of association with jaundice, had a bile acid pattern dominated by taurine conjugates (the ratio of glycine- to taurine-conjugated bile acid, G/T ratio, less than 1.00). In contrast, the bottle-fed infants without jaundice had a pattern dominated by glycine conjugates (G/T ratio, more than 1.00). Among the breast-fed infants with jaundice, the mean G/T ratio in those who had serum bilirubin levels over 10 mg/100 ml was significantly lower than that in those who had serum bilirubin levels of less than 10 mg/100 ml. The altered bile acid metabolism might be associated with the pathology of breast milk jaundice.

Urinary bile alcohol profiles in healthy and cholestatic children.

BACKGROUND Bile alcohols are normal constituents of urine. METHODS To better understand bile alcohol profile in childhood, urinary specimens from 41 healthy children and 10 children with cholestasis, and 3 healthy adults, were analyzed by GLC and GC-MS. RESULTS Five bile alcohols, 27-nor-5beta-cholestane-3alpha,7alpha,12alpha,24S,25R-pentol, 5beta-cholestane-3alpha,7alpha,12alpha,24S, 25-pentol, 5beta-cholestane-3alpha,7alpha,12alpha,24S,26-pentol, 5beta-cholestane-3alpha,7alpha, 12alpha,25,26-pentol, and 5beta-cholestane-3alpha,7alpha,12alpha,26,27-pentol were identified in all specimens. C(26)-Pentol was the most abundant constituent, constituting 29.5 to 65% of bile alcohols. Among healthy children (n=41), no significant relationship was seen between proportions of the C(26)-pentol and age, but older children (n=15, 6 to 14 years) showed a significantly greater mean percentage of the C(26)-pentol than young children (n=26, 0 to 5 years; 58.1+/-4.23% vs. 46.0+/-9.24%, p<0.001). In children with cholestatic liver diseases, the percentage of C(26)-pentol in urinary bile alcohols was significantly lower than age-matched controls. CONCLUSIONS There is an increased composition of C(26)-pentol in older children and relatively decreased composition of C(26)-pentol in children with cholestatic liver diseases.

Urinary bile alcohol profile in infants with intrahepatic cholestasis: identification of 5β-cholestane-3α,7α,24,25-tetrol

Urinary bile acids and bile alcohols were examined in six infants aged between 1 and 6 mo who had intrahepatic cholestasis. Following extraction, hydrolysis and solvolysis, cholanoids were analysed by gas‐liquid chromatography and gas‐liquid chromatography‐mass spectrometry. The relative ratio of the urinary excretion of bile alcohols to bile acids was very low (0.07‐0.22) in three patients with mild to severe cholestasis, whereas the urinary excretion of bile alcohols was 2–4 times greater than that of the total bile acids in three patients with slight cholestasis. The urinary bile alcohol spectrum in infants appears to be quite different from that in adults. Although the major bile alcohol was 27‐nor‐5β‐cholestane‐3α,7α,12α,24,25‐pentol, comprising more than 50% of total urinary bile alcohols in healthy adults, it accounted for only 35% of total urinary bile alcohols in our patients. In addition, bile alcohols carrying chenodeoxycholic acid type nucleus were detected in our patients by comparison of the retention times and mass spectra with those of authentic standards. The presence of 5β‐cholestane‐3α,7α,24,25‐tetrol confirmed for the first time in this study may represent an alternative pathway for chenodeoxycholic acid biosynthesis via a “25‐hydroxylation pathway” in early life.

Unconjugated, Glycine‐conjugated, Taurine‐conjugated Bile Acid Nonsulfates and Sulfates in Urine of Young Infants with Cholestasis

ABSTRACT. A direct assay system for conjugated bile acids using an enzymatic procedure and high‐performance liquid chromatography was used for the analysis of urinary bile acid profiles in young infants with intrahepatic cholestasis (idiopathic neonatal hepatitis syndrome) or extra‐hepatic biliary atresia. The major urinary bile acids were cholate and chenodeoxycholate conjugates, but a small amount of deoxycholate and 3β‐hydroxy‐5‐cholenate conjugates were detected. Although there was no significant difference in total bile acid excretion between patients with intrahepatic cholestasis and extrahepatic biliary atresia, mean ratios of cholate to chenodeoxycholate and sulfated to total urinary bile acids were different between the two groups examined (5.63±2.83 vs. 2.50±1.25, p <0.05, 15.8±9.9 vs. 34.5±9.9%, p < 0.005). The proportion of taurine‐conjugated chenodeoxycholate in the sulfate fraction to the total bile acid was lower in intrahepatic cholestasis, compared with that in biliary atresia (7.7±7.5 vs. 22.7±7.8 %, p < 0.005). The greater ratio of cholate to chenodeoxycholate and the reduced excretion of sulfated urinary bile acids in intrahepatic cholestasis was due to decreased taurine‐conjugated chenodeoxycholate sulfate excretion.

Alterations of serum bile acid profile in breast-fed infants with prolonged jaundice.

Summary: Serum bile acid conjugates in breast-fed infants with prolonged jaundice were analyzed by a newly developed procedure using high-performance liquid chromatography with fluorescence labeling. Major bile acids were cholate and chenodeoxycholate conjugates. Some of the breast-fed jaundiced infants had high levels of serum bile acid conjugates (>25 μmol/L), but the mean levels of individual bile acid conjugates found in jaundiced breastfed infants were not significantly different from those in breast-fed infants without jaundice. The glycine-to taurine-conjugated bile acid ratio in breast-fed jaundiced infants was significantly lower than in breast-fed nonjaundiced infants or bottle-fed nonjaundiced infants. In breast-fed infants, the portion of taurine-conjugated bile acids increased in proportion to serum bilirubin levels. These findings suggest that alteration in conjugated bile acid patterns of breast milk jaundice is related to an increased enterohepatic circulation of bile acids as well as bilirubin in infants fed on breast milk that contains high amounts of taurine.

Fecal and biliary bile acid patterns in children with bile acid malabsorption.

Bile acid metabolism was examined in two children with bile acid malabsorption, who were being treated with intravenous hyperalimentation. Fecal bile acid excretion was 1,261 mumol/m2/day in a child with bile acid malabsorption of unknown origin, and 1,877 mumol/m2/day in a child with secondary bile acid malabsorption after an operation for long-segment aganglionosis. These values were approximately 10 times higher than those in diarrheal or nondiarrheal children without apparent abnormalities in bile acid metabolism. Fecal bile acids in these patients with bile acid malabsorption were almost completely conjugated, with little unconjugated bile acid present. It is possible that the disturbed bile acid deconjugation in the intestine might be caused by a rapid intestinal transit time, which was found in our patients with bile acid malabsorption. In the analysis of biliary lipid composition, children with bile acid malabsorption were shown to have a chenodeoxycholate-dominant pattern, an increased glycine- to taurine-conjugated bile acid ratio, and markedly supersaturated cholesterol. Such profiles may be related not only to bile acid malabsorption but also to cholestasis, presumably due to intravenous hyperalimentation.