Spivak W, Sarkar S, Winter D, Glassman M, Donlon E, Tucker K J
J Pediatr. 1987 Jun;110(6):855-61. doi: 10.1016/s0022-3476(87)80396-7.
We retrospectively evaluated the utility of hepatobiliary scintigraphy and various clinical factors in differentiating intrahepatic cholestasis from biliary atresia in 28 consecutive infants with neonatal cholestasis. One millicurie of technetium-labeled diisopropyliminodiacetic acid (DISIDA) was administered intravenously, and images were obtained for up to 24 hours or until gastrointestinal excretion was noted. Nine separate studies in seven infants with biliary atresia were correctly interpreted as showing no gastrointestinal excretion of radionuclide. Of the 21 patients with intrahepatic cholestasis, only nine had gastrointestinal excretion on the first study; in eight without excretion, a second study was done, and five of these showed gut excretion. All infants with either neonatal hepatitis (six) or inspissated bile syndrome (three) had demonstrable gastrointestinal excretion either on the first or second DISIDA study. However, five of six infants with paucity of intrahepatic bile ducts, two of six infants with cholestasis secondary to total parenteral nutrition, and one infant with cholangiolitis did not show evidence of gastrointestinal excretion. The mean birth weight, mean gestational age, and mean weight at study were significantly greater (P less than 0.005) for infants with biliary atresia without excretion than for infants with intrahepatic cholestasis without excretion. The mean direct bilirubin concentration was 6.0 mg/dL for both infants with biliary atresia and infants with intrahepatic cholestasis without excretion; however, infants with excretion had a significantly lower (P less than 0.02) mean direct bilirubin value of 3.4 mg/dL. Excretion was noted in four infants with total bilirubin values greater than 10.0 mg/dL. The absence of gut excretion on the first DISIDA study was 100% sensitive but only 43% specific for biliary atresia. In infants without gut excretion of DISIDA, birth weight greater than 2200 g was 100% sensitive and 92% specific for biliary atresia. We conclude that DISIDA scanning, together with clinical data, is useful in differentiating extrahepatic from intrahepatic cholestasis. The absence of gut excretion on the first DISIDA study does not necessarily indicate extrahepatic obstruction; the study should be repeated if the diagnosis is not clear.
我们回顾性评估了肝胆闪烁显像及各种临床因素在28例连续性新生儿胆汁淤积症婴儿中鉴别肝内胆汁淤积和胆道闭锁的效用。静脉注射1毫居里锝标记的二异丙基亚氨基二乙酸（DISIDA），并获取长达24小时的图像或直至观察到胃肠道排泄。7例胆道闭锁婴儿的9项独立研究被正确解读为显示放射性核素无胃肠道排泄。在21例肝内胆汁淤积患者中，仅9例在首次研究时有胃肠道排泄；8例无排泄的患者进行了第二次研究，其中5例显示肠道排泄。所有新生儿肝炎（6例）或浓缩胆汁综合征（3例）婴儿在首次或第二次DISIDA研究中均有明显的胃肠道排泄。然而，6例肝内胆管稀少婴儿中的5例、6例全胃肠外营养继发胆汁淤积婴儿中的2例以及1例胆管炎婴儿未显示胃肠道排泄的证据。无排泄的胆道闭锁婴儿的平均出生体重、平均胎龄和研究时的平均体重显著高于（P<0.005）无排泄的肝内胆汁淤积婴儿。无排泄的胆道闭锁婴儿和肝内胆汁淤积婴儿的平均直接胆红素浓度均为6.0mg/dL；然而，有排泄的婴儿平均直接胆红素值显著较低（P<0.02），为3.4mg/dL。4例总胆红素值大于10.0mg/dL的婴儿有排泄。首次DISIDA研究中无肠道排泄对胆道闭锁的敏感性为100%，但特异性仅为43%。在无DISIDA肠道排泄的婴儿中，出生体重>2200g对胆道闭锁的敏感性为100%，特异性为92%。我们得出结论，DISIDA扫描结合临床数据有助于鉴别肝外胆汁淤积和肝内胆汁淤积。首次DISIDA研究中无肠道排泄不一定表明存在肝外梗阻；如果诊断不明确，应重复该研究。
