Журнал «Здоровье ребенка» 7 (50) 2013

Nowadays the problem of prolonged course of conjugational jaundice doesn’t loose its actuality because of its significant prevalence among neonates, the absence of the effective methods of its treatment, and because of the possibility of the complications development as the result of the long persistence of bilirubin in children’s organism.

Jaundice is considered to be prolonged when it is observed at a mature child being at the 14^th day of life and after the 21^st day at an aborted one which demands a thorough examination of a child. According to the literature data the prolonged conjugational jaundice (PCJ) is observed at 15-40% of children at early age, being on breast feeding. In accordance with contemporary notions the key moments in PCJ pathogenesis are considered to be the violations of indirect bilirubin and excretion of conjugational bilirubin processes. A certain role in the PCJ pathogenesis also performs to the deceleration of intestine peristalsis, irregular defecation and the violation of the intestinal microbiota normal formation of intestine, that leads to the increasing reabsorption of inderct bilirubin from intestine into the portal system.

Material and methods of investigation. There are 73 children with PCJ from 15 days till 3 months who were under the observation. 15 practically healthy children have completed the control group.

The complex of investigations included the analyses of the anamnesis data, the clinical inspection which embodied general analyses of blood, blood biochemical indicators (level of the general bilirubin in blood and its fractions, the activity of АlАТ and АsАт, alkaline phosphatase), the ultrasound investigation of neonates. To define the agile function of gall bladder the ultrasound dynamic cholecystitographics with cholekinetic breakfast (the extract from field artichoke) was conducted. The data of the investigations were processed with the methods of mathematical statistics, parametrical methods (Student’s criteria) were used. The critical meaning of the level significance had been taken equal to 5%. The analyses of the data was carried out with the help of the Excel XP programme.

Investigation results and their discussion. 69 infants were born full-termed, 4 ones were born prematurely (in gestation term 32-35w) and one child had the retardation of intrauterine development. The vast majority of infants with prolonged jaundice (95.9%) were breastfed, 2 children were on a mixed feeding and one child had an artificial.

The main complaint of all parents were jaundice of the skin and sclera that appeared in the early neonatal period. The general condition of the majority of children (67.12%) was assessed as average severity at admission. As more children (64.39%) had signs of hypoxic damage to the central nervous system. The clinical signs of functional disorders of the gastrointestinal tract (vomiting, bloating, loose stools, constipation or increased frequency of defecation) were significantly met more likely in children with PCJ than infants in the control group (in 31 (42.47%) children; p<0.001). The deficient (lower) weight due to mother`s hypogalactia and/or child`s sluggish sucking had been diagnosed at almost every fourth child (26,03%) during the initial examination. Moreover, the level of total bilirubin in the group of children with ineffective breastfeeding was significantly higher than in infants with adequate feeding (p<0.01) owing to increasing the enterohepatitis circulation of bilirubin due to slowing intestinal motility in insufficient flow of breast milk.

Blood biochemical investigation has revealed that almost every third child with the prolonged course of conjugational jaundice (39,73%) has the increased level of serum transaminases and direct bilirubin. The increase of the level of the total serum bilirubin (TSB) occurred because of its indirect fraction; the average meaning of this index is (234,86+13,2) mcmol/l. The level of direct bilirubin at neonates (94,5%) didn’t exceed 15% from the level of TSB and comprised (19,17+1,56) mcmol/l. The increased activity of АlАТ was marked at every fifth child (21,92%) with PCJ, the activity of АsАT was 51,05 U/l (the norm is 5-40 U/l by S. Sherlock and J. Duly). The increase of the activity of aminotranspheres occurs owing to structure violence of the liver cells, mainly hepatocytes, that is (at children with PCJ), perhaps, due to the toxic action of bilirubin on the neonates’ hepatocytes or pathology factors of perinatal period influence.

The results of the USI of hepatobiliary system witnessed that a greater majority of the neonates (53,43%) with prolonged course of conjugational jaundice had deviations, and that, to our point of view, reflects the increase of the loading on liver because of the hyperbilirubinemia and prolonged bilirubin persistence in a child’s organism. 

The results of the USI of hepatobiliary system are represented in table 1.

Table 1

The results of the USI of hepatobiliary system at the examined children

The table shows that increase in anteroposterior size of the liver diagnosed in 11 (15,07%) children with prolonged conjugational jaundice. Comparative analysis found no difference between the TSB in children with enlarged and normal size of the liver. Hyperehogenicity of liver parenchyma was found in 16 (21.92%) infants. TSB level and activity of ALT didn't significantly differ  in infants with high and normal liver parenchyma echogenicity.

The dynamic USI of gall bladder (GB) with the use of choleretic breakfast revealed certain differences at healthy children and neonates with PCJ.

The results of the USI are represented in table 2.

Table 2

The results of the USI of the dynamic cholecystotography

Note: p- the criteria of certainty

 As it is seen from the table the volume of gall bladder fasting at children with prolonged conjugational jaundice was nearly twice lesser than at healthy ones and was (0,94+0,05) sm³ and (1,7+0,14) sm³ respectively which witnesses about the GB being in partially reduced condition. The investigations of the reduced GB after the taking of cholekinetic breakfast revealed the decrease of the indexes of duration and intense of its reduction at children with jaundice in comparison with healthy ones. So, healthy children had the reduction for half an hour (during 30 minutes) (in average (62,3+3,5%)), and neonates with prolonged with prolonged jaundice – during 10-20 minutes (in average (38,6+4,8%)). The restoring of the initial size of GB for 40 minutes was marked at a greater majority (86,67%) of healthy children and only at one third (35%) of the neonates with PCJ. In addition, 15% of children with PCJ recorded an increase in volume of gall bladder in 1,4-2 times compared to the original data. The reduction of GB for less than 40% for 10-20 minutes of investigation, according to literature data, points on the hypomotorical dysfunction of gall bladder and spasms of bile ducts.

Conclusions. The dysfunctions, revealed by biochemical investigations at nearly one third of children with PCJ (39,73%), and during the ultrasound investigation of liver at the majority (53,43%) indicates the involvement of the liver in the process of pathology and the increased loading on hepatobiliary system. The results of the dynamic ultrasound investigation of gall bladder indicate on the violation of the PCJ children’s motor function of bile ducts,  that confirms the dysfunctional role at the pathogenesis of this pathology and justifies the prescription of the medicines with cholekinetic action.