CLINICAL TRIAL
Use of Lactobacillus casei rhamnosus to Prevent Cholangitis in Biliary Atresia After Kasai Operation
Tien-Hau Lien, yLing-Nan Bu, Jia-Feng Wu, Huey-Ling Chen, zAn-Chyi Chen, § Ming-Wei Lai, jjHsiang-Hung Shih, ôI-Hsien Lee, Hong-Yuan Hsu, Yen-Hsuan Ni, and Mei-Hwei Chang
ABSTRACT Objectives: Recurrent cholangitis may aggravate cholestatic liver cirrhosis in biliary atresia (BA) after the Kasai operation. This pilot study aimed to investigate whether Lactobacillus casei rhamnosus has the prophylactic efficacy for recurrent cholangitis in comparison with the conventional neomycin prophylaxis. Methods: Twenty jaundice-free patients with BA ages 0 to 3 years who underwent a Kasai operation were enrolled and randomized into 2 groups with 10 patients each: neomycin (25 mg kg1 day1 for 4 days/wk) and L casei rhamnosus (8 108 colony-forming unit per day) groups. The treatment duration was 6 months. Bacterial stool cultures were performed before treatment and 1, 3, and 6 months after starting treatment. In addition, 10 patients with BA with similar status but without prophylaxis served as the historical control group. Results: In the Lactobacillus group, 2 patients (20%, mean 0.03 0.07 episodes per month) developed cholangitis during the study period, with the same frequency as in the neomycin group and significantly lower than that in the control group (80%, P ¼ 0.005, mean 0.22 0.16 episodes per month). The mean change in body weight z score during the 6 months in the Lactobacillus group was 0.97 0.59, which was significantly better than that in the control group (0.01 0.79, P ¼ 0.006). In bacterial stool cultures, the Lactobacillus and Escherichia coli populations significantly increased and decreased, respectively, in the Lactobacillus group. Conclusions: The use of L casei rhamnosus was as effective as neomycin in preventing cholangitis in patients with BA who underwent Kasai operation, and therefore could be considered as a potential alternative prophylactic regimen.
Received June 13, 2014; accepted December 8, 2014. From the Department of Pediatrics, National Taiwan University Hospital, Taipei, the yDepartment of Pediatrics, Keelung Hospital, Department of Health, Executive Yuan, Keelung, the zDepartment of Pediatrics, China Medical University Hospital, School of Medicine, China Medical University, Taichung, the §Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, the jjDepartment of Pediatrics, Kaohsiung Medical University Hospital, School of Medicine, Kaohsiung Medical University, Kaohsiung, and the ôDepartment of Pediatrics, Chi-Mei Hospital, Tainan, Taiwan. Address correspondence and reprint requests to Mei-Hwei Chang, MD, Department of Pediatrics, National Taiwan University Hospital, No. 7 Chung-Shan S. Rd, Taipei 100, Taiwan (e-mail: [email protected]). This study was supported by the National Center of Excellence for Clinical Trial and Research of the National Taiwan University Hospital (NTUH project no NCTRC200709). www.clinicaltrials.gov registration number: NCT00166868. The authors report no conflicts of interest. Copyright # 2015 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition DOI: 10.1097/MPG.0000000000000676
Key Words: biliary atresia, cholangitis, lactobacillus, prophylaxis registration number: NCT00166868.
(JPGN 2015;60: 654–658)
B
iliary atresia (BA) is a progressive fibrosclerosing cholangiopathy of infancy with a yet unclear etiology. If untreated, it progresses to cirrhosis with portal hypertension and liver failure, leading to death within 2 to 3 years (1). The Kasai operation was first used for BA in 1959, with encouraging results; henceforth, it has become the first-line treatment for BA (2). With the Kasai operation, bile flow can be restored through biliary reconstruction via hepatic portoenterostomy to a jejunal loop. Ascending cholangitis, however, is a frequent and often recurrent complication after surgery (3). Recurrent cholangitis causes secondary failure of the restoration of bile flow and possible exacerbation of portal hypertension, resulting in an increase in the risk of mortality and worsened prognosis (4,5). Patients with multiple episodes of ascending cholangitis are more likely to require liver transplantation than those without multiple recurrences (5,6). Therefore, prevention of cholangitis is important for patients with BA who have undergone Kasai operation. Although the precise mechanism of cholangitis has not been established, ascending bacterial infection originating from the enteric conduit was reported as a possible explanation (3). Previous studies (5,7,8) demonstrated some oral antibiotics such as trimethoprim-sulfamethoxazole and neomycin to be effective as prophylactic agents against ascending cholangitis. A long-term antibiotic use may, however, increase the potential to develop antibiotic resistance and the psychological burden of the patient’s caregiver, suggesting the possibility of decreased compliance to antibiotic treatment. Therefore, other safe prophylactic agents, in addition to antibiotics, for ascending cholangitis are needed. Probiotics are live microorganisms that have been reported to have a suppressive effect on bacterial overgrowth and to prevent infection or inflammation of the gastrointestinal tract (9,10). Lactobacillus casei rhamnosus is a probiotics that is easily available in Taiwan. This also has been used for children with chronic constipation in our previous study (11). Accordingly, the present study aimed to investigate the possibility of using L casei rhamnosus in the prophylaxis of ascending cholangitis in patients with BA.
METHODS Between 2007 and 2011, all of our authors enrolled their patients with BA ages 0 to 3 years who underwent Kasai portoenterostomy in this open-label study. All of the participants had normal stool color and jaundice-free status (total serum bilirubin level 3, Lactobacillus); the second case was then assigned to the Lactobacillus group; the third was assigned to the neomycin group; and the fourth was in the Lactobacillus group in rotation by one-to-one ratio in sequence. Although this is an open-label study, our study staff and parents knew the patients would be in which group only after signing the consent. The treatment duration was 6 months. Bacterial culture of stool samples was performed before initiation of the treatment and at 1, 3, and 6 months after starting the treatment to evaluate the patterns of intestinal flora. We sampled approximately 0.2 to 0.3 g of stool and diluted it to a 10 times lower concentration. Then, we collected the diluted samples for the aerobic bacterial culture with 5% trypticase soy agar sheep blood culture media, anaerobic bacterial culture with anaerobic 6-benzylaminopurine culture media, Escherichia coli culture with the MacConkey agar culture media, and lactobacilli culture with the de Man-Rogosa-Sharpe agar culture media. Thereafter, we observed the changing patterns of the E coli and lactobacilli colony numbers against the total aerobic and anaerobic bacteria, respectively, in the stool samples. Once signs of cholangitis were observed, the patient was admitted for complete evaluation of blood counts, differential counts, C-reactive protein level, alanine aminotransferase (ALT) level, aspartate aminotransferase (AST) level, bilirubin level, urine culture, and blood culture. A diagnosis of cholangitis was made on the basis of unexplained fever (body temperature >388C), acholic stools, increased jaundice, or positive blood culture results. Abdominal sonography was performed to detect ascites, intrahepatic bile duct lake, or liver cirrhosis. Parenteral ceftriaxone administration was the first-line antibiotic treatment, with modifications according to culture results. If a patient with BA developed cholangitis, a 14-day treatment with intravenous antibiotics was completed. After hospital discharge, the patients continued receiving their original prophylactic agent, either neomycin or probiotics. From 1991 to date, no systemic change in post–Kasai operative care has been made, except in the concept of prophylactic
Biliary Atresia and Prophylaxis of Cholangitis antibiotic usage. Since 1997, most of the patients have been prescribed prophylactic antibiotics after operation (5). Therefore, for a historical control group, we randomly selected (by Excel’s RAND function) another 10 jaundice-free patients with BA among a total of 18 cases ages 0 to 3 years who underwent Kasai operation during 1991 to 1996 but did not receive prophylaxis of cholangitis. Ursodiol (ursodeoxycholic acid) is a naturally occurring bile acid found in normal human bile. All of our cases in treatment and control groups were prescribed with oral ursodiol. In addition, we suggested the semielemental formula with adequate calories intake for patients and educated parents for adding solid food when patients grew up. The dietary policy is the same in the 3 groups. After the 6-month study period, comparisons of the frequency of cholangitis, cholangitis-free survival time for primary outcome, and body weight (z score) for secondary outcome were performed between the 3 groups. Summary statistics of the demographic variables were presented using frequency, mean, and standard deviations. Comparisons of these variables were performed using the Student t test. The KaplanMeier method and log-rank test were also used to assess the different treatment groups affecting cholangitis-free survival time. A P < 0.05 was considered statistically significant.
RESULTS Comparisons Between Neomycin and Lactobacillus Groups All the subjects had no significant difference in background and were randomized into 2 groups at enrollment (Table 1). No significant difference in sex distribution was observed between the 2 groups (P ¼ 0.40). The mean ages at Kasai operation were 40.8 13.75 days in the neomycin group and 52.2 19.94 days in the Lactobacillus group (P ¼ 0.16). The mean ages at the time enrolled were 0.88 0.75 years in the neomycin group and 1 0.74 years in the Lactobacillus group (P ¼ 0.74). The AST and ALT levels at enrollment were, respectively, 112 52 and 117 74 IU/L in the neomycin group, and 99 59 and 99 72 IU/L in the Lactobacillus group (P ¼ 0.62 and P ¼ 0.59, respectively). The total and direct bilirubin levels at enrollment were 1.05 0.53 and 0.58 0.42 mg/dL in the neomycin group, and 0.91 0.60 and 0.55 0.45 in the Lactobacillus group (P ¼ 0.59 and P ¼ 0.88, respectively). The mean body weight z scores at enrollment were 0.71 1.71 and 0.19 1.35 in the neomycin and Lactobacillus
TABLE 1. Comparison of the general characteristics and treatment outcomes between the neomycin and Lactobacillus groups
Basic characteristics at enrollment Male/female Age at Kasai operation, mean SD, days Age at the time of enrollment, mean SD, y Serum level, mean SD AST, IU/L ALT, IU/L T-Bil, mg/dL D-Bil, mg/dL Body weight z score, mean SD Outcome after 6 mo Body weight z score, mean SD Change in body weight z score during the study period, mean SD Cholangitis during 6 mo, no. patients, % Frequency of cholangitis, mean SD (episodes per mo)
Neomycin (n ¼ 10)
Lactobacillus (n ¼ 10)
P
4/6 40.80 13.75 0.88 0.75
6/4 52.20 19.94 1.00 0.74
0.40 0.16 0.74
112 52 117 74 1.05 0.53 0.58 0.42 0.71 1.71
99 59 99 72 0.91 0.60 0.55 0.45 0.19 1.35
0.62 0.59 0.59 0.88 0.46
0.19 1.57 0.90 0.95 2 (20) 0.03 0.07
0.78 1.44 0.97 0.59 2 (20) 0.03 0.07
0.39 0.85 1 1
ALT ¼ alanine aminotransferase; AST ¼ aspartate aminotransferase; D-Bil ¼ direct bilirubin; SD ¼ standard deviation; T-Bil ¼ total bilirubin.
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Chang et al
JPGN
Volume 60, Number 5, May 2015
groups, respectively (P ¼ 0.46). All of the aforementioned data at enrollment were not significantly different between the 2 groups. After the 6-month treatment with the prophylactic protocol, the mean body weight z scores were 0.19 1.57 and 0.78 1.44 in the neomycin and Lactobacillus groups, respectively (P ¼ 0.39). The mean changes in the body weight z scores were 0.90 0.95 and 0.97 0.59 in the neomycin and Lactobacillus groups, respectively (P ¼ 0.85). Cholangitis occurred in 2 patients each in the neomycin and Lactobacillus groups (P ¼ 1). Each of the 4 patients only had 1 episode of cholangitis during the 6-month study period. The mean frequency of cholangitis (episodes per month) was consequently the same in the neomycin and Lactobacillus groups. Most important is that no adverse reaction was recorded during the 6-month study period in both groups.
49.3% 11.2%, which also significantly decreased to 32.8% 5.6% after treatment completion. The ratio of E coli to the total aerobes was not significantly different between the 2 groups after 6 months of treatment (P ¼ 0.17), implying that the strategy of substituting bad bacteria in the gut with probiotics may have worked and that the efficacy of decreasing the proportion of E coli is as good as the use of antibiotics (neomycin). In contrast, the initial ratio of Lactobacillus to the total anaerobes was 13.6% 5.8%, which significantly increased to 35.7% 6.5% after 6 months of treatment in the Lactobacillus group; however, it did not change significantly in the neomycin group. Furthermore, we also found that the significant difference in the ratio of Lactobacillus to the total anaerobes between the 2 groups was already evident since the first month of treatment.
Comparisons Between Lactobacillus and Control Groups
Cholangitis-Free Survival
No significant differences in sex distribution; age at Kasai operation; age at the time of enrollment; AST, ALT, and total and direct bilirubin levels; and body weight z score at enrollment were observed between the Lactobacillus and control groups (Table 2). Six months later, however, the body weight z score in the Lactobacillus group was significantly higher than that in the control group (P ¼ 0.005) and the change in body weight z score was significantly better in the Lactobacillus group than in the control group (P ¼ 0.006). Eight patients in the control group (8/10) experienced cholangitis at least once during the 6-month study period, which was significantly more than that in the Lactobacillus group (2/10, P ¼ 0.005). Among the 8 patients who experienced cholangitis in the control group, 3 patients had cholangitis twice and 1 patient had it 3 times. The mean frequency of cholangitis (episodes per month) was 0.22 0.16 in the control group, indicating a significantly higher rate than that in the Lactobacillus group (0.03 0.07) (P ¼ 0.005).
Bacterial Stool Culture In the neomycin group, the pretreatment ratio of E coli to the total aerobes was 51.7% 6.8%, which decreased significantly to 28.3% 8.7% after the 6-month treatment (Table 3). The baseline ratio of E coli to the total aerobes in the Lactobacillus group was
Cholangitis-free survival in the Lactobacillus and neomycin groups is presented in Figure 1. Two patients in the Lactobacillus group had cholangitis on the 2nd and 112th days after starting treatment, respectively. Another 2 patients in the neomycin group had cholangitis on the 26th and 38th days after starting treatment, respectively. No difference in cholangitis-free survival was observed between the Lactobacillus and neomycin groups (P ¼ 1.00). Eight patients in the control group experienced cholangitis at least once, occurring on the 24th, 32nd, 68th, 92nd, 152nd, 156th, 162nd, and 178th days, respectively. Figure 2 shows the significant difference in cholangitis-free survival between the Lactobacillus and control groups (P ¼ 0.01).
DISCUSSION BA is an obliterative cholangiopathy of unknown etiology. The Kasai operation targets the reconstruction of normal bile flow via the enteric conduit and is considered to be the first-line treatment for BA. Cholangitis, a common but serious complication after Kasai operation in patients with BA, may, however, result in bile flow obstruction with a subsequent deterioration of the hepatic function and ongoing cirrhosis (8). For patients who have had successful bile flow restoration with a timely portoenterostomy, the recurrence of ascending cholangitis is noted to be the single most significant variable pertaining to long-term prognosis (12). Nevertheless, the precise mechanism of cholangitis has not been
TABLE 2. Comparison of the general characteristics and treatment outcomes between the Lactobacillus and control groups
Basic characteristics at enrollment Male/female Age at Kasai operation, mean SD, days Age at the time of enrollment, mean SD, y Serum level, mean SD AST, IU/L ALT, IU/L T-Bil, mg/dL D-Bil, mg/dL) Body weight z score, mean SD Outcome after 6 mo Body weight z score, mean SD Change in body weight z score during the study period, mean SD Cholangitis during 6 mo, no. patients (%) Frequency of cholangitis, mean SD (episodes per mo)
Lactobacillus (n ¼ 10)
Control (n ¼ 10)
P
6/4 52.20 19.94 1.00 0.74
4/6 54.20 12.93 0.73 0.52
0.40 0.79 0.38
99 59 99 72 0.91 0.60 0.55 0.45 0.19 1.35
129 52 98 41 1.37 0.61 0.98 0.50 1.02 0.76
0.24 0.99 0.11 0.06 0.11
0.78 1.44 0.97 0.59 2 (20) 0.03 0.07
1.03 1.01 0.01 0.79 8 (80) 0.22 0.16
0.005 0.006 0.005 0.005
ALT ¼ alanine aminotransferase; AST ¼ aspartate aminotransferase; D-Bil ¼ direct bilirubin; SD ¼ standard deviation; T-Bil ¼ total bilirubin.
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Volume 60, Number 5, May 2015
Biliary Atresia and Prophylaxis of Cholangitis
TABLE 3. Changes in the results of the bacterial stool culture at pretreatment, 1, 3, and 6 months after starting treatment in the neomycin and Lactobacillus groups Neomycin (n ¼ 10)
Lactobacillus (n ¼ 10)
Escherichia coli/total aerobes ratio, mean SD, % 49.3 11.2y Pretreatment 51.7 6.8 1-mo posttreatment 45.4 7.4 47.5 8.3 3-mo posttreatment 32.3 10.7 37.0 7.3 6-mo posttreatment 28.3 8.7 32.8 5.6y Lactobacilli/total anaerobes ratio, mean SD (%) Pretreatment 16.2 5.3 13.6 5.8z 1-mo posttreatment 15.1 3.8 25.2 8.1 3-mo posttreatment 9.9 4.2 30.6 4.0 6-mo posttreatment 12.0 4.6 35.7 6.5z
P
0.53 0.52 0.25 0.17 0.28
Use of Lactobacillus casei rhamnosus to Prevent Cholangitis in Biliary Atresia After Kasai Operation
Tien-Hau Lien, yLing-Nan Bu, Jia-Feng Wu, Huey-Ling Chen, zAn-Chyi Chen, § Ming-Wei Lai, jjHsiang-Hung Shih, ôI-Hsien Lee, Hong-Yuan Hsu, Yen-Hsuan Ni, and Mei-Hwei Chang
ABSTRACT Objectives: Recurrent cholangitis may aggravate cholestatic liver cirrhosis in biliary atresia (BA) after the Kasai operation. This pilot study aimed to investigate whether Lactobacillus casei rhamnosus has the prophylactic efficacy for recurrent cholangitis in comparison with the conventional neomycin prophylaxis. Methods: Twenty jaundice-free patients with BA ages 0 to 3 years who underwent a Kasai operation were enrolled and randomized into 2 groups with 10 patients each: neomycin (25 mg kg1 day1 for 4 days/wk) and L casei rhamnosus (8 108 colony-forming unit per day) groups. The treatment duration was 6 months. Bacterial stool cultures were performed before treatment and 1, 3, and 6 months after starting treatment. In addition, 10 patients with BA with similar status but without prophylaxis served as the historical control group. Results: In the Lactobacillus group, 2 patients (20%, mean 0.03 0.07 episodes per month) developed cholangitis during the study period, with the same frequency as in the neomycin group and significantly lower than that in the control group (80%, P ¼ 0.005, mean 0.22 0.16 episodes per month). The mean change in body weight z score during the 6 months in the Lactobacillus group was 0.97 0.59, which was significantly better than that in the control group (0.01 0.79, P ¼ 0.006). In bacterial stool cultures, the Lactobacillus and Escherichia coli populations significantly increased and decreased, respectively, in the Lactobacillus group. Conclusions: The use of L casei rhamnosus was as effective as neomycin in preventing cholangitis in patients with BA who underwent Kasai operation, and therefore could be considered as a potential alternative prophylactic regimen.
Received June 13, 2014; accepted December 8, 2014. From the Department of Pediatrics, National Taiwan University Hospital, Taipei, the yDepartment of Pediatrics, Keelung Hospital, Department of Health, Executive Yuan, Keelung, the zDepartment of Pediatrics, China Medical University Hospital, School of Medicine, China Medical University, Taichung, the §Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, the jjDepartment of Pediatrics, Kaohsiung Medical University Hospital, School of Medicine, Kaohsiung Medical University, Kaohsiung, and the ôDepartment of Pediatrics, Chi-Mei Hospital, Tainan, Taiwan. Address correspondence and reprint requests to Mei-Hwei Chang, MD, Department of Pediatrics, National Taiwan University Hospital, No. 7 Chung-Shan S. Rd, Taipei 100, Taiwan (e-mail: [email protected]). This study was supported by the National Center of Excellence for Clinical Trial and Research of the National Taiwan University Hospital (NTUH project no NCTRC200709). www.clinicaltrials.gov registration number: NCT00166868. The authors report no conflicts of interest. Copyright # 2015 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition DOI: 10.1097/MPG.0000000000000676
Key Words: biliary atresia, cholangitis, lactobacillus, prophylaxis registration number: NCT00166868.
(JPGN 2015;60: 654–658)
B
iliary atresia (BA) is a progressive fibrosclerosing cholangiopathy of infancy with a yet unclear etiology. If untreated, it progresses to cirrhosis with portal hypertension and liver failure, leading to death within 2 to 3 years (1). The Kasai operation was first used for BA in 1959, with encouraging results; henceforth, it has become the first-line treatment for BA (2). With the Kasai operation, bile flow can be restored through biliary reconstruction via hepatic portoenterostomy to a jejunal loop. Ascending cholangitis, however, is a frequent and often recurrent complication after surgery (3). Recurrent cholangitis causes secondary failure of the restoration of bile flow and possible exacerbation of portal hypertension, resulting in an increase in the risk of mortality and worsened prognosis (4,5). Patients with multiple episodes of ascending cholangitis are more likely to require liver transplantation than those without multiple recurrences (5,6). Therefore, prevention of cholangitis is important for patients with BA who have undergone Kasai operation. Although the precise mechanism of cholangitis has not been established, ascending bacterial infection originating from the enteric conduit was reported as a possible explanation (3). Previous studies (5,7,8) demonstrated some oral antibiotics such as trimethoprim-sulfamethoxazole and neomycin to be effective as prophylactic agents against ascending cholangitis. A long-term antibiotic use may, however, increase the potential to develop antibiotic resistance and the psychological burden of the patient’s caregiver, suggesting the possibility of decreased compliance to antibiotic treatment. Therefore, other safe prophylactic agents, in addition to antibiotics, for ascending cholangitis are needed. Probiotics are live microorganisms that have been reported to have a suppressive effect on bacterial overgrowth and to prevent infection or inflammation of the gastrointestinal tract (9,10). Lactobacillus casei rhamnosus is a probiotics that is easily available in Taiwan. This also has been used for children with chronic constipation in our previous study (11). Accordingly, the present study aimed to investigate the possibility of using L casei rhamnosus in the prophylaxis of ascending cholangitis in patients with BA.
METHODS Between 2007 and 2011, all of our authors enrolled their patients with BA ages 0 to 3 years who underwent Kasai portoenterostomy in this open-label study. All of the participants had normal stool color and jaundice-free status (total serum bilirubin level 3, Lactobacillus); the second case was then assigned to the Lactobacillus group; the third was assigned to the neomycin group; and the fourth was in the Lactobacillus group in rotation by one-to-one ratio in sequence. Although this is an open-label study, our study staff and parents knew the patients would be in which group only after signing the consent. The treatment duration was 6 months. Bacterial culture of stool samples was performed before initiation of the treatment and at 1, 3, and 6 months after starting the treatment to evaluate the patterns of intestinal flora. We sampled approximately 0.2 to 0.3 g of stool and diluted it to a 10 times lower concentration. Then, we collected the diluted samples for the aerobic bacterial culture with 5% trypticase soy agar sheep blood culture media, anaerobic bacterial culture with anaerobic 6-benzylaminopurine culture media, Escherichia coli culture with the MacConkey agar culture media, and lactobacilli culture with the de Man-Rogosa-Sharpe agar culture media. Thereafter, we observed the changing patterns of the E coli and lactobacilli colony numbers against the total aerobic and anaerobic bacteria, respectively, in the stool samples. Once signs of cholangitis were observed, the patient was admitted for complete evaluation of blood counts, differential counts, C-reactive protein level, alanine aminotransferase (ALT) level, aspartate aminotransferase (AST) level, bilirubin level, urine culture, and blood culture. A diagnosis of cholangitis was made on the basis of unexplained fever (body temperature >388C), acholic stools, increased jaundice, or positive blood culture results. Abdominal sonography was performed to detect ascites, intrahepatic bile duct lake, or liver cirrhosis. Parenteral ceftriaxone administration was the first-line antibiotic treatment, with modifications according to culture results. If a patient with BA developed cholangitis, a 14-day treatment with intravenous antibiotics was completed. After hospital discharge, the patients continued receiving their original prophylactic agent, either neomycin or probiotics. From 1991 to date, no systemic change in post–Kasai operative care has been made, except in the concept of prophylactic
Biliary Atresia and Prophylaxis of Cholangitis antibiotic usage. Since 1997, most of the patients have been prescribed prophylactic antibiotics after operation (5). Therefore, for a historical control group, we randomly selected (by Excel’s RAND function) another 10 jaundice-free patients with BA among a total of 18 cases ages 0 to 3 years who underwent Kasai operation during 1991 to 1996 but did not receive prophylaxis of cholangitis. Ursodiol (ursodeoxycholic acid) is a naturally occurring bile acid found in normal human bile. All of our cases in treatment and control groups were prescribed with oral ursodiol. In addition, we suggested the semielemental formula with adequate calories intake for patients and educated parents for adding solid food when patients grew up. The dietary policy is the same in the 3 groups. After the 6-month study period, comparisons of the frequency of cholangitis, cholangitis-free survival time for primary outcome, and body weight (z score) for secondary outcome were performed between the 3 groups. Summary statistics of the demographic variables were presented using frequency, mean, and standard deviations. Comparisons of these variables were performed using the Student t test. The KaplanMeier method and log-rank test were also used to assess the different treatment groups affecting cholangitis-free survival time. A P < 0.05 was considered statistically significant.
RESULTS Comparisons Between Neomycin and Lactobacillus Groups All the subjects had no significant difference in background and were randomized into 2 groups at enrollment (Table 1). No significant difference in sex distribution was observed between the 2 groups (P ¼ 0.40). The mean ages at Kasai operation were 40.8 13.75 days in the neomycin group and 52.2 19.94 days in the Lactobacillus group (P ¼ 0.16). The mean ages at the time enrolled were 0.88 0.75 years in the neomycin group and 1 0.74 years in the Lactobacillus group (P ¼ 0.74). The AST and ALT levels at enrollment were, respectively, 112 52 and 117 74 IU/L in the neomycin group, and 99 59 and 99 72 IU/L in the Lactobacillus group (P ¼ 0.62 and P ¼ 0.59, respectively). The total and direct bilirubin levels at enrollment were 1.05 0.53 and 0.58 0.42 mg/dL in the neomycin group, and 0.91 0.60 and 0.55 0.45 in the Lactobacillus group (P ¼ 0.59 and P ¼ 0.88, respectively). The mean body weight z scores at enrollment were 0.71 1.71 and 0.19 1.35 in the neomycin and Lactobacillus
TABLE 1. Comparison of the general characteristics and treatment outcomes between the neomycin and Lactobacillus groups
Basic characteristics at enrollment Male/female Age at Kasai operation, mean SD, days Age at the time of enrollment, mean SD, y Serum level, mean SD AST, IU/L ALT, IU/L T-Bil, mg/dL D-Bil, mg/dL Body weight z score, mean SD Outcome after 6 mo Body weight z score, mean SD Change in body weight z score during the study period, mean SD Cholangitis during 6 mo, no. patients, % Frequency of cholangitis, mean SD (episodes per mo)
Neomycin (n ¼ 10)
Lactobacillus (n ¼ 10)
P
4/6 40.80 13.75 0.88 0.75
6/4 52.20 19.94 1.00 0.74
0.40 0.16 0.74
112 52 117 74 1.05 0.53 0.58 0.42 0.71 1.71
99 59 99 72 0.91 0.60 0.55 0.45 0.19 1.35
0.62 0.59 0.59 0.88 0.46
0.19 1.57 0.90 0.95 2 (20) 0.03 0.07
0.78 1.44 0.97 0.59 2 (20) 0.03 0.07
0.39 0.85 1 1
ALT ¼ alanine aminotransferase; AST ¼ aspartate aminotransferase; D-Bil ¼ direct bilirubin; SD ¼ standard deviation; T-Bil ¼ total bilirubin.
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Chang et al
JPGN
Volume 60, Number 5, May 2015
groups, respectively (P ¼ 0.46). All of the aforementioned data at enrollment were not significantly different between the 2 groups. After the 6-month treatment with the prophylactic protocol, the mean body weight z scores were 0.19 1.57 and 0.78 1.44 in the neomycin and Lactobacillus groups, respectively (P ¼ 0.39). The mean changes in the body weight z scores were 0.90 0.95 and 0.97 0.59 in the neomycin and Lactobacillus groups, respectively (P ¼ 0.85). Cholangitis occurred in 2 patients each in the neomycin and Lactobacillus groups (P ¼ 1). Each of the 4 patients only had 1 episode of cholangitis during the 6-month study period. The mean frequency of cholangitis (episodes per month) was consequently the same in the neomycin and Lactobacillus groups. Most important is that no adverse reaction was recorded during the 6-month study period in both groups.
49.3% 11.2%, which also significantly decreased to 32.8% 5.6% after treatment completion. The ratio of E coli to the total aerobes was not significantly different between the 2 groups after 6 months of treatment (P ¼ 0.17), implying that the strategy of substituting bad bacteria in the gut with probiotics may have worked and that the efficacy of decreasing the proportion of E coli is as good as the use of antibiotics (neomycin). In contrast, the initial ratio of Lactobacillus to the total anaerobes was 13.6% 5.8%, which significantly increased to 35.7% 6.5% after 6 months of treatment in the Lactobacillus group; however, it did not change significantly in the neomycin group. Furthermore, we also found that the significant difference in the ratio of Lactobacillus to the total anaerobes between the 2 groups was already evident since the first month of treatment.
Comparisons Between Lactobacillus and Control Groups
Cholangitis-Free Survival
No significant differences in sex distribution; age at Kasai operation; age at the time of enrollment; AST, ALT, and total and direct bilirubin levels; and body weight z score at enrollment were observed between the Lactobacillus and control groups (Table 2). Six months later, however, the body weight z score in the Lactobacillus group was significantly higher than that in the control group (P ¼ 0.005) and the change in body weight z score was significantly better in the Lactobacillus group than in the control group (P ¼ 0.006). Eight patients in the control group (8/10) experienced cholangitis at least once during the 6-month study period, which was significantly more than that in the Lactobacillus group (2/10, P ¼ 0.005). Among the 8 patients who experienced cholangitis in the control group, 3 patients had cholangitis twice and 1 patient had it 3 times. The mean frequency of cholangitis (episodes per month) was 0.22 0.16 in the control group, indicating a significantly higher rate than that in the Lactobacillus group (0.03 0.07) (P ¼ 0.005).
Bacterial Stool Culture In the neomycin group, the pretreatment ratio of E coli to the total aerobes was 51.7% 6.8%, which decreased significantly to 28.3% 8.7% after the 6-month treatment (Table 3). The baseline ratio of E coli to the total aerobes in the Lactobacillus group was
Cholangitis-free survival in the Lactobacillus and neomycin groups is presented in Figure 1. Two patients in the Lactobacillus group had cholangitis on the 2nd and 112th days after starting treatment, respectively. Another 2 patients in the neomycin group had cholangitis on the 26th and 38th days after starting treatment, respectively. No difference in cholangitis-free survival was observed between the Lactobacillus and neomycin groups (P ¼ 1.00). Eight patients in the control group experienced cholangitis at least once, occurring on the 24th, 32nd, 68th, 92nd, 152nd, 156th, 162nd, and 178th days, respectively. Figure 2 shows the significant difference in cholangitis-free survival between the Lactobacillus and control groups (P ¼ 0.01).
DISCUSSION BA is an obliterative cholangiopathy of unknown etiology. The Kasai operation targets the reconstruction of normal bile flow via the enteric conduit and is considered to be the first-line treatment for BA. Cholangitis, a common but serious complication after Kasai operation in patients with BA, may, however, result in bile flow obstruction with a subsequent deterioration of the hepatic function and ongoing cirrhosis (8). For patients who have had successful bile flow restoration with a timely portoenterostomy, the recurrence of ascending cholangitis is noted to be the single most significant variable pertaining to long-term prognosis (12). Nevertheless, the precise mechanism of cholangitis has not been
TABLE 2. Comparison of the general characteristics and treatment outcomes between the Lactobacillus and control groups
Basic characteristics at enrollment Male/female Age at Kasai operation, mean SD, days Age at the time of enrollment, mean SD, y Serum level, mean SD AST, IU/L ALT, IU/L T-Bil, mg/dL D-Bil, mg/dL) Body weight z score, mean SD Outcome after 6 mo Body weight z score, mean SD Change in body weight z score during the study period, mean SD Cholangitis during 6 mo, no. patients (%) Frequency of cholangitis, mean SD (episodes per mo)
Lactobacillus (n ¼ 10)
Control (n ¼ 10)
P
6/4 52.20 19.94 1.00 0.74
4/6 54.20 12.93 0.73 0.52
0.40 0.79 0.38
99 59 99 72 0.91 0.60 0.55 0.45 0.19 1.35
129 52 98 41 1.37 0.61 0.98 0.50 1.02 0.76
0.24 0.99 0.11 0.06 0.11
0.78 1.44 0.97 0.59 2 (20) 0.03 0.07
1.03 1.01 0.01 0.79 8 (80) 0.22 0.16
0.005 0.006 0.005 0.005
ALT ¼ alanine aminotransferase; AST ¼ aspartate aminotransferase; D-Bil ¼ direct bilirubin; SD ¼ standard deviation; T-Bil ¼ total bilirubin.
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Volume 60, Number 5, May 2015
Biliary Atresia and Prophylaxis of Cholangitis
TABLE 3. Changes in the results of the bacterial stool culture at pretreatment, 1, 3, and 6 months after starting treatment in the neomycin and Lactobacillus groups Neomycin (n ¼ 10)
Lactobacillus (n ¼ 10)
Escherichia coli/total aerobes ratio, mean SD, % 49.3 11.2y Pretreatment 51.7 6.8 1-mo posttreatment 45.4 7.4 47.5 8.3 3-mo posttreatment 32.3 10.7 37.0 7.3 6-mo posttreatment 28.3 8.7 32.8 5.6y Lactobacilli/total anaerobes ratio, mean SD (%) Pretreatment 16.2 5.3 13.6 5.8z 1-mo posttreatment 15.1 3.8 25.2 8.1 3-mo posttreatment 9.9 4.2 30.6 4.0 6-mo posttreatment 12.0 4.6 35.7 6.5z
P
0.53 0.52 0.25 0.17 0.28
