TOTAL PARENTERAL NUTRITION-ASSOCIATED CHOLESTASIS IN SURGICAL NEONATES MAY BE REVERSED BY INTRAVENOUS CHOLECYSTOKININ - A PRELIMINARY-REPORT

Neonatal infants who require total parenteral nutrition (TPN) after ma jor operations are susceptible to total parenteral nutrition-associate d cholestasis (TPNAC). A therapeutic dilemma ensues if cholestasis doe s not resolve after the institution of full enteral nutrition. The aut hors report the reversal of TPN-associated cholestasis by intravenous cholecystokinin in eight infants who had undergone major surgery durin g the neonatal period. The indications for surgery were necrotizing en terocolitis in three patients, midgut volvulus in one, gastroschisis i n one, diaphragmatic hernia in one, necrosis of the stomach in one, an d cardiac anomaly in one. Four of the infants were premature. Medial d uration of TPN was 25 days (range, 20 to 150 days). Seven patients wer e weaned from TPN before treatment with cholecystokinin was instituted . Mean duration of pretreatment full enteral nutrition in these seven patients was 35 days (range, 20 to 55 days). One girl with a short gut syndrome tolerated only 10% of her caloric needs via the enteral rout e. All patients had acholic stools, conjugated hyperbilirubinemia, no excretion of Technetium-labeled HIDA to the biliary tree or duodenum ( six patients), and significantly elevated liver enzyme values. In thre e patients, echography showed biliary sludge or stones in the gallblad der, Porcine cholecystokinin (2 IDU/kg) was administered intravenously for 3 to 5 days. If the stool color did not normalize, cholecystokini n injections were repeated using a larger dose (4 IDU/kg). In seven pa tients, including the girl with short gut syndrome, the clinical jaund ice and conjugated hyperbilirubinemia completely resolved within 1 to 6 weeks. No biliary sludge or stones were seen in the posttreatment ec hography in any of the patients. HIDA-biligraphy, which was performed 1 to 3 months after the treatment in seven patients, showed normal exc retion of the marker to the duodenum in all cases. One patient did not respond to repeated administration of cholecystokinin and underwent o perative irrigation of the biliary tree. This preliminary study sugges ts that TPN-associated cholestasis in neonatal infants who have underg one gastrointestinal operations may be reversed by intravenous cholecy stokinin in the majority of patients. Copyright (C) 1995 by W.B. Saund ers Company