Post on 17-Jan-2016
Case Based Discussion
LAP TOP 23rd August 2015
Case- 1
• 4 year old girl child• Presented with yellowish discoloration of
eyes and urine x 4 days• H/o Prodrome of fever and vomiting• No H/o pedal edema, clay colored stool ,
itching , altered sensorium and bleeding• Developmentally normal and Hepatitis B
Vaccine given; Hepatitis A not given
Dr Pradeep Kumar Sharma Dr Sanjay Sehta, Dr Utkarsh
Examination
• Liver 5cm BCM, Span 11cm; Slight Tender; round Border ; smooth surface
• Spleen : Not palpable• Shifting Dullness +• Bowel Sounds :
Normal• Rest System :WNL
Clinical Impression
• 4 year old child with prodromal symptoms and Jaundice ; Hepatomegaly with ascities S/o Hepatitis of Infective Etiology
Acute Viral Hepatitis
MalariaDengue
Enteric Fever
USG Abdomen: Hepatomegaly with Hypoechoic Liver;
Ascites ; and Minimal Rt Pleural Effusion
760/1230
Investigation Contd.
• PS for MP Negative• Dengue /NS-1 Negative• Typhidot Negative• Leptospira Negative• HbsAg , Anti HCV and
Anti HEV Negative• Ig M Anti HAV Positive• LKM /SMA/ANA Negative• Ceruloplasmin 35 mg/dl
All Viral Markers required ?
PT/INR must in all cases of
AVH ?
Ascites and Pleural Effusion
in AVH ?
Final Diagnosis
• Acute Viral Hepatitis (HAV related) with ascites and pleural effusion and anemia
12345
Dietary Advice ?When to admit patient with Acute Viral Hepatitis ?
IV Fluids ? Any Specific Medications ?
Vitamin Supplements ? Liver Tonics ?
Serial Monitoring of Liver Functions- When and What ?
MANAGEMENT
Answers by experts
• High Enzymes favor AVH• Ascites in 13% cases of AVH• Normal Diet, no restrictions• Admit if f/o Hepatic encephalopathy, Pt
prolonged and Liver size decreased• No specific medicines except UDCA in prurities• PT/INR and Serological markers (HBsAg, Ig M
Anti HAV , IgM Anti HEV)• No serial monitoring required , LFT after 2-3
months to see for normalization
Case- 2
• 45 day boy, Normal Delivery; BW 3.5kg
D0 D4 D10 D20 D30 D45
Ante Natal Uneventful
Breast Feeds
TB 16D 1.2
Phototherapy
Jaundice, Pigmented Stool and
High Colored Urine
Poor Wt Gain 10gm/dPoor feeding
? Seizure at D 42
Progressive Abdominal Distention
HIDA Excretory
Prof Mala Kumar, Dr Chavvi NandaDr Ashutosh Verma , Dr Salman Khan
History Contd…• History of 2 Sib deaths (<100 days).. 1
had seizures with aspiration and 1 had Jaundice with Ascites with ? septic shock
4 CM BCM
2 CM BCM
Free Fluid +
Examination
To look in Eye ?
Repeated Hypoglycemia
Summary
D45 male childJaundice , High Colored Urine & Pigmented stoolsNeonatal Cholestasis – Intrahepatic Sick Child with Ascites, Organomegaly, Cataract and Hypoglycemia.Family History of Sib Deaths with similar illness.
Galactosemia
Tyrosinemia
Hereditary Hemochromatosis
Mitochondrial Disorders
Metabolic Liver Disorders with early onset ascites ?
How To Investigate ?
• Hb 10.8gm%; • TLC 16,700 (P 78%)• Platelet 210000• CRP Positive• LFT (Bil 7.2/ D 4.0,
SGOT 134, SGPT 198, ALP 887 ,GGT 24,Pr 6.2 Alb 2.4 )
• PT 24 ; INR 2.0 (not Correctable to Vit. K)
• Blood Culture E. Coli
Blood Ascetic Fluid• High SAAG• TLC 350 (All
Lymphcyotsis)• Culture : Sterile
Specific Test• Urine Non Glucose
Reducing Sugar• S Ferritin• S Alpha Feto Protein
++++
Normal
Normal
GAL- 1- PUT ABSENT
Diagnosis : Galactosemia
• Management ?
• Spectrum of Infantile Metabolic Liver Disease in India ?
Answers by experts
• Look in eyes for Cataract Cherry red spot, posterior embryotoxon and chorioretinitis
• HIDA not essential if Stool pigmented• Most common MLD in infants is
Galactosemia. Diagnosis is essential cause it can be managed and treatement
Case 3
7 year old boy presented Pain abdomen for the past 3 yearIntermittent symptoms Periumblical, never nocturnalLasts 5 to 20 minutes, 2 to 3 times a dayNo weight loss, fever, vomiting, loose stools
Examination Normal growth parameters No abnormal physical finding
Prof. R. AhujaDr. Sanjay Niranjan, Dr Prashant Bhargava
1 yr 2yr 3yr 4yr
ATT(6 mo)
Ultrasound abdomen“Multiple mesenteric lymph nodes largest measuring 1 cm”“ Sub centrimetric Lymphnodes”“ Gaseous Distention of Bowel Loops”“ Abdomen is tender Sonographically”
Treatment History
No response
Interpretation ?
Is this abdominal tuberculosis ??
Periumblical painNo red flags --- ?Normal growthCorrect Diagnosis : Functional abdominal pain• Counseling• Fiber supplements
Subsequent visits - pain resolved
Management of ATT Induced Hepato-toxicity ?
How to suspect
& Confirm
Alternate ATT
How to resume
Case 4 –SOL LiverCase 4 –SOL Liver
5 year Boy; Wt: 18kg & Ht 105cm ;
H/o Skin Infection x 3weeks back
H/o High Grade Fever – 7 days with Pain RUQ
Examination :
Toxic Look ; Febrile ; Pallor +; Jaundice Absent
Tender Hepatomegaly
No Guarding, BS – Normal
Hb 8.9gm%;TLC 33400, P 80%, CRP Positive
LFT :WNL
3 CM BCM
Dr PK ShuklaDr. Amit Rastogi, Dr Abhishek Bansal
QuestionsQuestionsMicrobiology of Liver Abscess ?Role of amoebic serology ?Role CT Scan/MRI in liver abscess ?Drugs for treatment ? How long ?Single time aspiration vs Precutaneous Drainage ? When to remove drain ?Sonologist says its not liquefied, no use attempting STA or PCD …How True ?
USG reveals a hypoechoic mass with irregular borders and internal septation in Rt. Lobe of liver S/O Abscess(Vol 130ml)
Case 5 –Incidentally detected SOL LiverCase 5 –Incidentally detected SOL Liver
9 months Boy; Wt: 9kg & Ht 70cm
Normal growth and development
Incidentally detected hepatomegaly while visit for MMR vaccine
Examination :
Hepatomegaly firm , non tender
No splenomegaly , Rest system wnl
Investigations: CBC & LFT : WNL
3 CM BCM
Dr Ashutosh Pandey , Dr J D Rawat,Dr. S K Rai, Dr. Anurag Katiyar
QuestionsQuestionsFNAC VS Biopsy ? FNACFirst chemotherapy or surgery ? ChemoChemotheray regimen ?How to follow up after surgery ? With AFP
FNAC VS Biopsy ? FNACFirst chemotherapy or surgery ? ChemoChemotheray regimen ?How to follow up after surgery ? With AFP
AFP:50125 ng/ml ?
Hepatoblastoma
Thank you