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

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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