Download MBBS Pediatric PPT 6 Jaundice In Children Lecture Notes

Download MBBS (Bachelor of Medicine, Bachelor of Surgery) Pediatric PPT 6 Jaundice In Children Lecture Notes


APPROACH TO A CHILD WITH

JAUNDICE AND ASCITIS

LEARNING OBJECTIVES

What is jaundice
Basic patho -physiology of bilirubin

metabolism
Causes of jaundice
Approach to a child with jaundice
Ascites
INTRODUCTION

Symptom of disease rather than a disease
In adults and older children sclera appears jaundiced when serum bilirubin is

increased

Gives yel owish hue to the skin, sclera, and mucous membranes
Normal serum bilirubin <1mg%
It is not a visible til s. bilirubin exceeds 2 mg/dl.
In newborn->5 mg/dl
However it is difficult to see sclera in newborn due to difficulty in opening eye

BILIRUBIN

End product of hemoglobin metabolism that is excreted in bile.
It comes from

?

from catabolism of circulating RBCs

?

from ineffective erythropoiesis (bone marrow)

?

from turnover of heme proteins
What causes bilirubin?

1. Overproduction by reticuloendothelial system
2. Failure of hepatocyte uptake
3. Failure to conjugate or excrete
4. Obstruction of biliary excretion into intestine

Normal Range of Bilirubin

It is normal to have some bilirubin in your blood. Normal levels are:

?Direct (also cal ed conjugated) bilirubin: 0 to 0.3 mg/dL

?Total bilirubin: 0.3 to 1.9 mg/dL
Causes of Jaundice

Jaundice occurs when there is:

too much bilirubin being produced for the liver to remove

from the blood (for example, patients with hemolytic anemia

have an abnormally rapid rate of destruction of their red blood

cells that releases large amounts of bilirubin into the blood)

a defect in the liver that prevents bilirubin from being

removed from the blood, converted to bilirubin/glucuronic

acid (conjugated) or secreted in bile; or

blockage of the bile ducts that decreases the flow of bile

and bilirubin from the liver into the intestines. For

example, the bile ducts can be blocked by worms, cancer,

gallstones, or inflammation of the bile ducts. The

decreased conjugation, secretion, or flow of bile that can

result in jaundice is referred to as cholestasis: however,

cholestasis does not always result in jaundice.
Obstructive Jaundice

Obstructive jaundice is a condition in which there is blockage of the flow of bile out of the

liver

INTRAHEPATIC

EXTRAHEPATIC

CAUSES OF OBSTRUCTIVE JAUNDICE: INTRAHEPATIC

Primary biliary cirrhosis
Sclerosing cholangitis (Inflammation/scarring)

Primary biliary cirrhosis

Sclerosing cholangitis (Inflammation/scarring)
CAUSES OF OBSTRUCTIVE JAUNDICE: EXTRAHEPATIC

? Choledocholithiasis
? Worms
? Malignancy : neoplasia, L.N.

Choledocholithiasis

Malignancy : Pancreatic (head of pancreas) carcinoma
AN APPROACH TO A CHILD

WITH JAUNDICE

CLASSIC APPROACH

Proper detailed history

Proper physical examination

Appropriate investigations
IDENTIFY

Acute

Chronic (more than 6 months)

IDENTIFY

Hemolytic
Hepatocel ular
Cholestatic
TYPES OF JAUNDICE

TYPE

PRE

HEPATIC

POST

HEPATIC

HEPATIC

Urine color

normal

dark

dark

Stool color

normal

normal

acholic

Pruritis

no

No

yes

Signs and Symptoms

of Jaundice

1. yel ow discoloration of the skin, mucous

membranes, sclera of the eyes

2. light-colored stools

3. dark-colored urine

4. itching of the skin.

5. nausea and vomiting

6. abdominal pain

7. fever

8. weakness

9. loss of appetite

10. headache

11. confusion

12. swel ing of the legs and abdomen

13. Skin stigmata
Diagnosis of Jaundice

The health care provider wil perform a physical exam. This may reveal liver

swel ing.

?A bilirubin blood test wil be done.

Other tests vary, but may include:

?Hepatitis virus panel to look for infection of the liver

?Liver function tests to determine how wel the liver is working

?Complete blood count to check for low blood count or anemia

?Abdominal ultrasound
?Abdominal CT scan

?Endoscopic retrograde cholangiopancreatography (ERCP)

?Percutaneous transhepatic cholangiogram (PTCA)

?Liver biopsy

?Cholesterol level

?Prothrombin time

IN CHILDREN

Hepatocel ular (SGOT/SGPT more than twice of ALP)

Cholestatic (SGOT/SGPT less than twice of ALP)
Table of diagnostic tests

Function test

Pre-hepatic Jaundice

Hepatic Jaundice

Post-hepatic Jaundice

Total bilirubin

Normal / Increased

Increased

Conjugated bilirubin

Normal

Increased

Increased

Unconjugated bilirubin Normal / Increased

Increased

Normal

Urobilinogen

Normal / Increased

Increased

Decreased / Negative

Dark (urobilinogen +

Dark (conjugated

Urine Color

Normal

conjugated bilirubin)

bilirubin)

Stool Color

Normal

Normal/Pale

Pale

Alkaline phosphatase

Increased

levels

Normal

Alanine transferase and
Aspartate transferase

Increased

levels

Conjugated Bilirubin in Not Present

Present

Urine
Splenomegaly

Present

Present

Absent

REMEMBER

The prognostic value of

Albumin
Coagulation profile
NEONATAL JAUNDICE

?Jaundice is clinical y detectable in the newborn when the serum

bilirubin levels are greater than 5 mg/dl. This occurs in

approximately 60% of term infants and 80% of preterm infants.

?Neonatal jaundice first becomes visible in the face and forehead.

Blanching reveals the underlying color. Jaundice then gradual y

becomes visible on the trunk and extremities.

Signs and Symptoms of Neonatal Jaundice

Newborns, as the bilirubin level rises, jaundice wil typically
progress from the head to the trunk, and then to the hands and
feet. Additional signs and symptoms that may be seen in the
newborn include:

1. poor feeding
2. lethargy
3. changes in muscle tone
4. high-pitched crying
5. seizures.
ASCITES

DEFINITION

Accumulation of serous fluid in peritoneal cavity

oAs a part of generalized edema- anasarca

oIsolated collection or disproportionate
CAUSES

1. Isolated or disproportionate

Cardiac

?Hepatic

Constrictive pericarditis

Cirrhosis

Neoplastic

Congenital hepatic fibrosis

Lymphoma

Portal vein obstruction

Neuroblastoma

Budd chiari syndrome

Urinary

Neonatal cholestatis

Perforation

?Abdominal

Leakage from urinary tract

Peritoneal Tuberculosis

Chylous ascites

Acute pancreatitis

Gynecological

Renal

Ovarian tumor

Peritoneal dialysis

Ovarian rupture

Obstructive uropathy

2. Ascitis with generalized edema
?Renal- Nephrotic syndrome, AGN, renal failure
?Cardiac- CHF, constrictive pericarditis
?Polyserositis- SLE, Dengue fever, sepsis
?Severe Malabsorption
CLINICAL FEATURE

Abdominal distension-hal mark
Five classical signs

Bulging vein
Flank dullness and fullness
Shifting dullness
Fluid thrill
Puddle sign

Umbilical laughing/ herniation with tense ascites

D/D

?Gaseous distention
?Fecal retention
?Masses
?Obesity
?Pregnancy
EVALUATION OF CAUSE

?Generalized/ isolated or predominant
?Predominant- hepatic or intra-abdominal
?Age- Neonate- urinary, chylous

Infancy- cholestatic

?Look for signs and symptoms of hepatic disease
?H/o contact for TB with pulmonary findings
?Presence of L. N.

ASCITIC FLUID ANALYSIS

?Transudative/ exudative ( by SAAG ?serum albumin-ascetic fluid albumin gradient)
?SAAG- 1.1g/dl-transudative

<1.1g/dl- exudative

?Transudative- CLD and when ascites is a part of generalized edema
?Ascitic fluid- cytology, gram staining, culture

characteeristic

disease

Lymphocytic pleocytosis

tuberculosis

Polymorphic pleocytosis

Bacterial perotonitis

hemorrhagic

Malignancy, pancreatitis,

tuberculosis

Milky white

Chylous ascitis
OTHER INVESTIGATIONS

?Ultrasonography? quantity, etiology, L.N., hepatic echotexture, size of

portal vein

?Portal venous Doppler studies
?CT Abdomen-intra abdominal mass, malignancy etc.
?LFT
?UGI endoscopy- CLD and PH
?Chest X-ray
?Mantoux test

TREATMENT

?Low salt diet
?Diuretics
?IV albumin
?Repeated large volume paracentesis
?Depend on cause of ascites
AT T- TB
Antibiotics- bacterial infection
Interferons- Heptitis B and C
Steroids- autoimmune hepatitis
Surgery or propranolol- PH and Varices
Liver transplantation- decompensated liver, cirrhosis, portal hypertension
MCQ 1

Regarding bilirubin metabolism, whic h of

the following is true?

a) Normal elimination is through the urine and the stool
b) Serum bilirubin concentration is not influenced by medications
c) Bilirubin is primarily free in circulation
d) Heme protein is primarily broken down in circulation

MCQ 2

Followings are alarming signs in a patient with jaundice, except:
a) Altered sensorium
b) Raised INR
c) Raised ALT
d) Persistent vomiting

This post was last modified on 07 April 2022