Download MBBS Pediatric PPT 6 Jaundice In Children Lecture Notes

APPROACH TO A CHILD WITH

JAUNDICE AND ASCITIS

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LEARNING OBJECTIVES

What is jaundice
Basic patho -physiology of bilirubin

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

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

increased

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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

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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.

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It comes from

?

from catabolism of circulating RBCs

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?

from ineffective erythropoiesis (bone marrow)

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?

from turnover of heme proteins
What causes bilirubin?

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

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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

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

Jaundice occurs when there is:

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too much bilirubin being produced for the liver to remove

from the blood (for example, patients with hemolytic anemia

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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

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removed from the blood, converted to bilirubin/glucuronic

acid (conjugated) or secreted in bile; or

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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,

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gallstones, or inflammation of the bile ducts. The

decreased conjugation, secretion, or flow of bile that can

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result in jaundice is referred to as cholestasis: however,

cholestasis does not always result in jaundice.
Obstructive Jaundice

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

liver

INTRAHEPATIC

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EXTRAHEPATIC

CAUSES OF OBSTRUCTIVE JAUNDICE: INTRAHEPATIC

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Primary biliary cirrhosis
Sclerosing cholangitis (Inflammation/scarring)

Primary biliary cirrhosis

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

? Choledocholithiasis
? Worms

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? Malignancy : neoplasia, L.N.

Choledocholithiasis

Malignancy : Pancreatic (head of pancreas) carcinoma

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AN APPROACH TO A CHILD

WITH JAUNDICE

CLASSIC APPROACH

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Proper detailed history

Proper physical examination

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Appropriate investigations
IDENTIFY

Acute

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Chronic (more than 6 months)

IDENTIFY

Hemolytic

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Hepatocel ular
Cholestatic
TYPES OF JAUNDICE

TYPE

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PRE

HEPATIC

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POST

HEPATIC

HEPATIC

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Urine color

normal

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dark

dark

Stool color

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normal

normal

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acholic

Pruritis

no

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No

yes

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Signs and Symptoms

of Jaundice

1. yel ow discoloration of the skin, mucous

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membranes, sclera of the eyes

2. light-colored stools

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3. dark-colored urine

4. itching of the skin.

5. nausea and vomiting

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6. abdominal pain

7. fever

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8. weakness

9. loss of appetite

10. headache

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11. confusion

12. swel ing of the legs and abdomen

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13. Skin stigmata
Diagnosis of Jaundice

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

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swel ing.

?A bilirubin blood test wil be done.

Other tests vary, but may include:

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?Hepatitis virus panel to look for infection of the liver

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

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

?Abdominal ultrasound
?Abdominal CT scan

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?Endoscopic retrograde cholangiopancreatography (ERCP)

?Percutaneous transhepatic cholangiogram (PTCA)

?Liver biopsy

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?Cholesterol level

?Prothrombin time

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IN CHILDREN

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

Cholestatic (SGOT/SGPT less than twice of ALP)

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Table of diagnostic tests

Function test

Pre-hepatic Jaundice

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Hepatic Jaundice

Post-hepatic Jaundice

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Total bilirubin

Normal / Increased

Increased

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Conjugated bilirubin

Normal

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Increased

Increased

Unconjugated bilirubin Normal / Increased

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Increased

Normal

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Urobilinogen

Normal / Increased

Increased

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Decreased / Negative

Dark (urobilinogen +

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Dark (conjugated

Urine Color

Normal

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conjugated bilirubin)

bilirubin)

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Stool Color

Normal

Normal/Pale

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Pale

Alkaline phosphatase

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Increased

levels

Normal

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Alanine transferase and
Aspartate transferase

Increased

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levels

Conjugated Bilirubin in Not Present

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Present

Urine
Splenomegaly

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Present

Present

Absent

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REMEMBER

The prognostic value of

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Albumin
Coagulation profile
NEONATAL JAUNDICE

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

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

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

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?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.

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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

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feet. Additional signs and symptoms that may be seen in the
newborn include:

1. poor feeding
2. lethargy

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3. changes in muscle tone
4. high-pitched crying
5. seizures.
ASCITES

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DEFINITION

Accumulation of serous fluid in peritoneal cavity

oAs a part of generalized edema- anasarca

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oIsolated collection or disproportionate
CAUSES

1. Isolated or disproportionate

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Cardiac

?Hepatic

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Constrictive pericarditis

Cirrhosis

Neoplastic

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Congenital hepatic fibrosis

Lymphoma

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Portal vein obstruction

Neuroblastoma

Budd chiari syndrome

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Urinary

Neonatal cholestatis

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Perforation

?Abdominal

Leakage from urinary tract

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Peritoneal Tuberculosis

Chylous ascites

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Acute pancreatitis

Gynecological

Renal

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Ovarian tumor

Peritoneal dialysis

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Ovarian rupture

Obstructive uropathy

2. Ascitis with generalized edema

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?Renal- Nephrotic syndrome, AGN, renal failure
?Cardiac- CHF, constrictive pericarditis
?Polyserositis- SLE, Dengue fever, sepsis
?Severe Malabsorption
CLINICAL FEATURE

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Abdominal distension-hal mark
Five classical signs

Bulging vein

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Flank dullness and fullness
Shifting dullness
Fluid thrill
Puddle sign

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Umbilical laughing/ herniation with tense ascites

D/D

?Gaseous distention

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

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

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Infancy- cholestatic

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

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ASCITIC FLUID ANALYSIS

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

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<1.1g/dl- exudative

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

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characteeristic

disease

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Lymphocytic pleocytosis

tuberculosis

Polymorphic pleocytosis

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Bacterial perotonitis

hemorrhagic

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Malignancy, pancreatitis,

tuberculosis

Milky white

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Chylous ascitis
OTHER INVESTIGATIONS

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

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portal vein

?Portal venous Doppler studies
?CT Abdomen-intra abdominal mass, malignancy etc.

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?LFT
?UGI endoscopy- CLD and PH
?Chest X-ray
?Mantoux test

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TREATMENT

?Low salt diet
?Diuretics
?IV albumin

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?Repeated large volume paracentesis
?Depend on cause of ascites
AT T- TB
Antibiotics- bacterial infection
Interferons- Heptitis B and C

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Steroids- autoimmune hepatitis
Surgery or propranolol- PH and Varices
Liver transplantation- decompensated liver, cirrhosis, portal hypertension
MCQ 1

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Regarding bilirubin metabolism, whic h of

the following is true?

a) Normal elimination is through the urine and the stool

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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

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

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d) Persistent vomiting