Jaundice in Children

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Jaundice in Children

• Abdulwahab Telmesani
• FRCPC,FFAP
• Faculty of Medicine and Medical Science
• Umm Al-Qura University

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An Approach to a Child With Direct
Hyperbilirubinemia
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Classic Approach

• Proper detailed history
• Proper physical examination
• Formalize an impression of prioritized DDx
• Appropriate investigations

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Identify

• Acute
• Chronic (more than 6 months)

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In Children

• Acute
• Chronic (more than 6 months)

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Identify

• Hepatocellular
• Chlestatic

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In Children

• Hepatocellular (ALT/AST more than twice of ALP)
• Cholestatic (ALT/AST less than twice of ALP)

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Remember

• The prognostic value of
• Albumin
• Coagulation profile

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Etiology

• Infection
• Drugs
• Specific Entities
• Vascular

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Etiology

• Infection
• Drugs
• Specific Entities
• Vascular

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Infections

• Viral
• Bacterial
• Parasitic

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Viral Hepatitis

• Hepatotropic Viruss
• (replicate in the liver and causes
  hepatitis)
• Others

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Hepatotropic Viruses

• HBV (10-20 Chronic active hepatitis)
• HCV (70-80 Chronic active hepatitis)

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Hepatotropic Viruses

• Non B / C Viral Hepatitis
• HAV
• HEV
• HFV
• HGV
• TTV
• SEN

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Others

• EBV
• CMV
• Herpes
• Other

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Hepatitis A Virus

• Most common cause of community acquired hepatitis
  through out the world

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Hepatitis A Virus

• RNA Picorna Virus (Rhinovirus, Enterovirus,
  Cocxackievirus)
• Feco - oral transmission (Food borne /- Water
  borne)
• Day care centers account for 10 of cases

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Hepatitis A Virus

• Transmission in 50 of contacts

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Hepatitis A Virus

• Liver injury in HAV is secondary to immune
  response not to cytopathy

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Hepatitis A Virus

• Presentation
• Incubation period 4 weeks
• Prodrome 1 week
• Jaundice 1 3 weeks
• Hepatomegaly
• Liver enzymes 20 100 time upper normal
• Spontaneous resolution

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Hepatitis A Virus

• Presentation
• Sporadic
• Epidemic
• Endemic

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Geographic Distribution of HAV Infection
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Hepatitis A Virus

• Clinical Presentation in Endemic areas
• 10 of children below 6 years
• 40 of children 6 14 years
• 70 of subjects older than 14 years
• 70 100 of children have been infected

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Hepatitis A Virus

• Epidemic
• Tend to seasonal
• Symptoms as in sporadic cases

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Hepatitis A Virus

• No Chronic Sequelae

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Hepatitis A Virus

• Variants
• Relapsing course up to 1 year
• Cholestatic up to 2 years
• Immune-complex features ( vasculitis,
  arthritis)

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Hepatitis A Virus

• Fatalities
• Secondary to acute hepatic failure
• Less than 2
• More in older children and adults
• When on top of chronic hepatitis

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Hepatitis A Virus

• In Shanghais HVA epidemic, mortality was 5 times
  higher among patients with chronic hepatitis B

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Hepatitis A Virus

• Prevention
• Immunoglobulin
• Vaccination
• ( 2 doses 6 months apart above 1 year of age)

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Hepatitis A Virus

• ? Atopy protect against enteric infection
• including HAV
• P
  N Black Allergy 2005

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Hepatitis B Virus

• Vaccination decreased the incidence of hepatic
  
• carcinoma in children (in adults in future)

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Hepatitis C Virus

• Perinatal transmission about 6
• Elective C/S might lower the risk
• No evidence of risk of breast feeding

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Hepatitis E Virus

• Single Strand RNA
• Feco oral transmission
• Endemic in Tropical and Subtropical countries
• Mortalities 0.2 but as high as 4 in pregnant
  women

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Hepatitis E Virus

• Incubation period 2 9 weeks
• Presentation similar to Hepatitis A
• Diagnosed by Anti HEV IGM serology
• No chronic sequelae reported
• It worsens chronic hepatitis
• No vaccine available yet

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Hepatitis G Virus

• Enveloped RNA virus
• Parental transmission
• Detected by PCR
• 2-39 of non A-E hepatitis
• 16-43 of Fulminant hepatitis
• ? Hepatotropic
• No established serology

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TTV

• Single strand DNA
• Isolated from patients post transfusion (100 )
• Isolated from patients with non A-E Hepatitis
• Presents in health individuals 1 13 (89 )
• ? Feco oral transmission
• ? Normal human viral flora

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SEN Virus

• Single strand DNA virus
• Most recent cause of non A- E Hepatitis
• Found in Blood donors 1- 13
• In 70 of transfused patients
• ? Hepatotropic
• ? Feco oral transmission.

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Etiology

• Infection
• Drugs
• Specific Entities
• Vascular

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Paracetamol

• Commonest cause of acute liver failure in USA
• We all have it at home
• Toxic dose is more than 150 mg /Kg

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Paracetamol

• Need repeated serum drug level
• Follow Rumack-Matthew nomogram
• A point of irreversible liver damage (end stage
  liver disease)
• N-cetylcysteine is the anti-dote
  (oral/intravenous)
• Liver transplant when end stage liver disease

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Etiology

• Infection
• Drugs
• Specific Entities
• Vascular

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Specific Entities

• Wilsons Disease
• A1 Antitrypsin deficiency
• IBD Hepatitis
• Auto-immune Hepatitis
• Syndromatic Diseases
• Metabolic
• Progressive Familial Intrahepatic Cholestasis

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Wilsons Disease

• Autosomal Recessive Disease
• Low cerulplasmin
• Copper deposition in
• liver,
• brain,
• kidneys,
• eyes,
• heart,
• Hemolysis

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Wilsons Disease

• Presents in any of the following
• Acute liver disease
• Chronic liver disease
• Minimal neurological manifestations
• Sever neurological manifestations
• Psychiatric symptoms
• Renal tubular acidosis
• Bony deformities
• Hemolytic anemia

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Wilsons Disease

• An 18 years old male and 19 years female
  reported with Schizophrenic symptoms
• No Kayser -Fleischer ring
• Normal physical examination
• Low cerulplasmin, high serum copper and high 24
  HR urine copper
• Symptoms improved on D Penicillamine
• 
  Patrick Stiller J Psych. Neurosci 2002

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Wilsons Disease

• Liver biopsy and determination of hepatic copper
  is the golden standard for diagnosis of Wilsons
  Disease

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Wilsons Disease

• Diagnosis can be made based on at least two
• of the following
• Low serum Cerulplasmin
• High 24 HR urine copper
• K.F Ring
• 
  Ashish Bavdekar
• 
  J
  Gastr Hepat 2004

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Wilsons Disease

• Treatment
• D- Penicillamine
• Trientine
• Zinc

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Etiology

• Infection
• Drugs
• Specific Entities
• Vascular

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Vascular

• Sickle cell Disease
• Budd - Chiari Syndrome
• Constrictive Pericarditis
• Veno - occlusive disease seen with chemotherapy

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