Hepatic Encephalopathy with Hepatic Failure and Hepatorenal Syndrome

A boy of 2 years and 3 months presented with deep jaundice, in semiconscious condition and with bleeding per rectum.

When asked mother said that he developed jaundice I month back from which he gradually recovered. Then he was given antihelmenthic 3 days back after which his condition deteriorates
On examination, he was found to be deeply jaundiced with oedema and ascites.
On admission pulse was 126/m, BP 90/60 mmHg, temperature 102.5, respiratory rate 50/m, liver was not palpable.

On investigation, his Hb was 11.5 gm/dl(on admission), TLC-15200/cmm, N-78%, L-12%, bilirubin 28.8 mg/dl, direct 12.7, indirect-16.1, SALT 342 U/L , Alkaline phosphatase 487U/L , HBsAg negative, Prothrombin time 60 sec with control 22 sec, ratio 4.28, Index 23.3%, INR 5.56 Serum Albumin 3.4gm/dl. Random blood sugar 42.8 mg/dl, Serum creatinine .6 mg/dl, serum electrolytes-normal.

Patient was progressively deteriorating, develops convusions and anuria

Patient is labeled as Hepatic Encephalopathy with Hepatic failure and Hepatorenal Syndrome

The patient is kept on parental fluid, oxygen, antibiotics, lactoluse, konakion, pulv streptomycin, Inj Mannitol and blood , domamine etc.

The patient is fighting for his life.

[Note: When the liver in hepatitis patient regresses in size, it indicates grave sign and poor prognosis
Recovery from hepatorenal syndrome is also difficult
When Hepatic Encephalopathy is grade IV, mortality is also high]


Badrud Doza

Enteric fever with hepatitis and ASD

A 7 year old child from Sandvip, an Island west of Chittagong came to our hospital with fever for 22 days, jaundice and abdominal pain.

On examination, his jaundice was moderate, abdomen was tender on the epigastric, right lumber and Rt hypochondriac region. His liver was 5 cm enlarged, tender.

Ausculatation of the heart reveals a murmur which is systolic in nature at the left upper sternal border.

We thought it could be a) a case of Infective Endocarditis out of a noncyanotic congenital heart disease
b) Enteric fever with hepatitis
c) Hepatic abcess


We started treating the patient with Injection Ceftrixone and Inj penecillin.

In the meantime , the investigation reveals normal widal test, normal blood culture and X-ray shows mild cardiomegaly and Echocardiography suggests ASD.

The fever started to subside and sense of wellbeing improved on the 4th day and by 9th day, the patient become afebrile.

After review, we settled our final diagnosis as Enetric Fever with hepatitis and ASD.

Acute Hepatitis induced by prolonged use of Sodium Valproate

She has developed jaundice for the last 7 days. She is 4 and 7 months of age. No other complaints. No fever, no nausea or vomiting. even no abdominal pain, only anorexia.
But she was taking Sodium Valproate (Sup Valex) for the last 4 years. She was given this drug after convulsions at the age of 6 months. Since then she had no further convulsion and continued to take the medicine till date. She was vaccinated in infancy against Hepatitis B.

On examination, the patient was found moderately icteric.Liver was enlarged 8 cm, mildly tender. Other systems were normal.

Serum bilirubin was found 5.3 mg/dl, SGPT 535 IU/dl, Alkaline phosphatase 1388 IU/dl. Her HBsAg was found negative, prothrombin time normal.
Ultrasonography was consistent with Acute inflammation of the liver.

We conclude this could be a case of Acute Hepatitis induced by prolonged use of Sodium Valproate.
We withdrew the drug.,admit the patient in the hospital for better observation.
Patient was gradually improving. After 7 days, we repeat the Liver Function test. The Serum bilirubin come down to 1.3 mg/dl, SGOT 57 IU/dl, Alkaline Phosphatase 103 IU/dl.

Patient was discharged with advice to come after 7 days for follow up.


Bdoza

Thalassemia with jaundice

At this momont, we have two patients of thalassemia with jaundice. Both are male, age 7 yrs, both are from poor socioeconomic class and both are thalassemia intermedia.
The first case has taken blood transfusion 1 year back, the second case was on hydroxyurea.
Both are HBsAg negative.
The first one develops jaundice due to acute hepatitis-nonB virus.In second the jaundice is induced by the hepatoxicity of the hydroxyurea.