Abdominal Pain, Jaundice & Abnormal Liver Function Tests - PowerPoint Presentation

1. Abdominal Pain, Jaundice & Abnormal Liver Function Tests

2. An 8-year-old boy presents with three days history of abdominal pain lasting ~20 min. It occurs before breakfast & sometimes at school, where it will generally pass when he busies himself with activities. He has a tendency to constipation. His pains worsen when faced with tests at school or other stressors. Exam is normal.

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5. What Are The Signs &Symptoms Of ORGANIC Abdominal Pain?

6. Alarm features suggesting organic causes 1-Symptoms-Persistent RU or LQ pain-Pain causing nocturnal waking-Dysphagia or persistent vomiting -Nocturnal diarrhea-GI blood loss-FHx of IBD,CD,PUD2-Signs-Unexplained fever-Wt loss or deceleration of linear growth , delayed puberty -Arthritis-Perianal disease

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8. Diagnostic Approach to Acute Abdominal Pain History Onset Sudden or gradual, prior episodes, association with meals, Hx of injury Nature Sharp versus dull, colicky or constant, burning Location Epigastric, periumbilical, generalized, Rt or Lt lower quadrant, change in location over time Fever Presence suggests appendicitis or other infection Extra-intestinal symptoms Cough, dyspnea, dysuria, urinary frequency, flank pain Course of symptoms Worsening or improving, change in nature or location of pain. Physical Exam. General growth & nutrition, general appearance, hydration, degree of discomfort, body position Abdominal tenderness, distention, bowel sounds, rigidity, guarding, mass Genitalia Testicular torsion, hernia, PID, ectopic pregnancy Surrounding structures Breath sounds, rales, rhonchi, wheezing, flank tenderness, tenderness of abdominal wall structures, ribs, costochondral joints PR exam. Perianal lesions, stricture, tenderness, fecal impaction, blood Laboratory CBC, CRP, ESR Evidence of infection or inflammation AST, ALT, GGT, bilirubin Biliary or liver disease .Amylase, lipase Pancreatitis. GUE UTI , bleeding due to stone, trauma, or obstruction Pregnancy test (older females) Ectopic pregnancy .Radiology Plain flat & upright abdominal films Bowel obstruction, appendiceal fecalith, free intraperitoneal air, Renal stones . CT scan Rule out abscess, appendicitis, Crohn disease, pancreatitis, gallstones, renal stones .Ba. enema Intussusception, malrotation U\S Gallstones, appendicitis, intussusception, pancreatitis, Renal stones Endoscopy Upper endoscopy Suspected peptic ulcer or esophagitis

9. DiseaseOnsetLocationReferralQualityCommentsFunctional: irritable bowel syndromeRecurrentPeriumbilical, splenic and hepatic flexuresNoneDull, crampy, intermittent; duration 2 hrFamily stress, school phobia, diarrhea & constipation; hypersensitive to pain from distentionEsophageal refluxRecurrent, after meals, at bedtimeSubsternalChestBurningSour taste in mouth; Sandifer syndromeDuodenal ulcerRecurrent, before meals, at nightEpigastricBackSevere burning, gnawingRelieved by food, milk, antacids; family history important; GI bleedingPancreatitisAcuteEpigastric-hypogastricBackConstant, sharp, boringNausea, emesis, marked tendernessIntestinal obstructionAcute or gradualPeriumbilical-lower abdomenBackAlternating cramping (colic) and painless periodsDistention, obstipation, bilious emesis, increased bowel soundsAppendicitisAcutePeriumbilical or epigastric; localizes to right lower quadrantBack or pelvis if retrocecalSharp, steadyNausea, emesis, local tenderness, ± fever, avoids motionMeckel diverticulumRecurrentPeriumbilical-lower abdomenNoneSharpHematochezia; painless unless intussusception, diverticulitis, or perforationInflammatory bowel diseaseRecurrentDepends on site of involvementDull cramping, tenesmusFever, weight loss, ± hematocheziaIntussusceptionAcutePeriumbilical-lower abdomenNoneCramping, with painless periodsGuarded position with knees pulled up, currant jelly stools, lethargyLactose intoleranceRecurrent with milk productsLower abdomenNoneCrampingDistention, gaseousness, diarrheaUrolithiasisAcute, suddenBackGroinSevere, colicky painHematuriaPyelonephritisAcute, suddenBackNoneDull to sharpFever, costochondral tenderness, dysuria, urinary frequency, emesisCholecystitis and cholelithiasisAcuteRight upper quadrantRight shoulderSevere, colicky painHemolysis ± jaundice, nausea, emesis

10. FeatureCrohn DiseaseUlcerative ColitisMalaise, fever, weight lossCommonCommonRectal bleedingSometimesUsualAbdominal massCommonRareAbdominal painCommonCommonPerianal diseaseCommonRareIleal involvementCommonNone (backwash ileitis)StricturesCommonUnusualFistulaCommonVery rareSkip lesionsCommonNot presentTransmural involvementUsualNot presentCrypt abscessesVariableUsualIntestinal granulomasCommonRarely presentRisk of cancerIncreasedGreatly increasedErythema nodosumCommonLess commonMouth ulcerationCommonRareOsteopenia at onsetYesNoAutoimmune hepatitisRareYesSclerosing cholangitisRareYesComparison of Crohn Disease & Ulcerative Colitis

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13. StudiesInterpretationBlood TestsCBC with WBC differentialAnemia, elevated platelets suggest IBDESRElevated in many, but not all, IBD patientsC-reactive proteinElevated in many, but not all, IBD patientsASCAFound in most CD patients and few UC patientsAtypical p-ANCAFound in most UC patients and few CD patientsAnti-OmpCFound in some UC and CD patients, rare in non-IBDImaging StudiesUpper GI series with SBFTEssential to rule out ileal & jejunal CDCT scanUsed to detect abscess, small bowel involvementTagged WBC scanSometimes helpful in determining extent of diseaseEndoscopyUpper endoscopyEvaluate for CD of esophagus, stomach, & duodenum; obtain tissue for histological DxColonoscopyShow presence or absence of colitis & terminal ileal CD; obtain tissue for histologyCapsule endoscopyEmerging role in Dx of small bowel CD, more sensitive than upper GI series with SBFTDiagnostic Studies for Inflammatory Bowel DiseaseAnti-OmpC, antibody to outer membrane protein C; ASCA, anti-Saccharomyces cerevisiae antibody; atypical p-ANCA, atypical perinuclear staining by antineutrophil cytoplasmic antibody; CBC, complete blood count; CD, Crohn disease; ESR, erythrocyte sedimentation rate; GI, gastrointestinal; IBD, inflammatory bowel disease; SBFT, small bowel follow-through; WBC, white blood cell

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17. VIROLOGYHAV RNAHBV DNAHCV RNAHDV RNAHEV RNAIncubation (days)15-1960-18014-16021-4221-63Transmission• ParenteralRareYesYesYesNo• Fecal-oralYesNoNoNoYes• SexualNoYesYesYesNo• PerinatalNoYesRareYesNoChronic infectionNoYesYesYesNoFulminant diseaseRareYesRareYesYesFEATURES OF THE HEPATOTROPIC VIRUSES

18. HAVHBVHCVHDVHEVACUTE INFECTIONAnti-HAV IgMAnti-HBc IgMAnti-HCVAnti-HDV IgMAnti-HEV IgMBlood PCR positiveHBsAgAnti-HBsHBV DNA (PCR)HCV RNA (PCR)Blood PCR positiveHBsAgAnti-HBsBlood PCR positivePAST INFECTION (RECOVERED)Anti-HAV IgGAnti-HBsAnti-HBc IgGAnti-HCVBlood PCR negativeAnti-HDV IgGBlood PCR negativeAnti-HEV IgGBlood PCR negativeCHRONIC INFECTIONN/AAnti-HBc IgGHBsAg+Anti-HBsPCR positive or negativeAnti-HCVBlood PCR positiveAnti-HDV IgGBlood PCR negativeHBsAg+N/AVACCINE RESPONSEAnti-HAV IgGAnti-HBsAnti-HBcN/AN/AN/ADIAGNOSTIC BLOOD TESTS: SEROLOGY AND VIRAL PCRRises in serum levels of ALT, AST, bilirubin, ALP, 5′-nucleotidase, and GGT are almost universally found and do not help to differentiate the cause of hepatitis

19. The serologic course of acute hepatitis A. ALT, alanine aminotransferase; HAV, hepatitis A virus. (From Goldman L, Ausiello D: Cecil textbook of medicine, ed 22, Philadelphia, 2004, Saunders, p 913.)

20. The serologic course of acute hepatitis B. HBc, hepatitis B core; HBeAg, hepatitis B e antigen; HBs, hepatitis B surface; HBsAg, hepatitis B surface antigen; HBV, hepatitis B virus; PCR, polymerase chain reaction.(From Goldman L, Ausiello D: Cecil textbook of medicine, ed 22, Philadelphia, 2004, Saunders, p 914.)

21. The serologic course of acute hepatitis C. ALT, alanine aminotransferase; HCV, hepatitis C virus; PCR, polymerase chain reaction.(From Goldman L, Ausiello D: Cecil textbook of medicine, ed 22, Philadelphia, 2004, Saunders, p 915.)

22. Natural history of hepatitis B virus infection. HCC, hepatocellular carcinoma; OLT, orthotopic liver transplant

23. VACCINE DOSESCHEDULERecombivax HB (µg)Engerix-B (µg)UNIVERSAL PROPHYLAXISInfants of HBsAg− women510Birth, 1-2, 6-18 moChildren & adolescents (11-19 yr)5100, 1, and 6 moPOSTEXPOSURE PROPHYLAXIS IN SUSCEPTIBLE INDIVIDUALSContact with HBsAg-Positive SourceInfants of HBsAg+ women510Birth* (+HBIG[†]), 1 and 6 moIntimate Or Identifiable Blood Exposure0-19 yr old510Exposure (+HBIG[†]), 1 and 6 mo>19 yr old1020Exposure (+HBIG[†]), 1 and 6 moHousehold0-19 yr old510Exposure, 1 and 6 mo>19 yr old1020Exposure, 1 and 6 moCasualNoneNoneNone Immunocompromised]4040Exposure (+HBIG[†]), 1 and 6 moContact with Unknown HBsAg Status; Intimate or Identifiable Blood Exposure>19 yr old1020Exposure, 1 and 6 moImmunocompromised[‡]4040Exposure (+HBIG[†]), 1 and 6 moIndications And Dosing Schedule For Hepatitis B Vaccine And Hepatitis B Ig Both HBIG & vaccine should be administered within 12 hr of the infant's birth & within 24 hr of identifiable blood exposure. HBIG can ,HBIG dose: 0.5 µL for newborns of HBsAg-positive mothers, and 0.0 6 µL/kg for all others when recommended be given up to 14 days after sexual exposure Seroconversion status of immunocompromised patients should be checked 1-2 mo after the last dose of vaccine, and yearly thereafter. Booster doses of vaccine should be administered if the anti-HBs titer is <10 mIU/mL. Nonresponsive patients should be considered at high risk for HBV acquisition and counseled about preventive measures

24. Natural history of hepatitis C virus infection. HCC, hepatocellular carcinoma; OLT, orthotopic liver transplant.(From Hochman JA, Balistreri WF: Chronic viral hepatitis: always be current! Pediatr Rev 24:399–410, 2003.)

25. A 6-wk-old baby girl presents with jaundice since 2 wks. She is deeply jaundiced & has a 4-cm liver BCM. She is feeding well & gaining wt, continuing along the 50th centile. The stools are pale. An ultrasound scan shows no gall bladder. Alanine aminotransferase (ALT) is 300 U/L, Glutamyl transferase (GGT) 290 U/L, alkaline phosphatase (ALP) is 600 U/L & conjugated bilirubin is 14mgldL

26. Neonatal cholestasis. Conceptual approach to the group of diseases presenting as cholestasis in the neonate. There are areas of overlap: pts with biliary atresia might have some degree of intrahepatic injury. Pts with “idiopathic” neonatal hepatitis might, in the future, be determined to have a primary metabolic or viral disease

27. TESTRATIONALESerum bilirubin fractionation (i.e., assessment of the serum level of conjugated bilirubin)Indicates cholestasisAssessment of stool color (does the baby have pigmented or acholic stools?)Indicates bile flow into intestineUrine & serum bile acids measurementConfirms cholestasis; might indicate inborn error of bile acid biosynthesisHepatic synthetic function (albumin, coagulation profile)Indicates severity of hepatic dysfunctionα1-Antitrypsin phenotypeSuggests (or excludes) PiZZThyroxine & TSHSuggests (or excludes) endocrinopathySweat chloride & mutation analysisSuggests (or excludes) cystic fibrosisUrine & serum amino acids & urine reducing substancesSuggests (or excludes) metabolic liver diseaseUltrasonographySuggests (or excludes) choledochal cyst; might detect the triangular cord (TC) sign, suggesting biliary atresiaHepatobiliary scintigraphyDocuments bile duct patency or obstructionLiver biopsyDistinguishes biliary atresia; suggests alternative diagnosisValue Of Specific Tests In The Evaluation Of Patients With Suspected Neonatal Cholestasis

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29. Radioisotope scan (TBIDA) of liver showing good hepatic uptake of isotope and no excretion into bowel. This scan suggests extrahepatic biliary obstruction or atresia or severe intrahepatic cholestasis

30. Shortly after successful bile drainage by hepatoportoenterostomy (Kasai procedure) for biliary atresia

31. *Select patients with abdominal pain who require emergency Tx.*Elicit clinical findings which are key to establishing the most likely source of the pain.*Differentiate acute from chronic pain & organic from functional*Interpret abdominal x-rays*Conduct an effective plan of Mx for a pt with AP *Determine which pts have significant liver dysfunction & its cause*Differentiate between the causes of jaundice .*immunization status, past & FHx. *Discuss abnormal LFT in the context of the clinical presentation, & select pts requiring medical Mx.*Outline the epidemiology & natural Hx of viral hepatitis: Learning objectives

32. Learning Objectives:*Differentiate between the causes of jaundice & determine if treatable; ask about drugs,hepatitis risk factors & immunization status, past & FHx , travel, toxic exposure.* Describe & demonstrate complications related to the presence of liver disease.* List and interpret critical clinical & lab. findings which were key in the processes of exclusion,differentiation, & diagnosis. *Select & interpret an appropriate investigation for pts with jaundice (e.g., liver enzymes. *Order and interpret a blood smear in pts with unconjugated hyperbilirubinemia. *List the indications for an abdominal U\S, spiral CT, MRI, ERCP& PTC. *Conduct an effective plan of Mx for a pt with jaundice: *Outline a Mx plan for common causes of jaundice. *Outline a Mx plan for pts with acute hepatic failure. *Select pts in need of specialized care and/or in need of urgent hospitalization.

33. THANKS