1. Paediatric liver conditions Present with combinations of the following symptoms and signs
Jaundice
Encephalopathy (altered consciousness or behaviour)
Bleeding tendency
Abdominal distension and ascites
Hepatomegaly and/or hepatosplenomegaly

2. Paediatric Liver Conditions
Persistent Neonatal Jaundice
Hepatomegaly and hepatosplenomegaly
Acute onset jaundice
Acute liver failure
Ascites
Chronic liver disease
Chronic hepatitis
Hepatic schistosomiasis
Veno-occlusive disease
Cirrhosis
Portal hypertension

3. Neonatal jaundice Failure to clear bilirubin
Excess production of bilirubin
Liver immaturity
Liver disease/involvement in disease
Obstruction to bile flow
Persistence beyond 10 days to 2 weeks

4. Approach to neonatal jaundice
Onset day 1
Haemolytic disease
Intrauterine infection
Prematurity
Evaluation
Examine : Pale? splenomegaly? Heart failure? Other signs of illness
Tests : FBC, Coombs, Blood groups, TSB,
Cultures, TORCHeS

5. Approach to neonatal jaundice
Onset after day 2
Physiological jaundice
Haemolysis
Jaundice of immaturity
Infection
Evaluation
Examine:GA?, well?, pallor?, splenomegaly?
Tests: FBC, TSB, Blood groups, Urine dipstix, possible cultures for infection

6. Approach to neonatal jaundice
Onset after day 3 – 5
Infection (UTI, Sepsis)
Neonatal hepatitis
Metabolic disease
Biliary atresia
Breast milk jaundice
Evaluation
Examination: careful search for infection, liver? Stool colour?
Tests: FBC, CRP, TSB/conjugated, Urine, B/C, TORCHeS, Urine Clinitest, TFT, Stool bile pigments, LFT’s

7. Approach to neonatal jaundice
Jaundice persisting beyond 10 days
Neonatal hepatitis
Biliary obstruction/atresia
Metabolic disease
Breast milk jaundice
Infection (congenital/acquired)
Evaluation
Examination:Well?, liver and spleen?, Stool appearance?
Tests: TSB/conjugated, FBC, CRP, LFT’s, TFT, Urine mcs and clinitest, TORCHeS and Hepatitis viruses, Stool for bile pigment
Early referral of obstructive jaundice

8. Persistent neonatal jaundice
Failure to conjugate : Unconjugated
Haemolysis
Genetic
Hypothyroidism
Conjugated hyperbilirubinaemia (20%)
Liver disorder
Bile obstruction

9. Conjugated Hyperbilirubinaemia
Identifiable infections
TORCHES, sepsis, UTI
Metabolic conditions
Galactosaemia, 1Antitrypsin def.
Neonatal hepatitis syndrome
Idiopathic neonatal cholestasis
Intrahepatic biliary obstruction
Extrahepatic biliary obstruction
Biliary atresia, choledochus cyst

10. Hepatomegaly Inflammation Infection, Auto-immune,
Toxic and drug reactions
Reticulo-endothelial hyperplasia
Septicaemia, HIV, granulomata
Venous congestion
CCF, Constrictive pericarditis,
Hepatic vein/IVC obstruction

11. Hepatomegaly Infiltrations and neoplasia Extramedullary haemopoiesis
Leukaemia, lymphoma, hepatoma
Fat accumulation
Malnutrition, toxic damage
Storage disorders
Glycogen, lipid, mucopolysaccharides

12. Hepatosplenomegaly Same cause for both organs to be enlarged
Reticulo-endothelial hyperplasia, sepsis
Spleen enlarged secondary to liver
Portal hypertension
Spleen enlargement more significant than liver
Parasitic disease
Haematological and RES disorders

13. Investigation of liver disease
History
Feeding
Stooling
Abdominal pain
Previous illnesses of all relevant organ systems and progress
Examination
Growth and nutritional state
Careful inspection, palpation, percussion
Stool examination

14. Investigation II
Ultrasonography
Organ sizes and appearance
Free fluid
Masses
Specialized investigations for specific indications

15. Abdominal distension Definition
Abdominal wall on a higher plane than the xiphisternum in patients lying on their back on a straight firm surface
Normal lordotic posture giving appearance of pot-belly when standing up

16. Abdominal Distension Fluid Gaseous distension Faeces retention
Organ enlargement including bladder
Inflammatory masses
Tumours
Pregnancy

17. Abdominal Distension Gut distensibility Omentum Food Air/gas
Unabsorbed fluid contents
Omentum
Fat
Lymph nodes
Ascites fluid

18. Abdominal Distension Liver Span at different ages
Normal size measurements
Edge below the costal margin
Span of dullness to percussion in midclavicular line
Normal span varies with age
Relatively bigger liver in young children relative to body size
Span at different ages
4.5 – 5 cm at 1 week of age
7 – 8 cm at 12 years (boys)
6 – 6.5 cm at 12 years (girls)

19. Fluid in the abdomen Fluid in the bowel Ileus
Gut disease with secretion/absorption abnormalities
(May show shifting dullness, but not fluid thrill)
Fluid in the peritoneal cavity (ascites)

20. Ascites Exudate High protein content usually > 30g/l
Inflammatory cells
Transudate
Protein : serum protein ratio <0.5
Blood
Chyle
Milky fluid, lymphocytes

21. Ascites Lymphatic obstruction TB, congenital, neoplastic
Raised intravascular hydrostatic pressure
portal hypertension
Decreased intravascular oncotic pressure
hypoalbuminaemia
Inflammation and increased permeability
peritonitis

22. Abdominal Distension Organomegaly Masses and Tumours Liver Spleen
Kidneys
Bladder
Masses and Tumours
Kidney
Adrenal
Lymphoma
Retroperitoneal