2. Jaundice in Children Abdulwahab Telmesani FRCPC,FFAP Faculty of Medicine and Medical Science Umm Al-Qura University

3. An Approach to a Child With Direct Hyperbilirubinemia

4. Classic Approach Proper detailed history Proper physical examination Formalize an impression of prioritized DDx Appropriate investigations

5. Identify Acute Chronic (more than 6 months)

6. In Children Acute Chronic (more than 6 months)

7. Identify Hepatocellular Chlestatic

8. In Children Hepatocellular (ALT/AST more than twice of ALP) Cholestatic (ALT/AST less than twice of ALP)

9. Remember The prognostic value of Albumin Coagulation profile

10. Etiology Infection Drugs Specific Entities Vascular

11. Etiology Infection Drugs Specific Entities Vascular

12. Infections Viral Bacterial Parasitic

13. Viral Hepatitis Hepatotropic Virus’s (replicate in the liver and causes hepatitis) Others

14. Hepatotropic Viruses HBV (10-20% Chronic active hepatitis) HCV (70-80% Chronic active hepatitis)

15. Hepatotropic Viruses Non B / C Viral Hepatitis HAV HEV HFV HGV TTV SEN

16. Others EBV CMV Herpes Other

17. Hepatitis A Virus Most common cause of community acquired hepatitis through out the world

18. Hepatitis A Virus RNA Picorna Virus (Rhinovirus, Enterovirus, Cocxackievirus) Feco - oral transmission (Food – borne +/- Water – borne) Day care centers account for 10% of cases

19. Hepatitis A Virus Transmission in 50% of contacts

20. Hepatitis A Virus Liver injury in HAV is secondary to immune response not to cytopathy

21. 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

22. Hepatitis A Virus Presentation Sporadic Epidemic Endemic

23. Geographic Distribution of HAV Infection

24. 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

25. Hepatitis A Virus Epidemic Tend to seasonal Symptoms as in sporadic cases

26. Hepatitis A Virus No Chronic Sequelae

27. Hepatitis A Virus Variants Relapsing course up to 1 year Cholestatic up to 2 years Immune-complex features ( vasculitis, arthritis…)

28. Hepatitis A Virus Fatalities Secondary to acute hepatic failure Less than 2 % More in older children and adults When on top of chronic hepatitis

29. Hepatitis A Virus In Shanghais HVA epidemic, mortality was 5 times higher among patients with chronic hepatitis B

30. Hepatitis A Virus Prevention Immunoglobulin Vaccination ( 2 doses 6 months apart above 1 year of age)

31. Hepatitis A Virus ? Atopy protect against enteric infection including HAV P N Black Allergy 2005

32. Hepatitis B Virus Vaccination decreased the incidence of hepatic carcinoma in children (in adults in future)

33. Hepatitis C Virus Perinatal transmission about 6% Elective C/S might lower the risk No evidence of risk of breast feeding

34. 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

35. 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

36. 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

37. 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

38. 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.

39. Etiology Infection Drugs Specific Entities Vascular

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

41. 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

42. Etiology Infection Drugs Specific Entities Vascular

43. Specific Entities Wilson’s Disease A1 Antitrypsin deficiency IBD Hepatitis Auto-immune Hepatitis Syndromatic Diseases Metabolic Progressive Familial Intrahepatic Cholestasis

44. Wilson’s Disease Autosomal Recessive Disease Low cerulplasmin Copper deposition in; liver, brain, kidneys, eyes, heart, Hemolysis

45. Wilson’s 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

46. Wilson’s 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

47. Wilson’s Disease Liver biopsy and determination of hepatic copper is the golden standard for diagnosis of Wilson’s Disease

48. Wilson’s 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

49. Wilson’s Disease Treatment; D- Penicillamine Trientine Zinc

50. Etiology Infection Drugs Specific Entities Vascular

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