1. Liver Enzymes

5. Normal Value of Alkaline Phosphatase
according to the age for Girls

6. Screening
• CMP, GGT, Lipid profile, Liver Function Test:
Alkaline phosphatase, ALT, AST, Bilirubin,
• HbA1c, Insulin, THS and T4
• Biometric information; Weight, Height, BMI,
Waist and hip circumference and Percentage of
body fat
• Blood pressure
• Ultrasound of the liver if altered liver enzymes, or
complaining of RUQ pain or discomfort

7. Criteria for screening for liver disease
• Persistent Overweight BMI 85 to 90 %tile
• BMI above 95 %tile
• Rapid Increase in BMI no matter where it
starts
• Family history of Lipid disorder, liver or
gallbladder disease and Diabetes
• RUQ or epigastric discomfort

8. 8
11
20
27
0
5
9 9
0
5
10
15
20
25
30 Oct-10
Nov-10
Dec-10
Jan-11
Feb-11
Mar-11
Apr-11
May-11
Jun-11
Jul-11
Aug-11
Sep-11
Time table chart of GB disease follow up
total
male
female
Surgery

9. Fatty Liver by Ultrasound
• Ultrasound requested for all altered liver
enzymes
•467 Liver Ultrasound performed 25.6%
•217 patients Positive for fatty liver 46.6%
•5.8 % of total ultrasound positive for GB
disease and reflect 1.48% of our total
patient population

10. 0
10
20
30
40
50
60
70
80
90
Normal
liver ENZ
Alkaline
Phos.
AST ALT GGT Bilrirubin
≥99
95-98
85-90
NORMAL
Male
0
10
20
30
40
50
60
70
80
90
Normal
liver ENZ
Alkaline
Phos.
AST ALT GGT Bilrirubin
≥99
95-98
85-90
NORMAL
Female
Live Enzymes Value
according to the BMI

11. Figure 1. Normal appearance of the liver at US. The echogenicity of the liver is equal to or
slightly greater than that of the renal cortex (rc).
Hamer O W et al. Radiographics 2006;26:1637-1653
©2006 by Radiological Society of North America

12. Screening for Fatty Liver
The most effective
non-invasive method
is abdominal
ultrasound

13. BMI Male
# of Patient
# U/S
request
% Positive
FL
Female
# of
Patient
# U/S
request
% Positive
FL
NR 158 6 0 199 9 0
Risk 191 41 36.6 263 26 23.0
≥ 95 132 31 45.2 105 25 40.0
≥ 97 234 92 45.5 200 59 54.2
≥ 99 210 105 55.2 132 73 46.6
Total 925 275 50.5 899 192 42.7
Fatty Liver Reported to Laredo Pediatrics & Neonatology
2003-2010

15. Gall Bladder Disease
56 cases collected ( plus 6 HEN)
57% Male /43% Female (4 HEN Boys and 2 Girls)
Average age 13.76
46.6% fatty liver positive
5.8 % of total ultrasound positive for GB disease,
and represents1.48% of total patients in the study
34% of all GB disease BMI% 99 or over
98% of the cases BMI% ≥85

16. Abnormal U/S Reports and Outcomes
2012

19. Normal Findings of HB Scan
• Hepatocytes take up the
radiopharmaceutical in minutes after
injection
• Hepatic ducts seen in fifteen minutes
• Gallbladder seen within 45 to 60 miutes
• GBEF >40
• Small intestine seen by 30 minutes

21. This test examines the gallbladder and the ducts which connect to the liver.
DISIDA (Hepatobiliary) Scan

22. Acalculus Cholecystitis in Boys
2011-2012

23. Acalculus Cholecystitis in Girls
2011-2012

26. Surgical Gallbladder Cases
• 404 in 4,000,000 in 4 years = 1 in 40,000 per
year at Texas Children’s Houston (2005-2008)
73% women
• 11 in 2000 in 1 yr = 1 in 200 per year at Laredo
Pediatrics (2010 -2011) 63% women
• 8 other reported at local pediatric meetings

27. Criteria for screening for Gall bladder disease
•Persistently Abnormal liver enzymes
•Acute or persistent epigastric or non-
specific abdominal pain, postprandial
•Rapid decline in BMI
•Family history of Gall bladder disease
• persistently elevated GGT or Total
Bilirrubin

28. Diagnosis of Fatty Liver
The most effective Diagnostic
method for FL is Liver Biopsy
(Gold Standard)

29. Conclusion
•The Latest data suggest that 16% of children in
the United States are obese and 32% are
overweight. Therefore concern about prevalence
of NAFLD or NASH is appropriate
•The studies recognized rapid progression of
fibrosis in children with NAFLD/NASH over short
period of time. Therefore early detection is
warrant
•Although gallbladder disease is relatively
uncommon in the pediatric population, the rate
has increased in the past 10 years.
•Pediatric gallbladder disease was commonly
associated with hemolytic diseases or
hemoglobinopathies; however, now other factors
are recognized.

30. Conclusion
•Incidence of Gallbladder disease is on the rise on
overweight children.
•Gallbladder disease should be in the differential
diagnosis of any pediatric patient who presents with
localized pain in the epigastric, RUQ or ill-defined,
Jaundice or dyspepsia and asymptomatic patients with
BMI of ≥85
•Consider Liver ultrasound as primary tool over
more expensive and invasive procedures
•HB Scan helps identify adequate GB function

32. Hippocrates Master of Medicine:
460-377 B.C
“Thus Curiosity, Keenness of observation
and the value of scrupulous record
keeping became paramount priorities in
the new philosophy of Care”
Sherwin B Nuland describing Hippocrates Influence on Medicine