Case: 11 year child with fatty liver Presenter: Shilpa Hegde

1. 11YEAR OLD WITH FATTY LIVER11YEAR OLD WITH FATTY LIVER
Under guidance of-Dr. Sushant Mane
By-Dr. Shilpa Hegde
JR III
Pediatrics
GGMC & JJ Hospital, Mumbai

2. NAFLD
 11year old boy, 1st
by order of birth, born of non
consanguinous marriage
 c/o- pain in abdomen on & off since 1 year
 abdominal pain localised to right upper quadrant
with dull aching in nature,
 present on & off with no relation to food intake.
 There is no radiation of pain or no aggravating &
relieving factors

3. NAFLD
cont…
 Occasional nausea is present.
 No h/o vomiting, bowel disturbance, jaundice.
For these complaints child has visited several
doctors & he has undergone few lab
investigations & ultrasonography of the
abdomen.

4. NAFLD
 Past history- no h/o long term medication
no h/o previous admission
 Dietary history- h/o burger & pizza intake on
alternate day with carbonated
drinks present
high calorie diet present.
 Family history- obesity present
Type II diabetes mellitus in
both the parents present.
Father has
Hypercholesterolemia.

5. -BMI-31.62 (>97th
%tile)
BP-140/90mmhg (128/87-
99th
percentile)
-Weight- 62kg (>97th
%tile)
-Height- 140cm (25-50th
%tile)

8. Lipomastia
 Waist circumference-78cm(>95th
percentile)

9. NAFLD
cont…
 SMR staging- stage 2 (prepubertal)
 No goitre
 S/E- P/A- soft, non tender
- Liver 3cms palpable, smooth surface with
rounded borders.
consistency- firm
Liver span- 10cm
left lobe not palpable.
 Other S/E- normal

10. NAFLD
Problems in this case…
 Pain abdomen
 Obesity
 Palpable liver (Hepatomegaly: 10cm liver
span)
 Acanthosis nigricans
 Hypertension
 F/H: DM

11. Differntial diagnosis
 Non alcoholic fatty liver disease
 Autoimmune hepatitis
 Drug induced hepatotoxicity
 Hypothyroidism

12. NAFLD
Investigations.
 CBC- normal counts
 LFT-
 INR-1
T.bilirubin 0.7
Direct 0.4
SGOT/PT 78/60
GGT normal
ALP 187
T.Protein 7.1
Albumin 4.1

13. NAFLD
 HOMA IR- 3
Homeostatic Model assessment of Insulin
Resistance
HOMA IR= fasting Insulin X fasting glucose
(mg/dl)
405
Normal range- 1.7-2.5.
 Viral markers- normal
 S. Cortisol- normal
 Thyroid Function Test - normal.

14. NAFLD
 Lipid profile-
Value
(mg/dl)
Normal
range(mg/dl)
percentile
T.
Cholesterol
200 120-201 >95th
HDL 37 25-70 <50th
LDL 142 51-131 >95th
TG 106 45-188 >90th
VLDL 21

15. NAFLD
cont…
 USG abdomen- diffused increased echogenicity
of liver.
-renal cortex appears relatively hypoechoic
compared to liver parenchyma
- normal echogenic walls of portal vein & hepatic
vein.
Findings s/o Grade 1 fatty liver

16. To Summarize
 Obesity, insulin resistance,
Dyslipidemia,Hypertensive
 Strong family history
 Sedentary lifestyle & unhealthy, sugar loaded
diet
 Fatty liver
NAFLD in a setting of Metabolic syndrome.

17.  NAFLD- is it always related to obesity, is
there something else to rule out
in non obese children?

18. NAFLD
 Management:
- Lifestyle modification
-Physical exercise
- Dietary modification

19. NAFLD
USG grading of Fatty Liver
 Mild (Grade1): Minimal diffuse increase in
hepatic echogenity, diaphragm, and intrahepatic
vessel contours seem normal.
 Medium (Grade 2): Medium grade diffuse
increase in hepatic echogenity, mild
deterioration in the image of diaphragm and
intrahepatic vessels.
 Severe (Grade 3): Apparent increase in
echogenity. Posterior segment of the right
hepatic lobe is difficult to display. Intrahepatic
vessel structure and diaphragm contours are
vague or not seen.

20. IDF Consensus Definition of Metabolic
Syndrome in children.
 Age 6 to <10 years
 Obesity > 90th percentile as assessed by waist
circumference
 Metabolic syndrome cannot be diagnosed, but
further measurements should be made if family
history of metabolic syndrome, type 2 diabetes
mellitus, dyslipidaemia, cardiovascular disease,
hypertension, or obesity
 IDF suggests that a strong message for weight
reduction should be delivered for those with
abdominal obesity

21. cont…
 Age 10 to <16 years
 Obesity > 90th percentile (or adult cut-off if
lower) as assessed by waist circumference
 Triglycerides > 1.7 mmol/L (>150mg/dl)
 HDL-cholesterol <1.03 mmol/L( <40mg/dl)
 Blood pressure > 130 mm Hg systolic or >85
mm Hg diastolic
 Glucose > 5.6 mmol/L (100mg/dl) (oral glucose
tolerance test recommended) or known type 2
diabetes mellitus