A crisp case discussion on biliary atresia

1. Case Discussion
PRESENTER- DR.SHIVANJAN GOYAL (JR3)
DR. DATTA MADAVI (JR3)
MENTOR – DR. SANGEETA CHIVALE

2. History
• A 3 months old female child ,r/o Latur, B/O of non consanguineous marriage,
belonging to hindu community, 2nd by birth order, history given by mother with
chief complaints of
a) White colored stools since DOL 3
b) Yellowish discolouration of eyes and body since 1 month

3. History Of Presenting Illness
• Child on day of life 3 started to pass white coloured stools after passing greenish black stool
for first two days.
• 4-5 times per day
• Semi solid consistency
• Foul smelling
• Not associated with any blood and mucus.
• As baby was feeding well and no other complaints were there so parents did not consult any
doctor.

4. • On DOL 8 mother noticed while changing diaper that child had a mass protruding from
the abdomen in the umbilical area which was progressively increasing, increased on
crying and decreased when the child was resting. NO redness or discharge was
present.
• At age of 2 months parents initially noticed mild yellowish discoloration of the eyes
which gradually progressed in intensity and involved the entire body including palms
and soles.
• Mother also noticed dark yellow colored staining of diaper since then.

5. Course In Ward
• Child still having yellowish discolouration of the eyes and body including palms
and soles same as it was there at the time of admission. On breast feeds and
accepting well orally. Adequate weight gain +
• Clay coloured stool+
• Yellow diaper staining +
• Investigations done which will be discussed later.

6. Negative history
There is no history of
• Fever
• Vomiting
• Refusal to feed
• Lethargy
• Constipation
• Abnormal body movements
• Bleeding from any site
• Abdominal distension
• Blood transfusions

7. Birth history
a) Antenatal history-
• 1st trimester – h/o cough ,cold , fever + but no rash for which mother was admitted
for 4 days i/v/o viral URTI.
• Mother’s blood group – B +ve
• No other drugs other than iron and folic acid taken
• h/o decreased blood supply to baby in utero in the third trimester.

8. • Perinatal History-
• FT/LSCS ( I /v/o fetal distress )/ BCIAB.
• Birth weight = 2.5 kg
• No h/o nicu stay, child breast fed immediately after birth.
• Child was discharged after 3 days from the hospital.
Immunization History-
Child is Immunized till age of 6 weeks as per NIS.
Developmental History-
neck holding , social smile and cooing +
IMP- Developmentally normal as per age

9. Dietary History
1. Exclusive breast feeding on demand.
2. Passes urine 6-7 times /day
3. Passes stool 4-5 times/day
4. No h/o of cow’s milk or formula milk feeding
• Total calorie intake- approx. 638 kcal (Req calorie -100kcal/kg/day)
• Proteins intake- approx 6 g ( Req protein – 2g/ kg/ day)

10. Family History
• No similar complaints in the family
• Elder sibling had a history of umbilical hernia which resolved after 6
months.

11. Socioeconomic History
Housing Condition
• Type- Pukka
• No overcrowding
• Adequate ventilation
• Tap water with water cleaning facility +
• Sanitation good
Head of family father
Education- graduate
Occupation- shopkeeper
Income- Rs 15000/month
MKS class 4 (upper lower)

12. ANTHROPOMETRY
• Weight- 5.2 KG (0 TO-1 SD)
• Length = 59CM (0 TO -1 SD)
• HC = 37 CM ( -2 TO -3 SD)
• Wt/Length = -1 TO -2 SD
• IMP- Normal

13. Summary
3month old Fch B/o NCM, 2nd in birth order, R/o Latur, with complaints of clay
colored stools since DOL3 and yellowish discoloration of eyes and body since
last one month with adequate weight gain with normal development , incompletely
immunized, belonging to upper lower class with no symptoms s/o liver cell failure most probably
neonatal cholestasis.
Differential diagnosis-
Biliary atresia
Choledochal cyst
Idiopathic neonatal hepatitis
Hypothyroidism
TORCH infection
Sepsis
Inborn error of metabolism

14. On Examination
• Child active, playful, lying on bed comfortably
• Euthermic ( TEMP -37.5 C)
• HR 130 Beats/min
• RR – 34 Breaths/min
• B.P- 74/40 mm of Hg (50th centile)
• Spo2 – 98% on RA
• CRT<3SEC
• CP/PP WF
• Icterus present
• No pallor, cyanosis and clubbing present.

15. Head To Toe Examination
• Head shape normal
• AF open, at level
• No dysmorphic facies
• Icterus present
• No cataract or signs of micronutrient deficiency
• Umbilical hernia +
• Mongolion spot on buttocks present
• Genitals normal
• Spine normal
• No signs of ALF and coagulopathy

16. G/I system
Inspection – protuberant abdomen+ ,umbilical hernia +, No dilated veins, scar
marks, sinuses. No visible peristalsis and genitals normal.
Palpation- No tenderness ,guarding, rigidity present on superficial palpation
Liver palpable 4cm cm below RCM ,liver span firm in consistency , borders round.
Spleen Palpable around 3 cm
A 2.5 cm defect in the umbilicus (2 fingers breath)+, reducible, with skin over the
defect hyperpigmented.
Percussion- Tympanic note heard, no signs of free fluid +.
Auscultation- Bowel sounds present.
Systemic Examination

17. • Cardiovascular system
• No precordial bulge, no visible pulsations
• Apex beat palpable in 5th ICS lateral to mcl
• S1s2 +, no murmur
• Respiratory system
• Shape –normal, no visible sternal deformity, no skin tag, on retraction
• Chest movement equal on both side on respiration
• Air entry b/l equal on both side ,no added sound

18. Central nervous system
• Conscious, active, playful
• Cranial nerves examination normal
• Tone normal
• Power normal in all 4 limbs
• All superficial and deep Reflexes normal
• Neonatal reflexes present

19. Summary
• 3month old Fch B/o NCM, 2nd in birth order, R/o Latur, with complaints of clay colored stools
since DOL3 and yellowish discoloration of eyes and body since last one month with adequate
weight gain with developmentally normal, incompletely immunized, belonging to upper lower
class with icterus, umbilical hernia and hepatosplenomegaly with no signs of liver cell failure
most probably neonatal cholestasis.
D/D: Biliary atresia
Choledochal cyst
Idiopathic neonatal hepatitis
Congenital hypothyroidism

21. CBC 25/09 22/11 26/11 12/12
Hb 10.2 10.6 11 9.5
TLC 10500 9600 12000 10000
NEU 41% 34% 35% 34%
LYMP 50% 60% 63% 61%
PLT 4.39 2.24 2.49 2.20
Investigations

22. DATE 22/11 26/11 03/12 15/12
TOTAL BILIRUBIN 4.8 7.77 8.3 9.46
DIRECT BILIRUBIN 3.0 4.67 4.5 6.07
SGPT 108 129 118 108
SGOT 230 237 215 210
ALP 804 820 902 880
UREA 27 28.6 27.3 30.6
URIC ACID 1.8 1.9 1.9 1.8
CREATININE 0.5 0.47 0.32 0.26
SODIUM 140 142 138 130
POTASSIUM 5.6 5.85 5.2 5.12
ALBUMIN 3.45 3.40 3.57 3.6
PROTEIN 6.0 5.88 5.36 6.14

23. 29/11/2023 CMV ANTIBODY IgG 67.8 (REACTIVE)
CMV ANTIBODY IgM 0.12 (NEGATIVE)
C.M.V. PCR QUANTATIVE NEGATIVE
RUBELLA ANTIBODY IgG 1.20
RUBELLA ANTIBODY IgM 0.21
TOXOPLASMA ANTIBODY
IgG
0.10
TOXOPLASMA ANTIBODY
IgM
0.11
HSV 1&2 NEGATIVE <0.500

24. 27/11/23 GGT 249(high)
HIV NON REACTIVE
12/12/2023 PT 15.8
APTT 40.1
INR 1.16

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