The document summarizes the case of a 10-year-old boy admitted with fever, jaundice, and abdominal pain. Key findings include intermittent high fever for 4 days, jaundice for 4 days, and occasional right upper abdominal pain. He had a similar prior episode 2 months ago. Examination found him febrile but otherwise stable. Tests showed elevated liver enzymes and bilirubin. Ultrasound and MRCP found a fusiform dilated common bile duct suggestive of a choledochal cyst. He was started on antibiotics and vitamin K. His fever subsided after a few days but jaundice remained. A pediatric surgery consultation was requested.

1. Welcome to
Grand session
Presenters:
Dr Maimuna Sayeed
Dr Sharmin Akhter
Resident Phase B (year 4)
Paediatric Gastroenterology and Nutrition
BSMMU
Happy New Year

2. Particulars of the patient
Name : Arman
Age : 10 years
Sex : Male
Address : Madaripur
Date of admission: 20.11.2019
Date of examination: 20.11.2019
Informant : Mother

3. Presenting complaints
• Fever for 4 days
• Yellow discoloration of eyes and skin for 4 days
• Abdominal pain for 4 days

4. History of present illness
According to the statement of the mother, Arman
developed fever for 4 days which was high grade,
intermittent in nature, highest recorded
temperature was 105°F, occasionally associated
with chills and rigor, subsided after taking
antipyretics. He also developed yellow
discoloration of skin, sclera and urine which was
deepened gradually, associated with loss of
appetite but no nausea or vomiting.

5. History of present illness (cont’d.)
He occasionally developed abdominal pain, which
was mild and diffuse in nature, marked at right
upper abdomen, having no aggravating or
relieving factors, no radiation and no relation with
meal.
He had h/o similar attack of fever, jaundice and
occasional abdominal pain 2 months back, for
which he visited several physicians and
hospitalized twice.

6. History of present illness (cont’d.)
That time he was treated with injectable
antibiotics and other supportive medications.
During his hospital stay, fever subsided, jaundice
reduced, and he was discharged on request.
He had h/o taking street foods. There was no h/o
itching, drowsiness, altered sleep pattern,
unconsciousness, any bleeding manifestation.
As his condition was not improved and symptoms
reappeared, he was admitted to BSMMU for
further evaluation and management.

7. Past history
Nothing significant

8. Birth history
Antenatal history: uneventful
Natal history: He was delivered at term at home by
NVD with average birth weight.
Postnatal history : Uneventful.

9. Feeding history
Exclusively breast fed up to 6 months of age.
Complementary feeding started after 6 months of
age.
Now on family diet.

10. Developmental history
He was developmentally age appropriate.
Arman reads in class IV with good school
performance.

11. Immunization history
Immunized as per EPI schedule.

12. Family history
Arman is the only issue of non-consanguineous
parents.
No other family members had h/o liver diseases.

13. Treatment history
He was treated with injection ceftriaxone for 4
days followed by oral cefixime for 7 days in
adequate dose during his previous attack.

14. Socio-economic history
He belongs to middle socio-economic background.
Father is a businessman and mother is a
housewife.
They live in pakka-house, drink tube well water
and use sanitary latrine.

15. Travel history
Nothing significant.

16. Physical examination

17. General examination
• Appearance : Conscious, oriented, co-operative
• Anemia : Mild
• Jaundice : Present
• Cyanosis : Absent
• Clubbing : Absent
• Koilonychia : Absent
• Leuconychia : Absent
• Edema : Absent

18. General examination (cont’d.)
• Dehydration : Absent
• Bony tenderness : Absent
• Signs of meningeal irritation: Absent
• JVP : Not raised
• Eye : Normal
• ENT examination : Normal
• BSUA : Nil

19. General examination (cont’d.)
• Lymph nodes : Not palpable
• Skin Survey :
BCG mark present
No stigmata of CLD
No signs of coagulopathy
No scratch marks

20. General examination (cont’d.)
Vital signs:
• Temperature :101°F
• Pulse :96/min
• R/R :20/min
• BP :105/70mm Hg
(SBP & DBP, within 50th – 90th centile)

21. Anthropometry
• Weight: 29 kg
(25th - 50th centile)
• Height :139 cm
(50th - 75th centile)
• BMI : 15.2 kg/m2
(10th - 25th centile)

22. Systemic examination

23. Gastrointestinal system
Oral Cavity:
Healthy
No bleeding manifestations.
Abdomen proper:
• Inspection:
Size & shape: normal, not distended.
Umbilicus: Centrally placed, inverted
No visible mass, no scar mark.
No visible peristalsis or pulsation
Hernial orifices: intact

24. Gastrointestinal system (cont’d.)
Palpation:
Superficial palpation: soft, non tender, no lump.
Deep Palpation:
Liver: Just palpable, non-tender.
Spleen: Not enlarged.
Fluid thrill: Absent
Percussion:
Shifting Dullness : Absent.
Auscultation:
Bowel sound : Present

25. Central Nervous system
• Higher Psychic Function:
Appearance : Ill-looking.
• Examination of motor system:
Bulk of the Muscle: Normal
Tone of the Muscle: Normal
Power of the Muscle: Normal
Superficial Reflexes: Intact
Deep Reflexes : Intact
Gait : Normal

26. Central Nervous system (cont’d.)
• Examination of the Sensory system:
Intact
• Examination of cranial nerves:
Intact
• Flapping tremor:
Absent

27. Respiratory system
• Inspection:
Respiratory Rate: 20 breaths/min
Shape of the chest: Normal
Chest Movement: Symmetrical
• Palpation:
Trachea: Centrally Placed
Chest Expansibility: Symmetrical

28. Respiratory system (cont’d.)
• Percussion:
Percussion Note: Resonant all over the
chest.
• Auscultation:
Breath Sound: Vesicular, no Added sound

29. Cardiovascular system
• Inspection:
No visible pulsation
• Palpation:
Apex Beat: Located in the Left 5th ICS , just
medial to the midclavicular Line
Thrill: Absent
Left Parasternal Heave: Absent
Palpable P2: Absent

30. Cardiovascular system (cont’d.)
• Auscultation:
Heart Sound: 1st and 2nd heart sounds were
audible in all the four areas.
Murmur: Absent

31. Other systemic examinations revealed no
abnormality.

32. Salient feature
Arman, 10-year-old boy, only issue of non-
consanguineous parents, immunized as per EPI
schedule, presented with the complaints of high
grade intermittent fever for 4 days, highest
recorded temperature 105∘F, occasionally
associated with chills and rigors. He had jaundice
for same duration, associated with anorexia but
no nausea, vomiting. He had occasional
abdominal pain which was mild and diffuse in
nature involving mostly right upper abdomen.

33. Salient feature (cont’d.)
There was h/o similar attack 2 months back.
Symptoms subsided after being treated with
injection ceftriaxone and oral cefixime in adequate
dose and duration. He had h/o taking street foods.
No h/o any itching, no features of any
coagulopathy, encephalopathy.

34. Salient feature (cont’d.)
Arman was conscious, oriented, co-operative,
mildly pale, icteric, febrile, other vitals were
stable, no stigmata of CLD, anthropometrically
well thriving. Systemic examination of GIT
revealed abdomen was soft, not distended, non
tender, no palpable lump, liver just palpable,
non tender, no splenomegaly or ascites. Other
systemic examination revealed no abnormality.

35. Provisional diagnosis

36. Provisional diagnosis
Cholangitis most probably due to choledochal cyst

37. Differential diagnosis
Acute viral hepatitis (HAV)– relapse

38. Cholangitis
Points in favour
From history:
• Jaundice
• High grade fever
• Abdominal pain
• Recurrent attack
On examination:
• Icteric
• Febrile

39. Choledochal cyst
Points in favour Points against
From history:
• Recurrent jaundice
• Abdominal pain
On examination:
• Icteric • No abdominal lump

40. Acute viral hepatitis (HAV)- relapse
Points in favour Points against
From history:
• Jaundice - relapse
• H/o taking street
food
• High grade fever
• No prodromal
symptom eg. nausea,
vomiting
On examination:
• Icteric
• No stigmata of CLD
• No tender
hepatomegaly

41. Investigation

42. Investigation plan
• CBC with PBF
• Liver function test
• Urine R/E, C/S
• Blood C/S
• CRP
• Viral marker
• USG of HBS
• MRCP

43. Investigation (cont’d.)
Complete blood count
Hb 11.6 gm/dl
ESR 77 mm in 1st hour ↑
Total count WBC 17.5 x 109/L ↑
Differential count
Neutrophils
Lymphocytes
Eosinophils
Monocytes
79%
18%
03%
00%
↑
Platelet count 340 x 109/L
RBC count 4.35 x 1012/L
PBF Neutrophilic leukocytosis

44. Investigation (cont’d.)
Liver function test
S. Bilirubin (total) 2.2mg/dl ↑
ALT 302 U/L ↑
PT Control : 12.0 sec
Patient : 23.2 sec ↑
INR 1.89 ↑
Alkaline Phosphatase 878 U/L ↑
Gamma-
glutamyltransferase
358 U/L ↑

45. Investigation (cont’d.)
Anti HAV IgM Negative
CRP 18.3 mg/L ↑
Blood C/S No growth
Urine R/M/E Normal
Urine C/S No growth

46. Investigation (cont’d.)
USG of HBS
Liver: Mildly enlarged in size with homogeneous echotexture.
No focal lesion is seen.
Gall bladder is contracted. Wall is thickened.
Spleen: Normal on size with uniform echotexture.
Biliary channel: Intrahepatic biliary channel are not dilated.
CBD: Fusiform dilatation (3.8cm x 5.2cm x 5.8cm) of CBD
with soft tissue structure seen extending in distal part of
CBD compressing the head of the pancreas.
Impression:
1. Suggestive of choledochal cyst (infected or hemorrhagic –
type IVb)
2. Mild hepatomegaly.

47. Management

48. Treatment
Counseling
Supportive
• Bed rest
• Diet: Normal
• Inj. Meropenem (20mg/kg/dose 8 hourly)
• Inj. Vitamin K1
• Syp. Paracetamol

49. Follow up on Day2 (21.11.19)
Subjective Objective Assessment Plan
High grade fever
persisting
Patient was conscious,
co-operative, oriented
Jaundice- present
Anaemia- mild
Temp- 98∘F
RR- 18 br/m
Pulse- 84 b/m
BP- 100/70 mmHg
Lungs- clear
Heart- S1+S2+0
P/A/E- soft, non-tender,
liver just palpable
Skin survey- Normal
U/O- adequate
Bowel- moved
Static • To repeat PT,
INR
• To do MRCP

50. Follow up investigation
PT Control : 12.0 sec
Patient : 13.0 sec
INR 1.03

51. Magnetic Resonance Cholangiopancreatogram

52. MRCP (cont’d.)
Magnetic Resonance Cholangio Pancreatogram (MRCP)
Gross fusiform dilatation of CBD and CHD noted producing a
sac like mass approximately measuring about 4.3 cm x 2.7
cm in size. Intrahepatic biliary channels mildly dilated. Low
signal intensity was also noted within the dilated CBD.
Impression:
1. Suggestive of choledochal cyst (Type-IVb) with
sludge and secondary dilatation of intrahepatic
biliary radicles.

53. Follow up on Day5 (24.11.19)
Subjective Objective Assessment Plan
Afebrile for 1 day Patient was conscious, co-
operative, oriented
Jaundice- present
Anaemia- mild
Temp– 98∘F
RR- 16 br/m
Pulse- 80 b/m
BP- 100/70 mmHg
Lungs- clear
Heart- S1+S2+0
P/A/E- soft, non-tender,
liver just palpable
Skin survey- Normal
U/O- adequate
Bowel- moved
Improving Paediatric
surgery
consultation

54. Consultation from paediatric surgery-
• Need for surgical treatment for choledochal cyst
after completion of conservative management.

55. Follow up on Day14 (03.12.19)
Subjective Objective Assessment Plan
No new
complaints
Patient was conscious,
co-operative, oriented
Jaundice- present
Anaemia- mild
Temp– 98∘F
RR- 18 br/m
Pulse- 80 b/m
BP- 100/70 mmHg
Lungs- clear
Heart- S1+S2+0
P/A/E- soft, non-tender,
liver just palpable
Skin survey- Normal
U/O- adequate
Bowel- moved
Improving • To stop
antibiotics
• Discharged
with advice
for further
surgical
management

56. Final diagnosis
Choledochal cyst ( Type-IVb ) with
Cholangitis (Improved)