A 3-month-old female child presented with vomiting, jaundice, and fever. On examination, she had mild jaundice and an abdominal mass. Laboratory results showed elevated bilirubin and alkaline phosphatase. Imaging found a cystic lesion in the porta hepatis. The provisional diagnosis was choledochal malformation. The plan was laparotomy to further evaluate the mass.

1. Dr.Amit Hasan
Phase – B
Paediatric surgery
MMC

2. A 3 months old female child presented with vomiting.

3. Particulars of the patient:
Name: Mehrima
Age: 3 months
Sex: Female
Address: Trishal
Date of admission : 8/4/23
Date of examination : 8/4/23

4. Chief complaints :
1. Vomiting for 1 month.
2. Yellowish discoloration of skin,eyes for 1 month.
3. Fever for 7 days.

5. History of present illness :
According to the statement of the informent mother the
child is suffering from vomiting for 1 month. She vomits
about 2-3 times per day which was non projectile,
bilious and contains undigested food particles and the
child was not hungry after the vomiting.

6. She also added that the child is suffering from
yellowish discoloration of skin and eyes for 1 month
which is associated with pale colour stool and dark
urine. The intensity of skin discoloration is increasing
day by day. She furthur added that the child is suffering
from fever for last 7 days which is low grade in
severity,intermittent in nature and relieved by taking
paracetamol.

7. There is also abdominal distension which is suddenly
increasing in size during last two weeks. There is no
history of weight loss. Her bowel and bladder habit is
normal.

8. History of past illness :
There is no significant past history.

9. Developmental history :
Her development is age appropriate.

10. Family history :
Her family members are not suffering from such kinds
of health problem.

11. Drug history :
There is no history of drug allergy.

12. Immunization history :
She is immunized as per EPI schedule.

13. Treatment history :
At the age of 01 day she was admitted into NICU,
MMCH (01/02/23) with the complaints of
breathlessness and diagnosed as LBW with TTN and
treated conservatively and discharged on 08/02/23.

14. At the age of 13 days she again admitted into
NICU,MMCH with the complaints of breathlessness
and fever and diagnosed as LBW with LONS. She was
treated conservatively and discharged on 18/2/23.

15. On 01/3/23 she developed vomiting, yellowish
discoloration of skin and eyes , pale colour stool and
dark urine. Then she was taken to a pediatrician and
treated with oral antibiotics, antiemetic and
multivitamins but her condition was detoriated and
ultimately admitted into paediatric surgery department
on 8/4/23.

16. General examination :
 Appearance : anxious and ill looking.
 Body built : average
 Anaemia : absent
 Jaundice : mild icteric
 Cyanosis : absent
 Clubbing : absent
 Koilonychea: absent

17.  Leukonychia: absent
 Edema:absent
 Heart rate : 80 beats / min
 Respiratory rate : 30 breaths/ min
 Temperature : 100°F
 Hernial orifice : intact
 Skin survey : There was no scratch mark.
 There is an iv canula in situ.

18. Abdominal examination :
Inspection :
 Abdomen was distended specialy in the upper abdomen
with engorged veins. Umbilicus was centrally placed and
everted. Flanks were not full.
Palpation :
 Abdominal temperature was normal and non tender.
There was a palpable,circular shaped, mass measuring
about 16×14 cm in diameter situated specially in the
upper abdomen.

19. Temperature was normal,non tender,cystic in
consistency, fluctuant,free from overlying skin but fixed
with underlying structure.

20.  Percussion :
Percussion note was dull over the mass.
 Auscultation :
Bowel sound present.
 D/R/E: revealed no abnormality.
 Other systemic examination revealed no abnormality.

21. Salient feature :
Mehrima,3 months old,female child,hailing from
Trishal,Mymensingh presented to me with the
complaints of vomiting for 1 month which is non
projectile, bilious and contains undigested food
particles. She also suffering from jaundice for 1 month
which is intermittent in nature and associated with pale
colour stool and dark urine.

22. She also suffering from low grade, intermittent fever for
last 7 days and relieved by taking paracetamol. There
is also abdominal distension which is suddenly
increasing in size during last two weeks. There is no
history of weight loss. Her bowel and bladder habit is
normal.

23. Before admission into paediatric surgery department
she was admitted into NICU, MMCH and treated
conservatively and subsequently admitted into pediatric
surgery department.

24. She is mild icteric, non anaemic, non dehydrated, non
edematous with average body weight. All the stigmata
of chronic liver disease is absent. Her H/R is 80
beats/min,R/R is 30 breath /min,temperature is 100°F,

25. Abdomen was distended specially in upper abdomen
with engorged veins. Umbilicus was centrally placed
and enverted. Flanks were not full.Abdominal
temperature was normal and it was non tender. There
was a palpable,circular shaped, mass measuring about
16×14 cm in diameter, occupying almost all the
quadrant of the abdomen.

26. Temperature was normal, non tender, cystic in
consistency, fluctuant,free from overlying skin but fixed
with underlying structure. Percussion note was dull
over the mass. Bowel sound was present on
auscultation. D/R/E reveals no abnormality. Other
systemic examination was normal.

27. Provisional diagnosis(?)

28. My provisional diagnosis is choledochal malformation.

29. Differential diagnosis :
1. Mesenteric cyst
2. Omental cyst
3. Hepatic cyst
4. Hepatoblastoma

30. Investigation :

39. Plan:
Our plan was laparotomy and proceed.

41. Intraoperative findings :

51. Thank you Very much.

61. Differential diagnosis :
 Biliary stricture
 Pancreatic pseudocyst
 Warm in CBD

62. Investigation :
 CBC : HB%-10 mg/dl
 S.Bilirubin: 10.7 mg/dl (2/3/23)
 S.Bilirubin : 4 mg/dl (15/3/23)
 S.Direct bilirubin : 1.4 mg/dl(15/3/23)
 S.Indirect bilirubin : 2.6 mg/dl(15/3/23)
 S.ALP: 1219 IU/L
 S.SGPT: 197 U/L
 PT:15 second (control -13 second)

63.  USG of HBS: cystic structure in the porta hepatis
measuring (3.9×3.6 cm)
 CT scan of HBS : CBD and intrahepatic biliary
channels are not dilated. There is a (4×3.5 cm)
cystic lesion in porta hepatis.
(Further plan: MRCP)

73. Thank you very much.

76. 01936-085493