Chronic Liver Disease in pediatric: a case presentation and discussionDr Abdalla M. Gamal
A presentation from a tutorial about an interesting case that came to the Pediatric Department of Sebha Medical Center and was imaged by the Radiology Department.
The tutorial was a joint effort between Dr Zeinab Salem Ali (from Pediatric Department) and me (from Radiology Department). In her slides, Dr Zeinab presented the case history, examination, investigations, differential diagnosis and discussed the clinical presentation, investigations and management for chronic liver diseases in pediatric patients.In my slides, I discussed the definition, etiology, natural history of this condition and explained the role of imaging in its diagnosis.
These are my slides after some modifications. I added an aknowlegement page to illustrate Dr Zeinab effort and to thank Dr Khaled Aljasem from Pediatric Department for his effort in revising the original presentations and the constructive feedback he provided which improved the quality of the presented material. Then I added a summary for the parts Dr Zeinab has presented to make this powerpoint presentation complete.
This presentation was presented by Dr Zeinab Salem (from Pediatric Department) and me in a joint tutorial between Pediatric Department and Radiology Department of Sebha Medical Center.
CASE PRESENTATION ONCIRRHOSIS OF LIVER WITH PORTAL HYPERTENSION, HEPATIC EN...Akhil Joseph
A DETAIL CASE PRESENTATION ON CIRRHOSIS OF LIVER WITH PORTAL HYPERTENSION, HEPATIC ENCEPHALOPATHY AND GRADE II OESOPHAGEAL VARICES WITH CONGESTIVE GASTROPATHY. LIVER CIRRHOSIS AND ALL ITS COMPLICATION IN A PATIENT.
Chronic Liver Disease in pediatric: a case presentation and discussionDr Abdalla M. Gamal
A presentation from a tutorial about an interesting case that came to the Pediatric Department of Sebha Medical Center and was imaged by the Radiology Department.
The tutorial was a joint effort between Dr Zeinab Salem Ali (from Pediatric Department) and me (from Radiology Department). In her slides, Dr Zeinab presented the case history, examination, investigations, differential diagnosis and discussed the clinical presentation, investigations and management for chronic liver diseases in pediatric patients.In my slides, I discussed the definition, etiology, natural history of this condition and explained the role of imaging in its diagnosis.
These are my slides after some modifications. I added an aknowlegement page to illustrate Dr Zeinab effort and to thank Dr Khaled Aljasem from Pediatric Department for his effort in revising the original presentations and the constructive feedback he provided which improved the quality of the presented material. Then I added a summary for the parts Dr Zeinab has presented to make this powerpoint presentation complete.
This presentation was presented by Dr Zeinab Salem (from Pediatric Department) and me in a joint tutorial between Pediatric Department and Radiology Department of Sebha Medical Center.
CASE PRESENTATION ONCIRRHOSIS OF LIVER WITH PORTAL HYPERTENSION, HEPATIC EN...Akhil Joseph
A DETAIL CASE PRESENTATION ON CIRRHOSIS OF LIVER WITH PORTAL HYPERTENSION, HEPATIC ENCEPHALOPATHY AND GRADE II OESOPHAGEAL VARICES WITH CONGESTIVE GASTROPATHY. LIVER CIRRHOSIS AND ALL ITS COMPLICATION IN A PATIENT.
CHOLELITHIASIS, NEPHROLITHIASIS SECONDARY HYPERTENSION, DM TYPE 2, HYDRONEPH...Jack Frost
CHOLELITHIASIS, NEPHROLITHIASIS
SECONDARY HYPERTENSION, DM TYPE 2, HYDRONEPHROSIS
This presentation contains real names of persons involve of this particular study. This names should not be copied or rewritten. Used the data of this study as basis only. All rights reserved 2009.
Mohamed Anwer Naleef, I am Nurse at Hemas Hospital,
This is about care of patient with Cirrhosis Disease Condition. As a Nurse three days my Nursing Process, observation, Nursing care Plan, Nursing Care and Help to patient manage and adjust the disease condition. Because the Cirrhosis is majority of male patients are facing the srilanka due to Alcohol. Even developing countries people also facing this problem due to uncontrolled Alcohol Consumption.
In my Case Studies, I briefly explained about Liver Alcoholic Cirrhosis, Treatment Complaience , medical management, Nursing Care, Nursing assessment, Nursing diagnosis, Nursing Planning, Nursing Intervention, Health Education for a Patient when patient Discharge.
CHOLELITHIASIS, NEPHROLITHIASIS SECONDARY HYPERTENSION, DM TYPE 2, HYDRONEPH...Jack Frost
CHOLELITHIASIS, NEPHROLITHIASIS
SECONDARY HYPERTENSION, DM TYPE 2, HYDRONEPHROSIS
This presentation contains real names of persons involve of this particular study. This names should not be copied or rewritten. Used the data of this study as basis only. All rights reserved 2009.
Mohamed Anwer Naleef, I am Nurse at Hemas Hospital,
This is about care of patient with Cirrhosis Disease Condition. As a Nurse three days my Nursing Process, observation, Nursing care Plan, Nursing Care and Help to patient manage and adjust the disease condition. Because the Cirrhosis is majority of male patients are facing the srilanka due to Alcohol. Even developing countries people also facing this problem due to uncontrolled Alcohol Consumption.
In my Case Studies, I briefly explained about Liver Alcoholic Cirrhosis, Treatment Complaience , medical management, Nursing Care, Nursing assessment, Nursing diagnosis, Nursing Planning, Nursing Intervention, Health Education for a Patient when patient Discharge.
A personal loan can be used for just about anything. It is a loan made for any purpose not specifically defined or secured by a specific asset. Personal loans are usually made for general expense purposes.
There are several types of personal loans out there for borrowers. The two most commonly know are secured and unsecured personal loans.
INVESTIGACION HECHA POR LAS ALUMNAS MAYELI LOPEZ Y AMPARO GABRIELA DE LA LICENCIATURA COMERCIO Y FINANZAS INTERNACIONALES; MATERIA: ETICA PROFESIONAL IMPARTIDA POR EL PROFR. EULER FERRER
PresentationMachine Learning, Linear and Bayesian Models for Logistic Regres...Bohdan Pavlyshenko
In this work, we study the use of logistic regression in manufacturing failures detection. As a data set for the analysis, we used the data from Kaggle competition “Bosch Production Line Performance”. We considered the use of machine learning, linear and Bayesian models. For machine learning approach, we analyzed XGBoost tree based classifier to obtain high scored classification. Using the generalized linear model for logistic regression makes it possible to analyze the influence of the factors under study. The Bayesian approach for logistic regression gives the statistical distribution for the parameters of the model. It can be useful in the probabilistic analysis, e.g. risk assessment.
Jaundice otherwise called icterus, which may occurs due to high bilirubin level in blood. The slides here explains the epidemiology, metabolism of bilirubin, types of jaundice, their etiology, risk factors involved, symptoms diagnosis and treatment.
Ulcerative colitis is a diffuse non- specific inflammatory disease of the large intestine of unknown cause, primarily affecting the mucosa, characterized by erosions and/or ulcerations. The disease is characterized by repeated cycles of relapses and remissions, occasionally accompanied by extra-intestinal manifestations.
A variety of immunologic changes have been documented in UC. T cells accumulate in the lamina propria of the diseased colonic segment. these T cells are cytotoxic to colonic epithelium. This change is accompanied by an increase in the population of B cells and plasma cells, with increased production of immunoglobulin G (IgG) and immunoglobulin E (IgE).
Ant colonic antibodies have been detected in patients with UC. A small proportion of patients with ulcerative colitis have smooth muscle and ant cytoskeletal antibodies.
Microscopically, acute and chronic inflammatory infiltrate of the lamina propria, crypt branching, and villous atrophy are present in ulcerative colitis. Microscopic changes also include inflammation of the crypts of Lieberkühn and abscesses. These findings are accompanied by a discharge of mucus from the goblet cells, the number of which is reduced as the disease progresses. The ulcerated areas are soon covered by granulation tissue. Excessive fibrosis is not a feature of the disease. The undermining of mucosa and an excess of granulation tissue lead to the formation of pseudo polyps.
Primary biliary cirrhosis associated with gallstone
1. 1
University of sulaimani
College of pharmacy
Department of clinical pharmacy and therapeutic
Primary biliary cirrhosis associated with
gallstone
Prepared by : Muhammad Koksh Sdiq
2. 2
Q : 45 year old lady presented with excessive fatigue for more than one year ,
annoying nocturnal pruritus and O/E there was clubbing of finger , dark skin and
deep jaundice .the spleen was 4cm below costalmargin.
Answer: Because of the presence of feature of obstructive jaundice and
splenomegaly this make the diagnosis of primary biliary cirrhosis is the most likely
diagnosis anyhow I need to do certain diagnostic investigation include:
Antimitochondrial antibody titer. An Antimitochondrial antibody titer ≥1:40
is the serologic hallmark for the presence of primary biliary cirrhosis and in
90% to 95% of protein.
Serum alkaline phosphate.
Y-glutamatyltransferase values are usually elevated ten times or more above
normal.
Serum bilirubin level increases mainly direct.
The diagnosis is confirmed by liver biopsy, which characteristically shows
nonsuppurative cholangitis plus finding ranging from bile duct lesions to
cirrhosis.
Treatment:
Ursodeoxycholic acid improves the biochemical profile , reduces pruritus,
decreases progression to cirrhosis and delays the need for liver
transplantation. Therapy is usually continued indefinitely.
Liver transplantation is considered for patients with intractable pruritus or
complication from cirrhosis , and long term outcomes tend be better than
outcomes.
3. 3
Primary BiliaryCirrhosis(PBC)
What is primary biliary cirrhosis?
Primary biliary cirrhosis, or PBC, is a chronic, or long-term, disease of
the liver that slowly destroys the medium-sized bile ducts within the
liver. Bile is a digestive liquid that is made in the liver. It travels through
the bile ducts to the small intestine, where it helps digest fats and fatty
vitamins.
In patients with PBC, the bile ducts are destroyed by inflammation. This
causes bile to remain in the liver, where gradual injury damages liver
cells and causes cirrhosis, or scarring of the liver. As cirrhosis
progresses and the amount of scar tissue in the liver increases, the liver
loses its ability to function. Cirrhosis also prevents blood from the
intestines from returning to the heart.
PBC advances slowly. Many patients lead active and productive lives for
more than 10 to 15 years after diagnosis. Patients who show no
symptoms at the time of diagnosis often remain symptom-free for years.
Patients who have normal liver tests on treatment may have a normal life
expectancy. PBC is a chronic illness and may lead to life-threatening
complications, especially after cirrhosis develops.
What are the signs and symptoms of PBC?
Many people with PBC do not have symptoms (~50% asymptomatic at
diagnosis), especially in the early stages of the disease. When symptoms
do occur the most common is pruritus, or intense itching of the skin,
often in the arms, legs and back. Other symptoms may include fatigue,
jaundice, fluid build-up in the ankles and abdomen, and darkening of
the skin and collection of fatty deposits in the skin around the eye.
Jaundice, is an indication of how far the disease has progressed.
Several other disorders often occur with PBC. The most common is
problems with the tear and salivary glands, causing DRY EYES or
mouth( Sjögren's syndrome) . Arthritis and thyroid problems may also
be present. Renal stones and gallstones may develop. Bone softening
and fragility leading to fractures can occur in late stages of the disease.
4. 4
Gallstones and bile duct stones: If cirrhosis prevents bile from flowing
freely to and from the gallbladder, the bile hardens into gallstones.
Symptoms of gallstones include abdominal pain and recurrent bacterial
cholangitis—irritated or infected bile ducts. Stones may also form in and
block the bile ducts, causing pain, jaundice, and bacterial cholangitis.
What causes primary biliary cirrhosis?
The causes of primary biliary cirrhosis are unknown. Most research
suggests it is an autoimmune disease. In primary biliary cirrhosis, the
immune system attacks the small bile ducts in the liver.
Genetics, or inherited genes, can make a person more likely to develop
primary biliary cirrhosis. In people who are genetically more likely to
develop primary biliary cirrhosis, environmental factors may trigger or
worsen the disease, including
exposure to toxic chemicals
smoking
infections
Genetics can also make some people more likely to develop other
autoimmune diseases, such as
autoimmune hepatitis
Sjögren’s syndrome,
autoimmune thyroid dysfunctions
What are the complications of primary biliary cirrhosis?
Most complications of primary biliary cirrhosis are related to cirrhosis and start
after primary biliary cirrhosis progresses to cirrhosis. In some cases, portal
hypertension and esophagealvarices may develop before cirrhosis , Edema and
ascites , Varices ,Splenomegaly, Hepatic encephalopathy ,Metabolic bone
diseases. Gallstonesandbile duct stones, Steatorrhea, Liver cancer.
5. 5
Investigations
FBC is often normal but ESR is elevated.
Abnormal LFT s are usual but not invariable:
Alkaline phosphatase i s usually elevated as PBC is a cholestatic condition.
Less consistently , transaminases are raised.
Bilirubin is often normal at first but rises as the disease progresses. Rising
bilirubindemonstrates disease progression and heralds liver failure.
Partial thromboplastin time (PTT) and albumin are normal until a late
stage.
IgM is raised.
Lipid level s and cholesterol level s are raised i n 85% but risk of coronary
heart disease (CHD) is not raised as high-density lipoprotein (HDL)
cholesterol is elevated.
Autoantibodies are characteristic:
The most specific to PBC are antimitochondrial antibodies (AMAs), present
i n 90-95% of affected individual s (and 0.5% of normal control s, giving a
specificity of over 98%.)Evidence suggests that this anti body is directly
involved in the pathological process.
A round 0.5% of the general population is positive for AMA s. Studies
suggest that fewer than10% of patients with positive AMAs will develop
PBC, although almost all patients with PBC have positive AMAs.
About 35% also have antinuclear anti bodies.
There may also be other autoantibodies, especially related to the
thyroid.Thyroid function should be assessed and monitored.
Imaging of the liver is useful to exclude causes of obstruction like stones.
Ultrasound is most commonly used but CT and M RI scanning may be
employed. As the disease progresses there may be features suggestive of
portal hypertension and cirrhosis.
Cholangiography is occasionally helpful in order to exclude primary
sclerosing cholangitis.
Transient elastography is a non-invasive tool to evaluate the degree of liver
fibrosis.
Finally , liver biopsy is required to stage the disease. Histology will
demonstrate chronic non suppurative cholangitis of the interlobular and
septal bile ducts.
6. 6
How is PBC diagnosed?
Because many PBC patients have no symptoms, the disease is often discovered
through abnormal results on routine liver blood tests. A health care provider may
use the following tests to diagnose primary biliary cirrhosis:
a medical and family history , a physical exam , blood tests , imaging tests , a liver
biopsy
A health care provider usually bases a diagnosis of primary biliary cirrhosis on two
out of three of the following criteria:
a blood test showing elevated liver enzymes(high alkaline phosphatase,
elevated AST, ALT)
a blood test showing the presence of anti-mitochondrial antibodies (AMA)
tests ,This test is positive in nearly all PBC patients , antinuclear antibody
(the M2-IgG antimitochondrial antibody is the most specific test)
Ultrasound exams and a liver biopsyshowing signs of the disease in which a
small sample of liver tissue is removed with a needle, may also be
performed.
Goals of treatment
Slow disease progression
Treat complications
Course and cure of the disease:
- no known cure, but medication may slow the progression
- ursodeoxycholic acid (Ursodiol) is the most frequently used treatment. This
helps reduce the cholestasis and improves blood test results (liver function
tests).
- alcoholic beverages are contraindicated.
- in advanced cases, a liver transplant, if successful, results in a favourable
prognosis.
- multivitamins (esp. Vitamin D) and calcium are also recommended as
patients with PBC have poor lipid-dependent absorption of Vitamins A, D,
E, K.
7. 7
Treatment of Symptoms and Complications
- Itching. Antihistamines. However, antihistamines often cause drowsiness,
and a personshould take antihistamines just before bedtime to help with
nighttime itching. cholestyramine which reduces cholesterol in the blood.
- Dry eyes and mouth. artificial tears and saliva substitutes, respectively.
pilocarpine or cevimeline . People who have difficulty with dry eyes should
see an ophthalmologist. People with dry mouth should have regular dental
exams.
- Portalhypertension. a beta-blocker or nitrate to treat portal hypertension.
- Varices. Beta-blockers. Bleeding in the stomach or esophagus requires an
immediate upper endoscopyPeople who have had varices in the past may
need to take medication to prevent future episodes.
- Edema and ascites. diuretics—medications that remove fluid from the
body—to treat edema and ascites. A health care provider may remove large
amounts of ascitic fluid from the abdomen and check for spontaneous
bacterial peritonitis. antibiotics to prevent infection, oral antibiotics;
however, severe infection with ascites requires intravenous (IV) antibiotics.
- Hepatic encephalopathy. cleansing the bowel with lactulose, a laxative
given orally or as an enema—a liquid put into the rectum. add antibiotics to
the treatment. Hepatic encephalopathy may improve as other complications
of cirrhosis are controlled.
- Osteoporosis. bisphosphonatemedications to improve bone density.
- Gallstones andbile duct stones. A health care provider may use surgery to
remove gallstones. He or she may use endoscopic retrograde
cholangiopancreatography, which uses balloons and basketlike devices, to
retrieve the bile duct stones.
- Liver cancer. A health care provider may recommend screening tests every
6 to 12 months to check for signs of liver cancer. He or she may treat cancer
with a combination of surgery, radiation, and chemotherapy.
- When is a liver transplant consideredfor primary biliary cirrhosis?
A health care provider may consider a liver transplant when cirrhosis leads
to liver failure or treatment for complications is ineffective. Liver
transplantation is surgery to remove a diseased or an injured liver and
replace it with a healthy liver or part of a liver from another person, called a
donor.
8. 8
What lifestyle changes may be helpful for PBC patients?
A reduced sodium diet , Drinking ample water , Taking calcium and Vitamin
D supplements , Avoiding or reducing the consumption of alcohol ,
Reducing stress , Exercising, particularly walking , Skin Care , Regular
dental examinations , Artificial tears for dry eyes .