gallbladder disease in children2

Liver Enzymes

Normal Value of Alkaline Phosphatase according to the age for Girls

Screening

• CMP, GGT, Lipid profile, Liver Function Test: Alkaline phosphatase, ALT, AST, Bilirubin,

• HbA1c, Insulin, THS and T4• Biometric information; Weight, Height, BMI,

Waist and hip circumference and Percentage of body fat

• Blood pressure• Ultrasound of the liver if altered liver enzymes,

or complaining of RUQ pain or discomfort

Criteria for screening for liver disease

• Persistent Overweight BMI 85 to 90 %tile

• BMI above 95 %tile

• Rapid Increase in BMI no matter where it starts • Family history of Lipid disorder, liver or gallbladder disease and Diabetes

• RUQ or epigastric discomfort

Oct-10

Nov-10

Dec-10Jan

-11

Feb-11

Mar-11

Apr-11

May-11

Jun-11Jul-1

1

Aug-11

Sep-11

0

5

10

15

20

25

30

811

20

27

0

5

9 9

Time table chart of GB disease follow up

totalmalefemaleSurgery

Fatty Liver by Ultrasound

• Ultrasound requested for all altered liver enzymes •467 Liver Ultrasound performed 25.6%•217 patients Positive for fatty liver 46.6% •5.8 % of total ultrasound positive for GB disease and reflect 1.48% of our total patient population

Normal liver ENZ

Alkaline Phos.

AST ALT GGT Bilrirubin 0

10

20

30

40

50

60

70

80

90

≥9995-9885-90NORMAL

Male

Normal liver ENZ

Alkaline Phos.

AST ALT GGT Bilrirubin 0

10

20

30

40

50

60

70

80

90

≥9995-9885-90NORMAL

Female

Live Enzymes Value according to the BMI

Figure 1.  Normal appearance of the liver at US. The echogenicity of the liver is equal to or slightly greater than that of the renal cortex (rc).

Hamer O W et al. Radiographics 2006;26:1637-1653

©2006 by Radiological Society of North America

Screening for Fatty Liver

The most effective non-invasive method

is abdominal ultrasound

BMI Male # of Patient

# U/Srequest

% Positive FL

Female # of

Patient

# U/Srequest

% Positive FL

NR 158 6 0 199 9 0

Risk 191 41 36.6 263 26 23.0

≥ 95 132 31 45.2 105 25 40.0

≥ 97 234 92 45.5 200 59 54.2

≥ 99 210 105 55.2 132 73 46.6

Total 925 275 50.5 899 192 42.7

Fatty Liver Reported to Laredo Pediatrics & Neonatology 2003-2010

Gall Bladder Disease

56 cases collected ( plus 6 HEN) 57% Male /43% Female (4 HEN Boys and 2 Girls)Average age 13.7646.6% fatty liver positive 5.8 % of total ultrasound positive for GB disease, and represents1.48% of total patients in the study34% of all GB disease BMI% 99 or over98% of the cases BMI% ≥85

Abnormal U/S Reports and Outcomes

2012

Normal Findings of HB Scan

• Hepatocytes take up the radiopharmaceutical in minutes after injection

• Hepatic ducts seen in fifteen minutes• Gallbladder seen within 45 to 60 miutes• GBEF >40• Small intestine seen by 30 minutes

This test examines the gallbladder and the ducts which connect to the liver.

DISIDA (Hepatobiliary) Scan

Acalculus Cholecystitis in Boys2011-2012

Acalculus Cholecystitis in Girls2011-2012

Surgical Gallbladder Cases

• 404 in 4,000,000 in 4 years = 1 in 40,000 per year at Texas Children’s Houston (2005-2008) 73% women

• 11 in 2000 in 1 yr = 1 in 200 per year at Laredo Pediatrics (2010 -2011) 63% women

• 8 other reported at local pediatric meetings

Criteria for screening for Gall bladder disease

•Persistently Abnormal liver enzymes •Acute or persistent epigastric or non-specific abdominal pain, postprandial •Rapid decline in BMI•Family history of Gall bladder disease• persistently elevated GGT or Total Bilirrubin

Diagnosis of Fatty Liver

The most effective Diagnostic method for FL is Liver Biopsy

(Gold Standard)

Conclusion •The Latest data suggest that 16% of children in the United States are obese and 32% are overweight. Therefore concern about prevalence of NAFLD or NASH is appropriate •The studies recognized rapid progression of fibrosis in children with NAFLD/NASH over short period of time. Therefore early detection is warrant •Although gallbladder disease is relatively uncommon in the pediatric population, the rate has increased in the past 10 years.•Pediatric gallbladder disease was commonly associated with hemolytic diseases or hemoglobinopathies; however, now other factors are recognized.

Conclusion •Incidence of Gallbladder disease is on the rise on overweight children. •Gallbladder disease should be in the differential diagnosis of any pediatric patient who presents with localized pain in the epigastric, RUQ or ill-defined, Jaundice or dyspepsia and asymptomatic patients with BMI of ≥85•Consider Liver ultrasound as primary tool over more expensive and invasive procedures •HB Scan helps identify adequate GB function

Hippocrates Master of Medicine: 460-377 B.C

“Thus Curiosity, Keenness of observation and the value of scrupulous record keeping became paramount priorities in the new philosophy of Care”

Sherwin B Nuland describing Hippocrates Influence on Medicine