Hospital pediatrics. Differential diagnosis of liver diseases in children. Clinic, diagnosis, treatment (lecture notes)

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Hospital pediatrics. Differential diagnosis of liver diseases in children. Clinic, diagnosis, treatment (lecture notes)

Lecture notes, cheat sheets

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LECTURE No. 13. Differential diagnosis of liver diseases in children. Clinic, diagnosis, treatment

Stage I: inspection.

History: liver damage is established. Laboratory methods: (ALAT, AST, alkaline phosphatase, proteinogram, thymol, prothrombin index, bilirubin and urine urobiligen) - assumption of diagnosis. Hepatic parenchymal clearance of blood with technetium is the only or early sign of the disease (hepatitis, cirrhosis, amyloidosis).

Ultrasound and liver scintigraphy with technetium (confirmation of damage, differentiation of focal and diffuse pathology, determination of focal localization).

Stage II: making a nosological diagnosis (laparoscopy, selective angiography, targeted liver biopsy, latexagglutination reaction to echinococcosis).

For focal lesions deep in the organ - celiacography, selective hepatography (for contrasting the arteries of the liver, portal veins and vessels of the spleen).

Needle biopsy (if diffuse disease is suspected). Determination of mitochondrial antibodies to liver tissue.

Stage III: detailed diagnosis (activity of the process, stage of the disease, complications).

Biochemical studies (cholestasis syndrome - increased levels of cholesterol and conjugated bilirubin, alkaline phosphatase activity; cytolysis syndrome - increased conjugated bilirubin, transaminase activity; hepatoprival syndrome - decreased levels of cholesterol, albumin, procoagulants, fibrinogen; mesenchymal-inflammatory syndrome - increased content of g-globulins, indicators of diphenylamine and thymol samples, ESR indicator).

Immunological research.

Classification of hepatomegaly:

1) primary diseases of the liver parenchyma (hepatitis, pigmented hepatosis, liver cirrhosis, tumors);

2) metabolic disorders (fatty hepatosis, amyloidosis, hemosiderosis, glycogenosis, lipoidosis);

3) circulatory disorders (stagnation, heart attack in adults);

4) secondary infiltrative processes (acute and chronic infections and intoxications, blood diseases, collagenosis);

5) diseases of the biliary tract (cholangitis, disorders of the outflow of bile).

Idiopathic hemochromatosis - iron deposits in the liver, skin, heart, joints, glands. Autoimmune course of hepatitis, primary biliary cirrhosis - fibrosing alveolitis, thyroid iditis, tubulointerstitial nephritis, joint damage.

In viral chronic hepatitis, there are also glomerulonephritis, polyneuropathy, pulmonary vasculitis, pulmonary granulomatosis, myocarditis, and systemic vasculitis.

Classification of chronic hepatitis.

1. Viral (B, C, D, E, F, G).

2. Autoimmune (Epstein-Barr, cytomegaly, Coxsackie, herpes simplex viruses).

3. Medicinal (tuberculostatics, phenothiazines, poisonous mushrooms, DDT and its analogues).

4. Cryptogenic (etiology not established, possibly viral). Liver cirrhosis in childhood is rare, but it occupies a significant place among liver diseases in children.

Etiology: acute viral hepatitis (B, C, D), vascular disorders (Buddy-Chiari syndrome and disease), narrowing of v. portae - congenital or due to inflammation.

Clinical manifestations: enlarged, lumpy, dense liver with a necessarily enlarged spleen. Systemic disorders and complications are clearly expressed (dilation of the veins of the esophagus, stomach, hemorrhoidal veins (collaterals between the v. portae and vena cava), morphological - massive inflammation in the portal tracts and hexagonal lobules, regenerated nodes, fibrosis, degeneration of hepatocytes in combination with their necrosis .

Fundamentals of therapy of chronic diffuse liver diseases.

One of the main mechanisms of liver cell destruction is excessive activation of lipid peroxidation (LPO) and depletion of the antioxidant defense system.

Pharmacological regulation of LPO by hepatoprotectors and antioxidants is the most important direction in the treatment of chronic liver diseases.

For viral CKD, antiviral drugs: viferon (recombinant interferon-referon with the addition of antioxidants, interferon-intron A); possible with a preliminary short course of prednisolone.

Basic therapy for diffuse liver diseases in children. Basic (drug-free) therapy is traditional and is prescribed to all patients, regardless of the etiology of liver damage. Includes a protective regime (limitation of physical activity, bed rest during periods of exacerbations), adequate therapeutic nutrition (table 5, during exacerbations - 5a), a complex of multivitamins.

Nonspecific therapy should be as economical as possible, but sufficient. Not carried out when there is no process activity. It is important to prevent gastrointestinal dysfunction and intestinal autointoxication (prescription of enzymes, eubiotics, laxatives). Hepatoprotectors and antioxidants are used only in sick children with active inflammatory process and hyperenzyme. Preparations of plant origin with membrane-stabilizing, antitoxic and choleretic effects (karsil, legalon, hepatofalk, LIV-52, galstena, hepabene, pumpkinol, hofitol, heptral, silymar, tan-tsekhol, etc.). Relief of cholestasis - adsorbents (cholestyramine, bilignin, polyphepam), heptral, ursodeoxycholic acid preparations (ursofalk, ursosan), hemo- and plasmasorption. In case of pronounced cytolysis and disturbance of the protein-synthetic and detoxification functions of the liver - intravenous administration of detoxification agents (polyionic buffer solutions, 5% glucose solution), protein preparations (albumin, plasma, freshly heparinized blood, coagulation factors), solutions of amino acids (alvesin, aminofusin, hepasteril, aminosteril); methods of extracorporeal detoxification.

Author: Pavlova N.V.

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