CLINICAL, BIOCHEMICAL AND ETIOLOGICAL PATTERN OF ACUTE ON CHRONIC LIVER DISEASE IN CHILDREN
Abhinav Sharma*, Ujjal Poddar**, UC Ghoshal***, SK Yachha****
SGPGI, Lucknow *, SGPGI, Lucknow **, SGPGI, Lucknow ***, SGPGI, Lucknow ****
Introduction: India where goal of universal sanitary water supply yet remains to be achieved, acute viral hepatitis is an important public health problem. To the other end, chronic liver disease (CLD) constitutes a significant proportion of pediatric hepatobiliary diseases. So there is a possibility of an overlap of acute on chronic liver disease (ACLD) which is an entity poorly described in literature. We present clinical profile of children presenting with ACLD to our center.

Method: Children presenting with jaundice of <6 months duration were included in the study. ACLD was diagnosed by positive test for viral markers (IgM HAV or HEV or HBc) in a patient with established CLD (cirrhosis on biopsy/chronic hepatitis due to various etiologies). The cases were managed as per standard protocol according to underlying etiology either at presentation or on follow up.

Results: Between June 1998 and June 2005, total 151 children presented with jaundice <6 months duration; of these, 21 (14%) children (15 boys, median age 8, range 2-15 year) were diagnosed to have ACLD. Etiology of CLD was Wilson's 6, HBV 4, autoimmune 3, HCV 1 and cryptogenic 7. Liver biopsy was done in 11 children (cirrhosis 8, chronic hepatitis 2, and autoimmune hepatitis 1). Super-infection was due to HEV 9, HAV 6, HAV + HEV 3 and HBV 2. Median duration of symptoms at presentation was 60 days, range 5-180 days.


Their presentation included prodrome preceding jaundice 9, hepatomegaly 19, splenomegaly 10, ascites 12, mucosal bleed 2, and hepatic encephalopathy 6 (Figure). Their median (range) biochemical values were serum bilirubin 13.2 (0.4-44.6) mg/dL, AST 354 (46-1752 IU/L, ALT 188 (44-2240) IU/L, median AST/ALT ratio 0.97, range 0.24-3.57), serum albumin 2.8 (1.4-4.4) g/dL and INR 2.2 (1-3.8). Serum albumin was lower in children with ascites (median 2, range 1.4 3.1 g/dL) than those without ascites (median 3.2 range 2-4.4). Esophagogastroscopy revealed esophageal varices in 7/16 children (44%). Three (14%) children died due to advanced liver disease (HAV on Wilson's 1, HAV on autoimmune live disease 1, HAV + HEV on cryptogenic cirrhosis 1). On follow up after 6 months, 10 children improved and 3 had stable liver function tests. Of the remaining, one child had deterioration in liver functions, 3 died and 4 were lost to follow up.

Conclusion: ACLD occurs in 14% of jaundiced children. The entity should be suspected if features of ascites and/or encephalopathy are present in children with symptom duration of around 60 days. Hepatitis A and E cause super-infection.
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