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Chronic hepatitis - Diseases of digestive organs at children

Table of contents
Diseases of digestive organs at children
Oral cavity
Diseases of teeth
Malformations of the sky and soft tissues of an oral cavity
Diseases of a mucous membrane of an oral cavity and gums
Diseases of lips and language
Sialadens
Digestive tract
Basic reasons of gastrointestinal frustration
Gullet
Atresia and esophageal and tracheal fistula
Guttural and tracheal and esophageal crevice, inborn stenosis of a gullet
Other diseases of a gullet
Stomach and intestines
Peptic ulcer
Inborn hypertrophic pyloric stenosis
Inborn impassability of intestines
Inborn impassability of a duodenum
Disturbances of turn of intestines
Inborn impassability of a small bowel
Inborn megacolon
Diverticulums and duplikatura
The acquired impassability of intestines
Intestines invagination
Foreign bodys of a stomach and intestines
Motive frustration. stomach and intestines
Anomalies of a structure of anorectal area
Infectious diseases of intestines
Nonspecific ulcer colitis
Illness Krone
Necrotic coloenteritis of newborns
The coloenteritis connected with treatment by antibiotics
Gastrointestinal symptoms of anaphylactoid purpura, gemolitiko-uraemic syndrome
Intolerance of food proteins
Eosinophilic gastroenteritis
Absorption disturbance syndromes
Malabsorption
Immunodeficiency and intestines
Syndrome of "a congestive loop"
Syndrome of a short small bowel
Gee's disease
Sprue after acute enteritis
Tropical to a spr
Whipple's illness, intestines lymphangiectasia, Uolmap's illness, idiopathic diffusion defeat of mucous
Enzymopathies and disturbances of mechanisms of transport of nutrients
Irritable colon
Acute appendicitis
Diseases of an anus, direct and large intestine
Tumors of a digestive tract at children
Hernias of a digestive tract at children
Exocrine part of a pancreas
Pancreatitis
Embryonic development of structure and function of a liver
Diagnosis of diseases of a liver
Cholestatic states at babies
Parenchymatous jaundices at children of chest age
Disturbances of a metabolism of a liver and zhelchevydelitelny system
Anomalies of a structure of bilious ways
Cysts of bilious channels
Cholestasia and diseases of a liver connected with completely parenteral food
Medicinal damage of a liver
Ray's syndrome
Chronic hepatitis
Wilson's illness — Konovalova
Indian juvenile cirrhosis
Damages of a liver at chronic colitis
Cirrhosis and chronic liver failure
Portal hypertensia and varicosity of a gullet
Fatty infiltration of a liver
Cholecystitis
Peritoneum diseases
Peritonitis
Peritoneum hernias

CHRONIC DISEASES OF THE LIVER AND CIRRHOSIS
CHRONIC HEPATITIS
At adult patients hepatitis is considered chronic if persistirut more than 6 months. It is more difficult to define synchronization of process at children as it proceeds easier, than at adults, besides hepatitis A which prevails at children, never persistirut and does not pass into a chronic form. Communication between an acute viral infection and chronic hepatitis is not absolutely clear. Only the few patients with a chronic inflammation of a liver in the anamnesis have an acute viral disease, and at hepatitis virus carriers In chronic hepatitis develops seldom. However the virus of hepatitis B can persistirovat in an organism within many months and even years after acute attack. Communication between an acute hepatitis In and chronic damage of a liver is schematically presented on fig. 12-32.
Связь между острым гепатитом В
Almost all newborns infected with a hepatitis B virus by vertical transfer become carriers.
** The surface antigen of a virus of hepatitis B is found only in very small number of the children sick with chronic active hepatitis. The ratio recovery / death is much more favorable (8:1) at V-negative "lupoid" option.
Fig. 12-32. Communication between an acute hepatitis In, on the one hand, and persistent hepatitis, chronic active hepatitis and fulminant hepatitis — with another.
Печень при персистирующем гепатите

Fig. 12-33. A liver at persistent hepatitis. Hepatocytes are heterogeneous on coloring, the sizes and a form, however the structure of hepatic segments is kept. Inflammation cells (mainly lymphocytes) concentrate on the periphery of segments. Kaunsilmen (shooter's) little bodies are often observed. Fibrosis and a necrosis are absent. X 200.

Fig. 12-34. A liver at chronic active hepatitis. The portal zone (at the left below) has the broken structure, its borders are broken off by fibrous bunches, lymphocytes and plasmocytes, the fagotsitirovanny and died hepatocytes (a step necrosis). Besides, formation of pseudo-segments (shooter), swelling of hepatocytes and fibrous growths which pass into a liver parenchyma are noted, breaking a structure of sinusoid. X 200.
Disease and its outcome in chronic hepatitis depend on aggression of inflammatory process in a liver parenchyma. On the basis of histologic changes in bioptata of a liver distinguish two types of chronic inflammatory defeat: persistent hepatitis and chronic active hepatitis. Their characteristic signs are described in explanations to fig. 12-33 and 12-34.

CHRONIC PERSISTENT HEPATITIS

Clinical and datas of laboratory. Most of patients complain of unpleasant feelings in an abdominal cavity (optional in a liver), the indisposition, weakness, is noted weight loss owing to a small appetite. These complaints often ignore or regard them as symptoms of some viral illness. Sometimes at patients easy yellowness of scleras is observed. The liver at a palpation is painful, but, as a rule, is not increased.
Laboratory researches reveal moderate increase of level of serumal bilirubin approximately in 50% of cases; level of aminotransferases is with firmness increased, but its size fluctuates. An alkaline phosphatase, a seralbumin and globulin, and also a prothrombin time almost always within Enorma. Tests for HBsAg are positive less than at 10% of patients, mainly at teenagers. At other patients detection of IgM-antibodies to a virus of hepatitis A indicates recently postponed infection; existence of IgG-antibodies only confirms the contact with a virus taking place in the past.
Diagnosis. Persistirovaniye of intestinal symptoms and abnormal laboratory indicators for more than 3 months is the basis for a transdermal biopsy of a liver with the purpose to exclude chronic active hepatitis or other pathology of this body (see fig. 12-33).
Treatment. First of all it is necessary to calm parents, to convince them not to give to the child any drugs, to organize regular dietary food, to allow a moderate exercise stress. It is necessary to conduct careful survey of the child and biochemical researches each 3 months.
Forecast. The forecast is good as finally there comes the absolute recovery.

CHRONIC ACTIVE HEPATITIS

Clinical manifestations. Depending on whether the surface antigen of a virus of hepatitis B is found in serum, distinguish 2 forms of chronic active hepatitis. More than in 95% of cases the surface antigen is absent; such hepatitis call lupoid (tab. 12-19). Unlike a HBsAg-positive form lupoid hepatitis prevails at girls, mainly at prepubertal age. The beginning of a disease is characterized by extreme variability of symptoms. The alternating jaundice, weakness, appetite losses are often noted, but they can be expressed slightly, as at persistent hepatitis. Gepatosplenomegaliya is marked out in 50 — 80% of cases. Temperature increase, gastrointestinal bleedings, hypostases and an arthralgia can quickly develop in the period of aggravations and indicate the beginning liver failure. At a lupoid form of chronic active hepatitis often there are defeats of other bodies (a glomerulonephritis, colitis, a thyroiditis, etc.). It is necessary to influence these displays of an illness by means of very active treatment as are causes of death of children with chronic active hepatitis in the first 3 years after its beginning as the specified complications, and damage of the liver.
Datas of laboratory. Functional trials show resistant, sometimes considerable, activity increase aminotrapsferaz, a hyperbilirubinemia of various degree (from 0,02 to 0,3 g/l)
Table 12-19. Symptoms of chronic active hepatitis

 

HBjAg-negative

HBgAg-pozitivvy

Age

5 — 16 years

17 years are also more senior

Floor

Girls prevail (4:1)

Boys prevail (2:1)

Signs autoimmunno

Are usual

Are very rare

go defeats

 

 

Corticosteroid therapy

Fine results (remission> of 75%)

It is generally inefficient

Serum gamma globulin

2 — 4 times higher than norm

Higher than norm less than twice

Antinuclear antibodies

Are present
(60-80%)

 

Antibodies to smooth mousse

High caption

Low caption

to kulatura

 

 

Surface antigen of a virus of hepatitis B in serum

No

No

Antibodies to a surface antigen of a virus of hepatitis B in serum

No

Often are present

Direct test of Koombs

It is positive (about 70%)

It is negative

LE Cells

Find approximately in 50% of cases

No

(to 60% makes direct bilirubin); almost at all patients the content of gamma-globulin in serum exceeds 20 g/l. The prothrombin time is extended, and the level of an alkaline phosphatase and seralbumin is close to norm (an exception cases of a heavy current from the outcome in cirrhosis make). At chronic active hepatitis often find signs of nonspecific autoimmune reactions, including antinuclear antibodies (80%), LE cells (40%) and, more rare, antibodies to smooth muscles and mitochondrions.
Diagnosis. As the differential diagnosis includes Wilson's illness — Konovalova and insufficiency of a1-antitrypsin, with the purpose to exclude these diseases at the beginning of inspection it is necessary to carry out the corresponding tests. It is necessary to ask on medicine which the patient took within 3 months preceding the beginning of hepatitis carefully; it helps to exclude toxic damage of a liver. The histologic picture of chronic active hepatitis is presented on fig. 12-34.
Treatment. There are opposite points of view on need to appoint corticosteroids at HBsAg-nolozhiteln chronic active hepatitis. At HBsAg-negative type autoimmune signs (lupoid hepatitis) prevail; expediency and efficiency of corticosteroid
Table 12-20. Corticosteroid therapy of chronic active hepatitis
Initial course Histologic research of bioptat
Prednisonum of 0,002 g/(kg-days) in 2 receptions; the maximum dose of 0,06 g a day Monthly to determine the level of aminotransferases
To continue treatment in the specified doses until the level of enzymes decreases to norm or there will be no serious complications (obesity, osteoporosis, a hypertension, a growth inhibition, diabetes)
Remission
Histologic research of control bioptat; if the histologic picture was normalized or corresponds to persistent (benign) hepatitis, then it is necessary to reduce drug doses by 0,005 g every week (to 0,015 g/days), and then by 0,005 g each 2 weeks before full cancellation)
Serious complications
To apply the maximum doses (0,002 g/kg or 0,06 g/days)
To monthly determine the level of aminotransferases Lack of remission and activation of process at reduction of a dose Prednisonum with addition of Azathioprinum (0,05 — 0,1 g/days) Weekly to determine quantity of leukocytes and thrombocytes by 0,02 g/days, monthly — the level of aminotransferases to Continue the combined treatment before remission or emergence of serious complications of therapy in treatment of this contingent of patients are not subject to doubt. As the vast majority of children suffer from this type of hepatitis, the forecast at children and teenagers (especially at girls) it is better, than at adults.

The offered approaches to treatment are given in tab. 12-20. Treatment is begun with Prednisonum or Prednisolonum in a dose of 0,002 g/kg/days (the maximum daily dose of 0,06 g). Such doses enter until the content of aminotransferases does not decrease to level, less than twice exceeding norm (remission), or negative effects of hormonal therapy will not develop yet. In a remission stage the dose is gradually lowered by 0,005 g a week to 0,01 — 0,015 g/days (maintenance dose). If such complications as a growth inhibition, diabetes, osteoporosis, a hypertension or obesity, arise before remission, then the maximum medical dose should be given every other day (for example 0,04 g every other day if before transfer into a discontinuous course of the patient received 0,04 g daily). There are data on inefficiency of such mode at treatment of adults, but at children of prepubertal age with its help it is possible to control the course of process. At many patients, treated in such a way, growth was resumed, and cushingoid signs considerably decreased. When by means of a discontinuous course it is not possible to achieve remission or when against daily reception less than 0,02 g of Prednisolonum there is a recurrence, add Azathioprinum (0,05 — 0,1 g daily). Complex treatment is carried out until pe there comes remission or there will be no serious complications. When carrying out complex treatment it is necessary to define weekly quantity of leukocytes in peripheral blood, a leukocytic formula and quantity of thrombocytes. At corticosteroid therapy monthly investigate biochemical indicators of function of a liver. The repeated biopsy is carried out during this period when the level of aminotransferases decreases to normal amounts. If find disappearance of characteristic symptoms of active hepatitis (a step necrosis) or a histologic picture of persistent hepatitis, then the maintenance dose of Prednisolonum is reduced by 0,005 g by each 2          weeks before its full cancellation.
Forecast. Positive action of corticosteroid therapy is especially brightly shown in the first 3 years of an illness. Autoimmune extrahepatic complications most often arise in this initial stage and quickly give in to influence of immunosuppressors. At the children receiving corticosteroids, long remission can achieve approximately in 70% of cases. Some patients are forced to accept hormones continuously several years as attempt of their cancellation causes deterioration in clinical and biochemical indicators. Cirrhosis develops seldom, mainly at carriers of a surface antigen of a virus of hepatitis B. In process of emergence at such patients of portal hypertensia, ascites, gastric bleeding and liver failure carry out a symptomatic treatment.



 
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