Pediatrics
Liver Disorders
Paediatric liver disease for NEET-PG: acute and fulminant hepatitis, portal hypertension, LFT and viral marker interpretation, mapped to NMC PE26 codes.
MedNext Academy | 3 min read
Liver Disorders
Paediatric liver disease for NEET-PG: acute and fulminant hepatitis, portal hypertension, LFT and viral marker interpretation, mapped to NMC PE26 codes.
This chapter covers paediatric hepatology: acute and fulminant hepatitis, chronic liver disease and portal hypertension, together with the history-taking, examination and investigation skills that recognise danger early. It stresses INR-driven assessment of liver failure and the Indian burden of extrahepatic portal venous obstruction.
High-yield: Liver Disorders
- Paediatric acute liver failure is defined by severe liver injury with an INR of at least 1.5 with encephalopathy, or at least 2.0 without encephalopathy, after vitamin K correction.
- In children, encephalopathy may be absent or hard to grade, so acute liver failure can present as an irritable, sleepy, hypoglycaemic, acidotic and coagulopathic child.
- The urgency of paediatric liver failure is read from the INR after vitamin K rather than from the height of the alanine aminotransferase.
- A previously well child with jaundice who becomes drowsy needs glucose and INR checked before ordering viral markers, because hypoglycaemia and coagulopathy are the reversible killers.
- Sudden large painless haematemesis with splenomegaly and preserved consciousness is variceal bleeding from portal hypertension until proven otherwise.
- In India, extrahepatic portal venous obstruction is a leading cause of paediatric portal hypertension and may present with a variceal bleed before liver failure signs appear.
- In a child with haematemesis and splenomegaly, upper gastrointestinal endoscopy is both diagnostic and therapeutic, allowing band ligation or sclerotherapy after resuscitation.
- Endoscopy is never the first step in a bleeding child in shock; resuscitation comes first, then a vasoactive drug, then endoscopy.
- Chronic liver disease can exist with normal or only mildly raised transaminases, so severity is read from INR, albumin, ascites, encephalopathy, growth and portal hypertension.
- A liver panel is not a diagnosis: ALT and AST show injury, bilirubin and gamma-glutamyl transpeptidase show bile handling, and albumin and INR show synthetic function.
- Anti-HAV IgM indicates acute hepatitis A, while anti-HAV IgG indicates past infection or immunity and should not be mistaken for acute disease.
- After hepatitis B vaccination an anti-HBs level of at least 10 mIU/mL is protective, whereas HBsAg positivity means infection.
- Prevention of hepatitis B assumes paperwork can fail: screen every pregnant woman, give the birth-dose vaccine, add immunoglobulin for exposed newborns and complete the series.
- Prolonged neonatal jaundice beyond 2 weeks must not be assumed physiological, because delayed recognition of biliary atresia worsens outcome.
- Children with chronic liver disease still need dietary protein, and protein should only be temporarily modified by a specialist during severe encephalopathy.
Reading the sick liver
- **Paediatric acute liver failure:** INR at least 1.5 with encephalopathy or at least 2.0 without, after vitamin K.
- **Severity of chronic disease:** Read from INR, albumin, ascites, encephalopathy, growth and portal hypertension, not enzyme height.
- **Hepatitis A markers:** Anti-HAV IgM is acute infection; anti-HAV IgG is past infection or immunity.
- **Hepatitis B markers:** HBsAg means infection; anti-HBs of at least 10 mIU/mL after vaccination is protective.
NMC competencies in this chapter
- **PE26.1:** Acute Hepatitis in Children
- **PE26.2:** Fulminant Hepatic Failure in Children
- **PE26.4:** Portal Hypertension in Children
- **PE26.9:** Interpreting Liver Function Tests, Viral Markers, and Ultrasound
- **PE26.12:** Prevention of Hepatitis B Infection
Frequently Asked Questions
How is paediatric acute liver failure defined?
It is severe liver injury with an INR of at least 1.5 in the presence of encephalopathy, or at least 2.0 without encephalopathy, after vitamin K correction. Because encephalopathy is hard to grade in children, the INR is the key marker rather than the ALT height.
What is the first step in a child with haematemesis and splenomegaly?
Resuscitate first, then start a vasoactive drug and call for endoscopy. Endoscopy is diagnostic and therapeutic for varices but must never precede resuscitation in a child in shock.
How do you interpret hepatitis A and B serology?
Anti-HAV IgM means acute hepatitis A while anti-HAV IgG means past infection or immunity. For hepatitis B, HBsAg means infection, and an anti-HBs level of at least 10 mIU/mL after vaccination is protective.
Why is prolonged neonatal jaundice a concern?
Jaundice persisting beyond 2 weeks must not be assumed physiological, because it can indicate biliary atresia. Delayed referral worsens the outcome, so stool colour and conjugated bilirubin must be checked.
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