Ascites in Children: Clinical Case and Viva QnA

Clinical Case of Ascites in Children

Clinical Case: Ascites in a 7-year-old child

A 7-year-old boy is brought to the pediatric clinic by his parents with complaints of progressive abdominal distension over the past 3 weeks. The parents report that the child has been experiencing discomfort and a feeling of fullness after eating small amounts of food. They also noticed that his abdomen appears more prominent, especially when standing.

History:

• No history of fever, jaundice, or bleeding disorders
• No recent travel or exposure to contaminated water
• No family history of liver disease or autoimmune disorders
• Normal birth and developmental history
• Vaccinations up to date

Physical Examination:

• Weight: 25 kg (50th percentile), Height: 122 cm (50th percentile)
• Vital signs: Temperature 37°C, HR 90/min, RR 20/min, BP 110/70 mmHg
• Abdominal examination:
  • Distended abdomen with visible dilated superficial veins
  • Fluid thrill and shifting dullness present
  • No tenderness or organomegaly appreciated
• Mild pedal edema noted
• No signs of jaundice or pallor

Investigations:

• Complete blood count: Hb 11.5 g/dL, WBC 7,500/μL, Platelets 180,000/μL
• Liver function tests: ALT 65 U/L, AST 70 U/L, Total bilirubin 1.2 mg/dL, Albumin 2.8 g/dL
• Renal function tests: BUN 15 mg/dL, Creatinine 0.6 mg/dL
• Abdominal ultrasound: Moderate ascites, normal liver echotexture, no focal lesions, patent portal and hepatic veins
• Ascitic fluid analysis: SAAG (Serum-Ascites Albumin Gradient) 1.8 g/dL, protein 2.5 g/dL, cell count 100/μL (predominantly lymphocytes)

Diagnosis and Management:

Based on the clinical presentation, physical examination, and investigations, a diagnosis of portal hypertension secondary to liver cirrhosis is suspected. Further evaluation is needed to determine the underlying etiology, which may include autoimmune hepatitis, Wilson's disease, or other causes of chronic liver disease in children. Management will involve addressing the underlying cause, nutritional support, and symptomatic treatment of ascites.

Varieties of Presentations of Ascites in Children

Varieties of Presentations of Ascites in Children

1. Chronic Liver Disease-Related Ascites

   Presentation: Gradual onset of abdominal distension, often accompanied by other signs of chronic liver disease such as jaundice, spider angiomas, and palmar erythema. May have a history of failure to thrive or recurrent infections.

   Examples: Biliary atresia, autoimmune hepatitis, Wilson's disease

2. Acute Ascites in Nephrotic Syndrome

   Presentation: Rapid onset of generalized edema, including periorbital puffiness and ascites. Often accompanied by frothy urine and recent history of upper respiratory tract infection.

   Example: Minimal change disease

3. Cardiac Ascites

   Presentation: Ascites developing in the context of heart failure. Often associated with hepatomegaly, jugular venous distension, and peripheral edema. May have history of congenital heart disease or cardiomyopathy.

   Examples: Constrictive pericarditis, severe tricuspid regurgitation

4. Malignancy-Associated Ascites

   Presentation: Rapid onset of ascites, often accompanied by constitutional symptoms like weight loss, fever, and night sweats. May have palpable abdominal masses or lymphadenopathy.

   Examples: Lymphoma, ovarian tumors, hepatoblastoma

5. Infectious or Inflammatory Ascites

   Presentation: Acute onset of ascites with fever, abdominal pain, and signs of systemic inflammation. May have recent travel history or exposure to infectious agents.

   Examples: Tuberculous peritonitis, spontaneous bacterial peritonitis in a child with underlying liver disease

Knowledge Check: Question and Answers

This interactive quiz component covers essential viva questions and answers. It includes 30 high-yield viva questions with detailed answers.

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