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PE23.1-21 | Gastrointestinal and Hepatobiliary System — PBL Case

CLINICAL SETTING

Paediatric emergency unit, Government Medical College Hospital, a tier-2 city in India. It is 11 PM. The paediatric emergency SHO is on call when a family arrives in visible distress — a mother carrying a 9-year-old boy, Arjun, with bloodstained clothing. She says he has been vomiting blood for 30 minutes and 'was almost unconscious in the auto-rickshaw'. Arjun is now alert and frightened. The family is from a semi-urban area; the parents are agricultural workers.

Trigger 1: First Contact: The Frightened Boy

Arjun is a 9-year-old male, alert but pale and sweaty. His mother says this is the second episode of haematemesis in 3 months. He has had a progressively enlarging abdomen for 6 months and fatigue. He was born at a district hospital; she recalls that he had 'some infection in the belly button area' just after birth and was kept in the neonatal unit for 10 days with 'a tube in the belly button'. On examination: - Pulse: 118/min, BP 88/60 mmHg - Pallor: moderate; no jaundice, no spider angiomata, no palmar erythema - Abdomen: spleen palpable 6 cm below left costal margin; liver — not enlarged; no ascites on clinical assessment - Bowel sounds: present - GCS: 15/15

DISCUSSION POINTS

  • What are the immediate priorities in a child with active haematemesis and haemodynamic compromise? Outline your 'first 10 minutes' management.
  • What is the significance of the neonatal history (umbilical catheterisation, neonatal sepsis) in a child who now presents with haematemesis and splenomegaly at 9 years of age?
  • List the causes of haematemesis in a 9-year-old. What clinical findings here point most strongly to one aetiology?
Click to reveal Trigger 2: Investigations and Stabilisation (discuss previous trigger first!)

Trigger 2: Investigations and Stabilisation

Arjun is stabilised with IV access, fluid resuscitation, and vasoactive drugs (terlipressin). Blood investigations are sent. Results available: - Haemoglobin: 7.2 g/dL (MCV normal) - WBC: 3.2 × 10⁹/L (hypersplenism) - Platelets: 62 × 10⁹/L - LFTs: Total bilirubin 0.8 mg/dL (normal), ALT 22 IU/L (normal), AST 24 IU/L (normal), albumin 4.1 g/dL (normal), PT: 14 sec (normal) - HBsAg: negative; Anti-HCV: negative; anti-HAV IgM: negative - Renal function: normal - Abdominal Doppler USG: Cavernomatous transformation of the portal vein; portal vein replaced by multiple serpiginous collaterals at the porta hepatis; spleen 16 cm; no ascites; liver normal in size, parenchyma, and echotexture

DISCUSSION POINTS

  • Interpret the investigation results. What does the combination of normal LFTs + thrombocytopenia + splenomegaly + cavernomatous portal vein transformation indicate?
  • How does the pathophysiology of extrahepatic portal vein obstruction (EHPVO) explain haematemesis, splenomegaly, and hypersplenism in this child?
  • Why is abdominal Doppler ultrasound the key imaging investigation here? What are you specifically looking for, and how does it differentiate EHPVO from other causes of portal hypertension?
  • What is the immediate role of terlipressin in acute variceal haemorrhage? What pharmacological mechanism explains its effect?
Click to reveal Trigger 3: Upper GI Endoscopy Findings and Acute Management (discuss previous trigger first!)

Trigger 3: Upper GI Endoscopy Findings and Acute Management

After stabilisation and haemostasis with terlipressin, upper GI endoscopy is performed at 8 hours. Findings: grade III oesophageal varices in the lower third with stigmata of recent bleeding (red wale marks); portal hypertensive gastropathy — mild; no duodenal ulcer. Endoscopic variceal ligation (EVL) is performed successfully. A prophylactic antibiotic (ceftriaxone) is started. Next day: Arjun is stable, haemoglobin 7.0 g/dL, no further haematemesis. Surgical team is consulted regarding Meso-Rex bypass surgery.

DISCUSSION POINTS

  • Describe the endoscopic findings in oesophageal varices — what grades exist, and how does grade inform management decisions?
  • Why is EVL preferred over injection sclerotherapy as the primary endoscopic intervention for variceal bleeding in children?
  • What is the rationale for prophylactic antibiotics (ceftriaxone) in a child with acute variceal haemorrhage? What complications are they preventing?
  • What is the Meso-Rex bypass, and why is it a preferred surgical option for EHPVO in children compared to other shunt procedures?
Click to reveal Trigger 4: Follow-up: New Family Member, New Problem (discuss previous trigger first!)

Trigger 4: Follow-up: New Family Member, New Problem

Six months later, Arjun returns for his EVL follow-up. His 4-year-old sister, Priya, has also been brought along because she has had 3 weeks of watery diarrhoea (5–8 loose stools per day), abdominal distension, failure to gain weight, and pallor. She does not have bloody stools or fever. Anthropometry: weight for height Z-score −2.8 (underweight), MUAC 11.0 cm. She is irritable but alert and drinking. Stool examination: no RBCs, no mucus; hanging drop preparation shows motile organisms with flagella (Giardia lamblia trophozoites). Anti-tTG IgA is 4× upper limit of normal; total IgA is normal.

DISCUSSION POINTS

  • How do you interpret Priya's findings? Are Giardia and coeliac disease mutually exclusive, or can they coexist? What further investigation would confirm coeliac disease?
  • Classify Priya's nutritional status using WHO criteria — is she malnourished? What MUAC threshold defines SAM in a child aged 6–59 months?
  • What is the WHO-recommended treatment for Giardia lamblia in children, and what dietary intervention is required if coeliac disease is confirmed?
  • Based on this case family, what public health and preventive medicine messages would you deliver to the family (water purification, weaning foods, immunisation, early recognition of GI symptoms in children)?

Group Task Assignments

Group 1: Collaborative Task

Group 2: Collaborative Task

Group 3: Collaborative Task

Learning Issues

Research these questions and bring your findings to the discussion.

  1. [PE23.16] What are the causes of portal hypertension in Indian children, and what features distinguish extrahepatic (EHPVO) from intrahepatic (cirrhotic) portal hypertension?
  2. [PE23.20] How do you interpret a full liver function test panel, and what patterns differentiate hepatocellular injury from cholestatic disease?
  3. [PE23.4] What are the WHO IMNCI criteria for classifying dehydration severity in a child with diarrhoea, and what is the correct Plan A/B/C for each category?
  4. [PE23.6] What is the physiological basis of ORT, and what are the correct WHO specifications for reduced-osmolarity ORS (osmolarity, sodium content, glucose) and zinc supplementation?
  5. [PE23.12] How do coeliac disease and cystic fibrosis both cause malabsorption, and which investigations confirm each diagnosis?
  6. [PE23.14] What are the diagnostic criteria, causes, and prognostic indicators for fulminant hepatic failure in children?
  7. [PE23.21] What are the indications for upper GI endoscopy in children, and what are the standard endoscopic findings in oesophageal varices and portal hypertensive gastropathy?
  8. [PE23.5] Why are antibiotics contraindicated in EHEC dysentery but recommended in Shigella dysentery — what is the pathophysiological basis for this difference?