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LECTURE No. 13. Differential diagnosis of liver diseases in children. Clinic, diagnosis, treatment



Stage I: inspection.

Anamnesis: the presence of liver damage is established. Laboratory methods: (AlAT, AsAT, alkaline phosphatase, proteinogram, thymol, prothrombin index, bilirubin and urine urobiligen) - an assumption of a diagnosis. Hepatic parenchymal clearance of blood with technetium is the only or early sign of the disease (hepatitis, cirrhosis, amyloidosis).

Ultrasound and liver scintigraphy with technetium (confirmation of damage, differentiation of focal and diffuse pathology, determination of focal localization).

Stage II: formulation of a nosological diagnosis (laparoscopy, selective angiography, targeted biopsy of the liver, latexagglutination reaction to echinococcosis).

With focal lesions in the back of the organ - celiacography, selective hepatography (for contrasting the arteries of the liver, portal veins and spleen vessels).

Puncture biopsy (with suspected diffuse disease). Determination of mitochondrial antibodies to liver tissue.

Stage III: detailing the diagnosis (activity of the process, stage of the disease, complications).

Biochemical studies (cholestasis syndrome - an increase in cholesterol and bound bilirubin, alkaline phosphatase activity; cytolysis syndrome - an increase in bound bilirubin, transaminase activity; hepatoprivial syndrome - lowering cholesterol, albumin, procoagulants, fibrinogen; mesenchymal inflammatory syndrome - an increase in the content of y-globulins, indicators of diphenylamine and thymol samples, ESR indicator).

Immunological studies.

Hepatomegaly Classification:

1) primary diseases of the hepatic parenchyma (hepatitis, pigment hepatosis, cirrhosis, tumors);

2) metabolic disorders (fatty hepatosis, amyloidosis, hemosiderosis, glycogenosis, lipoidosis);

3) circulatory disorders (congestion, heart attack in adults);

4) secondary infiltrative processes (acute and chronic infections and intoxications, blood diseases, collagenoses);

5) diseases of the biliary tract (cholangitis, impaired outflow of bile).

Idiopathic hemochromatosis - deposits of iron in the liver, skin, heart, joints, glands. Autoimmune course of hepatitis, primary biliary CP - fibrosing alveolitis, thyroiditis, tubulointerstitial nephritis, joint damage.

In viral chronic hepatitis C, there are also glomerulonephritis, polyneuropathy, pulmonary vasculitis, pulmonary granulomatosis, myocarditis, and systemic vasculitis.

Classification of chronic hepatitis.

1. Viral (B, C, D, E, F, G).

2. Autoimmune (Epstein-Barr viruses, cytomegaly, Coxsackie, herpes simplex).

3. Medicinal (tuberculostatics, phenothiazines, poisonous mushrooms, DDT and its analogues).

4. Cryptogenic (etiology not established, possibly viral). Cirrhosis of the liver in childhood is rare, but it occupies a significant place among liver diseases in children.

Etiology: acute viral hepatitis (B, C, D), vascular disorders (syndrome and Buddy Chiari disease), narrowing v.
portae - congenital or due to inflammation.

Clinical manifestations: an enlarged, bumpy, dense liver with a necessarily enlarged spleen. Systemic disorders and complications (expansion of the veins of the esophagus, stomach, hemorrhoidal veins (collateral between the v. Portae and vena cava) are clearly pronounced, morphological - massive inflammation in the portal tracts and hexogonal lobules, nodes - regenerates, fibrosis, hepatocyte dystrophy in combination with their necrosis .

The basics of the treatment of chronic diffuse liver diseases.

One of the main mechanisms of liver cell destruction is excessive activation of lipid peroxidation (LPO) and depletion of the antioxidant defense system.

Pharmacological regulation of lipid peroxidation by hepatoprotectors and antioxidants is the most important area of ​​treatment for chronic liver diseases.

For viral CKD, antiviral drugs: viferon (recombinant interferon-referron with antioxidants, interferon-intron A); possible with a preliminary short course of prednisone.

Basic therapy of diffuse liver diseases in children. Basic (non-drug) therapy is traditional and is prescribed to all patients, regardless of the etiology of liver damage. It includes a protective regimen (limitation of physical exertion, bed rest during periods of exacerbation), adequate medical nutrition (table 5, with exacerbations - 5a), a multivitamin complex.

Nonspecific therapy should be as economical as possible, but sufficient. It is not carried out in the absence of activity of the process. Important - the prevention of gastrointestinal dysfunction and intestinal autointoxication (the appointment of enzymes, eubiotics, laxatives). Hepatoprotectors and antioxidants are used only in sick children with inflammatory activity and hyperfermentemia. Herbal preparations with a membrane-stabilizing, antitoxic and choleretic effect (Carsil, Legalon, Hepatofalk, LIV-52, Galstena, Hepabene, Pumpkin, Hofitol, Heptral, Silymar, Tanacechol, etc.). Relief of cholestasis - adsorbents (cholestyramine, bilignin, polypepam), heptral, preparations of ursodeoxycholic acid (ursofalk, ursosan), hemo- and plasma absorption. With pronounced cytolysis and impaired protein-synthetic and detoxification functions of the liver, iv administration of detoxification agents (polyionic buffer solutions, 5% glucose solution), protein preparations (albumin, plasma, freshly heparinized blood, coagulation factors), amino acid solutions (alvesine , aminofusin, hepasteryl, aminosteril); methods of extracorporeal detoxification.

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LECTURE No. 13. Differential diagnosis of liver diseases in children. Clinic, diagnosis, treatment

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