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

Stage I: inspection.

Anamnesis: established the presence of damage to the liver. Laboratory methods: (AlAT, AsAT, alkaline phosphatase, proteinogram, thymol, prothrombin index, bilirubin and urine urobiligen) - the assumption of the 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, the distinction between focal and diffuse pathology, the definition of focal localization).

Stage II: making a nosological diagnosis (laparoscopy, selective angiography, targeted liver biopsy, latex-glutination test for echinococcosis).

In case of focal lesion in the depth of the organ - celiaography, selective hepatography (to contrast the arteries of the liver, portal veins and spleen vessels).

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

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

Biochemical studies (cholestasis syndrome - increased levels of cholesterol and bound bilirubin, alkaline phosphatase activity; cytolysis syndrome - increased bound bilirubin, transaminase activity; hepatitis syndrome - decrease in levels of cholesterol, albumin, procoagulants, fibrinogen; mesenchymal inflammatory syndrome - increase in urosine inflammatory syndrome; indicators of the dinilaminovy ​​and thymol tests, an indicator of ESR).

Immunological studies.

Classification of hepatomegaly:

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

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

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

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

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

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

In viral CG, there are, in addition, glomerulonephritis, polyneuropathy, pulmonary vasculitis, pulmonary granulomatosis, myocarditis, 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 has not been established, possibly viral). Cirrhosis in childhood is rare, but occupies a significant place among liver diseases in children.

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

Clinical manifestations: enlarged, knobby, dense liver with necessarily enlarged spleen. Systemic disorders, complications (varicose veins of the esophagus, stomach, hemorrhoidal veins (collaterals between v. Portae and vena cava), morphological - massive inflammation in portal tracts and hexagonal lobules, regenerate nodes, fibrosis, degeneration of hepatocytes in combination with their necrosis are pronounced. .

Basics of treatment of chronic diffuse liver diseases.

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

Pharmacological regulation of POL by hepatoprotectors and antioxidants is the most important direction in the treatment of chronic liver diseases.

In viral CKD, antiviral drugs: viferon (recombinant-interferon-refeon with the addition of antioxidants, interferon-intron A); can be 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 protective mode (limitation of physical exertion, bed rest during periods of exacerbations), adequate medical nutrition (table 5, with exacerbations - 5a), multivitamin complex.

Non-specific therapy should be as economical as possible, but sufficient. Not carried out in the absence of activity of the process. It is important to prevent dysfunction of the gastrointestinal tract 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 membrane-stabilizing, anti-toxic and choleretic action (Kars, legalon, hepatofalk, LIV-52, galsthen, hepabene, pumpkin, hofitol, heptral, silimar, tanacehol, etc.). Chopping cholestasis - adsorbents (cholestyramine, bilignin, polyfepam), heptral, ursodeoxycholic acid preparations (ursofalk, ursosan), hemo- and plasma adsorption. In severe cytolysis and impaired protein-synthetic and detoxification functions of the liver - in / in the introduction of detoxification agents (polyion buffer solutions, 5% glucose solution), protein drugs (albumin, plasma, freshly parinized blood, clotting factors), amino acid solutions (alvezin , aminofuzin, hepasteril, aminosteryl); extracorporal detoxification methods.

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

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