Dr.Hamdi Katar- Conslt.Neonatologist Dr.Roya Arif- Sen.Registrar of ...

Dr.Hamdi Katar- Conslt.Neonatologist
Dr.Roya Arif- Sen.Registrar of Ped.dep
Dr.Ahmed Salama-Pediatric Resident.
Dr.Ahmed Ba’abad-Pediatric Resident.
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Sultan is 30 days old was c/o of:
- Fever for 1 day and vomiting for 2 days
prior to admission.
- Yellow discoloration of skin since of age
of 1 wk old.
- pale colour stool for the last 2 wks prior
to admission.

Patient sought medical advice in Private
polyclinic at the age of 2 wks old because of
yellow discoloration of the skin.
Investigated:according to the parents
S.bilirubin was within N range.
Was adviced to take good nutritional support.

Patient was seen again at the age of 30days
old with above mentioned complaines, blood
investigation showed
hyperbilirubinemia,mainly elevated D.Bil,so
transferred to our hospital for further
investigation and management.

Maternal history
** Mother was G3, P3, L2, -1.
** History of previous neonatal death (1 st
baby) was stillbirth of unknown cause.
** No maternal history of DM or
hypertension

Weigh 2.7 kg HC 33.5 cm HT 45 cm
Vital signs :
Temperature 36.5
RR -36/minute
HR -115/minute
BP - 66/46MAP60
Dextrostix 4.6mmol/l
Generally
Stable, afebrile , fully conscious ,no distinctive
features,no petechiae or other skin rash, deeply
jaundiced (lemon color), pale , well hydrated, well
perfused on room air.

Systemic ex:
Chest: Air entry bilateral equal,clear.
CVS: S1+ S2 + 0, PPP
Abdomen: Distended, liver 4cm below costal
margin,not tender,smooth surface, Spleen 8 cm
below costal margin, normal male genitalia.
CNS: conscious, alert,AF-flat, normal tone, reflexes.
Hips : Bilateral stable

CBC: WBC 5.8, Hb 8.5 Platelets 70
PT, PTT-N
Electrolytes: Na-140 mmol/l, K- 4.8
Glucose-4.8 T.protein-52, Albumin-27
TSB-293mmol/l, Direct S.Bil-219 , ALK.Ph- 604,
AST-587, ALT-212, Gamma GT-163
LDH 899 S.Ammonia-84
ABG: PH 7.4, PCO3 30,BE-5.9 HCO3 18.5
Blood culture: Negative
Urine analysis-N ,Urine c/s-no growth
CRP-neg
TORCH: Negative. Hep.pannel-negat.

G6PD ensyme-present
Fundus exam-N
TFT-N study
Metabolic Screening : unremarkable
Chromosomal study-N
Abdominal ultrasound : Enlarged liver and
spleen with gall bladder distended and
common bile duct visualized
CT Abdomen: Hepatosplenomegaly. No
other masses.
Echocardiogram: Normal study.
.

Tc-HIDA
HEPATOBILIARY
SCINTIGRAPHY

Neonatal Jaundice
Biliary Atresia
Hepatitis

Tc -HIDA Hepatobiliary Scintigraphy :
Early and good hepatic uptake with rapid
clearance of tracer from the intravascular
pool was seen .However no extra hepatic
excretion was seen up to 24 hours post
injection.
Comment : good hepatic function. Findings
are those of billiary atresia or intrahepatic
cholestasis .

Working diagnosis:
Neonatal cholestasis
(intra,extrahepatic)
SEPSIS
IDIOPATIC NEONAT.
HEPATITIS
METABOLIC

HOSPITAL COURSE

The baby admitted to NICU for close
observation and further investigation.
Next day of admission, Sultan developed
coffee-ground aspirate and
hematuria,treated accordingly(PT,PTT-N).

During being in the hospital the baby
was doing well, was on full PO feeding
with normal activity.
Patient started on PO Phenobarbitone ,
Vit.D3 and Multivitamins, PO
Ursodeoxycholic acid, IV Vit.K

Patient was transferred to general ward
with
the mother in quite stable condition but
still
was jaundiced and having clay coloured
stool on and off.

We discussed the case with Pediatric
Surgeon. Was advised to do preoperative
cholangiogram with liver
biopsy (because the common bile duct
was visualized by U/S) but the parents
refused,they asked it to be done in
Riyadh as they are living there.

Patient was accepted in Riyadh (AL-Shemesi)
and transferred for further investigation to
Al-Shemesi hospital.
We are following the case…