management of Hepatic encephalopathy Available options...

20171218 PICU 5 2 year female 13.5 kg Admitted with c/o irritability with icterus with distended abdomen with constipation(date 14/12/2017) Vitals WNL GCS 14/15 Abdominal paracentasis done with removal of 1 litre of ascitic fluid(14/12/2017) 18/12/2017 Pt became unconcious gradually Pupils b/l equally dilated with normaly reactive to light GCS V2E1M4 Babinski sign -ve Clonus? P/A soft better than before PR 150 SpO2 99% Temp wnl Ddx acute viral hepatitis fb hepatic encephalopathy Antibiotics+spirolactone+hepamerz+neotonic anema+FFP(up to now going on should i go for mannitol and /or dexona or prednisone??) What may be prognosis?? What else we can do?? Kindly suggest via your opinion Thank you

a 11 years child... vomiting after taking food mild fever.... pls rx plan

ABERNETHY MALFORMATION : I would like to share a rare case of Abernethy malformation. 38 yr old patient G2 P1 L1 PR LSCS. Consanguinous marriage. patient is obese,hirsute ,a known case of PCOD and hypothyroidism. I :Was treated for infertility./LSCS /Al female child /6 years/normal development. II : Was treated for secondary infertility. Tiffa normal. THERE WAS SINGLE UMBILICAL ARTERY. LSCS /CIAB /later developed cyanosis and was in NICU for 1 month.She was diagnosed as PPHN (Persistent pulmonary hypertension ). Now the baby is 2 years.Baby is having recurrent URTI. On examination,it was found that baby had abernethy malformation. ABERNATHY MALFORMATION (AM ). Congenital extra hepatic portosystemic shunt is a rare congenital anomaly that was first described by JOHN ABERNATHY in 1793 at autopsy of a 10 month old infant who died of unknown cause. AM is defined as congenital diversion of portal blood away from the liver by either end-to-side or side-to-side shunt. CLASSIFICATION OF CONGENITAL EXTRA HEPATIC PORTOSYSTEMIC SHUNT. Classified into two types. Type I and II. TYPE I SHUNT :Characterized by the absence of the intrahepatic portal vein and complete end -to-side shunt. There are 2 sub-types . TYPE I A :Superior mesenteric and spleenic vein drain separately into inferior vena cava. TYPE II B :Superior mesenteric and spleenic vein form a common trunk before draining into the inferior vena cava. TYPE II :Marked by the presence of a patent intra hepatic portal vein and a partial side-to-side shunt. AM is associated with several congenital malformations like *Congenital heart disease. *Polyspleenia. *Biliary atresia. *Duodenal atresia. *Malrotation. *Annular pancreas. *Situs inversus. *Renal anomalies. *Skeletal anomalies. CLINICAL FEATURES : 1.Dilatation of intra pulmonary vessels and hepato pulmonary syndrome. 2.Diversion of gut derived toxins to the systemic circulation leading to hepatic encephalopathy or diversion of vaso active mediators into the systemic circulation. 3.Digital clubbing (ventilation perfusion mismatch) 4.Varying degrees of dyspnea on exertion (porto pulmonary hypertension or hepato pulmonary syndrome ). 5.Hepatic encephalopathy. 6.Hypoglycemia. DIAGNOSIS. *USG. *CT. *MRI. MANAGEMENT. In patients with type I malformation,occlusion of the shunt is not an option since it represents the only drainage route for the mesenteric venous blood. Hence,these patients require clinical, biochemical and imaging follow up. Those who develop severe hepatic encephalopathy pr malignant liver nodules,liver trans plantation is the only treatment option. For patients with type II malformation and serious symptoms such as hepatic encephalopathy ,shunt occlusion can be performed,eithr surgically or by percutaneous transcathetar coli placement. Our baby has high levels of ammonia and is advised to undergo placement of stent.

11 years old boy with hepatitis A, bilirubin 11 mg/dl, presented with altered sensorium and seizures. Opinions please.