Case Report
Case Study: Importance of Timely Diagnosis of Non-Alcoholic Fatty Liver Disease in a Child with Vague Symptoms: Part 1
Atefeh Samadi-niya*
IRACA Solutions Inc, Canada
*Corresponding author: Atefeh Samadi-niya, IRACA Solutions Inc, 1096 Bancroft Drive, Mississauga, Ontario, L5V 1B9 Canada
Published: 30 Aug, 2016
Cite this article as: Samadi-niya A. Case Study: Importance
of Timely Diagnosis of Non-Alcoholic
Fatty Liver Disease in a Child with
Vague Symptoms: Part 1. Ann Clin
Case Rep. 2016; 1: 1111.
Abstract
Introduction: This article describes complications of misdiagnosed Non-Alcoholic Fatty Liver
Disease in an 8-year-old overweight child presented to Emergency Room due to vomiting and
severe epigastric pain. The child complained of headache, shortness of breath during physical
activities, tiredness, pressure on heart, and increased waist circumference for few months before
visiting hospital.
Materials and Methods: Initial assessments were completed by an Emergency Room physician, a
family physician, and a hepatologist in early 2016. Further assessments will be reported in follow-up
articles.
Results: The child who was misdiagnosed for indigestion or gastritis, due to family history of
positive H-pylori in his father, was found to have extremely high level of Liver Function Tests,
hepatomegaly, dyslipidemia, constipation, bloating, and a diet full of junk food. Based on the initial
assessments and referral to hepatologist, NAFLD is reported as the initial diagnosis.
Conclusion: Considering increasing prevalence of NAFLD in children, routine screening of
overweight and obese children for possibility of NAFLD is recommended so early interventions and
lifestyle changes can be implemented. Quality of life is affected a child with a large liver due to its
pressure on adjacent organs.
Keywords: Non-alcoholic fatty liver disease; Dyslipidemia; Obesity; Children; High liver functions; Hepatomegaly
Introduction
Hepatomegaly due to the Non-Alcoholic Fatty Liver Disease is prevalent in children of
industrial countries where children obesity is a public health issue as well as a primary care concern
[1]. Timely diagnosis of NAFLD in a child with vague symptoms could lead to prevention of
severe complications and chronic medical illnesses that are devastating in childhood and create
unnecessary expenditure for healthcare systems as they could cause chronic illnesses in adulthood
[2]. The concept of nourishment has been replaced by eating too much and not having a healthy
variety of foods suggested by the Nutrition Guides [3].
The Fatty Liver Disease can start as early as age four [4]. In fact, the childhood obesity rate has
increased in the past few decades and the timely diagnosis and correction of diet and lifestyle can save
lives, prevent chronic diseases, and save the healthcare budget [5,6]. The presence of hepatomegaly
due to Fatty Liver Disease should be considered a dire diagnosis that needs extreme attention and
continuous follow-up until the child is heathy again because the percentage of adolescents diagnosed
with the disease is increasing [7,8].
The NAFLD is asymptomatic until another medical condition accidentally reveals its presence
or leads to other consequences that are seen in this child who presented to the ER due to vomiting
and epigastric pain. The focus of this case report is on timely diagnosis and paying attention to
the possibility of misdiagnosis or late diagnosis of NAFLD. If healthcare care providers consider
NAFLD diagnosis in every cute, chubby, and possibly overweight child, early interventions can
change the course of treatment tremendously [9,10].
Case Presentation
The 8-year old overweight child presented to the emergency department with epigastric pain, vomiting and some strikes of blood in vomitus, which frightened the
family the most. He was assessed in the emergency department and
was kept under observation for few hours to rule out acute abdomen.
An X-ray of abdomen and a set of essential blood tests were ordered.
Past medical history
The family reported that the epigastric pain was repeated
frequently in the past few months but was interpreted for bloating
and extra gas in bowels and the urgent need for defecation. Each time
after defecation, the pain was lessened and the family assumed that
the pain was due to constipation. In addition, the family specified that
the child’s stool floated on the toilet water in the past few weeks. The
defecation had become extremely strenuous and the child had a very
large abdomen with extra bowel gas in his digestive system shown as
consistent passing of gas.
The child’s abdominal circumference began increasing in the
year previous to the Emergency Room visit and all the pants for
his age were too tight for him so size 18 pants (instead of size 8-10)
were purchased for this 8-year-old child. In the past few days before
arriving in the Emergency Room, severe epigastric pain and vomiting
were reported in the early morning but it was interpreted as extra
stomach acid. The child was complaining of heartache and showed
the left side of his chest as the pain was occurring. Very puzzling for
the family, the child complained of headaches, especially at night,
extreme sweating at night, tiredness, dry itchy skin, pain in the legs,
feeling of pressure on the heart, and shortness of breath. The child
became angry very often as he was being more sensitive than previous
months. He was also upset that his abdominal circumference had
increased tremendously and complained about it.
Family history
The family history of Gastroesophageal Reflux and Helicobacter Pylori in his father led to initial differential diagnosis of possible
gastritis due to excessive acid secretion. The family history showed
Diabetes in both paternal grandparents and in the child’s father. The
father was also diagnosed with Non-Alcoholic Fatty Liver Disease,
received medication to lower lipids and glucose, and was advised to
reduce weight.
Results
At the time of arrival at the hospital, weight was 45 Kg and height
136 cm. Please note that Canadian Diabetes Foundation emphasizes
that the children and elderly have a lower muscle mass so the lower
level of Body Mass Index of 24.3 in the 8-year-old child would be
considered obesity rather than normal range shown in adults [11,12].
Diet and lifestyle
The diet of the child was assessed and was full of junk food and
no vegetable or fruit [3]. The child was inactive due to playing digital
video-games. Child left the swimming class due to shortness of breath
after the speed and endurance of swimming lessons increased.
Abdominal x-ray
The plain x-ray showed residues of stool in large bowel in different
locations despite routine daily defecation. No other abnormality was
reported.
Ultrasound
The ultrasound reported hepatomegaly filled with fat measured
17 cm horizontally and no other abnormalities [13].
Blood work-up
The initial set of blood tests revealed extremely high level of Liver
Function Tests (AST and ALT), which were about 10 times higher than the normal level [14-17]. The first set of laboratory tests are summarized in Table 1.
After ER visit, the child was followed up in the office and the
Family Physician requested Abdominal Ultrasound and complete
blood and urine lab tests including the test for Helicobacter Pylori.
The child was scheduled to visit Family Physician to check the weight
and general conditions every month after hospital visit for 6 months
[18-21]. Table 2 shows the additional tests results. The Complete
Blood Count (CBC) and Urine Analysis were reported as normal.
As Table 2 shows the level of both AST and ALT has decreased
comparing to Table 1. The level of cholesterol was very high too.
After a period of 2 months of healthy diet and complete defecation of
bowels, weight started decreasing [10]. Therefore, the modifications
in diet and exercise showed positive results in this child immediately
after intervention, which is promising [22].
Referral to the hepatologist
American Association of Family Practise has provided guidelines
for assessment of Fatty Liver Disease [15,23]. Further referral to
the Hepatologist located at a Gastroenterology and Liver clinic of
a children specialty hospital led to further tests Ruling out other
reasons led to initial diagnosis of Non-Alcoholic Fatty Liver Disease
at this time. Thyroid function was reported as normal [24,25]. Further
assessment will be performed and the results will be reported in
follow-up articles.
Discussion
The statistics show that 73% of overweight people develop simple
fatty liver and 23% of them develop inflamed fatty liver [7]. The
holiday tradition of extra sweets and treats became every day diet of an
8-year-old child. The patient reported caused an extremely dangerous
high level of Liver Function Tests, dyslipidemia, 17 cm hepatomegaly,
increased abdominal circumference, headache, extra sweating,
epigastric pain, leg pain, itchiness, tiredness, and an irritable mood
If this medical condition had been left untreated or undiagnosed, it
might have led to cirrhosis and loss of liver tissue [16].
In this child, the rise of AST was almost 10 times more than the
normal limit (Table 1). A stool softener was prescribed for the child
for 10 days to remove all the residues of stool in the bowel due to the
size of the liver. This size of the liver explained the pressure on the
heart (heartache), incomplete defecation and remained stool in large
bowel, pain in epigastric area due to pressure of liver on stomach, and
shortness of breath due to pressure on lungs [13]. Quality of life of
children with NAFLD is affected by the size of liver and its pressure
on the adjacent organs [26]. Besides, the ability of children to perform
physical activity is less than normal [27]. Comparison of tests showed
decreasing level of Liver Function Tests, which is promising and
show the positive effects of early intervention and change in lifestyle
and diet [10].
Timely Diagnosis of Non-alcoholic Fatty Liver Disease in a
child with vague symptoms can save lives. If physicians consider the
possibility of NAFLD in overweight children and include the routine
screening for hepatomegaly, Liver Function Tests, and Dyslipidemia
especially in families with high risk factors such as diabetes, the
cost of prevention and early intervention is less than cost of more
advanced assessments and treatment options for undiagnosed or
misdiagnosed cases of hepatomegaly due to NAFLD. Families should
receive information pamphlets from schools, community centers,
healthcare professionals regarding NAFLD.
Conclusion
After a few months of avoiding sweet, fatty, and junk food
in a child who was initially diagnosed with Non-Alcoholic Fatty
Liver Disease, this child is now putting on size 14 pants, have no
abdominal pain or heartache, headache, or extra sensitivity. His
family has chosen a liver-friendly diet full of green vegetables and
healthy fruits and has cut down on the amount of consumed fat and
sugar. He is now able and willing to participate in sport activities in
school, community centers, and started his swimming lessons and
competitive swimming. He shows more positive attitude toward
friends and family members, and laughs more often. The repeated
tests (Table 2) show improvement just by changing lifestyle and diet
of an 8-year-old. Further follow-up tests and additional assessment
will be reported in future articles and will provide a better long-term
picture of changes in liver function tests.
This case report emphasizes the possibility of presence of
extremely large size liver in children who complain of headache,
abdominal pain, and extreme tiredness. It is crucial to remember the
hepatomegaly and possibility of Non-Alcoholic Fatty Liver Disease
(NAFLD) in children as well. Considering an early abdominal
ultrasound plus the complete laboratory tests including Lipid Profile,
Liver Function Tests, Blood Glucose, Urinalysis can save lives.
Children’ obesity and NAFLD should be treated as public health
issues that lead to many chronic diseases during childhood and
adulthood. A simple clinical picture of indigestion, bloating, and
epigastric pain in overweight or obese children could be NAFLD with
hepatomegaly, which significantly decreases quality of life and could
lead to chronic illnesses in adulthood if left untreated. Additionally,
referrals to dietitian, correction of lifestyle, and follow-up visits are
recommended.
Acknowledgement
This article is written for the first and special issue of the Annals of Clinical Case Reports Journal, Family Medicine and Public Health, published by Remedy Publications Inc. as an open-access article in the upcoming inaugural edition. Special thank to all healthcare professionals who save patients in different healthcare organizations and healthcare administrators or managers who consider adequate amount of budget for necessary tests in children that prevent higher healthcare budget expenditure in adulthood. Thanks for the opportunity to share this case report with other colleagues.
Table 1
Table 2
Discussion
Brain metastases are the most common cerebral tumours. The most common primary tumour sources are lung and breast [1-3]. Five to ten percent are from cutaneous melanoma [4]. The distribution of metastases closely follows the volume of the affected in the order cerebrum, cerebellum and brainstem [2] (approximately 10% [3]). In a large series of brain stem metastases [3] 9% were from melanoma. The most common symptoms were hemiparesis and cranial nerve palsies, with ataxia being uncommon. Ataxia is more likely to be a presentation of cerebellar metastases, but in this patient resulted from involvement of cerebellar connections.
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