The liver is the axis of body metabolism, its function is very complicated and some of its functions are closely related to the blood system and metabolism of glucose, protein, fat, water, electrolytes, vitamins and microelements. Liver is an hemopoietic organ when the fetus is 2-5 months and although bone marrow is the chief hemopoietic organ after birth, the liver still has close relation with hemopoiesis. Many hemopoietic factors like Vitamin B12, folic acid and iron are stored in liver to fulfill the need of bone marrow hemopoiesis. In pediatric hepatitis, viruses attack directly the bone marrow stem cells and the liver and bone marrow may be simultaneously injured by autoimmune response, leading to impairment of hemopoietic function.
The diseased child may suffer from prolonged loss of appetite due to chronic hepatitis and may also develop mal-absorption of the gastrointestinal tract and decrease storage of hepatic hemopoietic factors and the child may have chronic blood loss due to a bleeding tendency caused by hemolysis and liver disease. (In infants, it may be repeated epistaxis and in older girls it may be menorrhagia, menstrual disorders and in a few cases, intestinal polyps or hemorrhoids). Therefore, in chronic hepatitis, the incidence of anemia may reach 75% and it is often called hepatic anemia. Anemic conditions are often of mild to moderate degree. Besides the clinical characteristics of liver disease, the child may have contemporary manifestations of anemia such as paleness of skin and mucosa, vertigo, palpitation and insomnia. A small number of patients with virus hepatitis or in the post-hepatitis period (especially type B and type C hepatitis) may suffer from aplastic anemia. Clinically, it is called post-hepatitis aplastic anemia or hepatitis aplastic anemia syndrome. Aplastic anemia often occurs at the stage of recovery of acute icteric hepatitis; the incidence in young people is higher and about 90% occurs within one year after the attack of hepatitis.
In addition, when there is organic pathologic changes in the liver following virus hepatitis, various metabolic disturbances may be evoked and those commonly seen are as follows:
• Hepatogenic diabetes – in pediatric diabetes, enuresis may often be the first symptom; the onset may be acute and the symptom may be serious, associated with apparent emaciation, polydipsia, polyuria, polyphagia, getting hungry easily, fatigue and inactivity, susceptibility to infection; children suffering from prolonged illness may show dryness of skin, ichthyotic desquamation, pruritus and hairiness.
• Hepatogenic hypoglycemia – hypoglycemic encephalopathy manifestations such as susceptibility to hunger, palpitation, perspiration, tremor of hands, paleness of face, restlessness, and in severe cases, dizziness, headache, blurring of vision, slowness of response and even psychosis.
• Hypokalemia – may present weakness of muscle, bitterness of taste, loss of appetite, decrease of food intake, abdominal distension, hypotension, and in severe cases, restlessness, emotional instability and sleepiness.
• Hyponotremia – frequently encountered symptoms are listlessness, weakness, indifference, loss of appetite, thirst, anxiety, vertigo, distension of head, headache, anorexia, nausea, vomiting, paleness and coldness of limbs, and in severe cases, painful muscular spasm, blurring of vision, hypotension and postural fainting.
• Liver disease causes decrease of amount of liver cells as well as liver function, insufficient food intake and decrease of anabolism; these may lead to hypoproteinemia, nutritional disturbance and finally to malnutrition and underdevelopment.
Besides symptoms caused by metabolic disturbance, patients of this form often present thinness, a listless looking, fatigue, paleness of skin, conjunction and lips, whitish color of tongue mucosa, dryness or hyperkeratosis of skin, or even dermal desquamation or skin diseases showing fissures, eczema, rubella or sweat stains. The diseased child is susceptible to many kinds of infection due to decrease of immunologic function. Some of these patients may be irritable and cannot sleep well or become taciturn, indifferent to the surroundings or have regression of memory or childish behavior. The child shows also apparent malnutrition, soft and distended abdomen, shallow flat umbilicus (or even protruded), scarcity of subcutaneous fat, and the skin can be picked up easily by fingers. If there is significant hypoproteinemia, the patient may have edema of the ankles and pitting edema over the pretibial region (obvious pitting after pressing with the finger).
Introduction of cases – Nutritional disturbance or anemia form
|Case 3-1- Ho sisters; the sibling and parents all had hepatomegaly and typical symptoms of chronic hepatitis. No supportive results were found in the blood and ultrasound examinations.
Father, Ho (computer No. 355) male, age 48 yrs. He was diagnosed as chronic hepatitis complicated by weakness of liver and kidney. The man was extremely thin, malnourished and poorly developed. He had anomalies of both hypochondria (depression of left hypochondrium and buldging of the right), hepatomegaly of 3 cm with apparent percussion tenderness. He had plenty of white hair and multiple senile plaques on the upper arms. He often experienced insomnia and pain in the liver. After the first visit, which was on 14 August 14 1996, he took 19 parcels of TCM drugs and the liver returned to normal. Three months later, the senile plaques on the upper arms faded in color markedly and its size also decreased. Four months later, his white hairs decreased in number and he no more needed hair staining.
Mother, Chan (computer No. 67), female, age 39 yrs. She was diagnosed as chronic hepatitis complicated with hepatic heart disease. She often had vertigo, palpitation, hypochondriac pain, epistaxis, repeated common cold, sorethroat and repeated pain of the knee joints since delivery. On 28 December 1995, the day of first visit, her liver was found to be enlarged 3 cm and heart murmur was heard associated with a heart rate of 104/min. After taking 19 parcels of TCM drugs, the liver returned to normal and palpitation disappeared. Systemic therapy continued for 6 weeks. Abnormality was not found during a return visit in 1998.
Elder sister, Ho (computer No. 354) female, age 14 yrs. She first visited the clinic on 28 December 1995 with the chief complaint of repeated vertigo, abdominal distension and pain and diarrhea. She had menstruation for 2 years and had also menstrual disorders, dysmenorrhea and repeated bleeding. Physical examination: anemic and thin, hepatomegaly of 3 cm. After taking 12 parcels of TCM drugs, the liver returned to normal, but hepatomegaly reappeared for five times following postmenstrual blood loss. The liver returned to normal each time after administration of TCM therapy and nutritional support. After July 1996, hepatomegaly was not found following menstruation period and an observation of six months did not reveal any abnormality. She was followed up for another one more year and the last return visit was 9 January 1998, at which time no relapse was observed.
Younger sister, Ho (computer No. 353), female, age 10 yrs. Her first visit was on 26 December 1995. She was accompanied by her mother who said that the girl had repeated upper abdominal pain, constipation and diarrhea. She was diagnosed as stomache ache and given gastric drugs. Recently she frequently suffered from common cold, cough, expectoration, loss of appetite and yellowish urine. Physical examination: poor nourishment and development, tongue red without coating, hepatomegaly of 3 cm, tenderness below xyphoid process in upper abdomen. After taking 15 parcels of TCM drugs, the liver returned to normal. Systemic therapy lasted for 8 weeks and ceased on 21 March 21 1996. The patient was followed up.
This patient had hepatomegaly of 1.5 cm relapsed for 4 times, namely, 3 June 1996, 22 June 1996, 16 September 1997, 31 October 1998. The clinical manifestation was common cold with fever in two times and wetness–heat abdominal pain in the other two, but in all episodes the symptoms disappeared after TCM treatment. Every time, the hepatomegaly recovered after 3 to 6 days of TCM drug administration. Observation continued for 2 more years after treatment; the patient’s constitution improved significantly and anemia was corrected. Her body weight increased from 52 lbs to 76 lbs. The last return visit was on 2 January 1998; the girl’s appetite was good, she had no discomfort and her liver was normal.
Yuan (computer No. 1052) male, age 6 yrs. His father had type A icteric hepatitis five years ago and now he still suffered from fatigue, edema, palpitation, abdominal pain and distension. His mother had a history of carrier of type B hepatitis virus and she had also menstrual disorders. On 24 July 1999, when the three of them made their first visit to the clinic, all were found to have hepatomegaly. His mother had physical examination several months ago and was detected to have increased liver ferment.
The child had history of repeated constipation, rhino-sinusitis and otitis media and he frequently had enuresis. Physical examination: poor nourishment and development, skin pale and yellowish, abdomen distended, prominent veins over abdominal wall, hepatomegaly of 3 cm. After taking 7 parcels of TCM drugs, the liver was normal. Enuresis and other clinical symptoms disappeared after 6 weeks of systemic treatment.
A return visit was made on 20 November 1999. His mother said that her son took some refreshments in school together with 10 classmates and then they vomited. The vomiting was associated with diarrhea, coughing with abundant expectoration and abdominal distension. WM drugs were taken according to common cold but of no avail. Enuresis was cured after the previous treatment. Re-examination of the patient showed hepatomegaly of 3 cm which was the first relapse. He took half parcel of TCM drugs a day and the liver was normal after 6 days of administration and the clinical symptoms also completely disappeared. Systemic therapy persisted for 4 weeks, at the end of which clinical cure was obtained.
Au (computer No. 3508) female, age 10 yrs. Day of first visit: 4 August 2003. Her mother had suffered from chronic hepatitis.
The patient after had nasal hypersensitivity, loss of appetite, fatigue, sleepiness, fissures, edema and desquamation of lip mucosa and geographic tongue. Physical examination revealed thinness, paleness of skin, prominent eye-bags and dark colored skin around the eyes, poor nourishment and development, anemic looking
and hepatomegaly of 3 cm.
After taking 3 parcels of TCM drugs, the liver returned to normal, but nasal hypersensitivity was still present. She had frequent farting and fissuring of lip mucosa; however, the severity of geographic tongue decreased. When TCM drugs had been administered for 2 weeks, there was occasional coughing with much expectoration, but the tongue became normal and lip desquamation ceased. After 3 weeks of medication, the child’s cough stopped and dryness of lips decreased; urination in one episode was of the wetness-heat kind and she sometimes suffered from frequent urination. Systemic therapy lasted for 4 weeks, by the end of which clinical cure was obtained and she was followed up.
Lai (computer No. 3483), female, age 12 years. First visit: 19 July 2003. Height: 1.65m, weight: 42 kg; BMI = 15.5 (normal 16 – 21). She felt tired, suffered from nasal discomfort and frequent epistaxis. She was tall, lean with long limbs (typical female hormone deficiency stature). Interval between menstruations changed to 45 days; the menstrual blood was dark red, large in amount but without clots and dysmenorrhea. Leucorrheal discharge was abundant in amount and she had a hepatomegaly of 1.5 cm.
After taking 7 parcels of TCM drugs, she had no discomfort and liver was normal. TCM treatment was continued. She had premenstrual insomnia but leueorrhea and frequency of urination decreased. After the medication, her menstrual blood turned red, was more in amount and the liver was normal. At the third week of therapy, she travelled to Philippine and medication was interrupted. When she returned to Hong Kong, she had abdominal pain, wetness-heat stools and diarrhea, but the liver was not enlarged. TCM drugs were administered for another 3 weeks to complete the systemic therapy. She was clinically cured and followed up.
Chan (computer No. 3582), male, age 13 yrs. First visit: 2 October 2003. He was found to have diabetes two years ago and now he had to receive insulin injection treatment. He felt thirsty and had ozostomia; his tongue was purplish red with thin white coating in the centre. He had frequent nocturia, constipation and blood tinged toilet paper after defecation. Physical examination: the child had an ester odor in his breathing and a hepatomegaly of 1.5 cm. After taking 3 parcels of TCM drugs, the liver returned to normal and during therapy, he experienced mild vertigo.
After one week of TCM treatment, nocturia disappeared, ester odor in breathing and the purplish red color in tongue and lips alleviated. Bowl movements were smooth, no blood was seen in toilet paper after defecation and the liver was normal. Another 6 parcels of TCM drugs were given. On his return visit, examination revealed subsidence of edema of lip mucosa, but the fissures were still deep. In the recent two days, there was epistaxis but the amount of blood was small. There was still some blood on toilet paper after defecation; the liver was normal. He continued to take another 7 parcels of TCM drugs, and epistaxis stopped. Blood tinged toilet paper was occasionally seen after defecation. There was cough sometimes but no expectoration. Sleeping was well and the liver was normal. Therefore, another week of TCM drugs was given and after a course of 5 weeks of TCM therapy, the patient was cured clinically. He was followed up after cessation of treatment.
By WONG Kwok Hung
translated by Professor Zheng Wah En in 2006