The 4th form – Endocrine disorder form

       Most of the hormones in the human body are metabolized in the liver.  In the liver disease, metabolism of these hormones is affected and imbalance is formed among these hormones.  Hormonal imbalance can lead to nutritional metabolic disturbance and together with gastrointestinal absorptive dysfunction caused by chronic hepatitis, they can induce pediatric nutritional deficiency.  Due to decrease of growth hormone, the diseased child has calcium deficiency which causes osteal malnutrition and further, retardation of growth and development.  During the course of body development, the patient may suffer from acute or chronic hepatitis which may induce endocrine disorder and even, the formation of fatty liver and secondary obesity.  The stature of the diseased child, may therefore develop into one of the two extremities, that is “ricketic dwarfism” and “secondary obesity”.

(I)  Ricketic dwarfism

Children suffering from chronic hepatophilic virus disease are usually infected through mother-infant communication and close contact.  So, these infants have poor nutrition and in some of them, development may be affected.  The hepatic metabolic function in children is lower than adults, their protein synthetic ability is weaker.  When the liver is injured, the synthesis of albumin, fibrmogen and coagulative factors is insufficient and therefore these patients often present hypo-proteinemia, defective calcium absorption and bleeding tendency.  A small number of cases may develop into “hepatic dwarfism”.  The patient’s face loses brightness, the stature short and lean showing slow growth and retarded development; there is defect calcification of bones which leads to rickets.  In severe cases there are rachitic beads, chicken breast and anomaly of foot.   The diseased child usually presents a soft and distended abdomen, the abdominal wall showing telangiectasis or varicosities of collateral circulation.  The liver is usually enlarged and in elder children, percussion tenderness over the hepatic region may be detected or the patient may complain of pain of the right hypochrondrium.

If the child has bleeding tendency, there may be repeated epistaxis, hematochezia, bleeding of gingivae or occurrence of subcutaneous ecchymoses upon slight contusion.  When hepatitis attacks the patient during infancy or childhood, physical examination later in the school age or adolescent and middle age would reveal asymmetry of right and left hypochondria, the left side slightly depressed and the right side somewhat full or even buldging.

Ricketic dwarfism – Introduction of cases

Case 4-1

        Han (computer No. 1991) female, age 7 yrs.  First visit: 20 November 1999.  The mother said that the child had repeated nasal hypersensitivity and dermal eczema since infancy, exacerbating in the summer season every year.  Now, over the extensor side of the joints of limbs, one could still see local eczema, dryness scratch marks and desquamation.  The lower jaw and pelvic bone showed asymmetric anomaly.  The skin was palish yellow and dry, and generalized sweat stains could be seen.  The child was thin, tired looking and listless.  Physical examination revealed a soft abdomen, percussion tenderness over hepatic region and a hepatomegaly of 3 cm.  The diagnosis was chronic hepatophilic virus disease complicated with nasal hypersensitivity, sweat stains, pediatric eczema and osteal malnutrition.

        After taking 5 parcels of TCM drugs, the liver returned to normal.  Administration of TCM drugs was continued and the symptoms gradually alleviated and the skin lesions subsided slowly.  After 3 weeks, there was no nasal hypersensitivity, the eczema healed and the skin appearance was completely normal.  The patient was clinically cured after 4 weeks of TCM treatment and was followed up.

Case 4-2

        Jin (computer No. 3883) male, age 17 yrs.  First visit: 2 April 2004.  He had anomaly of the chest since infancy.  There was a depression below the xyphoid process at the anterior aspect of the chest.  He was lean, had long time multiple acne, the face showing multiple sebaceous glaud protrusions.  He often experienced abdominal pain, voiding of yellowish urine and passing of loose stools several times a day.  The lower edge of the upper lip presented a pearl like appearance; the tongue was enlarged with teeth prints and thin white coating.  The chest showed typical funnel shape; there was a hepatomegaly of 1.5 cm.  The diagnosis was chronic hepatophilic virus disease complicated with hepatic osteal malnutrition (rickets), endocrine disorder, viral gastrointestinal disease.

        After taking the first parcel of TCM drugs, he had diarrhea 3 times, the stools watery and after 3 parcels, he still had multiple acne and desquamation of lips, the tongue enlarged with teeth prints and thin white coating.  The liver returned to normal.  After taking another 6 parcels of TCM drugs, he did not feel any discomfort but he still suffered from diarrhea, twice a day.  He had occasional abdominal pain; sleeping was good and acne decreased.  Another 6 parcels of TCM drugs were taken and the acne subsided.  The stools were watery, 3 times a day, and the tongue coating was thick and yellow.  He took another 6 parcels of TCM drugs and the tongue coating became thin and white; he had no discomfort, the bowl movements were normal, the feces were in shape, being 1-2 times a day.  He slept well and the liver was normal.  He was cured clinically and followed up.

Case 4 -3 : The Lam brothers, twins

        Elder brother (computer No. 3564), male, age 12 yrs.  First visit: 20 September 2003.  He was fat since infancy, susceptible to diarrhea and wetness-heat abdominal pain and had to defecate right after meal.  He had tenesmus and passed loose stools 1-2 times a day.  He had acne for a year.  Weight 150 lbs (68 kg), Height 1.74 m, BMI = 22.51 (for 12 years, ideal BMI range: 16-22) hepatomegaly 1.5 cm.

        After taking 3 parcels of TCM drugs, he slept well without discomfort and his liver returned to normal.  He continued the TCM therapy and he still had diarrhea, stools 3 times a day, loose and large in amount.  During the second week of medication, he still used to defecate after meal and the stools were watery, 2-3 times a day.  Multiple acne were still present; the tongue was clean and sleeping was good.  In the 3rd week of medication, the skin was normal, sleeping was good. The tongue became thinner and without teeth prints.  Bowl movements were still 3-4 times a day; the liver was normal.  Medication stopped after attainment of clinical cure.

        Younger brother (computer No. 3563), male, age 12 yrs.  First visit: 20 September 2003.  His appetite was poor since infancy; he was lean and suffered from repeated acne for a year.  Height: 1.76 m, Weight 50 kg, BMI = 16.13. (for 12 years, the ideal BMI range:16 – 22.2)  Anomaly of hypochondria, hepatomegaly of 1.5 cm.

        After taking 3 parcels of TCM drugs, he had no discomfort, bowl movements normal, sleeping good and the liver was normal.  He continued the TCM therapy and his appetite improved markedly and he could sleep well.  He had no acne but on the forehead and face there were still many sebaceous protrusions.  He took another week of TCM drugs and the liver remained normal.  Acne and sebaceous protrusions decreased markedly.  The skin was smooth, bowl movements normal and the urine was not yellowish.  TCM drugs were taken for a total of 3 weeks and the treatment was stopped.  The patient was followed up.

Physician’s comment:

      The father of the twins had positive type B hepatitis antibodies and frequently suffered from nasal hypersensitivity, fatigue, sleepiness, insomnia and edema of lower limbs.  He received local injections for hemorrhoids.  His liver was found to be enlarged 3 cm in the first visit and was diagnosed as chronic hepatitis and treated with TCM drugs in our clinic.  The brothers, although under the same living condition, had very different body constitution, but they both had endocrine disorder.  The elder brother’s symptoms were of the chronic hepatitis wetness-heat vaporization form with gastrointestinal wetness-heat as the chief manifestation.  Prolonged gastrointestinal wetness-heat together with endocrine disorder formed secondary obesity, so that his BMI = 22.51.  The younger brother had loss of appetite, thinness, anomaly of hypochondria.  Due to malnutrition and poor development, his BMI was only 16.13.

        The body weight and development of the twins turned respectively to opposite extremities.  It might be the result of liver function damaged by hepatophilic virus infection.  The severity of damage was not the same in the two children and so the result was different.  Early administration of systemic TCM therapy and stoppage of damage of liver function to avoid malnutrition and underdevelopment are imperative.  As to the effectiveness of TCM therapy, a short course is enough to bring the liver back to normal and attain clinical cure, including the disappearance of the chief clinical symptoms.

Case 4 -4 : Lao (computer No. 3477) male, age 15 yrs.  First visit: 12 July 2003

        The child, after birth, was found to have microencephalic anomaly and tremor of eyes and funnel shape chest.  He had hematuric twice and was treated by WM drugs.  He had frequently sorethroat, common cold, asthma and also amblyopia and alternating strabismus.  He was weak, had occasional insomnia, bowl movements twice a day, lip mucosa edematous, tongue enlarged with fissure.  His intellectual ability was normal and had polylogia and a hepatomegaly of 3 cm.

        After taking 3 parcels of TCM drugs, the stools were watery, being 3 – 4 times a day.  The liver was normal.  TCM therapy continued for 1 week and urination was smooth, sleeping good and bowl movements normal.  There was occasional nasal hypersensitivitiy in the morning.  TCM drug administration continued for 6 weeks, at which time, there were nasal hypersensitivity, nasal obstruction with abundant discharge, occasional loose stools, 1 – 2 times a day and the urine was yellow and turbid.  After the 4th week of treatment, no apparent nasal hypersensitivity was experienced and the tongue showed medial vertical fissures.  No hepatomegaly was administered for a total of 6 weeks at the end of which the patient obtained clinical cure.

(II)   Secondary obesity

        In children, whose acute icteric hepatitis had been cured or who were suffering from chronic liver disease, especially cirrhosis of liver, complications of endocrine hormone abnormality were frequently encountered.  The hormonal metabolic disturbances are complicated and varied in liver disease; they may lead to high somatotropinemia, decreased 生長介素, disturbance of inactivation of rennin and sub-aldosterone, hypofunction of thyroid, rise of insulin blood level and decrease of glucose tolerance.  In liver disease, there is also inhibition of sex hormone stimulating hormone, significant increase of blood estrogens and prolactin and decrease of male hormone.  The above abnormal changes of the endocrine system can master the growth and developing tendency of the child, especially the child infected by type B and C hepatitis virus directly through mother-infant communication and such a child would manifest persisting infection and chronicity early in the infantile stage.  But the diagnosis of chronic hepatitis in infants and children is generally neglected by physicians and parents, so that often times the chance of treatment is lost and some people even refuse TCM therapy.  (Although TCM therapy can not provide radical cure but systemic TCM therapy can usually give clinical cure).  Therefore, if the disease is prolonged and persistent, the endocrine and metabolic disorders may increase gradually leading to decrease of glucose tolerance or hypoglycemia.  Some of the children have increase of appetite during the convalescent stage and if self-control ability is poor, it is easy to develop secondary obesity and fatty liver.

Post-hepatitis fatty liver has the following characteristics:

(1)    Most have history of becoming fat after hepatitis, usually over standard body weight (usually increase 6-50 lbs, average 20 lbs).

(2)    General condition good, usually no apparent symptoms.

(3)    Appetite good, no aversion to oily food.

(4)    Blood transaminase usually mild or moderate increase.

(5)    70% – 80% patients have significant increase of blood neutral fat.

Secondary obesity – Introduction of cases

Case 4-5: male, age 13 yrs, abnormally fat since infancy, liver function normal, ultrasound examination: hepatomegaly of 2 cm, diagnosed as chronic persisting hepatitis.

Case 4-6: brothers, age 9 yrs and 11 yrs, plump, grandfather died of liver diseasse complicated with abdominal distension in 1958, mother blood examination two months ago showing no abnormality.

Case 4-7: male, age 10 yrs, secondary obesity, grandfather died of carcinoma of liver in 1990.

Chan (computer No. 458) male, age 13 yrs.  First visit: Middle of July, 1996.  Grandfather had history of acute icteric hepatitis; his parents were sufferers of chronic hepatitis.

When the child was a fetus in his mother’s uterus, the mother suffered from chronic hepatitis complicated by threatened abortion and required hospitalization.  She took TCM drugs to treat the hepatitis and to stabilize the pregnancy and there after she achieved a normal delivery.  The child was abnormally fat since infancy.  He received type B hepatitis preventive injection 7 years ago, but one year after that, he suffered from acute icteric hepatitis and was hospitalized for treatment.  After discharge, he had repeated examinations and recently he was found to have positive type B hepatitis antibodies.  His liver function was normal and had hepatomegaly of 2 cm, examined by ultrasonography.  He was diagnosed as chronic persisting hepatitis.  He felt tired and could not sleep well.  Physical examination revealed secondary obesity, pulse rate 120/min, the breasts showed significant development, the external genitals were infantile and the hepatomegaly was 1.5 cm.

After taking 10 parcels of TCM drugs, the margin of liver dullness was normal.  After systemic TCM therapy, testosterone was given for 6 weeks and the development of the external genital organ showed significant improvement, the glans protruded and could be seen externally, giving a normal appearance.  BMI lowered from 23 to 22.86 (for 13 yrs male, the ideal BMI range : 16.6 – 22.8).

He had his vacation in Hong Kong in August, 2002.  A doubtful relapse happened with manifestations of acne over the forehead, temporal region and chest for one month accompanied by constipation abdominal pain and generalized sweat stains.  He made a return visit and was found to be in a good nutritional and developmental condition (weight 75 kg, height 1.77 m, BMI = 23.93).  The lips were lined clearly, the tongue enlarged with teeth prints, the hypochondria showing anomaly and the liver enlarged 1.5 cm.  After taking 4 parcels of TCM drugs, the liver was normal; he farted frequently and bowl movements were 1-2 times a day, the amount large and associated with tenesmus.  He slept well and the acne gradually subsided.  Systemic TCM therapy was given for 4 weeks, after which clinical cure was obtained and the boy returned to school in Singapore.

Case 4-6

Cheung brothers, maternal grandfather died of liver disease with tympanites in 1958, mother blood examination with no abnormality two months ago, but diagnosed in this clinic as chronic hepatitis, deficiency of yin and yang complicated with gout.

Elder brother Cheung – (computer no. 83) male, age 11 yrs.  He complained that he had long time insomnia, fatigue, vertigo, headache, a hot temper, urine yellowish and stinking and wetness-heat stools.  Physical examination: good nourishment and development, puffy, height 1.44 m, weight 45 kg, BMI = 21.7 (11 years, ideal BMI range :15.5 – 21.9), chest showing hypochondriac anomaly, left side depression, right side bulging, hepatomegaly of 3 cm, with percussion tenderness, external genital organ normal.

After taking 4 parcels of TCM drugs, the liver was normal, but percussion tenderness was still present.  There was also nasal discharge, occasional coughing and yellowish urine.  Through the continuation of TCM therapy, the symptoms disappeared 1 week later.  Treatment stopped after completion of a systemic 4-week course.  The patient was followed up and no abnormal condition was discovered up to the present.

Younger brother Cheung – (Computer No. 85) male, age 9 yrs.  For a long time, he suffered from fatigue, poor sleeping, difficulty in falling asleep after awakening, repeated nasal hypersensitivity and epistaxis, bleeding occasionally large in amount.  For 3 years, he had repeated abdominal distension and pain, diarrhea, bowl movements at the most reaching 12 times a day, belching and frequent farting, significant abnormal obesity and retardation of memory.  Physical examination: the child showed marked puffiness, skin color dark and yellowish, height 1.34 m, weight 47 kg, BMI = 26.18 (10 years ideal BMI range : 15.2 – 21.2), tongue enlarged with teeth prints, abdomen full and distended, right hypochondrium abvionsly bulging with percussion tenderness, hepatomegaly of 1.5cm, edmea (+) of lower extremities, external genitalia comparatively infantile in development.

After taking 4 parcels of TCM drugs, epistaxis stopped; he was not so weak but still had generalized soreness of the body, nasal hypersensitivity, abdominal distension, frequent farting and hepatomegaly of 1.5 cm.  He took another 4 parcels of TCM drugs and in his return visit, he showed no discomfort besides generalized soreness of the body.  The tongue coating was thick and whitish, the liver was normal but still showing percussion tenderness.  In the following days, he had no discomfort only for occasional nasal hypersensitivity and epistaxis.  He received totally 7 weeks of systemic TCM therapy and was then followed up.  Up to the present, he had 3 return visits and no relapse of hepatomegaly occurred.  These were occasional common cold symptoms and epistaxis.

Case 4-7

Lee – (computer No. 281) male, age 10 yrs.  His maternal grandfather died of carcinoma of liver in 1990 and several family members of the maternal side were carriers of type B hepatitis virus. 

His first visit was on 18 April 1997 at which time the child had secondary obesity with a height of 1.36 m, weight 44 kg and BMI = 23.78 (10 yrs child ideal BMI range : 15.2 – 21.2).  He had long term constipation (once in 5-7 days), repeated common cold attacks, abundant nasal discharge, coughing, sleepiness, distension of abdomen and hepatomegaly of 1.5 cm.  He did not receive treatment and was observed for three months, but the hepatomegaly was as before and his tongue coating was yellowish white and scanty.  He was given 2 parcels of TCM drugs and amount of stools was large, being three times a day.  His tongue coating detached and the liver was normal.  He received 6 weeks of systemic TCM therapy and then stopped the medication.

In the following year, on 26 March 1998, he had a return visit, complaining of exopathic fever and repeated coughing for 2 weeks.  He was treated with anti-inflammatory drugs for 9 days with no avail.  His tongue coating was thin and white, and had a hepatomegaly of 1.5 cm, which was the first relapse.  After taking 7 parcels of TCM drugs, the liver returned to normal and the cough stopped completely within 2 weeks.  He received systemic therapy and then stopped the medication.

In February, March, May and October 1999, he had repeated relapses of hepatomegaly but was not treated systemically.  Recently, he was hospitalized because of high fever, associated with sorethroat, vesicles at the mouth angles, shortness of breath, severe cough and icterus of skin and conjunctivae.  The Margaret Hospital ascertained the diagnosis of EBV (EB virus infection).

During hospitalization, he was not treated with WM drugs, but he received TCM drugs from our clinic and after 2 parcels of administration, the fever subsided and the transaminase dropped from 700u to 200u.  Six days later, he was discharged and continued the TCM treatment in our clinic. Physical examination showed a hepatomegaly of 1.5 cm.  After another 4 parcels of TCM drugs, the liver returned to normal.  He completed the 6-week systemic TCM therapy and his condition remained good.

Proper treatment of liver disease often stops the progression of secondary obesity

Recently, an investigation of the nutritional state of children in Hong Kong reveals: 13.7% of boys and 9.8% of girls are obese, and obesity increases with the increase of age, the climax of obesity in boys and girls being at the age of 11 years.  One third of the young people with obesity have the tendency of developing diabetes.  Another statistical data has shown that 5% – 8 % of chronic active hepatitis patients have hepatic diabetes.  These statistics demonstrate that obesity in children is a problem deserving attention.  But, is simple “over nutrition” and “bad eating habits” the only cause of such results?  This deserves our deeper consideration.  If a part of these fat children are sufferers of hepatitis, proper treatment of liver disease often times can stop the progression of secondary obesity, particularly those associated with decrease of male hormone and increase of serum estrogeus (male pediatric secondary obesity).  One may also encounter male patients with breast development and atrophy of testicles and external genitalia.  If these fat boys are treated with systemic TCM drugs and supplemented with adequate dose of male hormone, they would certainly obtain normal development.

In some types of hepatitis, there exists a virus infection phenomenon of “family coacervation”.  This may also explain the phenomenon that a number of fat people can be seen together in a family, a clan or in a district or village.  These fat people (especially secondary obesity) may not be due to heredity, and the possibility of the result of hepatitis virus infection should be considered.

Liver disease can also cause damage to the nervous system

Liver disease can also cause damage to the nervous system. Acute of chronic virus hepatitis can cause simultaneous or subsequent damage of the nervous system leading to psychotic and neurotic symptoms as well as diseases like acute or chronic hepatic encephalopathy, meningitis and epilepsy.  In fact, in the hypothalamus, there are two nuclei which regulate food eating activity, one is the ventromedial nucleus (satiation centre) the other ventral lateral nucleus (hunger centre).  Animal experiments show that if its ventral medical nucleus is destroyed, the animal increases its food intake and becomes fat.  In clinical practice, the sequelae of some encephalitis or meningitis patients are chiefly characterized by polyphagia and obesity.  In children having been attacked by acute hepatitis and also those with chronic hepatitis, the appearance of secondary obesity is related or not to the damage of hypothalamus, is a problem still to be investigated.  But children recovered from acute hepatitis and those having chronic active hepatitis, are often complicated by secondary obesity, and this is a fact with no controversy.

According to statistics, 70% – 80% virus hepatitis patients have symptoms of cranial nerve injury.  In chronic active hepatitis patients, 10% have hepatitis neural disease like radiculoneuritis and neurasthenia.  These conditions indicate that doubtlessly hepatitis virus causes damage to the nervous system.  But in children infected by hepatitis virus, whether their secondary obesity is the result of nerve tissue damage or due to endocrine disorder should be further investigated.

Besides an external obese stature, chronic hepatitis pediatric patients with secondary obesity may have the association of listlessness, laziness, failing memory, migraine, sleepiness, intolerance to labor, fatigue, shortness of breath, distension of abdomen, dark colored urine and in older children, vague pain over the right upper abdomen.  In addition, the diseased child may also have some obstinate and nearly incurable symptoms of chronic hepatitis (such as the symptoms mentioned above).  Physical examination would reveal hepatomegaly in the absolute majority of cases and in blood examination, one can find the respective positive results, so that, in general, the diagnosis is not difficult.

By WONG Kwok Hung

translated by Professor ZHENG Hua En in April 2006