A Study of Incidence of Fulminant Hepatic Failure in
regardless of the presence or absence of clinical features of hepatic encephalopathy
CAUSES OF FHF
Infectious agents: In approximately 50% of patients, FHF is caused by acute viral hepatitis, common hepatotropic viruses are A, B, C, D, & E. Many non hepatotropic viruses other than hepatitis are also recognized as cause of FHF in childhood, including Epstein Barr virus, cytomegalovirus (CMV);
paramyxovirus, varicella zoster virus, herpes virus types 1, 2 and 6; parvovirus and adenovirus.
Hepatotoxic drugs: These agents are the second most common causes of FHF, responsible for approximately 25% of cases, eg. Acetaminophen overdose, sodium Valproate etc.
Circulatory causes: Is uncommon cause of FHF. They include congestive heart failure, cardiomyopathy, sepsis, shock, cyanotic heart disease.
Other causes include Hodgkin’s disease, leukemic infiltration, and autoimmune hepatitis.
Idiopathic: Idiopathic FHF remains significant in children.
MATERIAL & METHODS: The present study was conducted in the Department of Pediatrics, SIMS Anwarpur Hapur for a period of 24 months from January 2010 to Dec. 2011. Random sampling was done and cases are selected from indoor and OPD, Department of Pediatric SIMS (Tertiary Level Care Center) Anwarpur Hapur. The study was conducted in collaboration with Departments of Pathology and Biochemistry.
Inclusion Criteria: The cases were selected randomly from OPD and ward; they comprised children between 6 months to 18 years of age belonging to both rural and urban areas and of various religions and socio- economic status, Children with signs and symptoms suggestive of liver disease and Children who fulfilled diagnostic criteria of FHF.
Exclusion Criteria: Children with pre existing liver disease were excluded.
A detailed case history was taken and a thorough clinical examination was done in each case. The findings were recorded in a specially prepared Performa.
The cases were subjected to following investigation:
HB, TLC, DLC, ESR, Hepatic Enzymes- SGPT, SGOT, Serum Alkaline Phosphatase, S. Bilirubin- Direct &
Indirect, RBS, Renal Function - S. Creatinine, S.Phosphorous, Serum Electrolytes - S. Na+, S.K+,
S.Ca++, Coagulation Profile - PT, APTT, Viral Studies- HBs Ag, IgM anti HBcAg, Anti HAV IgM, Anti HCV antibody, Anti HEV IgM IgG or IgM antibody against CMV, EBV and Herpes virus, Toxin and drug level in serum whenever indicated. A questionnaire was prepared to study the knowledge, attitude and behavior regarding etiology and treatment of jaundice
& FHF.
OBSERVATIONS
In this study following observations were made.
Out of sample size 38570, 54 Patients were diagnosed as FHF. Incidence rate calculated and it was found 1.4 per 1000 per year. (Table I). Out of total 1010 jaundiced patients, 40 patients were diagnosed as FHF.
It was found that cases of FHF were maximum (61.1%) in 5-15 year age group (Table II). The table shows that male female ratio is almost equal in case of FHF (1.25:1) (Table III). In our study etiological diagnosis was possible in 68.48% cases, out of which 61.08% were of viral etiology. Idiopathic FHF remains a significant cause in children (31.48%). Drug induced FHF was in 7.4% Cases and all cases were due to Paracetamol drug injury (Table IV). Jaundice in Urban and Rural Area was 36.63% and 63.36% respectively (Table V).
Regarding misconceptions among accompanying person, commonest misconception was that the cause of hepatitis is super natural and there is no need to go to Doctor, It was found 50% and 78.12% in Urban and Rural Areas Respectively. They go to super natural healers (Quacks) for treatment, who use Bhaboot and Necklace of Special Wood. Super natural healers also do Jharphook (Mantra Tantra) to treat this disease and they also use special herbs for treatment, 50% of Urban and 78.12% of rural accompanying person visited these so called healers before coming to hospital. About 70.54% from urban area and 84.37% from rural area think that they had to follow a special diet with restricted protein and Fat. They do not give Yellow Edible Things to eat like turmeric they also think that full milk should not be used. These thought misbeliefs lead to more malnourishment and increased risk of complications (Table VI). Knowledge and Awareness about immunisation safe Injection and Safe Water was observed, Immunisation against hepatitis A and hepatitis B is available but accompanying persons were not aware about Immunisation against these Viruses.
Regarding awareness about immunization 50% and 30% accompanying persons were aware from Urban and Rural area respectively. Safe Injection and use of disposable syringes is must to prevent hepatitis B and hepatitis C. In urban area 74.86% and in rural area only 50% had knowledge of safe Injection. Use of safe water is must to reduce the faeco-oral transmission of hepatitis A and E. In Urban area 74.86% and in rural
11 Daya chand 42-45.pmd 43 8/27/2012, 6:39 PM
area 39.06% had knowledge of safe water. (Table VII) Table I. Incidence of FHF
Total Patients No. of fulminant
(OPD + IPD) hepatic incidence
failure Patients
38570 54 1.4 per 1000
Table II. Age Incidence of FHF
Age group No. of patients %
Below 5 year 12 22.22
5-10 year 15 27.77
11-15 year 18 33.33
16-18 year 9 16.66
Total 54 100
Table III. Gender Incidence of FHF
Sex No. of patients %
Male 30 55.5
Female 24 44.44
Total 54 100%
Table IV. Etiology of FHF
Etiology No. of Patients 0//o
Hepatitis A 18 33.33
Hepatitis B 5 9.25
Hepatitis C 2 3.70
Hepatitis E 8 14.8
Drugs 4 7.40
Idiopathic 17 31.48
Total 54 100%
Table V. Demographic Pattern of Jaundice Patients N=1010 Jaundice Patients
AREA No of Patient of %
Jaundice
URBAN 370 36.63
RURAL 640 63.36
TABLE VI. Misconceptions regarding Jaundice in Rural and Urban Area
Misconception Urban/ No of %
Rural Patients
Disease is Super Urban 185 50%
Natural Rural 500 78.12%
Goes to Quacks Urban 185 50%
for treatment Rural 500 78.12%
Dietary Restriction Urban 261 70.54%
Rural 540 84.37%
TABLE VII. Knowledge and Awareness about immunization safe Injection and Safe Water
Have Urban/ No of %
Knowledge of Rural Patients
Immunisation of Urban 185 50%
hepatits A and B Rural 192 30%
Safe Injection Urban 277 74.86%
Rural 320 50%
Taking Safe Water Urban 277 74.86%
Rural 250 39.06%
DISCUSSION
The Incidence of FHF was 1.4 per 1000 per year. In the present study most of the patients [58.5%] were in 5-15 year age group. Bradley et al (1983)2 reported that disease affects the young adults predominantly. In the present study male: Female ratio was 1.25:1 i.e. males and Females were almost equally affected. Results were comparable with Raju et al (1989)3, Gimson et al (1983)4, U poddar et al (2002)5. In the present study viral etiology was present in 61.08%, out of which hepatitis A found in about 33.33%. HEV 14.8% and Hepatitis B in 9.25% cases. Similar observation was noted by MD Yohannan (1990)6, Thapa et al (1995)7, U Poddar et al (2002)5. Drug induced FHF was in 7.4%
cases, whereas paracetamol overdoses was prominent cause of FHF in Europe (42%) Gagan K Sood, Julian Katz (2011)8. No cause was found in 31.48% cases, the observation for idiopathic FHF was similar to Robert H et al (2008)9, various misconceptions and lack of knowledge were present in both rural and urban areas but they were more prevalent in rural areas.
Misconception like cause of hepatitis is super natural and can be treated by super natural healers was more in rural area (72.12%) then urban area (50%).
Misconception regarding restriction of diet in jaundice was more in rural area (88.2 %) then urban area (50 %). Dietary restriction was more in rural area (84.37%) than urban area (70.54%). Knowledge of immunization for hepatitis A and hepatitis B was more in urban area (50%) then rural area (30%) Knowledge of safe injection was present more in urban area (74.86%) then in rural area (39.06%) Use of safe water and safe sanitary practices was more in urban area (74.86%) then rural area (39.06%).
CONCLUSION
On the basis of this study following conclusion were drawn:- FHF has a low incidence. In our study incidence rate was 1.4 per 1000 per year. Incidence of FHF in jaundice patient was 2.5 %, in this study 61.1%
patients were of 5-15 year of age group. Our result showed that there is significant co-relation between knowledge, attitude and behavior on the occurrence
of Jaundice and its complications this calls for increasing awareness on all aspects of jaundice to minimize the complications. It is concluded that there is need to increase the public awareness by different educational programs regarding etiology of hepatitis and its prevention by immunisation for hepatitis A and B ,use of safe injection, safe water and hygienic Sanitary habits. Early detection of liver disease and management of case by a competent doctor is the mainstay to decrease the mortality from Jaundice.
KEY MESSAGE
• One of the most common causes of FHF is viral, so immunisation against hepatitis A & B must be introduced in immunization programme.
Education programmes regarding safe injection, etiology of hepatitis, immunization, personal and environmental hygiene must be introduced in schools.
ACKNOWLEDGEMENTS
Authors would like to acknowledge the help provided by Dr.Nishi Agrawal DGO and to offer grtitude to all parents who participated in this study.
Conflict of Interest- Nil Source of funding- None
BIBLIOGRAPHY
1. Nelson Textbook of pediatrics 18th edition volume 2 Page No. 1703-1705.
2. Bradley DW, Maynard JE, Popper H et a! : Post transfusion non A non B hepatitis, Physiochemical property of two distinct agents.
Infect, dis. 1983; 148: 254-265.
3. Raju GS, Broor S. Singh V. and Mehta Sk:
Fulminant viral Hepatitis : Indian experience Journal of Gastroenterology and Hepatology 1989; 4 : 161-165.
4. Gimson AES, White YS, Eddleston ALWF, Williams R : Clinical and prognostic differences in Fulminant hepatitis type A, B, and non A non B. Gut 1983; 124 : 1194-1198.
5. Poddar U, Thapa BR, Prasad A, Sharma AK, Singh K : Natural history and risk factors in fulminant hepatic failure. Arch Dis Child. 2002 Jul;87(1):54-56.
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7. Thapa BR, Singh K, Singh V, Broor S, Nain CK : Pattern of hepatitis A & hepatitis B virus markers in cases of acute sporadic hepatitis & in healthy school children from North West India : Journal of Tropical Pediatrics, 1995; 41 : 328-329.
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9. Ronald A. Sacher, James W. Shih, and Robert H.
Pureed : Hepatitis C Virus-Associated Fulminant Hepatic Failure. N Engl J Med 1996; 335:631-634.
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