Indian Pediatrics 1998; 35:650-652 

Ultrasonographic Evaluation of Hepatic Steatosis in Malnutrition

Protein Energy Malnutrition (PEM) is one of the common pediatric problems in our country. In children with PEM, the liver undergoes fatty infiltration. This has been previously studied with the help of biopsy(1) and ultrasonography (USG)(2). In this communication, we describe a group of PEM cases that were studied by USG for the extent of hepatic steatosis on admission and its improvement after adequate treatment.

Subjects and Methods

Fifty children that were admitted with a diagnosis of PEM at KEM Hospital, Mumbai between 1993-95 were included in the study. Detailed history and clinical examination was done. All the conditions, namely, pancreatic disease, obesity, pro- longed parenteral nutrition, diabetes, galactosemia, glycogenosis, Wilson's disease, abetalipoproteinemia, tyrosinemia and Reye's syndrome were ruled out. Also a history of ingestion of various drugs, namely, steroids, valparin or tetracycline that can cause hepatic steatosis was negative. All cases had grossly inadequate protein and calorie intake. Their age ranged from 5 months to 9 years. Twenty four were males and 26 females. According to Wellcome's classification(3), there were 15 undernourished, 32 marasmic, 2 kwashiorkor and 1 marasmic kwashiorkor patients.

USG evaluation of liver for fatty infiltration was done within 48 hours of admission. USG was performed by using sonoline SL-2 machine of Seimens Ltd. with 7.5 MHz probe. All USG evaluations were done by the same senior sonologist (RK) to avoid any subjective errors.

Utlrasound grading of severity. of hepatic steatosis was based on previously published criteria(2,4) as follows:

Grade  0: No increase in liver echogenecity and no echodiscrepancy between liver and kidney.

Grade 1: Minimal increase in liver echogenecity and minimal exaggeration of the echodiscrepancy between liver and kidney.

Grade 3: Loss of echoes from the walls of some of the portal veins, resulting in a featureless appearance with a degree of posterior beam attenuation and a greater discrepancy between the liver and kidneyechopattern.

Grade 5: Greater degree of posterior . beam attenuation, loss of echoes from most of the portal veins and marked, discrepancy between liver and kidney.

Grades 2 and 4 had intermediate appearance.

Liver function tests including serum transaminases were done on admission.

All the cases were admitted in pediatric ward and later transferred to nutritional rehabilitation ward, where measured frequent feeds were given. Feeds consisted of Rice Kanji,. Rice Moong dal paste, Egg flip and Milk. Sugar and Coconut oil were added to increase the density of calories. Fruits like banana were given. Vitamins, minerals and potassium were supplemented. The criteria for discharge from rehabilitation ward was attainment of 85% of weight for height. The average duration of stay was 4-5 weeks.

Results

The different grades of hepatic steatosis as evaluated by USG in each class of PEM are shown in Table 1. Serum transaminases were done in all cases on admission and showed no correlation between its levels and USG severity of hepatic steatosis.

Out of 50 cases, four cases (1 under- nourished, 3 marasmic) had no hepatic Steatosis (grade 0) on admission, two had expired due to septicemia and nine had taken discharge against medical advice before completing the treatment. The remaining 35 cases were re-evaluated at the time of discharge. Of the 35, 20 (57%) cases had shown improvement in the severity of hepatic steatosis.

Discussion

PEM results from prolonged dietetic deprivation of proteins and calories. Due to protein deficiency, there is lack of release of lipids from liver as lipoproteins and hence these get accumulated in liver leading to hepatic steatosis(5).

Earlier, fatty infiltration of liver was regarded as a characteristic feature of only edematous PEM cases(6). However, Waterlow had studied liver biopsy samples of PEM cases and had found a marasmic child having 35% of fatty infiltration.

Doherty had done the study of hepatic steatosis by USG(2). His study had included 55 cases, of which 24 were non- edematous PEM cases. Of these 24 non-edematous cases, 12 (50%) had shown hepatic steatosis on admission. Follow up USG after adequate weight gain had shown improvement in 75% cases.

Our study showed presence of hepatic steatosis in 91% of non-edematous cases on admission. There were only 3 cases of edematous PEM and all the 3 had shown hepatic steatosis. There was no correlation between the severity or type of PEM and USG grade of hepatic steatosis. In fact, one of the marasmic child had grade V hepatic steatosis.

Serum transaminases that were done in all the cases on admission showed no correlation with USG severity of hepatic steatosis. Repeat USG done after adequate weight gain showed improvement in 20 out of 35 cases (57%) in the form of decreased severity of hepatic steatosis.

Apart form being a non-invasive study, USG has a sensitivity of 94% and specificity of 84% in detecting hepatic steatosis(4,7-9). In conclusion, our study observed that hepatic steatosis in childhood malnutrition is not just confined to edematous PEM but also frequently present in non-edematous cases. Further, the severity of hepatic steatosis decreases after adequate weight gain.
 

 References