Case of the month

 A Case Requiring Liver Transplant

Treated by Dr. Dhiraj Nanda

Presenting Complaints

A 8 year old patient came on 23/03/07 with following complaints:
•Recurrent jaundice,
•White stools,
•High colored urine
•Fever & malaise since Jan 07
•Itching all over body 

Past H/o (including H/o PC)

•Ms.  A born on 28/04/1999 at Army Command Hospital, Pune, Southern Command Pune, India.

•Caesarean section baby with birth weight of 3.2 kgs. She had 2.2 mg /dl Bilirubin on the day of birth. She achieved all milestones normally but continued to get more and more yellow as days passed and on 01 July 1999, was diagnosed as having “extra hepatic bilary atresia” after the HIDA scan showed no tracer in the gut even after 24 hours and after phenobarbitone for five days and after repeat HIDA scan.

•Operated on 13 JULY 1999, Entire extra hepatic bilary tree and Gall bladder was found artitic. "KASAI'S" procedure was done. Operative notes: KASAI'S PORTO-ENTEROSTOMY. 

Liver Biopsy Report

•Gross: A -0.5 cm long tubelike structure with atretic gall bladder measuring 2.5 - 3 cms in length marked by silk.  The cystic duct and common hepatic duct appear to have no lumen, firm in consistency.  

B - wedge biopsy from liver (total of four blocks ). 

•Microscopy : microsection show complete atresia of the gall bllader and cystic duct.  The hepatic duct show a very narrow opening (<150 micro meter) and the common bile duct show  evidence of non - canalisation (concentric connective tissue with no ephithelial element ).  

•Multiple sections from the tissue at porta hepatis show small to medium sized channels totalling 10 (ten) in  number; out of which 04 (four) are greater than 150 micrometer.  The extra-hepatic bilary stump shows concentricallyarranged connective tissue with a very narrow central duct and few peripheral gland remnants.

•   Microsections from liver show effacement of lobular architecture.  Hepatocytes show marked feathery degeneration and multinucleate gaint cell formation.  Significant intraconalicular bile stasis and bile plugging is seen in the hepatic parenchyma, both in the intralobular and peri-portal areas.  The portal tracts are widened with both acute and chronic inflammatory cell infiltrate but there are no bile duct proliferations.  Bile ducts are seen in normal in the portal tracts, many of which are without any central lumen.  Hepatocytes show significant pseudo-acinar formation.  No significant portal or peri-portal fibrosis seen. 

• Opinion:  extra - hepatic bilary atresia with neonatal hepatitis.  

Family H/o

•Father – Stress Diabetes

•Two aunts of father had CA

•Mothers grand father had CA 

Physical Generals

•Appetite- Good,

•Thirst - Normal,

•Stool - On & off - loose,

•Urine - N / yellow color,

•Sleep - Normal

•Desire - Chocolate, Egg++, Milk++

•Aversion- vegetables 

Mind

•Mix up easily.

•Obedient & Yielding

•Hyperactive;

•Non-destructive, protects everything;

•Fear of crowd, noises, hospital, scared of rainy / windy weather;

•She has to be told once, from next time onwards she will remember and do it;

•She doesn’t like to drive fast;

•Likes drawing;

•Mimics elder ones;

•Caring in nature;

•She is very cautious, does all thing cautiously;

•She likes people come to home, want to serve them;

•Habit of nail biting; 

Analysis

•Miasm at level of mind – Psora

•Miasm at level of body – Psora / Syphilis

•Miasm at level disease – Syphilis 

•Miasmatic back-ground – Psoro-syphilis. 

The person before us

•She has to be told once, from next time onwards she will remember and do it – Obedient / Yielding / Conscientious.

•She likes people come to home, want to serve them & Caring in nature – Affectionate / Compassionate.

•She doesn’t like to drive fast & She is very cautious, does all thing cautiously – Cautious. 

Selection of Rubrics

•Conscientious

•Compassionate

•Affectionate

•Cautious

•Yielding

•Bites nails

•Fear crowd 

Repertorial Analysis

Selection of the Remedy

•Three remedies that cover the rubrics selected are

–Carc;

–Lyco; and

–Puls; 

•Of  these what should we give to our patient ?

Repertorial Analysis – 2

The Remedy

•So it is clear that we give our patient Carc.

•Other points favoring Carcinosin are:

          - Family history of Cancer;

          - Molding behavior & nature pointed by ‘She has to be told once, from next time onwards she will remember and do it’. This was confirmed before prescribing the remedy.

`