Pediatric Hepatology
Institute of Liver and Biliary Sciences (ILBS) was the first centre to officially establish a department of ‘Pediatric Hepatology'. Although pediatric liver units were working in the various centres of the world but “pediatric hepatology” as a specialty was not recognized in India. Department of Pediatric Hepatology at ILBS is a full fledged department with well trained faculty and senior residents. We have established a fully functional Pediatric Hepatology ward which is well equipped for prompt management of infectious, metabolic and hereditary liver diseases in neonates, children and adolescents.
There are a lot of structural, infective, inborn errors of metabolism and autoimmune diseases of the liver amongst children. These disorders are very distinct from the liver disease seen among adults. The OPD attendance in the department of Pediatric Hepatology has also shown remarkable exponential growth. Majority of the patients are referred cases of neonatal and childhood liver diseases from all parts of the country. We have referrals from various hospitals of Delhi where junior doctors accompany patient to learn the work and understand the management of the patients and then discuss the monitoring of the patient with us from time to time. The Department has about 60 admissions each month in the ward and PICU. There was pressing need of the increase in beds in PICU as well NICU. The second phase building has already given us the much required increase in beds in ward, NICU & PICU this year. Diagnostic and therapeutic Pediatric GI endoscopies and procedures like hepatic vein pressure gradient and hepatic vein angioplasty as well as stenting are being performed. Fully functioning Pediatric liver transplant unit at ILBS has done 60 Pediatric liver transplants in the last 6 years. Various research projects are initiated to tackle unanswered queries in the field of metabolic and infectious childhood liver disease. We have about 12 research projects involving the faculty and residents of the department. The academic activity of the department includes holding of regular lectures, case presentations, seminars and symposia, journal club, group discussions, clinical meetings and clinical grand rounds.
Our Mission
The dual mission of the Department of Pediatric Hepatology has been well sketched out. On one side we are dedicated to the state of art patient care. And at the same time we as a department have been making a continued effort in causing more awareness among the pediatricians regarding identification and management of common childhood liver diseases. From time to time we participate in mass awareness programs also, to help in the prevention and identification of the common hepatic diseases among children. Besides we have participated in the prevention of infective hepatitis on televisions and school health programs.
Service Highlights
- Outdoor facilities for evaluation of neonatal and childhood liver disease.
- Pediatric Hepatology Ward for prompt management of infectious, metabolic and hereditary liver diseases in neonates, children and adolescent.
- Age and clinical profile appropriate protocol based approach to various metabolic liver disease in neonates, children and adults.
- Diagnostic and therapeutic Pediatric GI endoscopies.
- Procedures like hepatic vein pressure gradient and hepatic vein angioplasty as well as stenting are being performed
- Plasmapharesis in the Acute liver failure and acute on chrnic liver failure patients to bridge the gap to liver transplant.
- Pre-transplant evaluation and post-transplant monitoring done by the department along with the HPB surgery and various specialities.
- Pediatric hepatobiliary surgeries like Kasai’s portoenterostomy, Hepaticojejunostomy and Partial Hepatectomy are being done routinely and we provide pre and postoperative care for these patients.
- Splenic artery embolization and radiofrequency ablation are the radiological interventions are performed routinely at ILBS for pediatric cases.
- Counseling is done to parents through ILBS website and are in the process of developing a “Query Corner” on ILBS website to help the general pediatricians with the diagnosis and management of different childhood liver diseases.
Services rendered by the Department for Common Pediatric Liver Disorders
Acute Liver Failure in Children
Acute liver failure (ALF) in children is an acute devastating condition with high risk of complications and even death if proper management is not done. In the department, with standardized protocol based management, we have achieved high survival rates and thus could avoid liver transplantation in majority of the children. This has been further strengthened by use of state of the art techniques of High Volume Plasmapheresis, Continuous renal replacement therapy etc in ILBS, as being done in the best centres in the world.
Outcome of Pediatric ALF: Department of Pediatric Hepatology has emphasis on saving the children with their own liver. For those, who fail to improve on medical therapy, we offer liver transplant. Our results are comparable with the best in the world with 46.6 % survival with own liver, without the need for liver transplant. Similarly, we have excellent results with 66.7 % survival with own liver in children with acute-on-chronic liver failure (ACLF).
Wilson's Disease in Children
This genetic disorder is one of the most common causes of liver disease in children, with high risk of poor outcomes if not diagnosed early or properly managed. With extensive experience of managing more than 100 such cases, we could save majority of cases with medicines and supportive strategies (like Plasmapheresis) only, avoiding the need of liver transplantation. Also, because of careful family screening, we could identify many silent cases in the families and treated them before they became symptomatic.
Outcomes of Pediatric Wilson’s Disease patients at ILBS
Chronic Hepatitis B Infection in Children
Of more than 400 cases of pediatric chronic hepatitis B infection managed in the department since beginning, majority were deemed not to require any treatment at all based on status of the disease with favourable outcomes in all of them. Thus, we could avoid any unnecessary treatment in children, decreasing the financial costs and also avoiding any medication related side-effects. In those requiring treatment, our department has achieved high success rates especially with innovative therapies like sequential therapy using Interferon/Oral antiviral drugs.
Autoimmune Liver Disease in Children (Autoimmune Hepatitis/Sclerosing Cholangitis)
We have diagnosed and managed more than 120 subjects with autoimmune liver disease in last 6 years, with excellent treatment responses (exceeding > 80 %) avoiding unnecessary liver transplantation. This is despite the fact that majority of subjects had advanced liver disease at presentation. These success rates are at par with those of the best pediatric liver units in the world.
Metabolic Liver Diseases
Despite presence of limited diagnostic facilities in the country, metabolic liver diseases are now being diagnosed and managed at our centre in a very cost effective manner, owing to the ‘Protocol Based Approach’ that our department follows. These include many common conditions like Galactosemia, Tyrosinemia, Glycogen Storage Disease etc, which, if diagnosed at a right age, can be effectively managed, and liver transplantation can be avoided.
Common Metabolic Liver Diseases managed at ILBS
Services Rendered
| Services | 2016 | 2017 | 2018 | |
|---|---|---|---|---|
| New patients attended OPD | 1709 | 2114 | 4500 | |
| Admissions in Pediatric ward | 587 | 682 | 884 | |
| Pediatric admissions in ICU | 26 | 52 | 80 | |
| Diagnostic UGIE | 211 | 263 | 338 | |
|
Therapeutic UGIE Sclerotherapy Band ligation FB removal |
30 37 1 |
28 51 1 |
45 125 2 |
|
| ERCP | 16 | 19 | 21 | |
| HVPG | 8 | 8 | 8 | |
| Colonoscopy | 26 | 20 | 38 | |
| Sigmoidoscopy | 9 | 15 | 15 | |
|
Liver Biopsies: Percutaneous TJLB HVPG HV Angioplasty IVC Angioplasty TIPSS |
139 06 8 3 2 - |
143 10 8 3 3 1 |
178 15 8 01 - 1 |
|
New Services and Facilities
- It was for the first time felt at our centre that algorithm guided approach to metabolic liver disease would help cost-effective investigative work up and early detection of the disorders. Diagnosis of the metabolic liver disease has been made easier and cost-effective by the development of age and clinical profile appropriate protocol based approaches to various presentations of liver disorder in neonates, children and adults. We have proven that it increases the case detection as well as decreases the cryptogenic/ indeterminate cases.
- Complete evaluation of the hereditary liver and pancreatic disorders is available in the department.
- Pediatric Liver Transplant Program available at the lowest cost in India.
Educational Activities
Details of the Educational activities (CME/Conf/workshop) hosted by the department in 2018:
- Pediatric Hepatology symposium at Asia Pacific Association for Study of Liver Diseases (APASL) Annual Meeting 2018 : The department of pediatric Hepatology in collaboration with APASL organized a full day pediatric hepatology symposia during the 27th Annual conference of APASL held in New Delhi, India [March 14th-18th, 2018]. This was the first time that a full day session was dedicated to pediatric hepatology. The sessions had participants from all over the world. It was a rare opportunity for budding pediatric hepatologists to interact with and listen to all the eminent stalwarts of the field. The areas of major interest during the symposia were cholestatic liver diseases, metabolic liver diseases, pediatric liver transplantation and recent advances in pediatric hepatology. The event saw extremely enthusiastic participation from delegates and faculty alike
- Teleconfrence meeting with department of Pediatric Hepatology, Texas Children’s Hospital, USA : The department runs a monthly teleconference with Texas Children’s Hospital, Houston, USA on first Tuesday of every alternate month. This teleconference is an opportunity for pediatric hepatology teams from each centre to discuss latest research, clinical approach and other topics on the subject. This conference gives an opportunity to our residents to interact with international faculty and discuss issues related to day-to-day management of patients, management protocols as well as research topics. So far we have had 10 such sessions.
Course Offered
| Name of the course | Number of candidates/year | Students admitted | Students passed |
|---|---|---|---|
| DM in Pediatric Hepatology | 1 | Dr Piyush Upadhyay | Dr Arti |
| PDCC in Pediatric Hepatology | 2 | Dr Prabir Majhi Dr Nishu Khemka |
Departmental Achievements
Conference Presentations
Annual Conference of American Association of Liver Disease ‘The Liver Meeting 2018’ held in San Francisco, USA.
- Poster presentation by Prof Seema Alam titled ‘AARC-ACLF Score: Best Predictor of Outcome in Children and Adolescents with Decompensated Wilson’s Disease’
- Poster presentation by Prof Seema Alam titled ‘Prognostic Markers in Pediatric Acute Liver Failure with Advanced Hepatic Encephalopathy’
- Poster presentation by Dr Snehavardhan Pandey titled ‘Plasma Exchange in Transplant Free Survival in Pediatric ALF with advanced Hepatic Encephalopathy
ISPGHAN 2018 (5th Annual Conference of the Indian Society of Pediatric Gastroenterology, Hepatology and Nutrition) held in Mumbai on 26th-28th October, 2018.
- Oral Plenary Presentation by Dr Snehavardhan Pandey titled ‘Predictors of Hepatitis A virus induced Pediatric Acute Liver Failure- An Etiology specific Study’
- Oral Presentation by Dr Priti Vijay titled ‘ Budd-Chiari syndrome in children – outcome following radiological intervention
- Poster Presentation by Dr Priti Vijay titled ‘Changing Spectrum of Pediatric Liver Abscess in Indian Subcontinent
- Poster Presentation by Dr. Snehavardhan Pandey titles ‘Natural History of Hepatopulmonary Syndrome in Biliary Atresia versus other Chronic Liver disease’
59th Annual Conference of Indian Society of Gastroenterology" (ISGCON 2018) at Kochi, Kerala, India [28thNovember-1st December 2018]
- • Oral Presentation by Dr Priti Vijay in the ‘Liver Clinics’ titled ‘A case of Pediatric Acute-on-chronic liver failure
Annual Conference of American Association of Liver Disease ‘The Liver Meeting 2017’ held in Washington DC, USA.
- Paper presentation by Dr Seema Alam titled ‘Decompensated Wilson’s disease: Advanced Hepatic Encephalopathy and High Bilirubin decide the need for Liver Transplantation. Does the New Wilson’s index help?’
- Paper presentation by Dr Seema Alam titled ‘Analysis of the efficacy and safety of sequential therapy using Pegylated Interferon and nucleos(t)ide analogue versus standard therapy for treatment of immunotolerant and immunoclearance cases of chronic hepatitis B infection in children’.
- Poster presentation by Dr Babu Lal Meena titled ‘HVOTO in Children- Etiology, Clinical Profile and Outcome following Radiological Interventions’
- Travel Award to Dr Arti for her paper ‘Plasma Lactate Predicts Mortality in children with Hyperacute Liver Failure’
European Society of Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) Annual Meeting 2018 held in Geneva, Switzerland (May 2018) [By Dr Vikrant Sood].
- As Oral Paper : Validation of diagnostic scores including the new proposed ESPGHAN score in Pediatric Autoimmune Liver disease
- As Poster Papers:
- Autoimmune liver disease in Indian children- is it different from the Western World?
- Predictive risk factors and transient elastography in pediatric non alcoholic fatty liver disease in Indian population
- Regression of fibrosis in pediatric liver diseases
Singapore Hepatology Conference 2018 (SHC 2018).
- Oral presentation by Dr Vikrant Sood titled ‘Hepatic Dysfunction Post Bone Marrow Transplantation in a Child’ at the Preceptorship Programme, held in Singapore (June 2018)
27th Annual conference of Asia Pacific Association for Study of Liver Diseases (APASL) Annual Meeting 2018 – March 14-18, 2018, New Delhi
- Oral paper presentation by Dr Bikrant Bihari Lal - A combination of AARC-ACLF and CLIF-SOFA score accurately predicts the need for liver transplantation in pediatric acute on chronic liver failure.
- Oral paper presentation by Dr Bikrant Bihari Lal – Weekly regimen of vitamin D is more efficacious than stoss regimen for treatment of vitamin D deficiency in children with chronic liver diseases.
- Oral paper presentation by Dr Snehavardhan Pandey – Liver involvement in celiac disease in children
Resident’s Awards (2018):
Plenary Award (First Prize) to Dr Snehavardhan Pandey for oral presentation titled ‘Predictors of Hepatitis A virus induced Pediatric Acute Liver Failure- An Etiology specific Study’ at the ISPGHAN 2018 (5th Annual Conference of the Indian Society of Pediatric Gastroenterology, Hepatology and Nutrition) held in Mumbai on 26th-28th October, 2018.
Visiting faculty to the department in 2018
- Prof. Anil Dhawan, Corporate medical Director for Paediatrics and Director – Paediatric Liver, GI and Nutrition Centre, King’s College hospital, UK
- Dr. Tamir Miloh, Director, Department of Pediatric Gastroenterology and Liver Transplantation, Texas Children’s Hospital, Houston, Texas, USA
- Dr Ronald J Sokol, Director, Digestive Health Institute, Children’s Hospital Colorado, Aurora, Colorado
- Prof Robert H Squires, Medical Director, Pediatric Liver Transplantation, and Professor of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children’s Hospital, University of Pittsburgh School of Medicine, Pittsburgh, USA
- Dr Nanda Kerkar, Director Pediatric Liver Disease & Liver Transplantation Program, Golisano Childrens Hospital, University of Rochester, New York
- Prof Richard Thompson, Professor, Molecular Hepatology, Institute of Liver Studies, King’s College Hospital, London
- Dr Roshni Vara, Evelina London Children’s Hospital, U.K
- Prof. S.K. Yachha, Department of Pediatric Gastroenterology, SGPGIMS, Lucknow, India
- Prof. Anshu Srivastava, Department of Pediatric Gastroenterology, SGPGIMS, Lucknow, India
- Prof B R Thapa, Division of Pediatric Gastroenterology, Department of Department of Gastroenterology, PGIMER, Chandigarh, India
- Dr Naresh Shanmugam, Global Hospital, Chennai, India
- Dr Malathi Sathiyasekaran, Kanchi Kamakoti Child’s Trust Hospital, Chennai, India
- Dr V.S Sankaranarayanan, Chennai, India
- Dr Ashish Bavdekar, KEM Hospital, Pune, India
- Dr Rohan Malik, Division of Pediatric Gastroenterology, Department of Pediatrics, AIIMS, New Delhi
- Dr Moinak Sen Sarma, Department of Pediatric Gastroenterology, SGPGIMS, Lucknow, India
- Dr J. Barath, Department of Pediatrics, JIPMER, Pondicherry, India
