The liver in choledochal cyst.

BACKGROUND/PURPOSE: Hepatic changes due to choledochal cyst have not been given due emphasis in the published literature. In this study the gross and microscopic appearance of the liver in patients with choledochal cyst have been correlated with clinical features, liver function tests and postoperative complications. METHODS: A retrospective evaluation of patients treated for choledochal cysts between January 1989-December 1998 was undertaken. The case records were reviewed and liver biopsies taken at surgery were analysed. RESULTS: The case records of 22 patients were reviewed (16 girls, 6 boys; mean age 4.6 years, range 1 month-10 years). The presenting features included jaundice (59%; 85.7% in < 1 year), abdominal pain (59%; 86.7% in > 1 years) and fever in 40.9% cases. A palpable abdominal mass and hepatomegaly was present in 32% cases. A type IV cyst was present in 1 case; all others had type I cysts (14 cystic and 7 fusiform). The liver looked grossly 'normal' in 16 and 'cirrhotic' in 6 cases. Liver biopsies were available for review from 5 of the 'cirrhotic' and 7 of the 'normal' looking livers. All the liver biopsies showed varying degrees of bile duct proliferation, cholestasis, parenchymal damage, inflammatory cell infiltration and pericentral fibrosis. Histological features of cirrhosis were evident in 6 cases (4 'cirrhotic' and 2 'normal' looking livers), 4 of these cases were infants. Liver function tests were deranged in 5 cases with histological features of cirrhosis and hepato-biliary scintigraphy showed obstructive features in 3 of these cases. There was an increased risk of postoperative complications in the cases with histological features of cirrhosis, 2 died from hepatic insufficiency and one each had transient ascitic and biliary leak. CONCLUSION: Liver histology showed significant changes in all the cases of choledochal cyst in whom it was studied; even normal looking livers showed evidence of significant changes. Presence of cirrhosis, more common in infants, correlated with jaundice, deranged liver function tests, obstructive features on hepatobiliary scintigraphy and a greater risk of postoperative complications.

Infant and child mortality in Bhil tribe of Jhabua district.

Nearly 25 million children are born in India every year of which almost 2.7 million die before attaining the age of five years. Forty seven per cent of births take place in the four states, namely Uttar Pradesh, Madhya Pradesh, Bihar and Orissa, while fifty per cent of all deaths below five years also take place in these states. The present study was carried out in Jhabua district in which five per cent villages of each tehsil were selected by random sampling. Information was obtained on 430 households of 67 villages on infant and child mortality, birth order, age, sex and cause of death. 38.2% households reported the death of at least one child below the age of five years. Out of these 59.3%, 27.2% and 13.2% reported the death of one, two or three and more children respectively. 46% of infant deaths or 29.3% of all deaths occurred in the neonatal period. The major causes of death were preventable such as tetanus, diarrhoea, measles, ARI and fever. 51.3% deaths were of children who were third or more in birth order. 54.8% deaths were males and 47.59% were females. The study shows the need for an effective Dai (Midwife) Training Programme to upgrade the skills and an urgent necessity to improve the outreach services in remote tribal areas to bring down the infant mortality.