History Taking for a 7-Year-Old Child with Jaundice and Abdominal Distension
Immediate Priority: Differentiate Life-Threatening from Chronic Causes
The history must immediately focus on identifying biliary obstruction, acute liver failure, or metabolic crisis, as these require urgent intervention. 1, 2
Essential History Components
Onset and Progression of Symptoms
- Duration of jaundice: Acute onset (days) suggests biliary obstruction, hepatitis, or hemolysis; chronic (weeks to months) suggests cirrhosis, metabolic disease, or chronic liver disease 3, 4
- Progression of abdominal distension: Rapid progression over days suggests acute ascites from liver failure or biliary rupture; gradual progression suggests chronic liver disease with portal hypertension 5, 6
- Associated fever: Presence suggests cholangitis, hepatitis, or spontaneous bacterial peritonitis 7, 8
Gastrointestinal Symptoms
- Stool color: Acholic (pale/clay-colored) stools indicate biliary obstruction and require urgent imaging 8
- Urine color: Dark urine confirms conjugated hyperbilirubinemia 7
- Vomiting: Bilious vomiting suggests intestinal obstruction; non-bilious vomiting may indicate liver disease 5
- Abdominal pain location and character: Right upper quadrant pain suggests biliary pathology; diffuse pain with distension suggests ascites or peritonitis 9, 7
- Poor appetite and weight loss: Suggests chronic liver disease with malnutrition 5
Bleeding and Coagulation History
- Easy bruising, epistaxis, or gum bleeding: Indicates coagulopathy from liver synthetic dysfunction 5, 3
- Hematemesis or melena: Suggests variceal hemorrhage from portal hypertension 5
Neurological Symptoms
- Altered mental status, confusion, or lethargy: Suggests hepatic encephalopathy or acute liver failure requiring immediate evaluation 5, 4
- Seizures: May indicate metabolic decompensation 4
Growth and Development
- Growth failure or poor weight gain: Common in chronic liver disease and should prompt evaluation for cirrhosis 5
- Developmental delays: May suggest underlying metabolic or genetic disorders 5
Critical Past Medical History
Neonatal and Infant History
- Neonatal jaundice beyond 3 weeks: Suggests cholestatic liver disease 1
- Previous episodes of jaundice or liver disease: Important for identifying chronic or recurrent conditions 5
Infectious Exposures
- Hepatitis A exposure: Recent travel, contaminated food/water, or sick contacts 7
- Hepatitis B/C risk factors: Blood transfusions, maternal transmission 2
- Recent viral illness: May precede acute hepatitis 7
Medication and Toxin Exposure
- All medications (prescription and over-the-counter): Drug-induced liver injury is common 1, 2
- Herbal supplements or traditional remedies: Hepatotoxicity risk 1, 2
- Acetaminophen use: Dose and duration to assess for toxicity 2
Metabolic and Genetic Screening
- Family history of liver disease, early childhood deaths, or consanguinity: Suggests Wilson disease, tyrosinemia, or other metabolic disorders 5, 3, 4
- Neurological symptoms in family members: Wilson disease can present with liver disease before neurological manifestations 3
- Obesity or metabolic syndrome: NAFLD is increasingly common in children 5
Physical Examination Clues to Elicit in History
Skin and Mucous Membranes
- Pruritus (itching): Suggests cholestasis 5
- Bruising or petechiae: Indicates coagulopathy 5, 3
- Spider angiomata or palmar erythema: Signs of chronic liver disease (though less common in children) 5
Abdominal Findings
- Hepatomegaly: Ask about previous documentation of enlarged liver 5, 3
- Splenomegaly: Suggests portal hypertension 5, 3
- Palpable abdominal mass: May indicate choledochal cyst or tumor 8
- Ascites: "Ballotable fluid" or increasing abdominal girth 5
Respiratory Symptoms
Red Flags Requiring Immediate Action
- Bilious vomiting: Suggests intestinal obstruction requiring surgical evaluation 5
- Abdominal tenderness with fever: Suggests peritonitis or cholangitis 5, 7, 8
- Altered mental status: Hepatic encephalopathy or metabolic crisis 5, 4
- Coagulopathy with bleeding: Acute liver failure 5, 3
- Rapid accumulation of ascites: May indicate portal/hepatic vein obstruction or bacterial peritonitis 5
Systematic Disease-Specific History
For Biliary Obstruction (Choledochal Cyst, Stones)
- Intermittent jaundice with pain: Classic triad of jaundice, pain, and abdominal mass 8
- Previous biliary surgery or procedures: Risk for strictures 2
For Chronic Liver Disease/Cirrhosis
- Recurrent infections or cholangitis: Suggests primary sclerosing cholangitis 5, 8
- Inflammatory bowel disease symptoms: Associated with PSC 5
- Autoimmune symptoms: Joint pain, rashes suggest autoimmune hepatitis 3
For Metabolic Disorders
- Developmental regression or neurological symptoms: Wilson disease, tyrosinemia 3, 4
- Rickets features: Suggests tyrosinemia type 1 4
- Consanguinity: Increases risk of autosomal recessive metabolic diseases 3, 4
For Portal Hypertension
- Previous variceal bleeding: History of hematemesis or melena 5
- Umbilical hernia: Common with ascites 5
Social and Environmental History
- Travel history: Hepatitis A endemic areas 7
- Dietary history: Malnutrition in chronic liver disease; exposure to contaminated food/water 5, 7
- School attendance and sick contacts: Infectious hepatitis transmission 7
- Access to healthcare: Delayed presentation increases risk of complications 8
Common Pitfalls to Avoid
- Do not assume viral hepatitis without excluding biliary obstruction: Acholic stools mandate urgent imaging for biliary atresia or obstruction 8
- Do not miss Wilson disease: Normal ceruloplasmin does not exclude Wilson disease; genetic testing may be required 3
- Do not overlook drug-induced liver injury: Always ask about all medications, supplements, and herbal remedies 1, 2
- Do not delay evaluation for ascites: Rapid accumulation requires investigation for portal vein thrombosis or bacterial peritonitis 5