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Introduction of liver tract embolisation significantly reduced haemorrhagic complications in our patient cohort. Utilisation of this method has the potential to reduce the morbidity and mortality burden associated with post-PTC haemorrhage by preventing bleeding from the liver access tract.

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A 15 year old girl was referred to the paediatric outpatient clinic by her GP with a 2 year history of chest pain at rest and during exercise. Pectus excavatum was noted and on examination there was tenderness of the costochondral joints.A chest x-ray revealed apparent cardiomegaly, possibly secondary to the pectus excavatum. While the results of the initial echocardiogram were unremarkable, ECG changes were noted in the ST-T segments for the inferior leads. Subsequently, exercise tolerance tests were carried out, consisting of 12 min on a treadmill. This elicited ST-T changes in the anterior leads. An heart MRI scan showed a dialted right ventriclu with impaired right ventricular systolic function. A repeat MRI scan with dobutamine confirmed this with the EF being 37%. Left ventricular systolic function was found to be at the lower end of normal, potentially consequent to the right ventricular dilatation.The patient continued to experience chest pain and breathlessness at rest, and repeat echocardiogram confirmed dilatation of the right ventricle with right ventricular dysfunction (left ventricle had normal contactility and no dilatation). There was also mild trucusipd regurguation at 2.6m/sec. Repair of the pectus excavatum took place 6 months later. During the surgery, it was noted that removal of the xiphisternum resulted in immediate decompression of the right ventricle. Thoracic surgeons were able to release tissues and increase the AP diameter of the chest with a modified Ravitch procedure using prolene mesh. The post-operative echocardiogram showed improved right ventricular contactility, no tricuspid or mitral regurgiation and no outflow obstruction. The patient has had a repeat stress test which was completely normal 6 months post surgery.ConclusionIn patients with pectus esxavatum, impaired cardiac function consequent to the distortive effects of chest wall deformity is an important differential diagnosis to consider. Surgical correction has the potential to very quickly and radically improve the patient’s symptoms and future quality of life.

CaseA 4 year old girl referred by the GP with acute abdominal pain, anorexia, fever and tachycardia. She exhibited generalised abdominal tenderness and distension with guarding in the RIF. She was grunting intermittently with fever. Initial investigation showed negative urine dip and a CRP of 7 with neutrophils of 10.6.Following a differential diagnosis of appendicitis, and abdo/pelvic USS showed a large amount of free fluid with echogenic contents. The appendix was clearly visualised and was normal. Chest x-ray showed no free air under the diaphragm. The patient was treated with analgesia and was transferred out to a tertiary surgical unit as an acute surgical case to exclude intussusception, obstruction with possible. The repeat bloods showed CRP of 250 and was started on IV antibiotics.Re-examination of the case revealed a two month history of intermittent bloating and eye puffiness which was being treated in the primary care as suspected dairy allergy. The patient was noted to have periorbital swelling and puffy hands.Spontaneous bacterial peritonitis secondary to nephrotic syndrome was suspected. Repeat urinalysis showed 2+ of protein and 3+ of blood. Investigation revealed a urine albumin of 514 and ACR of 73.4 Blood cultures grew streptococcus and ASOT titers were 200untis/ml.The patient was transferred back to DGH and was started on 60 mg/m2 of daily oral prednisolone and penicillin prophylaxis. Since then she has had regular reviews in outpatient clinics and discussions with tertiary renal units. 3 months post presentation hasn't achieved remission yet and alternatives methods of treatment are being discussed.ConclusionDifferential diagnosis of acute abdominal pain in paediatrics is broad and challenging but peritonitis secondary to rupture appendix is the most common one. The child might be brought to hospital due to symptoms related to infection such as fever, abdominal pain, diarrhoea, lethargy. If the child’s proteinuria and oedema is not appreciated then the acute abdomen can be mistaken for peritonitis secondary to appendicitis. Untreated peritonitis can lead to septicaemia, meningitis and death. Children with nephrotic syndrome are at high risk of peritonitis during the period of heave proteinuria.