JRA

[Catharine Shaner, MD]

13 year old with JRA for 9 years, uveitis, bilateral renal calculi (with 1 in right ureter), hypercalcuria, hematuria, osteopenia, gastric reflux, gallstones, non-functioning gallbaldder (removal scheduled for next week), 2.8 cm liver cyst in the area of the portahepatis anterior to the portal vein, asthma/allergies.  Meds include methotrexate (SQ), Tolectin, asthma/allergy meds, vitamins, thiazide diuretic (Naqua), prednisolone eye drops, Amoxicillin prophylaxsis and she was on 1 year of oral prednisone in 97-98.  She has had abdominal pains for 18 months.  Started around the time of methotrexate; switching to SQ seemed to help for a time.  Peds gastroenterologist thought it might be ulcerative and she also has gastric reflux; trial of Zantac was +/-.  Occurs intermittently; not consistently related to food (but sometimes seems better); is made worse with motion (dance class, horseback riding); seems to be worse in early AM and late afternoon, has bouts where it is a problem for a few days - week and then none for a while.  Renal calculi found in October 1999, but pain does not seem to be related to those.  Liver cyst/ gallstones seen on US 2/00, but CT of kidneys 1/00 reports "normal liver".  Gallbladder contracted on both imaging studies.  Gallbladder is coming out next week.  We are hoping that the gallbladder will be the cause of her abdominal pains. My question concerns the liver cyst.  Rheumatologist feels it is not from the methotrexate.  Any thoughts on management of her multiple problems would be greatly appreciated.  Thank you! - ***@****

[HFHSm.D.-Gastro-rf]

Dear Catharine,

The case that you desribe is very complex and requires the expertise of a pediatric gastroenterologist.  I agree with your consultants that the hepatic cyst is unliely to be related to the methotrexate treatment.