Cases حلوة Flashcards
(18 cards)
A 21-year old male during blood donation, he was detected to have the following results:
ALT, 30 IU/L, total bilirubin 2.4 mg/dL, direct bilirubin 0.4 mg/dL, alkaline phosphatase
95 IU/L, haptoglobin 79 mg/dL(40-220mg/dL), normal urine analysis
A-What is the most likely diagnosis?
Gilbert syndrome
B-What is the confirmatory test?
genetic test to detect mutations in the UGT1A1 gene,
C-Describe treatment line of this case.
No specific treatment
Just Avoid risk factors:
Fasting, dehydration, stress, and illness
A 26-year old woman is under investigation at the infertility clinic. She has malaise and
secondary amenorrhea . She is obese with abdominal striae and spider nevi. A firm tender
liver edge could be palpated under the right costal margin. Investigations show: Hb11.3
g/dL,WBC 4.8 ҳ 109
/L, PLT 128 ҳ 109
/L,electrolytes normal, Albumin3.2 g/dL, total
protein 8.6 g/dL, total bilirubin 3 mg/dL, AST512 IU/L, ALT 600 IU/L.
A-What is the most probable diagnosis?
Hemochromatosis
وقلب غالبا cirrohtic
ليه؟
*Obesity
*Spider navei , thrombocytopenia,albumin قليل
ودي من علامات chronic liver او cirrhosis
B-What are the most important investigations?
C-What treatment would you recommend
قول لوحدك
For patients with chronic liver disease and LSM = 10 kPa by transient
elastography, the 3-year risk of decompensation is:
A) Extremely high.
B) High.
C) Moderate.
D) Negligible.
D- negligible يعنيLow
Regarding Baveno VII consensus, the abbreviation “cACLD” refers to:
A) Chronic advanced cirrhotic liver dysfunction.
B) Cirrhosis advancing chronic liver disorder.
C) Comorbidities associated with chronic liver disease.
D) Compensated advanced chronic liver disease.
E) Cumulative active cirrhotic liver dynamics.
D
A 25-year-old man who is known to have diabetes mellitus and suffers from recurrent chest infections is referred to the gastroenterology team with chronic diarrhea. The patient has had persistently abnormal liver function tests over the last three months and an abdominal ultrasound scan showed a fatty liver and gallstones.
The most likely diagnosis is Cystic Fibrosis (CF).
Supporting features:
*Diabetes mellitus (likely CF-related diabetes)
*Recurrent chest infections (chronic lung disease in CF)
*Chronic diarrhea (malabsorption from pancreatic insufficiency)
*Abnormal liver function tests and fatty liver (CF-related liver disease)
*Gallstones (common in CF due to altered bile composition and gallbladder dysfunction)
In cystic fibrosis …
What are complications
1-Pulmonary Complications
*Chronic bronchitis and bronchiectasis
*Recurrent respiratory infections (e.g., Pseudomonas aeruginosa)
*Hemoptysis
*Pneumothorax
*Respiratory failure
*Nasal polyps and chronic sinusitis.
2. Gastrointestinal and Hepatobiliary Complications
*Pancreatic insufficiency → malabsorption, steatorrhea, vitamin A/D/E/K deficiency
*CF-related diabetes
*CF-related liver disease (CFLD): steatosis, focal biliary cirrhosis, multilobular cirrhosis
*Gallstones and cholecystitis
*Portal hypertension (in advanced liver disease)
3. Nutritional Complications
*Failure to thrive
*Malnutrition
*Fat-soluble vitamin deficiencies
*Hypoproteinemia and edema
4. Reproductive Complications
*Infertility in males (due to congenital bilateral absence of vas deferens)
*Reduced fertility in females (thick cervical mucus)
5. Musculoskeletal Complications
*Osteopenia and osteoporosis
*Arthropathy (CF-related arthritis)
*Muscle wasting (from malnutrition and chronic illness)
6. Psychological and Social Complications
Depression and anxiety
A 30-year old obese man is referred by his family physician to the hepatology clinic. His
father had haemochromatosis and he is about to get married, so he is wondering whether
he is likely to be affected. His serum ferritin was elevated.
A-What would be the best first-line screening test in this case?
*Transferrin Saturation (TS%)
This is calculated as: (Serum iron / Total iron-binding capacity) × 100
A TS > 45% is considered suggestive of iron overload.
*If elevated, HFE genetic testing (especially for C282Y and H63D mutations) is warranted.
B-What are the differential diagnoses for elevated serum ferritin?
1-Iron Overload Conditions
*Hereditary haemochromatosis
*Repeated blood transfusions
2. Thalassemia major
3-Acute infections
4-HLH
5-Malignancy
6-Autoimmune disease,,sle, rheumatoid arthritis
7-Metabolic syndrome
6 A 19-year-old man is sent to your clinic for evaluation of abnormal liver enzymes. He is essentially asymptomatic but complains of occasional itching. His appetite is good and his weight has been stable. He denies abdominal pain, fever, chills, and change in urine or stool color. He has no other medical problems and is not taking any prescribed medications but does take several protein supplements and vitamins. He is an offensive lineman on the university football team. He has undergone cholecystectomy when he was 17 for cholecystitis although no records are available. He recalls being jaundiced at that time but he made a full recovery. He denies any substance abuse and denies significant alcohol. His family history is significant for hypertension in his mother and father but there is no history of liver disease or cancer. On exam, he looks well. Vital signs show height 165cm, weight 80kg. His blood pressure and pulse are normal. There is no scleral icterus and his cardiovascular, respiratory, and abdominal exams are all normal. Laboratory StudiesHb 14.7 g/dl Platelets 125,000/μl INR 1.3 Tbili 1.8 mg/dl AST 68 iu/l ALT 85 iu/l ALP 265 iu/l GGT 187 iu/l Albumin 3.8 g/dl Creatinine 1.4 mg/dl Ultrasound of the right upper quadrant is normal Questions
A:What is the next best test
MRCP
. B:Are there any other blood tests that are necessary?
*.p-ANCA: Often positive in PSC (though not specific).
*. IgG4: To rule out IgG4-related cholangitis, which can mimic PSC.
*. Anti-mitochondrial antibody (AMA): To rule out Primary Biliary Cholangitis (PBC).
*. Inflammatory bowel disease workup: Even if asymptomatic, do colonoscopy to screen for UC, which is present in >70% of PSC cases.
*.Hepatitis serologies and iron studies (already partly ruled out by history and demographics).
* Autoimmune hepatitis panel (ANA, ASMA, anti-LKM).
C:Is this a treatable condition?
No, but Ursodeoxycholic acid may be used for symptom control,Liver transplant is definitive in advanced disease.
D:Is there a risk of cancer in this condition?
Yes, significantly increased risk of:
1. Cholangiocarcinoma (~10–15% lifetime risk)
2. Gallbladder cancer
3. Colorectal cancer, especially if associated with ulcerative colitis
So,Regular screening (MRCP, CA 19-9, colonoscopy) is recommended.
Liver lesion that yields “anchovy paste” upon aspiration.
amoebic liver abscess
Asian immigrant + intra- and extrahepatic stone disease + diffuse bile duct
dilatations and strictures.
Recurrent pyogenic cholangitis (“Oriental” cholangiohepatitis)
Acute liver failure upon withdrawal of steroids in polyarteritis nodosa.
reactivation of hepatitis B virus (HBV) due to immune reconstruction
A 46-year-old man presents in the emergency department with acute-onset right upper quad-
rant pain with radiation to the right shoulder. The patient is a recent immigrant from Hong
Kong. His pain began 2 days prior to admission. It builds steadily, stays elevated for several hours, and wanes—but has not disappeared since beginning 2 days ago. One day prior to admission he became yellow, developed nausea, and vomited. On the day of admission, he developed chills and subjective fevers. He reports similar episodes
on and off for the past 3 years, but has not sought treatment until now. He does not drink alcohol and does not use prescription medications or herbal supplements. There is no history of viral hepatitis. There is no recent weight loss.
On examination, he has a fever of 101.4°F, BP of 110/80 without orthostatic hypotension, pulse
of 110, respiratory rate of 16, and oxygen saturation of 98% on room air. He is jaundiced. There are no stigmata of chronic liver disease. The gallbladder is not palpable, and the Murphy’s sign
is negative. However, he is tender to palpation in the right upper quadrant. The liver edge is not palpable. There is no rebound or guarding.
Labs include total bilirubin = 12.8 (direct = 9.1); AST = 60; ALT = 72; INR = 1.1; albumin = 3.3;
ALP = 620; WBC = 16.2 (90% PMNs); creatinine = 1.4. An ultrasound in the emergency depart-ment reveals diffuse intra- and extrahepatic duct dilation, along with innumerable stones in both
the intra- and extrahepatic ducts. A subsequent ERCP is performed with direct cholangioscop
What is the most likely diagnosis?
Recurrent pyogenic cholangiohepatitis, also known as “Oriental” cholangiohepatitis.
▶ What are the short-term and long-term management steps?
*Management of acute attacks includes intravenous fluids and antibiotics, with attempts to
remove as many stones as possible through ERCP +percutaneous t-tube drainage, or even surgical resection of
affected hepatobiliary segments.
A 45-year-old woman with episodes of right upper quadrant discomfort is found to havecholelithiasis, including a large stone in the distal bile duct. She undergoes ERCP. Biliary cannulation is challenging and requires a precut papillotomy. After the bile duct is cannulated, a large biliary sphincterotomy is performed, and the stone is successfully removed with a balloon. Following the procedure, the patient reports right upper quadrant pain and back pain. On examination, there is mild tenderness in the right upper quadrant. Vital signs are temperature 38.5 C, blood pressure 130/80 mm Hg, heart rate 88 beats/minute, and oxygen saturation 98% on room air. WBC count and serum lipaseare normal. An abdominal MRI is obtained
A: What is the diagnosis and how to manage?
*retroperitoneal air (pneumoretroperitoneum) due to a small perforation of the duodenum or bile duct following precut sphincterotomy during ERCP.
*MRI (or CT) typically shows retroperitoneal air around the duodenum.
Treatment
*Conservative management is appropriate in stable patients:
(NPO) – bowel rest
IV fluids
IV antibiotics (to cover gut flora)
Close clinical monitoring for signs of deterioration (e.g., peritonitis, sepsis)
Surgical intervention is reserved for Signs of generalized peritonitis
patient with tense ascites undergoes paracentesis that yields 18 L of fluid. She is then
started on strict sodium restriction and diuretic therapy ,beginning with furosemide 40
mg daily and spironolactone 100 mg daily. The ascites does not improve, and a spot
urine sodium is 5 mmol/L, with a urine sodium:potassium ratio below 1.0. The diuretics
are increased, and she is concurrently treated with serial large-volume paracenteses. But
these measures do not help the ascites persists. The diuretic dose is gradually pushed to
160 mg daily of furosemide and 400 mg daily of spironolactone. At this level, the
creatinine rises from a baseline of 1.0 to its current level of 2.3. The fractional excretion
of sodium (FENa) is low, and the bicarbonate is elevated at 32. The patient is also noted
to be increasingly encephalopathic in parallel with the increase in diuretic dosage.
A: What is the most likely reason for the elevated creatinine?
*Azotemia due to dieuresis
B: what is the next step in managing this patient?
*Stop dieuretic
*Albumin
*Midodrine
28-year-old worker has been feeling generally unwell for the last 4 days, and off his food.
Although usually a smoker (10–15 cigarettes per day), he gave it up since his illness began.
Since yesterday, he has complained of a vague ache below his ribs on the right side. He
noticed that his urine had become very dark, and his friends told him today that his eyes
looked yellow. He has no relevant past medical history. On examination by his local primary
care physician, he was pyrexial (38.5 ºC) and clinically jaundiced. The only other sign of note
was some right upper quadrant abdominal tenderness, but no guarding.
A) What is the differential diagnosis?
B) What are the recommended investigations for this patie
DD
Acute viral hepatitis
Dili
AIH
Ascending cholangitis
Leptospirosis
