hepato

Question 1

MELD vs Child pugh

Answer 1

MELD - liver transplant candidates
Child pugh - predict survival and assess portal HTN

in cirrhosis

Question 2

alcohol abuser with liver cirrhosis, portal HTN and splenomegaly. Pancytopenia, cause?

Answer 2

This patient demonstrates stigmata of chronic liver disease in the context of alcohol misuse and given the palpable mass below the left costal margin, likely has liver cirrhosis with portal hypertension and splenomegaly. Hypersplenism is the most likely explanation of pancytopenia in this scenario.

Question 3

In females with unexplained extreme fatigue and skin itchiness, particularly those with a history of Sjogren’s syndrome, consider

Answer 3

testing for anti-mitochondrial antibodies as these are strongly associated with primary biliary cholangitis.

Question 4

PBC vs PSC men and women?

Answer 4

PBC = women ( b for boobs)

Question 5

sleep wake cycle change and mood change

Answer 5

hepatic encephalopathy

Question 6

bloods in alcohol related liver disease

Answer 6

An AST:ALT ratio of >2:1 and an elevated GGT is suggestive of alcohol-related liver disease.

Question 7

SBP diagnosis

Answer 7

A diagnosis of spontaneous bacterial peritonitis (SBP) can be made when the white cells in the ascitic fluid are greater than 250/mm^3 and predominantly neutrophils (PMNs) or of the fluid contains more than 250/mm^3 of neutrophils.

there can be blood present - In the event of a traumatic ascitic tap then one neutrophil is subtracted for every 250 red cells to correct for the serum contamination. The gram stain is often negative and does not rule out SBP.

Question 8

pancytopenia while on azathioprine?

Answer 8

Azathioprine is a purine synthesis inhibitor that can suppress the bone marrow, particularly in patients with reduced thiopurine methyltransferase (TPMT) activity. This patient has developed pancytopenia while on treatment, making azathioprine the most likely cause.

Question 9

The most critical factor in determining the prognosis of patients with non-alcoholic fatty liver disease (NAFLD) is the

Answer 9

presence and extent of hepatic fibrosis.

Question 10

NAFLD RF

Answer 10

NAFLD is increasingly recognised as a major public health issue, often associated with conditions such as obesity, hyperlipidaemia, and hypertension. Type 2 diabetes mellitus is one of the most significant risk factors for non-alcoholic fatty liver disease (NAFLD). Insulin resistance, which is a hallmark of type 2 diabetes, promotes fat accumulation in the liver,

Question 11

liver pathology + signs and symptoms of COPD without COPD ?

Answer 11

Alpha 1 antitrypsin deficiency

Question 12

acute liver failure pt who was intubated, now presents with respiratory sx. Dx?

Answer 12

Infection is the most common complication of acute liver failure; bacterial infection is recorded in up to 80% of patients. The most common is pneumonia (around 50% of all infections) and it often presents atypically, with a fever and raised white cell count absent in around 30% of patients. This patient is especially at risk due to previous intubation, and likely has a hospital-acquired pneumonia. Prompt treatment with antibiotics in these cases (as per the sepsis 6) is essential to maximise the potential for recovery. Gentamicin should not be used due to the increased risk of renal failure

Question 13

CT thorax finding in alpha 1 antitrypsin deficiency

Answer 13

Panacinar emphysema is commonly associated with alpha-1 antitrypsin deficiency

Question 14

only carry out liver biopsy when INR is below

Answer 14

1.5

Question 15

pregnancy lady with acute liver failure, most likely cause?

Answer 15

Budd-Chiari syndrome, caused by obstruction of the hepatic veins (often by thrombosis), presents with a classic triad of abdominal pain, ascites and hepatomegaly. It is rare but dangerous, and requires a high index of suspicion for diagnosis. This woman is at increased risk due to her pregnancy. The diagnosis could be confirmed through a Doppler ultrasound of the hepatic veins

Question 16

Budd Chiari triad

Answer 16

abdominal pain, ascites and hepatomegaly.

Question 17

HCV acute presentation very unwell first step

Answer 17

Capillary blood glucose

Question 18

ascites long term med

Answer 18

Aldosterone antagonists, such as spironolactone, are used to manage ascites as they address the underlying mechanism of sodium retention in cirrhosis by blocking aldosterone in the distal renal tubules. This promotes sodium and water excretion while preserving potassium.

Question 19

abdo swelling in old lady, with low serum albumin in the ascitic fluid

dx?

Answer 19

Symptoms of abdominal swelling in a 72 year old woman raises the suspicion of ovarian cancer. Ovarian cancer with peritoneal metastases causes ascites with a low Serum Ascites Albumin Gradient (SAAG). CA 125 should be measured and the patient should undergo abdominal imaging. Ascitic fluid should be sent for cytological analysis.

Question 20

alcoholic hepatitis presentation

Answer 20

jaundice, elevated liver enzymes with an AST>ALT ratio typically greater than 2, and systemic symptoms such as fever and confusion. This condition can also precipitate or worsen portal hypertension, leading to ascites.

Question 21

liver biopsy PBC vs PSC

Answer 21

Presence of granulomas in PBC (women)

Fibro-obliterative scarring of the biliary tree in PSC (men)

Question 22

serum ascites albumin gradient in portal htn

Answer 22

A SAAG <1.1g/dL indicates causes of ascites that are not associated with raised portal pressure

Question 23

hereditary haemochromatosis avoid

Answer 23

fruit juice such as orange

Question 24

first line treatment for ascites

Answer 24

Spironolactone

Furosemide can be used in conjunction

Question 25

UC, with fatigue and jaundice, most likely complication

Answer 25

colorectal cancer from PSC This patient’s longstanding ulcerative colitis, in conjunction with fatigue, pruritus, jaundice, and hepatomegaly, suggests a diagnosis of primary sclerosing cholangitis (PSC). Patients with both inflammatory bowel disease (IBD) and PSC are at an increased risk of developing colorectal cancer. Regular surveillance colonoscopy is recommended in these patients due to this elevated risk

Question 26

TIPSS negative outcome

Answer 26

Hepatic encephalopathy

Question 27

A 45 year old man is brought to A&E by his wife due to abdominal swelling and confusion. He has a past medical history of diabetes, erectile dysfunction, and takes ibuprofen for joint pain in his hands. His father had liver cirrhosis and died of heart failure at age 60. On examination, his observations are normal. The patient has jaundice, skin hyper-pigmentation and spider naevi over the arms and chest. He is confused and slurring his speech. You cannot palpate a liver edge and his abdomen is distended but non-tender with shifting dullness. Which investigation is most important for confirming the diagnosis?

Answer 27

Ferritin level and transferrin saturation This is the correct answer. Hereditary haemochromatosis (HH) is a genetic condition of increased intestinal iron absorption that results in joint pains (especially in 2nd & 3rd MCP joints), erectile dysfunction, slate-grey skin pigmentation, cirrhosis, dilated cardiomyopathy and osteoporosis. It usually presents in men in middle age. This patient has acute-on-chronic liver failure. A ferritin level of over 1mg/L and transferrin saturation of over 45% are highly suggestive of HH - the diagnosis can be confirmed through genetic studies. Treatment is with regular venesection

Question 28

Dm and HF with Fh of liver issues

Answer 28

HH (not wilsons)

Question 29

kings college criteria for paracetamol induced liver transplant

Answer 29

King's College Hospital Criteria for Liver Transplant (paracetamol induced): The criteria for paracetamol induced liver failure are as follows: Arterial pH <7.3 24h after ingestion OR Pro-thrombin time >100s AND creatinine >300µmol/L AND grade III or IV encephalopathy. King's College Hospital Criteria for Liver Transplant (non-paracetamol liver failure):

Question 30

kings college criteria for non paracetamol induced transplant

Answer 30

The criteria for non-paracetamol liver failure are as follows: Prothrombin time >100s OR Any three of: Drug-induced liver failure Age under 10 or over 40 years 1 week from 1st jaundice to encephalopathy Prothrombin time >50s Bilirubin >300µmol/L.

Question 31

A high SAAG > 1.1g/dL indicates

Answer 31

the ascites is due to portal hypertension,

Question 32

raised ALP and Bilirubin, mildly raised transaminases medication cause?

Answer 32

Co-amoxiclav The bloods show a mainly cholestatic picture, with a raised alkaline phosphatase and bilirubin. The transaminases are also mildly raised. This can be seen with co-amoxiclav. Amoxicillin alone does not cause cholestatic jaundice, but in combination with clavulanic acid it can.

Question 33

3 drugs causing raised transaminases

Answer 33

Simvastatin, amiodarone and isoniazid

Question 34

sign associated with increased oestrogen

Answer 34

In liver cirrhosis, an increased oestrogen level induces vascularisation and leads to palmar erythema, a red colouration, particularly in hypothenar and thenar eminences. Other features of increased oestrogen include the development of gynaecomastia and spider naevi.

Question 35

when to start NAC immediately

Answer 35

N-acetylcysteine should be started immediately in staggered overdose, ingestion more than 15 hours ago or if there is uncertainty about timing.

Question 36

SBP prophylaxis

Answer 36

Prophylactic ciprofloxacin or norfloxacin is recommended as per NICE guidelines for those at high risk of spontaneous bacterial peritonitis, including those with cirrhosis and ascites with a level of ascitic protein of 15 g/L or less, until the resolution of ascites.