Gastroenterology and Hepatology Board Review II

December 7, 2012

Question 1 Stem and Answer Choices

Which of the following is the most appropriate management for this patient?

1. Begin interferon therapy2. Evaluation for liver transplantation3. Endoscopic retrograde

cholangiopancreatography4. Corticosteroids

Question 1

A 32 YO M is evaluated for a 2-wk hx of n/v, malaise, low-grade fever, and jaundice. He has no other significant PMH and takes only ibuprofen for HA and fever. On PEX, the T is 37.6 °C (99.7 °F), the BP is 110/75 mm Hg, the PR is 90/min, and the RR is 22/min; the BMI is 25. Exam reveals scleral icterus, jaundice, 1+ pitting LEE, hepatomegaly, mild asterixis, and somnolence. There are no stigmata of chronic liver disease

Labs

• Bilirubin (total) 17.5 mg/dL (393.3 µmol/L)

• Bilirubin (direct) 7.2 mg/dL (123.1 µmol/L)

• AST 8790 U/L• ALT 7650 U/L• Alk Phos 195 U/L• INR 2.3

• Hep B surface Ag Positive

• Hep B core Ag (IgM) Positive

• HepC Ab Negative• Hep A total Ab Positive• Blood alcohol Negative• Acetaminophen

Undetectable

Imaging Studies

• Ultrasonography shows hepatomegaly and increased echogenicity, a normal spleen, and perihepatic ascites. There is no ductal dilatation.

Question 1 Stem and Answer Choices

Which of the following is the most appropriate management for this patient?

1. Begin interferon therapy2. Evaluation for liver transplantation3. Endoscopic retrograde

cholangiopancreatography4. Corticosteroids

Question 1 Stem and Answer Choices

Which of the following is the most appropriate management for this patient?

1. Begin interferon therapy2. Evaluation for liver transplantation3. Endoscopic retrograde

cholangiopancreatography4. Corticosteroids

Explanation

• This patient has acute Hep B infection• 5% of patients develop acute progressive hepatitis B

with hepatic decompensation and need urgent liver transplantation.– INR >1.5, encephalopathy indicate fulminant hepatic failure

• Therapy with Telbivudine, lamivudine, adefovir, and entecavir

• Liver transplantion evaluation BEFORE elevated ICP and sepsis set in

• In US fulminant hepatic failure OLT within 1 wk

Explanation

Which of the following is the most appropriate management for this patient?

1. Begin interferon therapy hepatic necroinflammation

2. Evaluation for liver transplantation3. Endoscopic retrograde

cholangiopancreatography no e/o ductal dilatation

4. Corticosteroids has been studied, doesn’t help and increases risk of infection

Question 2

A 55 YO F is evaluated for elevated liver chemistry tests detected on exam for life insurance. She has no symptoms of liver disease and no history of jaundice, ascites, lower extremity edema, or encephalopathy. She used recreational injection drugs between the ages of 20 and 25 years. She has no significant PMH and takes no meds. She drinks about six cans of beer a day. On PEX, VS are normal. There are spider angiomata on the upper body and the presence of a nodular liver edge and splenomegaly.

Labs

• Plt ct 88,000/µL (88 × 109/L)

• INR 1.4• Tbili 1.1 mg/dL (18.8

µmol/L)• AST 48 U/L• ALT 96 U/L

• Alk phos 186 U/L• Alb 3.6 g/dL (36 g/L)• Hep B surface Ag

Negative• Hep C virus Ab Positive• HCV RNA 500,000

copies/mL

Imaging Studies

Ultrasonography shows coarsened hepatic echotexture; CT scan shows changes in the liver consistent with cirrhosis and splenomegaly.

Question 2 Stem and Answer Choices

Which of the following is the most appropriate next step in the management for this patient?

1. Esophagogastroduodenoscopy2. Evaluation for liver transplantation3. Lamivudine4. Pegylated interferon and ribavirin

Question 2 Stem and Answer Choices

Which of the following is the most appropriate next step in the management for this patient?

1. Esophagogastroduodenoscopy2. Evaluation for liver transplantation3. Lamivudine4. Pegylated interferon and ribavirin

Explanation

• Upper Endoscopy is indicated in patients with new diagnosis of cirrhosis– 25-40% of patients with cirrhosis get variceal

hemorrhage

Question 2 Stem and Answer Choices

Which of the following is the most appropriate next step in the management for this patient?

1. Esophagogastroduodenoscopy2. Evaluation for liver transplantation if ESLD or

fulminant hepatic failure 3. Lamivudine could be considered for Hep B,

not Hep C4. Pegylated interferon and ribavirin needs

further evaluation, discussion

Hepatitis C UpdateScreen these patients:• US born between 1945 and 1965 “Baby boomers”• IVDU or intranasal cocaine• Received clotting factors made before 1987 • Received blood/organs before July 1992 • Blood transfusion from infected donor• On chronic hemodialysis • Liver disease, especially with elevated ALT• HIV infected• Children born to HCV-infected mothers. • Needle stick injury or mucosal exposure to HCV-positive blood • Current sexual partner of an HCV-infected person • Incarcerated

Chronic HCV Treatment

• Peginterferon and ribavirin for patients with advanced fibrosis or compensated cirrhosis who are otherwise candidates for antiviral therapy

• Patients with genotype 1 should also receive a protease inhibitor ie boceprevir

Question 3

• A 57 YO F is evaluated in the ICU for rapidly progressive renal failure requiring dialysis. The patient had been hospitalized for advanced liver disease including MS changes secondary to encephalopathy. She has ascites. The liver disease is the result of chronic hep C virus infection. The patient has no history of renal insufficiency and has not received abx, intravenous contrast agents, or other nephrotoxic agents. Her medications are lactulose, nadolol, midodrine, octreotide, and albumin. She does not drink alcohol. On physical examination, the T is 97.8 °F, the BP is 110/70 mm Hg, the PR is 97/min, and RR is 12/min; the BMI is 22.

Labs and Imaging

• Creatinine 5.4 mg/dL (412.0 µmol/L)• Urea nitrogen 120 mg/dL (42.8 mmol/L)• Urine sodium less than 5 meq/L (5 mmol/L)• Urinalysis Negative

Ultrasonography shows normal-size kidneys andno obstruction.

Question Stem and Answer Choices

Which of the following is the most appropriate management for this patient?

1. Add lisinopril2. Kidney and liver transplantation3. Kidney transplantation4. Liver transplantation5. Peritoneovenous shunt

Question Stem and Answer Choices

Which of the following is the most appropriate management for this patient?

1. Add lisinopril2. Kidney and liver transplantation3. Kidney transplantation4. Liver transplantation5. Peritoneovenous shunt

Explanation

• Hepatorenal syndrome (HRS) Type 1– In setting of advanced liver failure– r/o other causes of AKI and infection– Failure to improve after w/d of diuretics and 1.5L

IVF• Reverses with liver transplantation

Question Stem and Answer Choices

Which of the following is the most appropriate management for this patient?

1. Add lisinopril no effect on HRS2. Kidney and liver transplantation not

indicated3. Kidney transplantation not indicated4. Liver transplantation5. Peritoneovenous shunt improves Cr but not

mortality