Hepatology Board Review Scott Gabbard, MD 06/09/2009.

Hepatology Board Review

Scott Gabbard, MDScott Gabbard, MD

06/09/200906/09/2009

Question 1Question 1

A 53-year-old man with hepatitis C and cirrhosis comes for a follow-A 53-year-old man with hepatitis C and cirrhosis comes for a follow-up office visit. He feels fatigued but has no other new signs or up office visit. He feels fatigued but has no other new signs or symptoms. The patient has a history of alcohol abuse but has been symptoms. The patient has a history of alcohol abuse but has been abstinent for 8 months following a treatment program. He now abstinent for 8 months following a treatment program. He now attends weekly Alcoholics Anonymous meetings. Complications of attends weekly Alcoholics Anonymous meetings. Complications of the hepatitis C and cirrhosis have included ascites and the hepatitis C and cirrhosis have included ascites and encephalopathy, both of which are controlled by medications.encephalopathy, both of which are controlled by medications.

Physical examination discloses mild jaundice, spider angiomata, Physical examination discloses mild jaundice, spider angiomata, splenomegaly, and mild peripheral edema.splenomegaly, and mild peripheral edema.

Labs: Hgb 13; Plt 80; AST and ALT in the 70s; total bili 3; INR 1.4; Labs: Hgb 13; Plt 80; AST and ALT in the 70s; total bili 3; INR 1.4; Alpha fetoprotein normalAlpha fetoprotein normal

Abdominal ultrasonography discloses a coarse echotexture of the Abdominal ultrasonography discloses a coarse echotexture of the liver, mild ascites, and a 2.2-cm hyperechoic hepatic mass that was liver, mild ascites, and a 2.2-cm hyperechoic hepatic mass that was not seen on previous imaging studies. A CT scan of the liver shows not seen on previous imaging studies. A CT scan of the liver shows vascular enhancement of the mass.vascular enhancement of the mass.


What is the diagnosis?What is the diagnosis? Metastatic cancerMetastatic cancer HCCHCC Focal nodular hyperplasiaFocal nodular hyperplasia Cavernous hemangiomaCavernous hemangioma Regenerative noduleRegenerative nodule

HCCHCC

Answer: HCCAnswer: HCC Patients with hepatitis C and cirrhosis are at increased risk for Patients with hepatitis C and cirrhosis are at increased risk for

developing hepatocellular carcinoma, and the finding of a developing hepatocellular carcinoma, and the finding of a new hepatic mass with vascular enhancement in such new hepatic mass with vascular enhancement in such patients almost certainly indicates hepatocellular carcinoma.patients almost certainly indicates hepatocellular carcinoma.

Although metastases are the most commonly diagnosed Although metastases are the most commonly diagnosed malignant hepatic masses in patients without cirrhosis, they malignant hepatic masses in patients without cirrhosis, they are uncommon in patients with cirrhosis, especially those who are uncommon in patients with cirrhosis, especially those who do not have a history of another malignancy. do not have a history of another malignancy.

Focal nodular hyperplasia and cavernous hemangiomas are Focal nodular hyperplasia and cavernous hemangiomas are unusual in patients with cirrhosis and would not explain the unusual in patients with cirrhosis and would not explain the finding of a new lesion. finding of a new lesion.

Regenerative nodules may occur in patients with cirrhosis, Regenerative nodules may occur in patients with cirrhosis, but these nodules usually do not show vascular enhancement. but these nodules usually do not show vascular enhancement.


A 42-year-old woman has a 1-year history of A 42-year-old woman has a 1-year history of progressive fatigue without dyspnea, chest pain, or progressive fatigue without dyspnea, chest pain, or other systemic symptoms. She sleeps well at night other systemic symptoms. She sleeps well at night and does not have features of sleep apnea. The and does not have features of sleep apnea. The patient has hypothyroidism, managed with patient has hypothyroidism, managed with levothyroxine, and dysmenorrhea, treated with an levothyroxine, and dysmenorrhea, treated with an estrogen/progesterone combination.estrogen/progesterone combination.

On physical examination, the thyroid is slightly On physical examination, the thyroid is slightly enlarged but nontender. Xanthomas are present on enlarged but nontender. Xanthomas are present on the extensor surfaces. Abdominal examination the extensor surfaces. Abdominal examination discloses mild hepatomegaly. discloses mild hepatomegaly.

Labs: CBC normal; AST 25; ALT 35; Alk phos 300; total Labs: CBC normal; AST 25; ALT 35; Alk phos 300; total bilirubin 1.1bilirubin 1.1


In addition to a fasting serum lipid profile, which of the In addition to a fasting serum lipid profile, which of the following studies would most likely help establish the following studies would most likely help establish the diagnosis?diagnosis?

Antimitochondrial antibodyAntimitochondrial antibody Serum 25-hydroxyvitamin DSerum 25-hydroxyvitamin D Endoscopic retrograde Endoscopic retrograde

cholangiopancreatographycholangiopancreatography Abdominal ultrasonographyAbdominal ultrasonography

Primary biliary Primary biliary cirrhosiscirrhosis Answer: Antimitochondrial antibodyAnswer: Antimitochondrial antibody This patient most likely has primary biliary cirrhosis. This patient most likely has primary biliary cirrhosis. Key words: fatigue, woman 40-60, other autoimmune Key words: fatigue, woman 40-60, other autoimmune

disease, skin findings, metabolic bone diseasedisease, skin findings, metabolic bone disease Diagnosis: Antimitochondrial antibody titer of 1:40 or Diagnosis: Antimitochondrial antibody titer of 1:40 or

more occur in >90% of patients with primary biliary more occur in >90% of patients with primary biliary cirrhosis. Then proceed with biopsy, which cirrhosis. Then proceed with biopsy, which characteristically shows nonsuppurative cholangitis plus characteristically shows nonsuppurative cholangitis plus findings ranging from bile duct lesions to cirrhosis.findings ranging from bile duct lesions to cirrhosis.

Treatment with ursodeoxycholic acid improves the Treatment with ursodeoxycholic acid improves the biochemical profile, reduces pruritus, decreases biochemical profile, reduces pruritus, decreases progression to cirrhosis, and delays the need for liver progression to cirrhosis, and delays the need for liver transplantation.transplantation.


A 66-year-old woman comes for her annual physical A 66-year-old woman comes for her annual physical examination. She reports only mild fatigue. The examination. She reports only mild fatigue. The patient has prediabetes that is managed by diet alone. patient has prediabetes that is managed by diet alone. She takes no medications and drinks one glass of wine She takes no medications and drinks one glass of wine each day.each day.

On physical examination, blood pressure is 132/86 On physical examination, blood pressure is 132/86 mm Hg. BMI is 32. The remainder of the examination mm Hg. BMI is 32. The remainder of the examination is normal.is normal.

Labs: Hgb 13; Plts 80; AST 130; ALT 120; Total Bili 0.8; Labs: Hgb 13; Plts 80; AST 130; ALT 120; Total Bili 0.8; Albumin 2.9; Hepatitis serologies negativeAlbumin 2.9; Hepatitis serologies negative

Ultrasound demonstrates evidence of mild fatty Ultrasound demonstrates evidence of mild fatty infiltration of the liverinfiltration of the liver


In addition to weight loss, which of the following is the In addition to weight loss, which of the following is the most appropriate next step for managing this patient's most appropriate next step for managing this patient's liver chemistry abnormalities?liver chemistry abnormalities?

Rosiglitasone and repeat LFTs in 6 monthsRosiglitasone and repeat LFTs in 6 months Alcohol counselingAlcohol counseling Liver biopsyLiver biopsy Evaluation for liver transplantEvaluation for liver transplant

NAFLDNAFLD

Answer: Liver biopsyAnswer: Liver biopsy Although a liver biopsy is not required for all patients Although a liver biopsy is not required for all patients

with NAFLD, biopsy should be considered for those with NAFLD, biopsy should be considered for those who are older than 45 years of age, are obese, have who are older than 45 years of age, are obese, have diabetes mellitus, or have a serum aspartate diabetes mellitus, or have a serum aspartate aminotransferase to serum alanine aminotransferase aminotransferase to serum alanine aminotransferase ratio (AST:ALT) >1, as these may be predictors of ratio (AST:ALT) >1, as these may be predictors of fibrosis.fibrosis.

Rosiglitazone or pioglitazone may be indicated for Rosiglitazone or pioglitazone may be indicated for patients with nonalcoholic steatohepatitis and features patients with nonalcoholic steatohepatitis and features of the metabolic syndrome in order to prevent of the metabolic syndrome in order to prevent progression of the liver disease.progression of the liver disease.


A 44-year-old man was recently found to have abnormal A 44-year-old man was recently found to have abnormal serologic test results for viral hepatitis when he serologic test results for viral hepatitis when he attempted to donate blood. The patient is asymptomatic. attempted to donate blood. The patient is asymptomatic. He used injection drugs and drank alcohol excessively He used injection drugs and drank alcohol excessively for 2 years 25 years ago but has not used either drugs or for 2 years 25 years ago but has not used either drugs or alcohol since. Medical history is otherwise unremarkable, alcohol since. Medical history is otherwise unremarkable, and he takes no medications.and he takes no medications.

Physical examination discloses a BMI of 23, no stigmata Physical examination discloses a BMI of 23, no stigmata of chronic liver disease, and a normal-sized liver.of chronic liver disease, and a normal-sized liver.

Labs: AST 50; ALT 70; total bili 0.9; HbsAg negative; anti-Labs: AST 50; ALT 70; total bili 0.9; HbsAg negative; anti-HBs positive; IgG anti-HBc positive; IgM anti-HBc HBs positive; IgG anti-HBc positive; IgM anti-HBc negative; anti-HCV positivenegative; anti-HCV positive


Which study should be done Which study should be done next?next?

Hepatitis B e antigen (HBeAg)Hepatitis B e antigen (HBeAg) Hepatitis B virus DNA (HBV DNA)Hepatitis B virus DNA (HBV DNA) Hepatitis C virus RNA (HCV RNA)Hepatitis C virus RNA (HCV RNA) IgM antibody to hepatitis A virus (IgM IgM antibody to hepatitis A virus (IgM

anti-HAV)anti-HAV)

Hepatitis C VirusHepatitis C Virus

Answer: HCV viral RNAAnswer: HCV viral RNA This patient has elevated serum aminotransferase values and This patient has elevated serum aminotransferase values and

positive antibodies to hepatitis C virus (anti-HCV). In a patient positive antibodies to hepatitis C virus (anti-HCV). In a patient with a history of injection drug use, these findings are highly with a history of injection drug use, these findings are highly suggestive of hepatitis C, and an HCV RNA study should be suggestive of hepatitis C, and an HCV RNA study should be done to confirm the presence of viremia.done to confirm the presence of viremia.

Positive tests for antibody to hepatitis B surface antigen (anti-Positive tests for antibody to hepatitis B surface antigen (anti-HBs) and IgG antibody to hepatitis B core antigen (IgG anti-HBs) and IgG antibody to hepatitis B core antigen (IgG anti-HBc) are consistent with immunity from prior infection, and HBc) are consistent with immunity from prior infection, and determination of hepatitis B e antigen (HBeAg) and HBV DNA determination of hepatitis B e antigen (HBeAg) and HBV DNA is therefore not necessary. is therefore not necessary.

Testing for IgM antibody to hepatitis A virus (IgM anti-HAV) is Testing for IgM antibody to hepatitis A virus (IgM anti-HAV) is not indicated because acute hepatitis A tends to cause not indicated because acute hepatitis A tends to cause systemic symptoms, jaundice, and more marked elevations in systemic symptoms, jaundice, and more marked elevations in serum aminotransferase values.serum aminotransferase values.


A 30-year-old woman is evaluated because of an A 30-year-old woman is evaluated because of an abnormal serum total bilirubin level detected when abnormal serum total bilirubin level detected when she had a life insurance examination. Medical history she had a life insurance examination. Medical history is unremarkable. Her only medication is an oral is unremarkable. Her only medication is an oral contraceptive agent. Physical examination is normal.contraceptive agent. Physical examination is normal.

Labs: Hgb 13; MCV 90; Total bilirubin 2.4; Direct Labs: Hgb 13; MCV 90; Total bilirubin 2.4; Direct bilirubin 0.2; AST 23; ALT 25; Alk phos 90bilirubin 0.2; AST 23; ALT 25; Alk phos 90


Which of the following is the most appropriate Which of the following is the most appropriate management at this time?management at this time?

Discontinue the oral contraceptive agentDiscontinue the oral contraceptive agent Repeat the liver chemistry tests in 3 monthsRepeat the liver chemistry tests in 3 months Evaluate for the presence of hemolysisEvaluate for the presence of hemolysis Schedule abdominal ultrasonographySchedule abdominal ultrasonography No additional diagnostic studies are indicatedNo additional diagnostic studies are indicated

Gilbert’s syndromeGilbert’s syndrome

Answer: Do nothing (very appealing to all the third years here)Answer: Do nothing (very appealing to all the third years here) This patient has indirect (unconjugated) hyperbilirubinemia, which This patient has indirect (unconjugated) hyperbilirubinemia, which

in an asymptomatic patient with a normal hemoglobin level and in an asymptomatic patient with a normal hemoglobin level and otherwise normal liver tests is suggestive of Gilbert's syndrome. otherwise normal liver tests is suggestive of Gilbert's syndrome.

Gilbert's syndrome is the most common inherited disorder of Gilbert's syndrome is the most common inherited disorder of bilirubin metabolism. In adults, it is a benign disorder, and no bilirubin metabolism. In adults, it is a benign disorder, and no additional diagnostic studies or therapy is required at this time.additional diagnostic studies or therapy is required at this time.

Cholestasis due to an oral contraceptive agent will cause Cholestasis due to an oral contraceptive agent will cause conjugated (direct) hyperbilirubinemia and an elevated serum conjugated (direct) hyperbilirubinemia and an elevated serum alkaline phosphatase levelalkaline phosphatase level

Patients with hemolysis significant enough to cause unconjugated Patients with hemolysis significant enough to cause unconjugated hyperbilirubinemia generally have a low hemoglobin level and hyperbilirubinemia generally have a low hemoglobin level and abnormal values for mean corpuscular volumeabnormal values for mean corpuscular volume


A 37-year-old woman has a 1-week history of fatigue, A 37-year-old woman has a 1-week history of fatigue, jaundice, and slight fever. The patient has jaundice, and slight fever. The patient has hypothyroidism for which she has taken levothyroxine hypothyroidism for which she has taken levothyroxine for the past 10 years. She traveled to Mexico 5 for the past 10 years. She traveled to Mexico 5 months ago and received one dose of hepatitis A months ago and received one dose of hepatitis A vaccine before her trip. Physical examination discloses vaccine before her trip. Physical examination discloses mild jaundice and hepatomegaly.mild jaundice and hepatomegaly.

Labs: CBC normal; TSH normal; AST 310; ALT 450; Alk Labs: CBC normal; TSH normal; AST 310; ALT 450; Alk phos 180; total bili 2.3phos 180; total bili 2.3


Which will confirm the diagnosis?Which will confirm the diagnosis? Antimitochondrial antibodyAntimitochondrial antibody Antinuclear antibody and anti–smooth muscle Antinuclear antibody and anti–smooth muscle

antibodyantibody IgM antibody to hepatitis A virus (IgM anti-HAV)IgM antibody to hepatitis A virus (IgM anti-HAV) Serum acetaminophenSerum acetaminophen Endoscopic retrograde Endoscopic retrograde

cholangiopancreatographycholangiopancreatography

Autoimmune hepatitisAutoimmune hepatitis

Answer: ANA and AMSA (and antibody to liver/kidney Answer: ANA and AMSA (and antibody to liver/kidney microsome type 1)microsome type 1)

This patient most likely has autoimmune hepatitis This patient most likely has autoimmune hepatitis because of her concomitant autoimmune thyroid because of her concomitant autoimmune thyroid disease and abnormal liver test results. Antinuclear disease and abnormal liver test results. Antinuclear antibody and anti–smooth muscle antibody titers antibody and anti–smooth muscle antibody titers should therefore be obtained; titers >1:80 for both should therefore be obtained; titers >1:80 for both assays support the diagnosis.assays support the diagnosis.

Key words: woman 20-40; concomitant autoimmune Key words: woman 20-40; concomitant autoimmune disease (thyroiditis, UC, synovitis)disease (thyroiditis, UC, synovitis)

Prednisone alone or prednisone plus azathioprine is Prednisone alone or prednisone plus azathioprine is effective in inducing remissions in patients with effective in inducing remissions in patients with autoimmune hepatitis.autoimmune hepatitis.


A 23-year-old woman has an 8-month history of dyspnea A 23-year-old woman has an 8-month history of dyspnea and dry cough. Medical history is unremarkable, and her and dry cough. Medical history is unremarkable, and her only medication is an oral contraceptive agent.only medication is an oral contraceptive agent.

On physical examination, vital signs are normal. On physical examination, vital signs are normal. Crackles are heard in both lung fields. Cardiac Crackles are heard in both lung fields. Cardiac examination is normal. Abdominal examination discloses examination is normal. Abdominal examination discloses

mild hepatomegaly.mild hepatomegaly. Labs: CBC normal; AST 45; ALT 55; Alk phos 430Labs: CBC normal; AST 45; ALT 55; Alk phos 430 A chest radiograph shows mild diffuse pulmonary A chest radiograph shows mild diffuse pulmonary

infiltrates. Heart size is normal. A tuberculin skin test is infiltrates. Heart size is normal. A tuberculin skin test is negative. Abdominal ultrasonography shows mild negative. Abdominal ultrasonography shows mild hepatomegaly without bile duct dilatation.hepatomegaly without bile duct dilatation.


What is the most likely diagnosis?What is the most likely diagnosis? AmyloidAmyloid SarcoidSarcoid TuberculosisTuberculosis Primary biliary cirrhosisPrimary biliary cirrhosis OCP induced cholestasisOCP induced cholestasis

Liver sarcoidosisLiver sarcoidosis

Answer: SarcoidosisAnswer: Sarcoidosis A high serum alkaline phosphatase level is commonly A high serum alkaline phosphatase level is commonly

associated with an infiltrative liver disorder, and the associated with an infiltrative liver disorder, and the presence of pulmonary infiltrates and hepatomegaly presence of pulmonary infiltrates and hepatomegaly are suggestive of sarcoidosis. are suggestive of sarcoidosis.

Amyloid is usually accompanied by evidence of other Amyloid is usually accompanied by evidence of other organ involvement, such as the nephrotic syndrome or organ involvement, such as the nephrotic syndrome or neuropathy. In addition, amyloidosis is rare in patients neuropathy. In addition, amyloidosis is rare in patients this young.this young.

Liver biopsy showing noncaseating granulomas will Liver biopsy showing noncaseating granulomas will confirm the diagnosis of sarcoidosis.confirm the diagnosis of sarcoidosis.

The majority of patients are asymptomatic, and thus do not require specific treatment


A 26-year-old woman who is 36 weeks pregnant is A 26-year-old woman who is 36 weeks pregnant is evaluated because of right-sided abdominal pain. The evaluated because of right-sided abdominal pain. The patient has had mild preeclampsia for 4 weeks. She patient has had mild preeclampsia for 4 weeks. She vomited twice this morning but is able to drink liquids. She vomited twice this morning but is able to drink liquids. She also developed a nosebleed this morning.also developed a nosebleed this morning.

On physical examination, blood continues to ooze from her On physical examination, blood continues to ooze from her nostrils. Temperature is normal, pulse rate is 105/min, and nostrils. Temperature is normal, pulse rate is 105/min, and blood pressure is 135/85 mm Hg. Abdominal examination blood pressure is 135/85 mm Hg. Abdominal examination discloses right upper quadrant tenderness and uterine discloses right upper quadrant tenderness and uterine enlargement consistent with gestational age. There is 2+ enlargement consistent with gestational age. There is 2+

bilateral lower extremity edema.bilateral lower extremity edema. Labs: Hgb 8; WBC 9.5; Plt 45; AST 160; ALT 170; total bili Labs: Hgb 8; WBC 9.5; Plt 45; AST 160; ALT 170; total bili

4.8; INR 1.04.8; INR 1.0


Which of the following is most Which of the following is most appropriate at this time?appropriate at this time?

Prompt delivery of the infantPrompt delivery of the infant Endoscopic retrograde Endoscopic retrograde

cholangiopancreatographycholangiopancreatography Administration of a corticosteroidAdministration of a corticosteroid Administration of acyclovirAdministration of acyclovir Administration of magnesium sulfateAdministration of magnesium sulfate

HELLPHELLP

Answer: Prompt delivery of the infantAnswer: Prompt delivery of the infant This patient has HELLP syndrome (hemolysis, elevated liver This patient has HELLP syndrome (hemolysis, elevated liver

enzymes, low platelets). enzymes, low platelets). HELLP develops in 5% to 10% of pregnancies associated with HELLP develops in 5% to 10% of pregnancies associated with

preeclampsia or eclampsia.preeclampsia or eclampsia. Diagnosis:Diagnosis:

microangiopathic hemolytic anemia with an abnormal peripheral microangiopathic hemolytic anemia with an abnormal peripheral blood smear, low serum haptoglobin, and elevated serum indirect blood smear, low serum haptoglobin, and elevated serum indirect bilirubin and lactate dehydrogenase levelsbilirubin and lactate dehydrogenase levels

serum aspartate aminotransferase value greater than twice the serum aspartate aminotransferase value greater than twice the upper limit of normalupper limit of normal

thrombocytopenia with a platelet count <100thrombocytopenia with a platelet count <100

The treatment of choice is prompt delivery of the infant. The treatment of choice is prompt delivery of the infant. Following delivery, the mother's condition often resolves Following delivery, the mother's condition often resolves within 48 hourswithin 48 hours


A 42-year-old man is evaluated after an elevated A 42-year-old man is evaluated after an elevated serum alkaline phosphatase value was noted during a serum alkaline phosphatase value was noted during a life insurance examination. The patient does not have life insurance examination. The patient does not have pruritus, abdominal pain, or jaundice. He has had pruritus, abdominal pain, or jaundice. He has had loose bowel movements for many years and loose bowel movements for many years and occasionally has rectal bleeding, which he attributes occasionally has rectal bleeding, which he attributes to hemorrhoids. Physical examination is to hemorrhoids. Physical examination is unremarkable.unremarkable.

Labs: Hgb 12; MCV 75; AST 45; ALT 55; Alk phos 620; Labs: Hgb 12; MCV 75; AST 45; ALT 55; Alk phos 620; total bilirubin 2.0; direct bilirubin 1.6total bilirubin 2.0; direct bilirubin 1.6


Which of the following diagnostic studies is Which of the following diagnostic studies is most appropriate at this time?most appropriate at this time?

ERCPERCP RUQ USRUQ US CT abd/pelvisCT abd/pelvis HIDA scanHIDA scan CEA levelCEA level

Primary sclerosing Primary sclerosing cholangitischolangitis

Answer: ERCPAnswer: ERCP Most patients with primary sclerosing cholangitis also Most patients with primary sclerosing cholangitis also

have ulcerative colitis. Because of his chronic loose have ulcerative colitis. Because of his chronic loose bowel movements and rectal bleeding, this patient is bowel movements and rectal bleeding, this patient is also likely to have this inflammatory bowel disorder.also likely to have this inflammatory bowel disorder.

Key words: men aged 20-30, ulcerative colitis, Key words: men aged 20-30, ulcerative colitis, recurrent bacterial cholangitisrecurrent bacterial cholangitis

The diagnosis is confirmed when either endoscopic The diagnosis is confirmed when either endoscopic retrograde cholangiopancreatography or magnetic retrograde cholangiopancreatography or magnetic resonance cholangiopancreatography shows a “string resonance cholangiopancreatography shows a “string of beads” pattern of the biliary treeof beads” pattern of the biliary tree

Treatment: supportive until liver transplantTreatment: supportive until liver transplant


A 22-year-old woman with hepatitis C becomes A 22-year-old woman with hepatitis C becomes pregnant for the first time. She is at 10 weeks pregnant for the first time. She is at 10 weeks gestation, and the pregnancy has been uneventful. gestation, and the pregnancy has been uneventful. Hepatitis C was diagnosed 5 years ago and was Hepatitis C was diagnosed 5 years ago and was believed to be acquired following blood transfusions believed to be acquired following blood transfusions when the patient was 3 years old and was being when the patient was 3 years old and was being treated for hemolytic uremic syndrome. The patient is treated for hemolytic uremic syndrome. The patient is HCV genotype 1 and has an HCV RNA viral load of 3 HCV genotype 1 and has an HCV RNA viral load of 3 million copies/mL. Liver biopsy 6 months ago showed million copies/mL. Liver biopsy 6 months ago showed grade 1 (mild) inflammation and stage 0 (no) fibrosis.grade 1 (mild) inflammation and stage 0 (no) fibrosis.

Physical examination is normal.Physical examination is normal. Labs: CBC normal; LFTs normal; albumin normal; INR Labs: CBC normal; LFTs normal; albumin normal; INR

normal; HIV negative; HBs negative; anti-HBs positive; normal; HIV negative; HBs negative; anti-HBs positive;


Which of the following is most Which of the following is most appropriate?appropriate?

Administer pegylated interferon and Administer pegylated interferon and ribavirin to the mother nowribavirin to the mother now

Administer pegylated interferon to the Administer pegylated interferon to the mother nowmother now

Administer pegylated interferon and Administer pegylated interferon and ribavirin to the infant soon after birthribavirin to the infant soon after birth

Check the serum HCV RNA in the infant Check the serum HCV RNA in the infant 4 months after birth4 months after birth

Vertical HCV Vertical HCV transmissiontransmission Answer: Check the serum HCV RNA in the Answer: Check the serum HCV RNA in the

infant 4 months after birthinfant 4 months after birth The overall risk of maternal–fetal The overall risk of maternal–fetal

transmission of hepatitis C is about 5%.transmission of hepatitis C is about 5%. Mother-to-fetus placental transfer of antibody Mother-to-fetus placental transfer of antibody

to hepatitis C virus (anti-HCV) is common, to hepatitis C virus (anti-HCV) is common, and anti-HCV can be detected in the newborn and anti-HCV can be detected in the newborn for up to 15 months.for up to 15 months.


A 67-year-old man has a 1-year history of idiopathic A 67-year-old man has a 1-year history of idiopathic chronic pancreatitis. Because of diarrhea, pancreatic chronic pancreatitis. Because of diarrhea, pancreatic enzyme supplements were started at the time of enzyme supplements were started at the time of diagnosis. The patient currently takes 10,000 units of diagnosis. The patient currently takes 10,000 units of an enteric-coated enzyme preparation in one total an enteric-coated enzyme preparation in one total dose during each meal. However, his diarrhea has dose during each meal. However, his diarrhea has persisted, and he has lost 2.6 kg (6 lb). He does not persisted, and he has lost 2.6 kg (6 lb). He does not have lower abdominal pain. Stools are light-colored, have lower abdominal pain. Stools are light-colored, and the patient describes what appears to be “oil” in and the patient describes what appears to be “oil” in the toilet bowl after defecation.the toilet bowl after defecation.


Which of the following is the most Which of the following is the most appropriate therapy at this time?appropriate therapy at this time?

Add omeprazole to the current enzyme Add omeprazole to the current enzyme regimenregimen

Increase his enzymes to 6 pills with Increase his enzymes to 6 pills with each meal (60,000 units/meal)each meal (60,000 units/meal)

Space enzymes out before, during, and Space enzymes out before, during, and after each meal (3 pills with each meal)after each meal (3 pills with each meal)

Change to another brand of pancreatic Change to another brand of pancreatic enzyme supplementsenzyme supplements

Pancreatic enzymesPancreatic enzymes

Answer: Space enzymes out before, during, and after Answer: Space enzymes out before, during, and after each meal (3 pills with each meal)each meal (3 pills with each meal)

Approximately 30,000 units of lipase are required with Approximately 30,000 units of lipase are required with each meal for pancreatic enzyme supplementation.each meal for pancreatic enzyme supplementation.

The supplements need to be spaced out before, The supplements need to be spaced out before, during, and after meals to better mimic endogenous during, and after meals to better mimic endogenous enzyme secretion.enzyme secretion.


A 49-year-old man is evaluated because of progressive A 49-year-old man is evaluated because of progressive jaundice, mild right upper quadrant abdominal pain, and jaundice, mild right upper quadrant abdominal pain, and weight loss over the last 3 months. The patient has a 25-weight loss over the last 3 months. The patient has a 25-year history of primary sclerosing cholangitis but has not year history of primary sclerosing cholangitis but has not seen a physician for more than 10 years. He takes no seen a physician for more than 10 years. He takes no medications and drinks two cans of beer each evening.medications and drinks two cans of beer each evening.

On physical examination, he is cachectic and jaundiced. On physical examination, he is cachectic and jaundiced. Abdominal examination discloses a firm liver edge and Abdominal examination discloses a firm liver edge and moderate ascites.moderate ascites.

Labs: Hgb 11; Plts 75; total bili 5.8; AST 75; ALT 82; Alk Labs: Hgb 11; Plts 75; total bili 5.8; AST 75; ALT 82; Alk phos 1000phos 1000

RUQ US shows a nodular liver with moderate dilatation of RUQ US shows a nodular liver with moderate dilatation of the intrahepatic bile ducts, splenomegaly, and ascites.the intrahepatic bile ducts, splenomegaly, and ascites.


Which of the following is the most Which of the following is the most likely diagnosis?likely diagnosis?

CholedocholithiasisCholedocholithiasis Metastatic colon cancerMetastatic colon cancer Pancreatic adenocarcinomaPancreatic adenocarcinoma CholangiocarcinomaCholangiocarcinoma Hepatocellular carcinomaHepatocellular carcinoma

CholangiocarcinomaCholangiocarcinoma

Patients with primary sclerosing cholangitis have a Patients with primary sclerosing cholangitis have a 10% to 30% lifetime risk of developing 10% to 30% lifetime risk of developing cholangiocarcinoma.cholangiocarcinoma.

Approximately 60% to 80% of cholangiocarcinomas Approximately 60% to 80% of cholangiocarcinomas arise near the porta hepatis (Klatskin's tumor), 20% arise near the porta hepatis (Klatskin's tumor), 20% are located in the distal bile duct, and <5% are are located in the distal bile duct, and <5% are intrahepaticintrahepatic

Approximately 90% of patients have obstructive Approximately 90% of patients have obstructive jaundice, and patients with advanced disease may jaundice, and patients with advanced disease may have hepatomegaly or a distended palpable have hepatomegaly or a distended palpable gallbladder (Courvoisier's sign)gallbladder (Courvoisier's sign)

Treatment: hepatic resection if tumor is confined to Treatment: hepatic resection if tumor is confined to intrahepatic ductsintrahepatic ducts


A 42-year-old woman has a 2-week history of jaundice, low-A 42-year-old woman has a 2-week history of jaundice, low-grade fever, and fatigue. Medical history is noncontributory. grade fever, and fatigue. Medical history is noncontributory. The patient lives in Honduras but was born in the United The patient lives in Honduras but was born in the United States and returned to this country when she became ill. She States and returned to this country when she became ill. She has consumed at least one bottle of rum daily for 15 years and has consumed at least one bottle of rum daily for 15 years and has taken acetaminophen, 1 g daily, for the past 3 days. She has taken acetaminophen, 1 g daily, for the past 3 days. She has no history of injection drug use, blood transfusions, or has no history of injection drug use, blood transfusions, or known exposure to anyone with hepatitis.known exposure to anyone with hepatitis.

On physical examination, temperature is 37.9 °C (102.9 °F), On physical examination, temperature is 37.9 °C (102.9 °F), pulse rate is 100/min and regular, and blood pressure is pulse rate is 100/min and regular, and blood pressure is 110/70 mm Hg. Jaundice, spider angiomata, and mild muscle 110/70 mm Hg. Jaundice, spider angiomata, and mild muscle wasting are noted. Abdominal examination shows mild wasting are noted. Abdominal examination shows mild splenomegaly, no hepatomegaly, and no ascites. splenomegaly, no hepatomegaly, and no ascites.

Labs: Hgb 12.8; WBC 4; Plts 90; AST 125; ALT 57; Total bili 6; Labs: Hgb 12.8; WBC 4; Plts 90; AST 125; ALT 57; Total bili 6; Direct bili 4; INR 2.4; Albumin 3.4; IgG anti-HAV positiveDirect bili 4; INR 2.4; Albumin 3.4; IgG anti-HAV positive



Hepatitis AHepatitis A SepsisSepsis Acetaminophen hepatotoxicityAcetaminophen hepatotoxicity Alcoholic hepatitisAlcoholic hepatitis Autoimmune hepatitisAutoimmune hepatitis

Alcoholic hepatitisAlcoholic hepatitis

Fever, alcoholism, findings consistent with chronic Fever, alcoholism, findings consistent with chronic liver disease, and a serum aspartate aminotransferase liver disease, and a serum aspartate aminotransferase to serum alanine aminotransferase ratio (AST:ALT) >2 to serum alanine aminotransferase ratio (AST:ALT) >2 are associated with alcoholic hepatitis.are associated with alcoholic hepatitis.

The discriminant function (DF) uses the patient's The discriminant function (DF) uses the patient's prothrombin time (PT) and serum bilirubin level to prothrombin time (PT) and serum bilirubin level to estimate disease severity: (DF = 4.6 [PTpatient - estimate disease severity: (DF = 4.6 [PTpatient - PTcontrol] + serum bilirubin [mg/dL]). A DF score of PTcontrol] + serum bilirubin [mg/dL]). A DF score of >32 identifies patients with a 50% mortality rate >32 identifies patients with a 50% mortality rate within 30 days.within 30 days.

Treatment options for DF>32: pentoxifylline, Treatment options for DF>32: pentoxifylline, prednisoloneprednisolone


A 24-year-old woman comes to the emergency department A 24-year-old woman comes to the emergency department because of acute right upper quadrant abdominal pain and because of acute right upper quadrant abdominal pain and syncope. Medical history is unremarkable. On physical syncope. Medical history is unremarkable. On physical examination, pulse rate is 124/min and regular, and blood examination, pulse rate is 124/min and regular, and blood pressure is 80/60 mm Hg. The abdomen is distended but pressure is 80/60 mm Hg. The abdomen is distended but nontender. An urgent CT scan demonstrates a 5-cm lesion in nontender. An urgent CT scan demonstrates a 5-cm lesion in the liver and high-density fluid in the peritoneal cavity, the liver and high-density fluid in the peritoneal cavity, consistent with blood.consistent with blood.

The patient's condition stabilizes following administration of The patient's condition stabilizes following administration of intravenous fluids and blood transfusions. Physical intravenous fluids and blood transfusions. Physical examination discloses abdominal distention. There are no examination discloses abdominal distention. There are no

stigmata of chronic liver disease.stigmata of chronic liver disease. Labs: Hgb 7, WBC 12; Plts 200; AST 34; alpha-fetoprotein 3.5; Labs: Hgb 7, WBC 12; Plts 200; AST 34; alpha-fetoprotein 3.5;

alk phos 150alk phos 150



Hepatocellular carcinomaHepatocellular carcinoma Hepatic cystHepatic cyst Focal nodular hyperplasiaFocal nodular hyperplasia Hepatic adenomaHepatic adenoma Cavernous hemangiomaCavernous hemangioma

Liver massesLiver masses

Hepatic adenomas are the most likely benign liver tumor Hepatic adenomas are the most likely benign liver tumor to cause bleeding.to cause bleeding.– Hepatic adenomas are estrogen sensitive and should be Hepatic adenomas are estrogen sensitive and should be

resected whenever possible because of their potential for resected whenever possible because of their potential for becoming malignant and their risk for bleeding.becoming malignant and their risk for bleeding.

Cavernous hemangiomas are benign lesions that are found Cavernous hemangiomas are benign lesions that are found in 2% of the general population.in 2% of the general population.

Pyogenic liver abscesses are most likely due to biliary tract Pyogenic liver abscesses are most likely due to biliary tract infectioninfection

An amebic abscess to Entamoeba histolytica should be An amebic abscess to Entamoeba histolytica should be suspected in a patient from a developing country who suspected in a patient from a developing country who presents with a liver mass and symptoms suggestive of an presents with a liver mass and symptoms suggestive of an infection.infection.– Treatment: flagylTreatment: flagyl

ReferencesReferences

MKSAPMKSAP UpToDate.comUpToDate.com

Hepatology Board Review Scott Gabbard, MD 06/09/2009.

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Transcript of Hepatology Board Review Scott Gabbard, MD 06/09/2009.