1. Cases & Quizzes
LET THE
FUN
BEGIN !

2. Some points about LFTs LFTs include the following:
Bilirubin ( direct, indirect & total)
ALT, AST ( called aminotransferases)
Alkaline Phosphatase (AP)
Gamma Glutamyl transferase (GGT)
P.T./ INR tell us about the
Serum albumin synthetic function
of the liver

3. REMEMBER ! If mainly the ALT & AST are high, means
damage to the hepatocytes (hepatitis, drug
induced liver injury etc)
2) If mainly Alk.Phos & GGT are high, means
there is obstruction to the flow of bile outside
the liver (eg. CBD stone, CBD stricture,
Ca. pancreas etc.) or there is stasis of bile
inside the liver ( intra-hepatic cholestasis) eg.
Primary biliary cirrhosis, mass lesions in the
liver, Primary sclerosing cholangitis,pregnancy

4. So, in Summary Mainly high AST & ALT: * Hepatitis * Drug injury
2) Mainly high Alk.Phos & GGT:
* Post - Hepatic obstruction ( post hepatic
cholestasis)
* Intrahepatic cholestasis
Easy , Right?

5. Normal ranges of LFTs Total Bili: 0.3 – 1.5 mg%
Direct: 0.1 – 0.3 mg% Please
Indirect: upto Remember
ALT: 5-40 iu/L These
AST : iu/L
Alk. Phos : U/L
GGT: upto 58U/L
Slight variations possible in various labs.

6. Lets Juggle Our Brains ! Bilirubin : 4mg% ( high)
Indirect : 3.7 ( high)
Direct : ( normal)
Urine: No bilirubin, but urobilin present
No signs of chronic liver disease
What picture is this:
Prehepatic b) Hepatic c) Posthepatic

7. Answer 1
PREHEPATIC !

8. Ques.2
* Total Bilirubin : 8 mg% * Direct: 7mg% ( high) * Indirect : 1 mg% (min high) * AST: 90 ( high) * ALT : 86 (high) * Alk. Phos : 320 ( very high) * GGT: 150u/L ( high) What picture is this ? a) Prehepatic b) Hepatic c) Post hepatic

9. Answer 2
POST HEPATIC ( VERY HIGH GGT & ALK PHOS)

10. Ques 3
* Total bilirubin : 6mg% * Direct Bili : 4.5 ( high) * Indirect Bili : 1.5 ( high) * AST : 320 ( v.high) * ALT : 430 ( v. high) * Alk Phos : 110 * GGT : 55 ( little high) What is this picture? a) Prehepatic b) Hepatic c) Hepatic

11. Answer 3
Hepatic. Most likely hepatitis. ( mainly ALT & AST are high)

12. Ques. 4
A 20 yr old man is found to have mild jaundice. He gives a similar history off and on but denies any problems from it.
Jaundice : Present * No anemia
Bilirubin : high * All other LFTs normal
Direct bili: normal * Indirect bili: high
Urine: no bili but urobilin present
What is the most likely diagnosis? What treatment?

13. Answer 4
Gilbert’s Syndrome. No specific treatment. Reassurance only

14. Ques 5
A 16 yr old female has jaundice. She has a past history of some “blood disorder” & often gets admitted in the hospital due to body pain.
Total Bili: 5mg%(high) * Direct: 0.2 (norm)
Indirect bili: 4.8 mg% (high)
Other LFTs normal * Hb.: 6mg%
Peripheral smear:
What type of jaundice
is it? What is the diagnosis?

15. Answer 5
Prehepatic jaundice ( HEMOLYSIS)
Sickle cell disease

16. Ques 6
A 40 yr old female c/o severe colicky pain in the upper abdomen since many weeks. It comes and goes. More after eating.Now, she also c/o yellow discoloration of her eyes & vomiting.
Jaundice present * Obese
Bilirubin: 6mg% *Direct: 4.5mg%(high)
Indirect: 1.5mg% * Alk Phos: 326 ( high)
GGT: 100 (high) * Urine bili: present
What is the most likely diagnosis? What is the treatment?

17. Answer 6
* Common bile duct stone * Removal of the stone by ERCP/ surgery

18. Ques. 7
A 55 yr old female c/o severe itching since few months. She has no DM, HTN etc but is taking treatment for high cholesterol.
Jaundice present * No hepatomegaly
Scratch marks on the skin
Yellow plaques on the eyes
Pale stools
Total bili: 5mg% * Direct bili: 4.5
AlkPhos: 250( high) * AST: 64( little high)
AST : 82( little high)
What is the most likely diagnosis? What is the diagnostic blood test? What is the treatment?

19. Answer 7 Diagnosis: Primary biliary cirrhosis
Diagnostic blood test: AMA (antimitochondrial antibody present)
Treatment: * urso-deoxy-cholic acid
* Liver transplant
In PBC, there is intrahepatic cholestasis, due to compression & obstruction of the intra hepatic bile ducts. So bile excretion in the intestine is impaired. Its like an obstructive picture.

20. Ques 8
A 40 yr old male c/o joint pain & skin discoloration since a few yrs.
Jaundice: present * skin: greyish discolor
No joint swelling * Blood sugar : high
Bilirubin, AST, ALT & Alp Phos: High
( DM + liver disease + skin pigmentation)
What is your diagnosis?
What tests will you do to confirm
What is the treatment?

21. Answer 8 Diagnosis: Hemochromatosis Diagnostic tests: Serum iron: high
Serum Ferritin : High
Liver biopsy ( gold standard)
Treatment:
Repeated phlebotomy( removing blood)

22. Question 9
A 60 yr old male c/o severe weakness, anorexia and tiredness since few months. He has noticed his abdomen getting big. No H/O any medical problems. History of iv drug abuse in the past & sharing needles.
Jaundice: present * Cachexia
Abdomen: distended with shifting dullness
Nails very white & clubbing
Breasts: enlarged
LFTs : deranged * Albumin: low

23. Question 9 (contd) What is your diagnosis?
Name 2 “diagnostic” investigations?
Name 2 possible causes for this condition in this patient
Name some treatments for the causes
What complications can occur in this condition?

24. Answer 9 Diagnosis: Liver cirrhosis
Diagnostic tests: * U/S * Liver biopsy
Chronic Hep B & C ( H/O iv drug use)
Treatments:
* Hep B : nucleotide analogues, nucleoside
analogues, Interferon
* Hep C: Ribavirin, Direct acting antivirals
4) Complications of Cirrhosis:
* Ca. Liver * encephalopathy * portal HTN
* Ascites * Malnutrition * Hepatorenal
syndrome

25. Some small questions Can Hep A cause cirrhosis?
Can LFTs be normal in cirrhosis?
Why are there low platelets in cirrhosis?
Which drug is used in portal HTN to prevent variceal bleeding?
Which antibody in Primary biliary cirrhosis?
Name 2 liver diseases caused by alcohol?
Which substance is thought to cause hepatic encephalopathy?

26. Answers to small questions
No, Hep A cant cause cirrhosis
Yes
Cirrhosis portal HTN splenomegaly
low platelets
4) Propranolol
5) Antimitochondrial ab. (AMA)
6) Alcoholic hepatitis & cirrhosis
7) Ammonia (NH3)

27. Questions
8) Name some causes of cirrhosis? 9) Name some complications of cirrhosis? 10) Name 3 things which can be seen in the hand examination of a cirrhosis patient? 11) Name 2 things which can be seen in the chest exam of a cirrhosis patient? 12) Name the findings in the abdomen of a cirrhosis patient? 13) In cirrhosis, is the liver enlarged or small?

28. Answers
8) Chr. Hep B & C, primary biliary cirrhosis, hemochromatosis, Wilson’s disease, Auotimmune hepatitis, idiopathic, alcohol, drugs 9) Ascites, portal HTN, Encephalopathy, Liver carcinoma, Hepatorenal syndrome, infections 10) Clubbing, palmar erythema, Contractures 11) Gynecomastia, spider nevi 12) Ascites, Bulging umbilicus, caput medusae, splenomegaly, hepatomegaly 13) Can be large or small.

29. Case 1
A 24 year old male presents with 1 episode of massive hematemesis ( about half a jug of blood). He is not on any medicines for any medical problem. Past hist: i.v. drug use, multiple sexual partners No follow up with any doctor, so does not know if he has any disease or not On exam: Skin & sclera yellow, liver not palpable, abdomen distended

30. Questions of case 1 What is your diagnosis?
Name some treatments used to treat this hematemesis acutely?
Name the medicine used to prevent hematemesis in such cases?

31. Answers of case 1
Esophageal varices rupture causing hematemesis. He most likely has cirrhosis due to Hep B or Hep C.
i.v. octreotide, banding, sclerotherapy
Propranolol

32. More questions of cirrhosis
14) Name some causes of portal HTN? 15) Name some complications of portal HTN? 16) Name some things which can precipitate encephalopathy in a cirrhosis patient? 17) Name some treatments used in hepatic encephalopathy? 18) Name 2 blood tests which indicate severity severity of liver disease? 19) Name the scoring system used for prognosis of cirrhosis?

33. Answers
14) Cirrhosis, portal vein thrombosis 15) Esophageal varices, splenomegaly, ascites, caput medusae ( dilated veins around the umbilicus), 16) GI bleeding, constipation, infection, low blood K, use of sedatives (diazepam), excess proteins in the diet 17) Lactulose (for constipation), iv Proton pump inhobitors ( for GI bleed), Neomycin/ Rifaximin ( to kill GI bacteria)

34. Answers (contd)
18) Severity of liver disease: P.T./ INR & serum albumin 19) Child-Pughs scoring system

35. Questions
20) What is the gold standard test for the diagnosis of hemochromatosis? 21) What is the gene causing hemochromatosis? 22) What are the screening tests for hepatocellular carcinoma in a patient with cirrhosis?

36. Answers
20) Liver biopsy 21) Gene: C 282 Y 22) Ultrasound & serum alpha fetoprotein levels ( once a year or every 6 months)

37. Small questions of leukemias
Which is the commonest leukemia seen in
children?
2) Which leukemia shows Auer rods in the cells?
3) Which leukemia shows Philadelphia chromosome in the cells?
4) CLL is a malignacy of which lymphocytes?

38. Answers of leukemias
ALL
AML
CML
B lymphocytes

39. Question 10
An obese male, who has DM, was found to have slightly elevated liver enzymes. He is asymptomatic. No history of any past medical or surgical history. Denies any alcohol intake.
Ultrasound shows slight hepatomegaly & fat deposition in the liver.
What is your diagnosis?
Which 2 factors in this patient, are causing this liver pathology?
Can it progress to cirrhosis?

40. Answer 10
NASH ( non-alcoholic steato-hepatitis) or Non alcoholic fatty liver disease ( NAFLD)
DM, Obesity
Yes, in some cases, it can progress to cirrhosis

41. Case 11
A 23 yr old student c/o cough with sputum since 3 days. Few days before this she had features of flu, myalgias & headache. On exam, she has fever of 38C, no significant findings on chest exam. Skin shows a rash.

42. Case 11 What is your diagnosis?
Name 2 other features, besides the rash, which may be seen in this condition?
Which antibiotic would you use?

43. Answer 11 Mycoplasma pneumonia * Hemolytic anemia * myocarditis
* Myringitis ( inflammation of ear drum)
Azithromycin or clarithromycin ( macrolides)

44. Some questions Which bacteria cause typical “Community
Acquired pneumonia”?
2) Which bacteria cause atypical pneumonia?
3) Can chest examination be normal in Mycoplasma pneumonia?
4) In COPD patients, which bacteria is commonly the cause of pneumonia?
5) In Legionella pneumonia, which test can you do for diagnosis?

45. Answers Pneumococci, H.Influenzae Mycoplasma, Chlamydia, Legionella
Yes, it can be
H.Influenzae
Legionella antigen in the urine

46. Wanna see some X-Rays?
PLEASE DON’T SAY NO !

47. Normal CXR

48. Normal CXR

49. Normal CXR

50. Lobar pneumonia

51. Lobar Pneumonia

52. Case 12
A 40 year old male was found to have huge splenomegaly on routine exam. He only c/o some fatigue since a few months.
CBC: WBC count 45,000 ( mature looking cells)
Low Hb & Low platelets
Peripheral smear:
Chromosomal analysis shows
Philadelphia chromosome

53. Questions case 12 What is the diagnosis
What is the name of the drug which is used?

54. Answer 12
Diagnosis: CML
Drug: Imatinib

55. Case 13
A 40 year old male c/o tiredness, weakness since 3 wks. Physical exam showed anemia, hepatomegaly and splenomegaly.
CBC: WBC count 40,000
Hb. : 9 g/100 ml Platelets : 30,000
Peripheral smear showed large numbers of immature looking WBCs
(blast cells).

56. Ques. case 13 What is your diagnosis?
What do you see inside the abnormal cells?
Name the drugs used to treat?
What are the factors which increase the risk of getting AML?

57. Answers case 13 AML ( acute myeloid leukemia Auer rods
C.D. ( cytarabine, daunorubicin)
Things which increase the risk:
* Radiation therapy
* Chemotherapy for other cancers
* Down’s syndrome
* MDS ( myelodysplastic syndrome)

58. Some Quickies Which is the most likely leukemia in each case:
Philadelphia chromosome?
Auer rods
A small child with leukemia
An old patient with very high lymphocte count in the blood ( 50,000)
Middle aged man with massive splenomegaly
A man with a past history of chemotherapy for lung cancer

59. Answers of Quickies
CML
AML
ALL ( remember atfall)
CLL

60. Last question
What are the medicines used to treat CLL?

61. Last answer
Chocolate Cake From Riyadh Chlorambucil, Cyclophosphamide, Fludarabine Rituximab

62. Thank you
Enjoy your evening