1. Gastroenterology and Hepatology Board Review II December 7, 2012

2. Question 1 Stem and Answer Choices Which of the following is the most appropriate management for this patient? 1.Begin interferon therapy 2.Evaluation for liver transplantation 3.Endoscopic retrograde cholangiopancreatography 4.Corticosteroids

3. 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

4. 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

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

6. Question 1 Stem and Answer Choices Which of the following is the most appropriate management for this patient? 1.Begin interferon therapy 2.Evaluation for liver transplantation 3.Endoscopic retrograde cholangiopancreatography 4.Corticosteroids

7. Question 1 Stem and Answer Choices Which of the following is the most appropriate management for this patient? 1.Begin interferon therapy 2.Evaluation for liver transplantation 3.Endoscopic retrograde cholangiopancreatography 4.Corticosteroids

8. 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

9. Explanation Which of the following is the most appropriate management for this patient? 1.Begin interferon therapy  hepatic necroinflammation 2.Evaluation for liver transplantation 3.Endoscopic retrograde cholangiopancreatography  no e/o ductal dilatation 4.Corticosteroids  has been studied, doesn’t help and increases risk of infection

10. 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.

11. Labs Plt ct 88,000/µL (88 × 10 9 /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

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

13. Question 2 Stem and Answer Choices Which of the following is the most appropriate next step in the management for this patient? 1.Esophagogastroduodenoscopy 2.Evaluation for liver transplantation 3.Lamivudine 4.Pegylated interferon and ribavirin

14. Question 2 Stem and Answer Choices Which of the following is the most appropriate next step in the management for this patient? 1.Esophagogastroduodenoscopy 2.Evaluation for liver transplantation 3.Lamivudine 4.Pegylated interferon and ribavirin

15. Explanation Upper Endoscopy is indicated in patients with new diagnosis of cirrhosis – 25-40% of patients with cirrhosis get variceal hemorrhage

16. Question 2 Stem and Answer Choices Which of the following is the most appropriate next step in the management for this patient? 1.Esophagogastroduodenoscopy 2.Evaluation for liver transplantation  if ESLD or fulminant hepatic failure 3.Lamivudine  could be considered for Hep B, not Hep C 4.Pegylated interferon and ribavirin  needs further evaluation, discussion

17. Hepatitis C Update Screen 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

18. 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

19. 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.

20. 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 and no obstruction.

21. Question Stem and Answer Choices Which of the following is the most appropriate management for this patient? 1.Add lisinopril 2.Kidney and liver transplantation 3.Kidney transplantation 4.Liver transplantation 5.Peritoneovenous shunt

22. Question Stem and Answer Choices Which of the following is the most appropriate management for this patient? 1.Add lisinopril 2.Kidney and liver transplantation 3.Kidney transplantation 4.Liver transplantation 5.Peritoneovenous shunt

23. 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

24. Question Stem and Answer Choices Which of the following is the most appropriate management for this patient? 1.Add lisinopril  no effect on HRS 2.Kidney and liver transplantation  not indicated 3.Kidney transplantation  not indicated 4.Liver transplantation 5.Peritoneovenous shunt  improves Cr but not mortality