1. A 57-year-old man presents with fatigue for several months. He underwent a blood transfusion with several units in 1982 after car accident. Physical examination reveals generalized jaundice, a firm nodular liver edge, and a mildly protuberant abdomen with a fluid wave. Initial laboratory studies show, mildly elevated transaminases, increased serum bilirubin(total&direct) as well as hypoalbuminemia and coagulopathy (prolonged PT).

3. 1-What is the most likely diagnosis? 2- What are the possible etiologies of this disorder? 3- What other tests would be appropriate? 4- What are the possible complications?

4. Answers ◆ Most likely diagnosis: Chronic hepatitis/cirrhosis. ◆ Possible etiologies of this disorder: Most commonly caused by chronic viral infection( HBV orHCV) or ◆ Other appropriate tests: Hepatitis virus serologies and possibly a liver biopsy. ◆ Possible complications: Hepatic failure, gastrointestinal bleeding, hepatocellular carcinoma.

5. Case 45 year old man with cirrhosis and ascites admitted with 2 days of confusion. On lactulose for 1 year, wife doesn’t know if compliant. Wife says no fever, abdominal pain, cough, diarrhea. Examination reveled blood pressure 100/60,pulse 72, afebrile. Sleepy but arousable. Spiders angiomas, jaundice, ascites, edema, +ve reflexes Investigations reveled : WBC = 8,000, Hb: 10.0, pltatlets = 70,000. Na = 129, K = 3.0, = 21; creatinine = 0.9. Albumin= 2.5, bilirubin = 3.9, NH4 = 65. CXR and Urine Analysis was negative.

6. Clinical questions 1.Does this patient have hepatic encephalopathy? 2.Should I order a CT scan of head? 3.Should I do a diagnostic paracentesis to exclude SBP? 4.Where should this patient be admitted? 5.Will initial therapy be lactulose, rifaximin, or both?

7. Diagnosis of HE 1.Identify underlying liver disease – Acute with severe transaminitis – Chronic - portal HTN 2.Ascertain neuropsychiatric symptoms: – Sleep disturbance, alteration in level of consciousness, confusion 3.Elicit neurologic signs – Asterixis, hyperreflexia, clonus, +Babinski 4.Exclude other causes