337 Cirrhosis

Question 1

58M known cirrhotic sec to chronic HBV infection presents with severe generalized abdominal pain. He is on spironolactone, furosemide and propanolol. PE +icteric sclera, distended abdomen with positive fluid wave, and shifting dullness and tenderness on all quadrants. If peritoneal fluid culture yielded E. Coli and Enterococcus sp., what will be the next step?
A. broad spectrum antibiotics
B. abdominal radiography
C. repeat culture
D. Refer to surgery

Answer 1

D. Refer to surgery

Culture point to ruptured viscus

Question 2

Regardless of cause, what is the pathologic feature of cirrhosis

Answer 2

Development of fibrosis to the point ot architecturL distortion with the formation of regenerative nodules

Question 3

Significant complicating feature of decompensated cirrhosis and is responsible for development of ascites and bleeding from esophageal varices

Answer 3

Portal hypertension

Question 4

What is the diameter of the nodules in alcoholic cirrhosis

Answer 4

Nodules usually less than 3 mm in diameter

Question 5

Where is ethanol mainly absorbed

Answer 5

Small intestines

Question 6

Majority of ethanol oxidation occurs where

Answer 6

ADH

Question 7

3 enzyme system that account for metabolism of alcohol in the liver

Answer 7

1. Cytosolic ADH
2. Microsomal ethanol oxidizing system (MEOS)
3. Peroxismal catalase

Question 8

Highly reactive molecule oxidized from ethanol

Answer 8

Acetaldehyde

Question 9

Unique form of hemolytic anemia in patients with severe alcoholic hepatitis charcaterised by spur cells and acanthocytes

Answer 9

Zieve’s syndrome

Question 10

AST ALT ratio which point to alcoholic cirrhosis

Answer 10

AST/ALT ratio 2:1

Question 11

Cornerstone therapy for patients with alcoholic liver disease

Answer 11

Abstinence

Question 12

Other therapy for alcolohic cirrhosis which decrease production of TNF alpha

Answer 12

Pentoxifylline

Question 13

Grams of acetaminophen that may be given to patient with liver disease

Answer 13

4 grams per day

Question 14

How many percent of HCV will develop chronic HCV and how many will develop cirrhosis

Answer 14

HCV 80% become chronic then 20-30% develop cirrhosis

Question 15

Factors that point to severe complications of interferon based therapy

Answer 15

Platelet less than 100K
Albumin less than 3.5 g/dl
MELD score more than 10

Question 16

Test for autoimmune hepatitis

Answer 16

ANA or

Anti smooth muscle antibody (ASMA)

Question 17

Major causes of chronic cholestatic syndromes

Answer 17

Primary biliary cirrhosis
Autoimmune cholangitis
Primary sclerosing cholangitis
Idiopathic adulthood ductopenia

Question 18

Characterized by portal inflammation and necrosis of cholangiocytes in small and medium sized bile ducts

Answer 18

Primary biliary cirrhosis

Question 19

Treatment of choice for decompensated cirrhosis from PBC

Answer 19

Liver transplantation

Question 20

Is the only approved treatment for PBV by slowing the rate of progression of the disease

Answer 20

UDCA

Question 21

Antibodies present in 90% of PBC

Answer 21

Antimitochondrial antibodies (AMA)

Question 22

4 stages of Primary Biliary cirrhosis

Answer 22

1. Chronic nonsuppurative destructive cholangitis
2. Involving peri portal areas
3. Bridging fibrosis
4. Cirrhosis

Question 23

Seen in approx 50% of patients with PBC

Answer 23

Pruritus

Question 24

True or false. Pruritus that presents prior to development of jaundice indicated milder disease

Answer 24

False. Severe disease and poor prognosis

Question 25

Dosage of UDCA in PBC

Answer 25

13-15 mg/kg/day

Question 26

How is pruritus treated in patients with PBC

Answer 26

Antihistamines
Narcotic receptor antagonist (naltrexone)
Rifampicin
Cholestyramine

Question 27

Chronic cholestatic syndrome characterized by diffuse inflammation and fibrosis involving the entire biliary tree resulting in chronic cholestasis

Answer 27

Primary sclerosing cholangitis

Question 28

What is concurrent in patient with PSC and what investigations should be done

Answer 28

PSC will have overlap with AIHA

50% of patients with PSC will have uclerative colitis thus Colonoscopy is peformed

Question 29

What is the typical cholangiographic findings in PSC

Answer 29

Multifocal sticturing and beading involving the intrahepatic and extra hepatic biliary tree. Strictures are typically short and with intervening segments of normal or slightly dilated bile ducts

Question 30

Dreaded complication of PSC

Answer 30

Cholangiocarcinoma

Question 31

What is the pathology of cardiac cirrhosis

Answer 31

Elevated venous pressure transmitted via the Inferior vena cava and hepatic veins to the sinusoids of the liver which became dilated and engorged with blood. Liver becomes enlarged and swollen

Question 32

True or false. Patient with cardiac cirrhosis will also have chances of developing variceal hemorrhage and encephalopathy

Answer 32

False. It is unlikely patient will develop variceal hemorrhage or encephalopathy

Question 33

Difference between cardiac hepatopathy and Budd Chiari Syndrome

Answer 33

In Budd Chiari Syndrome there is extravasation of RBC

Question 34

Inherited disorder of iron metabolism that results in progressive increase in hepatic iron deposition which over time can lead to portal based fibrosis progressing to cirrhosis

Answer 34

Hemochromatosis

Question 35

Major complication of cirrhosis

Answer 35

1. Portal hypertension
2. Gastroesoohageal variceal hemorrhage
3. Splenomegaly
4. Ascites
5. Hepatic Encephalopathy
6. SBP
7. Hepatorenal syndrome
8. HCC

Question 36

Definition of portal hypertension

Answer 36

Elevation of hepatic venous pressure gradient to (HVPG) to more than 5 mmHg

Question 37

What is the pathophysiology of portal hypertension

Answer 37

1. Increased intrahepatic resistance to passage of blood

2. Increased splanchnic blood flow secondary to vasodilation within splanchnic vascular bed

Question 38

Complications directly related to portal hypertension

Answer 38

1. Variceal hemorrhage

2. Ascites

Question 39

Immediate life threatening problem in portal hypertension with a 20-30% Mortality rate

Answer 39

Variceal hemorrhage