Abdomen

Question 1

Grades of hepatic encephalopathy

Answer 1

West Haven Criteria:
Grade 0- clinically normal but with small changes in memory or mentation
Grade 1- mild confusion, euphoria or depression; short attention span; impaired mental tasks such as addition; disordered sleep patterns
Grade 2- drowsiness, lethargy, mild disorientation mainly for time but also sometimes for place, inappropriate behaviour and personality change, impaired mental task such as subtraction
Grade 3- somnolent but rousable, usually with verbal stimuli sufficing, grossly confused and disorientated, speech may be incomprehensible, amnesia often present
Grade 4- comatose

Question 2

Child pugh score- parameters

Answer 2

Bilirubin (adjusted levels for e.g.) PBC and PSC), INR, ascites, encephalopathy, albumin
Class A (5-6 points), Class B (7-9 points), Class C (10-15 points)- corresponding to 1 year survival of 100%, 80% and 50%

Question 3

Top 3 causes of hepatomegaly

Answer 3

CCF
Malignancy
Lymphoma

Question 4

Scoring systems for the evaluation of patients presenting with acute alcoholic hepatitis

Answer 4

Maddrey’s discriminant function test- involves prothombin time and bilirubin- a score of >32 carried 50% mortality rate- indication for tx with steroids
Mayo end stage liver disease score- bilirubin, creatinine and INR- predicts survival probability over 90 days
Glasgow alcoholic hepatiits score- performed on D1, predicts 28 day outcome

Question 5

Genetic basis for Wilson’s disease

Answer 5

• mutation of the adenosine triphosphate 7b gene
• gene is a key element in the transport of copper into the secretory pathway of the cell for incorporation into copper-containing enzymes and excretion of excess copper in the bile
• mutation in this gene -> accumulation of free copper in hepatocytes-> eventual spill over into the blood and the urine
  + the level of copper containing enzymes e.g. caeruloplasmin decrease

Question 6

What is the natural hx of PBC

Answer 6

• female to male ratio of 9:1
• anti-mitochondrial antibodies are directed against the the pyruvate dehydrogenase complex E2 found on the inner mitochondrial membrane- AMA is positive in 90% of patients with PBC
  -in many cases disease progression is so slow that lifespan is unaffected and PBC may be diagnosed incidentally e.g. at cholecystectomy BUT symptomatic patients are unlikely to survive >2 years

Question 7

Symptomatic triad of haemachromatosis

Answer 7

• fatigue
  -arthralgia
  -sexual dysfunction

Question 8

Genetics of haemochromatosis

Answer 8

HFE gene
- most common allele = C282Y allele
- another is H63D but this usually results in biochemical iron overload without the other phenotypical features of the disease

Question 9

Criteria for referral to a liver unit for transplantation

Answer 9

Paracetamol induced
- arterial lactate >3.5 4 hours after resuscitation
-OR pH < 7.3 OR arterial lactate >3 12 hours after resuscitation OR all the following- INR >6.5, creatinine >300, encephalopathy grade III or IV

Non paracetamol indiced
- arterial lactate >3.5 4 hours after resuscitation
- OR INR >6.5
- OR any 3 of INR >3.5, <10, >40, serum bilirubin >300, jaundice > 7 days, aetiology is a drug reaction

Question 10

Forms of liver support aside from transplantation

Answer 10

-MARS- molecular adsorbent recirculation system- 2 circuits- in the 1st patients blood= exposed to albumin via a semi-permeable membrane allowing toxins such as ammonia, bile acids and bilirubin to be bound. 2nd circuit removes these bound toxins from the albumin
- ECLAD- extracorporeal liver assist device / Demetriou- hepatoblastoma cell lines attached to semipermeable membrane columns
- heterotopic liver transplantation

Question 11

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