chapter 8
Liver disorders
Questions
1.A 65-year-old man with known Child-Pugh A alcohol-related cirrhosis was admitted with abdominal pain.
Investigations:
| CT triple phase liver | 5 × 5 cm mass in right liver lobe enhancing vividly during late arterial phase and becoming hypoattenuating in the portal venous phase. |
After multidisciplinary team discussion, the man was referred for transarterial chemoembolization (TACE), which required access to the hepatic arterial blood supply.
From which artery does the common hepatic artery (HA) directly arise?
2.The confluence of which structures lead to the formation of the structure marked in the image (Fig.8.1)?
Fig. 8.1 CT abdomen
Courtesy of Dr Shahana Shahid, OUH NHS Foundation Trust
A. Inferior mesenteric vein and splenic vein
B. Left and right hepatic duct
C. Left and right hepatic duct and cystic duct
D. Superior mesenteric artery and splenic artery
Which is the most appropriate regarding further surveillance and treatment?
B. Repeat gastroscopy in one year, without current primary prophylaxis for varices
C. Repeat gastroscopy in 2–3 years, without current primary prophylaxis for varices
E. Repeat gastroscopy with endoscopic variceal ligation (EVL) in 4–6 weeks.
5.A 58-year-old woman came to clinic to discuss the results of a recent liver biopsy that confirmed cirrhosis due to autoimmune hepatitis (AIH). She had not previously had a gastroscopy.
Investigations:
| Serum alanine aminotransferase (ALT) | 32 U/L |
| Serum aspartate transaminase (AST) | 38 U/L |
| Serum bilirubin | 21 μmol/L |
| Serum albumin | 34 g/L |
| International normalized ratio (INR) | 1.1 |
| Platelet count | 178 × 109/L |
A. Absence of ascites on transabdominal ultrasound
B. Enhanced liver fibrosis (ELF) score of 10.6
C. Hepatic venous pressure gradient (HVPG) measurement of 11 mmHg
D. Liver stiffness reading of 18.4 kPa
6.A 46-year-old man with cirrhosis had his first screening gastroscopy, which showed small gastro-oesophageal varices.
Which of the following is the strongest predictor for the progression from small to large varices?
A. Hyponatraemia is a recognized side effect of terlipressin
B. Optimal timing for diagnostic endoscopy is at 12–24 hours after presentation
C. Packed red blood cells should be transfused when haemoglobin falls below 9 g/dL
8.A 44-year-old woman from Pakistan presented to the emergency department with new ascites.
Investigations:
| Haemoglobin | 120 g/L |
| White cell count | 9.6 × 109/L |
| Platelet count | 150 × 109/L |
| Serum bilirubin | 30 µmol/L |
| Serum ALP | 120 U/L |
| Serum ALT | 25 U/L |
| Serum creatinine | 75 µmol/L |
| Serum albumin | 30 g/L |
| Serum Ca 125 | 200 U/mL |
| Ascitic fluid white cell count | 100 cells/mm3 (75% neutrophils) |
| Ascitic fluid albumin | 15 g/L |
| Ascitic fluid protein | 20 g/L |
| Ascitic fluid Gram stain | No organisms |
What is the most likely diagnosis?
Investigations:
| Ascitic fluid cell count | 1,555 cells/mm3 (90% neutrophils) |
| Ascitic fluid culture at 24 hours |
What is the next best approach to management?
A. Continue ceftriaxone and add metronidazole
B. Continue ceftriaxone and repeat diagnostic paracentesis in 48 hours
C. Give 1.5 g/kg human albumin solution
D. Perform large volume paracentesis
10.A 53-year-old woman with alcohol-related cirrhosis was admitted with hepatic encephalopathy (HE). Her medications were lactulose 20 ml three times a day and carvedilol 3.75 mg once a day.
Investigations:
| Serum sodium | 130 mmol/L |
| Serum potassium | 4.7 mmol/L |
| Serum urea | 1.6 mmol/L |
| Serum creatinine | 90 µmol/L |
| Serum creatinine five days previously | 40 µmol/L |
| Serum bilirubin | 50 µmol/L |
| Serum ALT | 30 U/L |
| Serum ALP | 150 U/L |
| Serum albumin | 20 g/L |
| INR | 1.4 |
| Haemoglobin | 13 g/L |
| Liver ultrasound | irregular liver edge, moderate ascites, normal portal vein flow, spleen 15 cm |
| Renal ultrasound | normal |
| Full septic screen | negative |
What is the most appropriate next management step for the patient’s renal dysfunction?
A. Infusion of crystalloid 1L over eight hours
B. Large volume paracentesis with human albumin replacement.
D. Terlipressin (1 mg four times a day)
E. Twenty per cent human albumin solution (1 g/kg) for two consecutive days
Investigations:
| baseline serum creatinine | 40 µmol/L |
| peak serum creatinine before terlipressin | 102 µmol/L |
| serum creatinine after 48 hours of terlipressin | 94 µmol/L |
What would be the next most appropriate management step?
A. Continue current doses of terlipressin and human albumin
B. Continue terlipressin 1 mg every 6 hours and increase human albumin to 80 g daily
C. Increase terlipressin to 2 mg every six hours and continue 40 g human albumin daily
12.
Which of the following is the earliest feature in the pathogenesis of HRS-AKI?
A. Activation of the renin–angiotensin–aldosterone system (RAAS)
D. Splanchnic arterial vasodilation
13.
A. Low fractional excretion of sodium (<1%)
B. Low fractional excretion of urea (<35%)
C. Normal renal ultrasound scan
14.
Which of the following statements is correct regarding ammonia in HE?
15.
Which of the following is correct regarding the natural history of hepatocellular carcinoma (HCC)?
A. A high serum Hepatitis B virus (HBV) DNA level is not a risk factor for HCC
B. Approximately half the cases of NASH-related HCC arise in non-cirrhotic patients
D. Ten per cent of patients with cirrhosis will develop HCC during their lifetime
16.A 62-year-old man with compensated cirrhosis due to HCV was diagnosed with HCC. He was asymptomatic and had unlimited exercise tolerance. Sustained viralogical response was achieved three years previously.
Investigations:
| Magnetic resonance imaging (MRI) liver | 28 mm HCC lesion in segment 5 and 18 mm HCC lesion in segment 7; no macroscopic vascular invasion or extrahepatic spread; portosystemic collaterals; no ascites |
| Gastroscopy | Grade 1 oesophageal varices |
| Serum alpha fetoprotein | 54 ng/ml |
| MELD | 8.5 |
What would be the preferred management approach for this patient?
Investigations:
| CT liver triple phase | Well-demarcated mass with early enhancement in the arterial phase before iso-attenuation in the portal venous phase |
| MRI liver | Hyperintense lesion on T1 and T2 weighted imaging, with early enhancement with gadolinium. |
18.A 36-year-old man with alcohol-related cirrhosis presented to the emergency department with haematemesis. On examination, he had moderate ascites and Grade 2 encephalopathy. A gastroscopy showed three columns of Grade 3 varices, which were banded. His oral intake remained inadequate on the ward for 48 hours after the procedure.
Investigations:
| Haemoglobin | 97 g/L |
| White cell count | 11.5 × 109/L |
| Platelet count | 89 × 109/L |
| Serum bilirubin | 163 µmol/L |
| Serum ALP | 213 U/L |
| Serum ALT | 79 U/L |
| Prothrombin time | 29 seconds |
What is the most appropriate nutritional management?
Investigations:
| Serum bilirubin | 15 µmol/L |
| Serum ALT | 86 U/L |
| Serum creatinine | 65 µmol/L |
| Haemoglobin | 120 g/L |
| Platelet count | 214 × 109/L |
| HBsAg | Positive |
| HBeAb | Positive |
| HBeAg | Negative |
| HBV DNA | 21,000 IU/ml |
| HCV antibody | Negative |
| Hepatitis D (HDV) antibody | Negative |
| HIV antibody | Negative |
| Ultrasound abdomen | Normal |
What is the best next step in her management?
A. Liver biopsy and start treatment with tenofovir if evidence of cirrhosis
B. Start treatment with tenofovir
D. TE and start treatment with pegIFNα if LSM >9 kPa.
20.A 35-year-old Vietnamese man was referred to clinic after his primary care doctor investigated abnormal LFTs and subsequently found him to be positive for HBsAg.
Investigations:
| HBsAg | Positive |
| HBeAg | Positive |
| HBV DNA | 230,000 IU/mL |
| Serum ALT | 99 U/L |
| Liver stiffness | 8.2 kPa |
What should be the main goal of antiviral treatment?
Investigations:
| Serum ALT | 34 U/L |
| Serum bilirubin | 4 umol/L |
| HbsAg | Positive |
| HbeAg | Negative |
| HbeAb | Positive |
| HBV DNA | 310 copies/ml |
| Liver stiffness | 3.4 kPa |
What is the next most appropriate approach to her management?
A. Advise haematologist to avoid Rituximab
C. Prophylaxis with entecavir throughout R-CHOP treatment and for 6 months after its discontinuation
22.
Which of the following combinations is a pangenotypic treatment regimen for HCV?
23.A 61-year-old man with HCV cirrhosis developed progressive jaundice, ascites, and encephalopathy, and was listed for LT.
What is the best approach to treating his HCV infection with DAAs?
A. Treat with DAAs post-LT if MELD ≥18–20 and time to transplantation likely to be <6 months
B. Treat with DAAs post-LT if MELD <18-20 irrespective of likely time until transplantation
C. Treat with DAAs post-LT irrespective of MELD and waiting time
D. Treat with DAAs pre-LT if MELD ≥18–20 and time to transplantation likely to be <6 months
E. Treat with DAAs pre-LT irrespective of MELD and waiting time
Investigations:
| Haemoglobin | 145 g/L |
| White cell count | 5 × 109/L |
| Platelet count | 190 × 109/L |
| Serum ALT | 600 U/L |
| Serum bilirubin | 25 μmol/L |
| Serum creatinine | 84 μmol/L |
| HBsAg | Positive |
| HBeAg | Negative |
| HBeAb | Positive |
| HDV RNA | Detectable |
| HBV DNA | 1,900 U/L |
| HCV Ab | Negative |
| HIV antibody | Negative |
| Liver ultrasound | Normal |
| Liver stiffness | 8.7 kPa |
What is the most appropriate approach to his management?
25.A 66-year-old woman had a liver biopsy performed as part of her work-up for abnormal LFTs.
Investigations:
| Liver biopsy | A dense infiltrate of immune cells in the lobules and within the portal tracts with prominent interface hepatitis. There is a predominance of plasma cells, as well as some lymphocytes, and the presence of hepatic rosette formation and emperipolesis. There is some steatosis (40%), bridging fibrosis with nodule formation, and Ishak fibrosis score 6/6. |
How would you treat this patient?
B. Budesonide 9 mg daily and azathioprine 50 mg daily
C. Observe with repeat liver biochemistry in three months’ time.
26.A 31-year-old man presented with three weeks of lethargy and arthralgia.
Investigations:
| Serum ALT | 710 U/L |
| Serum ALP | 210 U/L |
| Serum bilirubin | 50 µmol/L |
| Platelet count | 233 × 109/L |
| Antinuclear antibody (ANA) | Positive 1:40 |
| Liver kidney microsomal antibody | Positive 1:40 |
| IgG | 28 g/L |
| HCV Ab | Negative |
| HBsAg | Negative |
| Hepatitis E IgM | Negative |
| Hepatitis A IgM | Negative |
| Liver biopsy histology | Interface hepatitis with lymphoplasmocytic-rich infiltrate in portal tracts extending into the lobule. |
27.A 40-year-old woman with AIH, previously treated with prednisolone and azathioprine for three years, and who has been in complete biochemical remission for one year on azathioprine monotherapy, asks whether her treatment can be stopped.
Which of the following is true?
B. Immunosuppressive treatment should be continued for at least five years
C. Relapse commonly occurs within the first year of treatment withdrawal
D. The majority of patients will stay in remission without maintenance therapy
E. There is no role for repeat liver biopsy prior to withdrawal of treatment
Investigations:
| Serum bilirubin | 13 µmol/L |
| Serum ALP | 211 U/L |
| Serum ALT | 55 U/L |
| Serum albumin | 39 g/L |
| Full blood count | Normal |
| INR | 0.9 |
| ANA | Negative |
| Antinuclear cytosplasmic antibody | Negative |
| Anti-mitochondrial antibody | Positive |
| Anti-smooth muscle antibody | Negative |
| IgA | 0.9 g/L |
| IgG | 10.1 g/L |
| IgM | 3.5 g/L |
| HBV/HCV | Negative |
| Liver ultrasound | Normal |
What is the most likely diagnosis?
B. Drug-induced liver injury (DILI)
C. Non-alcoholic fatty liver disease (NAFLD)
D. Primary biliary cholangitis (PBC)
Investigations:
| Serum bilirubin | 17 µmol/L |
| Serum ALP | 256 U/L |
| Serum ALT | 67 U/L |
| Serum albumin | 35 g/L |
| Full blood count | Normal |
| INR | 1.0 |
| ANA | Positive, 1:320, nuclear dot pattern |
| Anti-mitochondrial antibody | Negative |
| Anti-smooth muscle antibody | Negative |
| Anti-sp100 | Positive |
| Anti-gp210 | Negative |
| IgA | 1.5 g/L |
| IgG | 12 g/L |
| IgM | 4.1 g/L |
| HBsAg | Negative |
| HCV antibody | Negative |
| Ultrasound upper abdomen | Normal |
What would be the next best step?
30.A 31-year-old man with PBC presented one year after starting UDCA 500 mg twice a day. His baseline alkaline phosphatase (ALP) prior to starting UDCA was 401 U/L. He was asymptomatic, had normal clinical examination, and was taking no other medications. His weight was 70 kg.
Investigations:
| Serum bilirubin | 21 µmol/L |
| Serum ALP | 321 U/L |
| Serum ALT | 80 U/L |
| Serum albumin | 37 g/L |
| Liver ultrasound | Normal |
How would you manage this patient?
A. Consider second-line therapy with obeticholic acid (OCA)
B. Continue current management
C. Increase UDCA to 750 mg twice a day
D. Refer for early consideration of LT
Investigations:
| Serum ALT | 75 U/L |
| Serum ALP | 338 U/L |
| Serum bilirubin | 35 µmol/L |
| Serum albumin | 37 g/L |
How would you counsel her regarding her prognosis?
A. Good prognostic group because her ALP has reduced by >15% from baseline on OCA
B. Good prognostic group because she is asymptomatic, female, and less than 45 years old
C. Poor prognostic group because her ALP is above 2 × ULN and her bilirubin is above the ULN.
D. Poor prognostic group because she is female and her albumin is <40 g/L.
32.A 31-year-old man with ulcerative pancolitis attended clinic to discuss his up-to-date investigations after finding abnormal liver function tests six months previously.
Investigations:
| Serum bilirubin | 18 µmol/L |
| Serum ALP | 432 IU/L |
| Serum ALT | 85 IU/L |
| Haemoglobin | 134 g/L |
| White cell count | 8 × 109/L |
| Platelet count | 210 × 109/L |
| ANA | Positive 1:160 |
| Antineutrophilic cytoplasmic antibody | Positive (p-ANCA) |
| Anti-mitochondrial antibody | Negative |
| Anti-smooth muscle antibody | Negative |
| Anti-sp100 | Negative |
| Anti-gp210 | Negative |
| IgA | 1.45 g/L |
| IgG | 16.7 g/L |
| IgM | 1.59 g/L |
| Liver ultrasound | Normal liver, biliary tree and gallbladder; no cholelithiasis |
What would be the best next step?
33.A 40-year-old man presented with abnormal liver biochemistry. He was asymptomatic.
Investigations:
| Serum ALT | 78 IU/L |
| Serum ALP | 327 IU/L |
| Serum bilirubin | 17 µmol/L |
| Serum albumin | 39 g/L |
| Liver ultrasound | Normal liver echotexture, normal biliary tree, and gallbladder |
| MRCP | Normal |
| Liver biopsy histology | (See Fig. 8.2) |
Fig. 8.2 Liver biopsy histology specimen. See also Plate 17Image courtesy of Dr Eve Fryer, OUH NHS Foundation Trust, Oxford
34.A 56-year-old man with PSC was followed up in clinic. He complained of increasing pruritus affecting his hands, feet, and back, fluctuating during the day and typically worse after a hot bath. Blood tests revealed cholestatic liver biochemistry with preserved synthetic function.
Which of the following options is true regarding pruritus in this case?
A. Pruritus is not an indication for LT
B. Pruritus usually gets worse as liver disease progresses and end-stage liver disease ensues
C. Rifampicin causes drug-induced hepatitis and significant liver dysfunction in 5% of patients
E. UDCA can cause paradoxical worsening of pruritus in cholestatic liver disease
35.
Which one of the following blood results usually remains unchanged throughout pregnancy?
36.A 28-year-old woman who was 32 weeks’ pregnant presented with worsening pruritis. Initially, this was confined to her palms and soles but progressed to affect her entire body. Her husband commented that she had become yellow over the last week. On examination, she was jaundiced with widespread excoriations.
Investigations:
| Haemoglobin | 108 g/L |
| White cell count | 10.4 × 109/L |
| Platelet count | 160 × 109/L |
| Bilirubin | 74 µmol/L |
| ALP | 306 IU/L |
| ALT | 106 IU/L |
| Prothrombin time | 14.5 seconds |
| Serum bile acids | 70 µmol/L |
What is the most appropriate first-line treatment for this patient?
Investigations:
| Haemoglobin | 88 g/L |
| White cell count | 13.4 × 109/L |
| Platelet count | 76 × 109/L |
| Blood film | Spherocytosis with schistocytes present; no platelet clumps |
| Serum bilirubin | 40 µmol/L |
| Serum ALT | 381 IU/L |
| Serum ALP | 204 IU/L |
| Prothrombin time | 15 seconds |
| Serum LDH | 805 mmol/L |
| Urine dipstick protein | 3+ |
| Liver ultrasound | Hepatomegaly, no biliary dilatation; non-obstructing gallstones |
Which is the most likely diagnosis?
A. Acute fatty liver of pregnancy (AFLP)
C. Haemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome
38.
What is the estimated global population prevalence of NAFLD?
Which test result would be most predictive of advanced (bridging) fibrosis on liver biopsy?
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