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GI-Liver Session 20th March 2025 Katherine Wostenholme, Alexander WallaceLearningOutcomes ● Cirrhosis: Complications (ascites, encephalopathy), management ● Liver disease differentials including PBC/PSC/Wilson’s disease ● Jaundice: Differential diagnosis (obstructive vs hepatocellular) ● Liver transplant: Indications, contraindications, post-transplant care ● Hepatocellular carcinoma: Risk factors, diagnosis, treatmentQuestion 1 A 65-year-old man with a history of chronic alcohol use presents with increasing abdominal distension. He has a history of cirrhosis, and his recent ultrasound shows ascites. His liver function tests show a drop in albumin levels and elevated bilirubin. What is the most appropriate first-line treatment for his ascites? A) Paracentesis with albumin infusion B) Diuretics (spironolactone and furosemide) C) Liver transplantation D) Antibiotic therapy E) Referral for liver biopsyQuestion 1 A 65-year-old man with a history of chronic alcohol use presents with increasing abdominal distension. He has a history of cirrhosis, and his recent ultrasound shows ascites. His liver function tests show a drop in albumin levels and elevated bilirubin. What is the most appropriate first-line treatment for his ascites? A) Paracentesis with albumin infusion B) Diuretics (spironolactone and furosemide) C) Liver transplantation D) Antibiotic therapy E) Referral for liver biopsyQuestion 1-Explanation Ascites is a common complication of cirrhosis, and diuretics (spironolactone and furosemide) are the first-line treatment to manage fluid retention. Paracentesis can be used for symptom relief, but diuretics are usually the initial management. Albumin infusion may be required in some cases.Causes ofAscites ● Liver-related causes: ○ Cirrhosis (most common) ○ Alcoholic liver disease ○ Hepatitis B or C ○ Hepatic vein obstruction (Budd-Chiari syndrome) ● Cancer-related causes ● Cardiac causes ○ Congestive heart failure ○ Constrictive pericarditis ● Kidney-related causes: ○ Nephrotic syndrome ● Infections & Inflammatory causes: ○ Tuberculous peritonitis ○ Spontaneous bacterial peritonitis (SBP) ○ Pancreatitis ● Other causes: ○ Hypoalbuminemia (low protein levels) ○ Meigs' syndrome (ovarian tumor with ascites and pleural effusion) ○ Chylous ascites (due to lymphatic obstruction)Treatment ofAscites General Measures: - Sodium restriction (<2g/day) - Fluid restriction (for severe hyponatremia) Medications: - Diuretics (Spironolactone ± Furosemide) - Antibiotics (for spontaneous bacterial peritonitis, e.g., cefotaxime) Procedures: - Paracentesis (for large or refractory ascites) - Transjugular intrahepatic portosystemic shunt (TIPS) (for refractory ascites in cirrhosis) Management of Underlying Cause: - Treat liver disease (e.g., antiviral therapy for hepatitis, alcohol cessation) - Treat malignancy (chemotherapy, surgery) - Manage heart failure (diuretics, ACE inhibitors) Supportive Therapy: - Albumin infusion (for large-volume paracentesis or SBP) - Liver transplant (for end-stage liver disease)Question 2 A 48-year-old man with a history of heavy alcohol use presents to the emergency department with jaundice, nausea, and vomiting. He reports recent heavy drinking. His liver function tests show an AST/ALT ratio of 2:1, with elevated bilirubin and gamma-glutamyl transferase (GGT). What is the most likely diagnosis? A) Alcoholic hepatitis B) Hepatitis B C) Hepatitis A D) Non-alcoholic fatty liver disease (NAFLD) E) CirrhosisQuestion 2 A 48-year-old man with a history of heavy alcohol use presents to the emergency department with jaundice, nausea, and vomiting. He reports recent heavy drinking. His liver function tests show an AST/ALT ratio of 2:1, with elevated bilirubin and gamma-glutamyl transferase (GGT). What is the most likely diagnosis? A) Alcoholic hepatitis B) Hepatitis B C) Hepatitis A D) Non-alcoholic fatty liver disease (NAFLD) E) CirrhosisQuestion 2-Explanation The elevated AST/ALT ratio (typically >2:1 in alcoholic liver disease), along with a history of heavy alcohol consumption, suggests alcoholic hepatitis. This condition is common in patients with a history of chronic alcohol use and can present with jaundice, nausea, vomiting, and liver enzyme abnormalities.Question 3 A 55-year-old man with a history of gallstones presents to the hospital with jaundice and fever. His liver function tests show an elevated ALP and GGT. An ultrasound reveals a dilated common bile duct. What is the most likely diagnosis? A) Cholestasis due to biliary obstruction B) Hepatitis A C) Hepatocellular carcinoma D) Cirrhosis E) Acute pancreatitisQuestion 3 A 55-year-old man with a history of gallstones presents to the hospital with jaundice and fever. His liver function tests show an elevated ALP and GGT. An ultrasound reveals a dilated common bile duct. What is the most likely diagnosis? A) Cholestasis due to biliary obstruction B) Hepatitis A C) Hepatocellular carcinoma D) Cirrhosis E) Acute pancreatitisQuestion 3-Explanation This patient presents with jaundice, fever, and an ultrasound showing a dilated common bile duct, which are signs of biliary obstruction (likely gallstones in his case). The elevated ALP and GGT further support this diagnosis. Common causes of biliary obstruction include gallstones, cholangitis, or a tumor.Gallstones Risk Factors- The 4 Fs: ● Female (more common in women) ● Fat (obesity, high-fat diet) ● Fourty (age >40 years) ● Fertile (pregnancy, estrogen therapy) Clinical Features: 1. Asymptomatic (most common) 2. Symptomatic Gallstones (Biliary Colic): ○ Intermittent RUQ or epigastric pain ○ Occurs after fatty meals ○ Nausea, vomiting ○ Pain resolves within hours 3. Complications: ○ Cholecystitis (Gallbladder Inflammation) → Persistent RUQ pain, fever, Murphy’s sign ○ Choledocholithiasis (Stone in Common Bile Duct) → Jaundice, dark urine, pale stools ○ Cholangitis (Biliary Infection) → Charcot’s Triad: Fever, jaundice, RUQ pain ○ Gallstone Pancreatitis → Epigastric pain radiating to back, high amylase/lipaseGallstones Diagnosis: 1. Ultrasound (First-line test) → Detects gallstones, gallbladder wall thickening 2. MRCP (Magnetic Resonance Cholangiopancreatography) → For bile duct stones 3. ERCP (Endoscopic Retrograde Cholangiopancreatography) → Diagnostic & therapeutic 4. Blood Tests: ○ ↑ WBC (if infection) ○ ↑ Bilirubin, ALP, GGT (if bile duct obstruction) ○ ↑ Amylase/Lipase (if pancreatitis) Treatment: Asymptomatic Gallstones: ● No treatment unless complications develop Symptomatic or Complicated Gallstones: 1. Pain Management: ○ NSAIDs (e.g., ibuprofen) ○ Antispasmodics (e.g., hyoscine) 2. Definitive Treatment: ○ Laparoscopic Cholecystectomy (Gold Standard) → Removal of gallbladder ○ ERCP + Sphincterotomy (if common bile duct stones) ○ Ursodeoxycholic Acid (for non-surgical patients with cholesterol stones) Question 4 A 62-year-old man with known cirrhosis presents with confusion and drowsiness. His family reports he has been sleeping excessively and has developed hand flapping movements (asterixis). What is the most appropriate initial treatment? A) Lactulose B) Furosemide C) Albumin infusion D) Rifaximin E) Paracentesis Question 4 A 62-year-old man with known cirrhosis presents with confusion and drowsiness. His family reports he has been sleeping excessively and has developed hand flapping movements (asterixis). What is the most appropriate initial treatment? A) Lactulose B) Furosemide C) Albumin infusion D) Rifaximin E) Paracentesis Question 4 - Explanation The patient has symptoms of hepatic encephalopathy, a complication of cirrhosis due to elevated ammonia levels that affects brain function. Lactulose is the first-line treatment as it promotes ammonia excretion by acidifying the colon. Rifaximin is an adjunct therapy for recurrent cases. Clinical Features (Stages of HE): Grade 1 - Subtle cognitive impairment, mood changes, sleep disturbances Grade 2 - Asterixis (flapping tremor), lethargy, confusion, personality changes Grade 3 - Marked confusion, disorientation, aggression, somnolence Grade 4 - Coma, unresponsive to pain - Asterixis (flapping tremor) → Seen in Grade II or higher - Fetor hepaticus → Sweet, musty breath due to dimethyl sulfide accumulation Question 5 A 50-year-old woman presents with fatigue, pruritus, and jaundice. Blood tests reveal elevated alkaline phosphatase (ALP) and IgM, and anti-mitochondrial antibodies (AMA) are positive. What is the most likely diagnosis? A) Autoimmune hepatitis B) Primary sclerosing cholangitis (PSC) C) Primary biliary cholangitis (PBC) D) Hepatitis B E) Cholangiocarcinoma Question 5 A 50-year-old woman presents with fatigue, pruritus, and jaundice. Blood tests reveal elevated alkaline phosphatase (ALP) and IgM, and anti-mitochondrial antibodies (AMA) are positive. What is the most likely diagnosis? A) Autoimmune hepatitis B) Primary sclerosing cholangitis (PSC) C) Primary biliary cholangitis (PBC) D) Hepatitis B E) Cholangiocarcinoma Question 5 - Explanation PBC is a chronic liver disease affecting middle-aged women, characterized by anti-mitochondrial antibodies (AMA) and cholestatic liver enzyme pattern (elevated ALP). Ursodeoxycholic acid (UDCA) is the first-line treatment. Pathophysiology: 1. Autoimmune destruction of small intrahepatic bile ducts 2. Bile accumulation (cholestasis) → Liver inflammation & fibrosis 3. Progression to cirrhosis and liver failure if untreated Clinical Features: - Early Symptoms: ● Fatigue (most common early symptom) ● Pruritus (itching) due to bile salt accumulation ● Dry eyes and dry mouth (Sjögren’s association) Question 5 - Explanation Later Symptoms: ● Jaundice (due to bilirubin retention) ● Right upper quadrant (RUQ) discomfort ● Hepatosplenomegaly Diagnosis: Blood Tests: ● Elevated alkaline phosphatase (ALP) & gamma-glutamyl transferase (GGT) ● Mildly elevated AST/ALT ● Elevated IgM ● Positive anti-mitochondrial antibodies (AMA) (95%) → Highly specific Imaging: ● Ultrasound → Excludes bile duct obstruction ● MRCP (Magnetic Resonance Cholangiopancreatography) → Excludes primary sclerosing cholangitis (PSC) Liver Biopsy → Not always needed but confirms diagnosis in uncertain cases Question 6 A 21 year old male presents to the GP with yellowing of his skin. On further questions it is revealed he has a tremor and has been experiencing some depression. What is the most likely diagnosis? A Wilson’s disease B Haemochromatosis C A1AT D Gilbert’s syndrome E Autoimmune hepatitisAnswer 6 A 21 year old male presents to the GP with yellowing of his skin. On further questions it is revealed he has a tremor and has been experiencing some depression. What is the most likely diagnosis? A Wilson’s disease B Haemochromatosis C A1AT D Gilbert’s syndrome E Autoimmune hepatitisQuestion 7 A 34 year old female presents to be GP with jaundice, a fever and amenorrhea. She has no history of alcohol use. Blood tests reveal a raised serum aminotransferases, immunoglobulin G, and smooth muscle antibody (SMA). What is the most likely diagnosis? A Gilbert’s syndrome B Autoimmune haemolytic anaemia C Acute hepatitis E D Autoimmune hepatitis E Vitamin B12 deficiencyAnswer 7 A 34 year old female presents to be GP with jaundice, a fever and amenorrhea. She has no history of alcohol use. Blood tests reveal a raised serum aminotransferases, immunoglobulin G, and smooth muscle (SMA) antibody. What is the most likely diagnosis? A Gilbert’s syndrome B Autoimmune haemolytic anaemia C Acute hepatitis E D Autoimmune hepatitis E Vitamin B12 deficiencyCauses of pre-hepaticjaundice Gilbert’s - raised unconjugated bilirubin (jaundice) in response to stress (fasting, illness), no treatment Haemolytic anaemia - premature RBC breakdown - Sickle cell anaemia - Thalassemia - Hereditary spherocytosis - Glucose-6-phosphate dehydrogenase deficiencyCauses of intra-hepaticjaundice Metabolic: - Haemochromatosis (HFE gene AR) - mood disturbance, pigmented skin, fatigue - raised transferrin and ferritin, low TIBC, MRI - venesection - Wilson’s (AR) - psychiatric & neurological (tremor, Parkinsonisms) problems, Kayser-Fleischer rings - low serum caeruloplasmin & reduced total serum copper - penicillamine (copper chelation) - A1AT (AR) - Emphysema (obstructive) and liver cirrhosisCauses of intra-hepaticjaundice conc. Autoimmune: - Hepatitis: raised IgG, SMA antibody, ANA antibody. Tx steroids and immunosuppression (azathioprine) - PSC: UC associated, MRCP diagnosis (beads on a string), tx: ERCP and cholestyramine - PBC: anti-mitochondrial, middle aged women, raised IgM, tx ursodeoxycholic acid + cholestyramine Malignancy: hepatocellular carcinoma, cholangiocarcinoma Other intra-hepatic jaundice causes covered early in this lecture: viral, alcohol, NAFLDCauses of post-hepaticand obstructive jaundice Cholelithiasis - when causes obstruction of the biliary duct tract - ascending cholangitis (Charcot’s triad - pain, fever, jaundice) Surgical structures e.g. following cholecystectomy Pancreatic cancer Liver investigations: Pre-hepatic: mainly unconjugated bilirubin (normal colour urine and stool). ALT>AST (unless alcohol AST>ALT) Intra-hepatic: mixed unconjugated and conjugated bilirubin (dark urine and normal colour stool). Alcohol ^^ GGT Post-hepatic: mainly conjugated bilirubin (dark urine and pale stool) Raised ALT (specific) & AST (non-specific): hepatic pathology Raised GGT (specific) & ALP (non-specific): biliary pathology Amylase (sensitive and non-specific) & lipase (specific): pancreatic disease Albumin (produced by liver): low either means increase loss (e.g. nephrotic disease) or reduced production (liver disease) Coagulation screen (liver produces clotting factors) so raised PT and INRQuestion 8 A 57 year old male has been diagnosed with chronic hepatitis C for 5 years. He receives a liver US annually. His most recent liver US reports nodularity of the surface of the liver and a corkscrew appearance to the hepatic arteries. What other investigation should be considered as a screening tool? A Alpha-fetoprotein (AFP) B Endoscopy (OGD) C CT TAP (thorax abdomen pelvis) D Liver biopsy E Liver function tests (LFTs)Answer 8 A 57 year old male has been diagnosed with chronic hepatitis C for 5 years. He receives a liver US annually. His most recent liver US reports nodularity of the surface of the liver and a corkscrew appearance to the hepatic arteries. What other investigation should be considered as a screening tool? A Alpha-fetoprotein (AFP) B Endoscopy (OGD) C CT TAP (thorax abdomen pelvis) D Liver biopsy E Liver function tests (LFTs)Hepatocellular carcinoma Risk factors: most common cause is liver Diagnosis: biopsy, CT for staging cirrhosis secondary to: - Chronic hepatitis C & B Poor prognosis, unless diagnosed early - Alcohol - Haemochromatosis - Primary biliary cirrhosis Treatment: - Aflatoxin - Resection or transplant if amenable Screening: - Radiofrequency ablation - Transarterial chemoembolisation (TACE) - high risk groups - Radiotherapy - liver cirrhosis secondary to - Kinase inhibitors and monoclonal antibodies hepatitis B & C or haemochromatosis - men with liver cirrhosis secondary to alcohol - Liver US and AFPQuestion 9 A 24 year old female with a history of bipolar disorder and self-harm takes an intentional overdose of 160 500mg paracetamol tablets at 6pm yesterday. She was admitted to a medical ward and treated with IV acetylcysteine. You assess the patient at 7pm today, she is still very drowsy and confused with slurred speech. She is tender in the RUQ. You decide to take some further bloods to assess her. Bloods: FBC within range, U&E within range except a raised creatinine at 200, prothrombin time is raised at 40 seconds, LFTs demonstrate a raised ALT (300) and AST (53), Her VBG shown a pH of 7.28. Serum paracetamol level is 27 (above the acetylcysteine treatment line for 25 hours post ingestion). What aspect of her investigations meets the KIng’s criteria for urgent liver transplantation? A Prothrombin time above 20 seconds 24 hours post paracetamol dose B Blood pH <7.3 24 hours post paracetamol dose C Stage III encephalopathy 24 hours post paracetamol dose D Serum paracetamol above the acetylcysteine treatment line for 24 hours post ingestion E Having taken over 150 paracetamol tablets all at onceAnswer 9 A 24 year old female with a history of bipolar disorder and self-harm takes an intentional overdose of 160 500mg paracetamol tablets at 6pm yesterday. She was admitted to a medical ward and treated with IV acetylcysteine. You assess the patient at 7pm today, she is still very drowsy and confused with slurred speech. She is tender in the RUQ. You decide to take some further bloods to assess her. Bloods: FBC within range, U&E within range except a raised creatinine at 200, prothrombin time is raised at 40 seconds, LFTs demonstrate a raised ALT (300) and AST (53), Her VBG shown a pH of 7.28. Serum paracetamol level is 27 (above the acetylcysteine treatment line for 25 hours post ingestion). What aspect of her investigations meets the KIng’s criteria for urgent liver transplantation? A Prothrombin time above 20 seconds 24 hours post paracetamol dose B Blood pH <7.3 24 hours post paracetamol dose C Stage III encephalopathy 24 hours post paracetamol dose D Serum paracetamol above the acetylcysteine treatment line at 24 hours post ingestion E Having taken over 150 paracetamol tablets all at onceLiver transplantation Indications: - Acute liver failure (paracetamol overdose, acute viral hepatitis) *priority* - Chronic liver failure - Hepatocellular carcinoma Contraindications: - Significant co-morbidities (severe kidney, lung or heart disease) - Current illicit drug use - Continuing alcohol misuse (generally 6 months of abstinence is required) - Untreated HIV - Current or previous cancer (except liver cancer) Surgery rooftop or mercedes Benz incision: Post-operation care: - immunosuppression (steroids, azathioprine and tacrolimus) - Monitor LFT and clinical signs of rejection (jaundice, fever) Liver transplantation King’s college for urgent liver transplantation: - Arterial pH < 7.3, 24 hours after ingestion - or all of the following: ● prothrombin time > 100 seconds ● creatinine > 300 µmol/l ● grade III or IV encephalopathyQuestion 10 A 53 year old man presents to his GP with yellowing or his skin for the past 2 months. On further questioning he admits to pale stools. Examination reveals a non-tender palpable gallbladder and excoriation marks over his arms and abdomen. The patient has a background of ulcerative colitis and primary sclerosing cholangitis. What is the most likely diagnosis: A Hepatocellular carcinoma B Pancreatic carcinoma C Cholelithiasis D Cholangiocarcinoma E PancreatitisAnswer 10 A 53 year old man presents to his GP with pale stools and yellowing or his skin for the past 2 months. On further questioning he admits to pale stools. Examination reveals a non-tender palpable gallbladder and excoriation marks over his arms and abdomen. The patient has a background of ulcerative colitis and primary sclerosing cholangitis. What is the most likely diagnosis: A Hepatocellular carcinoma B Pancreatic carcinoma C Cholelithiasis D Cholangiocarcinoma E PancreatitisCholangiocarcinoma Adenocarcinoma of bile ducts Risk factors: primary sclerosis cholangitis (UC), liver flukes (parasite) Presentation: - obstructive jaundice (pale stool, dark urine, itchiness) - Courvoisier’s law: palpable gallbladder and jaundice is unlikely to be gallstones; more likely cholangiocarcinoma or pancreatic cancer Diagnosis: - CA19-9 (non-specific) - CT TAP/MRI - Biopsy - MRCP - ERCP Treatment: - Stent (ERCP) relieve obstruction, radiotherapy and chemotherapy - Curative surgery is rare SEEYOUNEXT https://linktr.ee/medtic.teaching THURSDAY! Sign up to our next session on MedAll Take part in our research survey See all our upcoming events www.medticteaching.com | Email: medticteaching@gmail.com | Youtube @medtic | Instagram @medtic.teaching | Tiktok @medticteaching