Case Reports - Liver

1. Case Reports - Liver PBL 6 May 2011

2. Question 1 • Three weeks after a meal at a diner, a 28-year-old man develops malaise, fatigue and loss of appetite. He notes passing dark urine. On physical examination, he has mild scleral icterus and RUQ tenderness. • Lab studies show serum AST of 62 U/L and ALT of 58U/L. Total serum bilirubin is 3.9mg/dL and direct bilirubin is 2.8mg/dL • His symptoms abate over the next 3 weeks. He later finds that the diner has been closed by the city’s health department. • Which of the following serologic test results is most likely to be positive in this patient? • A: Anti-HBs • B: IgM anti-HDV • C: Anti-HCV • D: IgM anti-HAV • E: Anti-HBc

3. Question 2 • A 41yo woman who works as a tattoo artist has increasing malaise and nausea for 14/7. • O/E: She has icterus and mild RUQ tenderness • LFTs: • AST: 79 • ALT: 85 • Total bilirubin: 3.3 • Direct bilirubin: 2.5 • She continues to have malaise for the next year. A liver biopsy is done and shows minimal hepatocyte necrosis, mild steatosis and minimal portal bridging fibrosis.

4. Question 2 (cont’d) • An infection with which of the following is most likely to produce these findings? • A: HAV • B: HBV • C: HCV • D: HEV • E: Coinfection with HBV and HDV

5. Question 3 • A 17yo woman (G2P1) gives birth to a term infant after an uncomplicated pregnancy. The infant does well for 3 weeks but then develops abdominal enlargement, light-coloured stools and dark urine • O/E the infant is icteric. There is hepatomegaly but no splenomegaly or lymphadenopathy. Lab studies show AST of 101, ALT of 112, glucose of 81mg/dL and creatinine of 0.4mg/dL. • A liver biopsy shows lobular disarray with focal hepatocyte necrosis, giant cell transformation, cholestasis, portal mononuclear cell infiltrates, Kupffer cell hyperplasia and extramedullaryhaematopoesis. • The infant recovers in 1/12 and by age 1 all lab findings are normal

6. Question 3 (cont’d) • What is the most likely diagnosis? • A: Erythroblastosisfetalis • B: Extrahepatic biliary atresia • C: Galactosaemia • D: Idiopathic neonatal hepatitis • E: Primary biliary cirrhosis • F: Von Gierke disease

7. Question 4 • A 48yo man has noticed increasing abdominal girth and a yellowish colour to his skin over the past 5/12 • O/E he has scleral icterus and generalised jaundice. His abdomen is distended with shifting dullness • Lab studies show: • Total bilirubin 5.2 mg/dL • Direct bilirubin 4.2 mg/dL • AST of 380 U/L • ALT of 158 U/L • ALP of 95 U/L • Total protein6.4g/dL • Albumin 2.2 g/dL • Prothrombin time is 18 seconds • Partial thromboplastin time is 30 seconds • Blood ammonia is 105mmol/L

8. Question 4 (cont’d) • What is the most likely cause of these findings? • A: Choledocholithiasis • B: Acute HAV infection • C: Metastatic adenocarcinoma • D: Primary biliary cirrhosis • E: Alcohol liver disease

9. Question 5 • A 44yo man has developed increasing arthritic pain, swelling of the feet and reduced exercise tolerance over the past 3 years. He has smoked 1 pack/day for 20 years. • Lab studies show serum glucose 201mg/dL, creatinine of 1.1mg/dL, and ferritin of 893 ng/mL (RR 30-400ng/ml for males) • CXR shows bilateral pleural effusions, pulmonary oedema and cardiomegaly • Liver biopsy shows the following with a Prussian blue stain:

11. Question 5 (cont’d) • Based on these findings, what is the best advice to give this patient: • A: You need to reduce your alcohol consumption • B: A cholecystectomy should be performed • C: Your siblings may be at risk of developing the same condition • D: You will most likely develop acute fulminant hepatitis • E: Smoking for many years has led to this condition

12. Question 6 • A 36yo woman has become increasingly icteric for 1 month. In the past 3 years, she has had several bouts of colicky, mid abdominal pain. • O/E she has generalised jaundice with scleral icterus. The is tenderness in the RUQ and the liver span is normal • A liver biopsy shows bile duct proliferation and intracanalicular bile stasis, but no inflammation or hepatocyte necrosis • Which of the following serum laboratory findings is most likely to be present? • A: Markedly increased antimitochondrial antibody • B: Positive hepatitis C antibody • C: Markedly elevated indirect bilirubin • D: Elevated alkaline phosphatase • E: Increased blood ammonia

13. Question 7 • A 42yo woman has had fever, chills and bouts of colicky RUQ pain for the past week. • O/E she has scleral icteric and jaundiced skin • Laboratory studies show total serum bilirubin of 7.1mg/dL and direct bilirubin of 6.7mg/dL • An abdominal US shows cholelithiasis, dilatation of the CBD and two cystic lesions (0.8cm and 1.5cm) in the right lobe of the liver • Which of the following infectious agents is most likely to produce these findings? • A: Clonorchissinensis • B: Cryptosporidium parvum • D: Cytomegalovirus • E: Entamoebahistolytica • F: Escherichia coli

14. Question 8 • 7 years ago, a 30yo man saw a physician because he had malaise, fever and jaundice for 2/52 • O/E there were needle tracks in the left antecubital fossa and a murmur of MR. Serologic test results were positive for HBsAG, HBV DNA and IgG anti-HBc. He did not return for follow-up • Two years later he was seen in ED with haematemesis and ascites. Serologic tests were similar to previous reuslts. Sclerotherapy was used to treat the oesophegeal varices and he was discharged, but did not return for follow up • Now, 5 years later, he sees the physician due to 5kg weight loss, worsening abdo pain and rapid enlargement of his abdomen over the last 1/12. O/E there is increased liver span

15. Question 8 (cont’d) • Which of the following lab tests is most likely to be diagnostic of the most recent presentation? • A: Prolonged prothrombin time • B: Elevated serum alpha-fetoprotein • C: Elevated serum ALT • D: Elevated serum alkaline phosphatase • E: Elevated serum ferritin • F: Increased blood ammonia