Tutorial

Tutorial:

باطنية
د. ضياء الليلة

عدد الاوراق (5)

8-11-2012

Question 1

A sample of ascitic albumin gradient more 1.1g/dl
State 3 possible diagnoses?

Abdominal paracentesisMost rapid and cost-effective method of diagnosing the cause of ascites
Indications:
1. Inpatients and outpatients with new onset of ascites.
2.Patients with ascites admitted to the hospital.

Serum-ascitesAlbumin gradient (SAAG)SAAG≥1.1g/dl:

PHT with an accuracy of 97%
Accuracy not modified by infection, diuresis, therapeutic paracentesis, IV infusion of albumin


High gradient >1.1g/dlCirrhosis
Alcoholic hepatitis
Cardiac ascites
Mixedascites
Massive liver metastases
FHF
Budd-Chiari syndrome
Portal vein thrombosis
Veno-occlusive disease
Myxedema
Fatty liver of pregnancy

Low gradient <1.1g/dlPeritoneal carcinomatosis

Tuberculous peritonitis
Pancreatic ascites
Bowel ob. or infarction
Biliary ascites
Nephrotic sd.
Lymphatic leak
Connective tissue disease



Question 2
Q2: A middle-aged woman was jaundiced and pruritic
What is the role of the abdominal uss?
The uss was normal:
What is the most likely diagnosis?
What further investigations are suggested?
What are the thereaputic options?

Question 3

A 23-yrs-old lady presented with a 6 month history of lassitude and amenorrhea and was found to have the following lab.features:
Plasma bilirubin: 100 micromole/l
ALT: 159 iu/ I
AST: 390 iu/I
S.Albumin: 38g/L
S.Globulin: 63 g/L
What does the above data suggest?
What further investigations are useful diagnostically?
Mention 2 effective drugs.


Question 4
A 58-yrs-old man presented with progressive anorexia and pitting edema.
Investigations:
Urine normal
Liver enzymes: normal..
Serum Albumin: 27 g/100 ml.
What is the probable explanations of these features.
Answer
1. Mmalabsorption
2. Protein loosing enteropathy


Question 5
A man aged 40 yrs with celiac disease controlled with diet developed frequent bowel actions. Fecal fat excretions was markedly increased.
A. what were the 2 most likely diagnosis?
B. How may these diagnosis be made?

Answer

1. Reintroduction of gluten
2. Small bowel lymphoma

Question 6

A 55 yrs old man presented with exertional dyspnea and ascites.
Physical examinations was relevant for low BP and soft heart sounds.
Investigations:
Serum albumin: 40 g/l
AST 45, ALT 34, serum bilirubin 16 mmol
What was the cause of the ascites.

Answer

Ascites of liver origin is always associated with hypoalbuminemia.
Constrictive pericarditis is a well recognized cause of ascites.


Question 7
A 44-yrs-old woman presented with severe epigastric pain, sudden in onset.
Investigations:
Glucose: 8.2 mmol/l, bilirubin 22, serum calcium 1.85, blood urea 9.5 mmol/l.
What was the most likely diagnosis?
Suggest further investigations
What condition needed to be excluded subsequently?

Answer

Acute pancreatitis
Gallstones should be excluded

Question 8

A 60-yrs-old woman underwent a technically difficult cholecystectomy. 2 days post.op jaundiced developed.
Investigations:
Bilirubin: 667 micmol/l
ALP 89 iu/l
ALT 82
AST 75
Suggest 2 possible diagnoses.


Answer
Sepsis is the most likely diagnosis
Causes of postoperative jaundice:
Blood transfusion (stored blood)
Hematoma
Anesthetic damage
Prolonged eipsode of hypotension
Drug-induced

Question 9

A 60-yrs-old man had the following blood tests as an outpatient:
Hb: 21.5, PCV 68%, WBC 12X109/l ,
platelet count 570 X109/l , ESR 3mm .
The following day he was admitted to the hospital with abdominal pain and vomiting.
Investigations:
Serum amylase 150iu/l
GPT 95, ALP163 , bilirubin 29, albumin 36
What was the most likely diagnosis?
What complication had occurred?
What other signs would be expected to develop?
What further investigation would be necessary?


Answer
Budd-Chiari syndrome
Radioisotope scan
CT angiography

Question 10

The following investiagations were obtained from a woman aged 56 yrs:
Bil 50 mmol
ALT 25
ALP 727
Serum copper 31.2 mmol (hypercupremia)
Urine copper 264 mmol/24 (hypercupriuria)
Ceruloplasmin 2 mmol/l (normal)
What was the diagnosis?
How it might be confirmed?

Answer

Normal ceruloplasmin is much against the diagnosis
of Wilson disease
PBC is the most likely diagnosis.


Scoring system for Wilson disease
 SHAPE \* MERGEFORMAT 


Question 11

An asymptomatic 40-yrs-old man presented with mild hyperbilirubinemia (30 mmol)
ALT 15
ALP 85
s. Albumin 42
Urine negative for biliruin or urobilinogen
Reticulocte count 0.7 %
50% of bilirubin unconjugated
USS normal
What was the diagnosis
Was a liver biopsy indicated.
What additional test might assist in confirming the diagnosis?

Answer

Normal hepatocellular function
No evidence of hemolysis
No evidence of obstruction to bile flow
Gilbert syndrome is the most likely diagnosis
Fasting for 36-48 hrs will result in further rise in serum bilirubin


Congenital hyperbilirubinemia

SyndromeInheritanceAbnormalityClinical features/treatmentUnconjugated hyperbilirubinaemiaGilbert'sAutosomal dominant↓ Glucuronyl transferase
Mild jaundice, especially with fasting

↓ Bilirubin uptake

No treatment necessary

Crigler-Najjar

Type I
Autosomal recessive
Absent glucuronyl transferase
Rapid death in neonate (kernicterus)

Type II

Autosomal dominant
↓↓ Glucuronyl transferase
Presents in neonate



Phenobarbital, ultraviolet light or liver transplant as treatment

Conjugated hyperbilirubinaemia

Dubin-Johnson
Autosomal recessive
↓ Canalicular excretion of organic anions, including bilirubin
MildNo treatment necessary

Rotor's

Autosomal recessive
↓ Bilirubin uptake
Mild

↓ Intrahepatic binding

No treatment necessary

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