WBR0628

Author	[[PageAuthor::Mugilan Poongkunran M.B.B.S [1]]]
Exam Type	ExamType::USMLE Step 3
Main Category	MainCategory::Emergency Room
Sub Category	SubCategory::Gastrointestinal, SubCategory::Gastrointestinal
Prompt	[[Prompt::64 year old Caucasian male, is brought to the emergency department by his family members because of an episode of bloody vomiting. He also complaints of fatigue, lethargy, malaise, anorexia, nausea and abdominal pain for the past few weeks. He is a chronic alcoholic for the past 25 years. He smokes 2 packs of cigarettes a day, but denies any illicit drug use. His past history is insignificant and his family history is unremarkable. His vitals are stable and there no active bleeding. The physical examination shows spider angiomata, peripheral edema and mild heptomegaly. Other system examinations are normal. His serum biochemistry results are Na:135 mEq/L, K: 3 mEq/L, Cl:104mEq/L, Bi: 24 mEq/L, BUN: 30 mg/dl, glucose:126 mg/dl, Mg:1mg/dl and Ca: 8mg/dl. The liver fuction test results are as follows: Alanine aminotransferase : 70 U/L Aspartate aminotransferase : 50 U/L Alkaline phosphatase : 130 U/L Total bilirubin : 3.2 mg/dl Prothrombin time : 16 sec Serum albumin : 2.8 g/dl Hepatits A IgM : negative HbsAg : negative HBc Antibody : negative HCV Antibody : negative An USG abdomen reveals mild ascitis and his liver biopsy reveals micronodular cirrhosis. Which of the following is the most appropraite treatment option?]]
Answer A	AnswerA::Refer him for portocaval shunt
Answer A Explanation	[[AnswerAExp::Incorrect : Portocaval shunt are the last resort to treat portal hypertension. It is usually done in patients who have contraindications for liver transplant.]]
Answer B	AnswerB::Octreotide for hematemesis
Answer B Explanation	[[AnswerBExp::Incorrect : Patient has no bleeding now and his vitals are stable. Hence there is no need for octreotide.]]
Answer C	AnswerC::Refer him for liver transplanation
Answer C Explanation	[[AnswerCExp::Correct : This patient has a CTP score of > 7 and hence liver transplantation is the appropriate choice.]]
Answer D	AnswerD::Observation and follow-up
Answer D Explanation	AnswerDExp::'''Incorrect''' : This patient has decompensated liver disease and hence just managing supportively is not an choice.
Answer E	AnswerE::Albumin infusion
Answer E Explanation	[[AnswerEExp::Incorrect : Though albumin infusion help in improving the patients albumin levels, this therapy does not help much in decompensated liver disease patients on a long term.]]
Right Answer	RightAnswer::C
Explanation	[[Explanation::The score employs five clinical measures of liver disease. Each measure is scored 1-3, with 3 indicating most severe derangement. Measure 1 point 2 points 3 points units Bilirubin (total) <34.2 (<2) 34.2-51.3 (2-3) >51.3 (>3) μmol/l (mg/dL) Serum albumin >35 28-35 <28 g/L INR <1.7 1.71-2.3 > 2.3 no unit Ascites None Suppressed with medication Refractory no unit Hepatic encephalopathy None Grade I-II (or suppressed with medication) Grade III-IV (or refractory) no unit It should be noted that different textbooks and publications use different measures. Some older reference works substitute PT prolongation for INR. If the PT is <4 seconds than control, it is assigned 1 point. If 4-6 seconds over control, then it scores 2 points and >6 seconds over control, scores 3 points. In primary sclerosing cholangitis (PSC) and primary biliary cirrhosis (PBC), the bilirubin references are changed to reflect the fact that these diseases feature high conjugated bilirubin levels. The upper limit for 1 point is 68 μmol/l (4 mg/dL) and the upper limit for 2 points is 170 μmol/l (10 mg/dL). Chronic liver disease is classified into Child-Pugh class A to C, employing the added score from above. Points Class One year survival Two year survival 5-6 A 100% 85% 7-9 B 80% 60% 10-15 C 45% 35% Not only this, one can also use Child-Pugh to predict development of complications of cirrhosis. A Child-Pugh class C indicates higher chance of developing a bleeding varix than those with class A.[1] Educational Objective: References: ]]
Approved	Approved::Yes
Keyword	WBRKeyword::Child-Pugh score, WBRKeyword::Liver transplant
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