Chapter 38 – Liver Diseases & Hepatitis (QE) Sample Questions
1. JK is a 50-year-old patient who presented to his family physician with swollen abdomen, swollen ankles, pitting edema and breathlessness. He further reported of black stools and bloody vomitus. Suspecting ascites, the doctor ordered laboratory test for JK which came back with following results:
Total protein 49 g/L (63–80 g/L)
Albumin 20 g/L (32–50 g/L)
Total bilirubin 114 micromol/L (<17 micromol/L)
ALP 382 IU/L (100-300 IU/L)
ALT 88 IU/L (5-42 IU/L)
INR 1.6
GGT 306 IU/L (<50 IU/l)
Ascites as diagnosis was then confirmed and JK started on therapy of Spironolactone 200 mg daily. Patient’s current medical conditions include hyperlipidemia and diabetes for the past 10 years. The doctor called you for your input on JK’s treatment plan to ensure good prognosis of his condition. Which medication should you recommend the doctor to add in case of inadequate response to JK’s initial therapy of spironolactone?
- A. Metolazone
- B. Furosemide
- C. Amiloride
- D. Hydrochlorothiazide
Ans:
B
Tips: RxTx/CTC 2019. Chronic Liver Disease (Ascites). Spironolactone and furosemide can be started simultaneously, which often provides more predictable diuresis with better electrolyte balance. Give diuretics as single morning doses. Use the lowest effective dose to achieve adequate diuresis and monitor serum electrolytes, urea and creatinine before therapy, weekly until stabilized, then monthly. Doses can be reduced after diuresis is initiated.
Interpretation of JK’s laboratory tests:
Low albumin may indicate chronic liver disease since this protein is synthesized in the liver.
High bilirubin results from low albumin level to which bilirubin forms conjugate with. Alkaline phosphatase (ALP) is present in high concentrations in the cells lining the biliary tract and an ALP level exceeding 300 IU/L, together with a raised is indicative of cholestasis.
Alanine aminotransferase (ALT) is present in high concentrations in the liver and the enzyme is released during hepatocellular damage and a modestly raised level is indicative of chronic liver disease. The increased susceptibility to bleeding observed in patients with liver failure (raised INR) results from depressed fibrinogen levels and the reduced synthesis of clotting factors by the cirrhotic liver. In addition, the absorption of fat-soluble vitamin K is impaired in cholestasis and subsequently the synthesis of vitamin K-dependent clotting factors is reduced.
Gamma-glutamyl transferase (GGT) is found in the liver, but this test is relatively non-specific. It is released following tissue damage and is raised in cholestasis in parallel with ALP. GGT release is stimulated by alcohol and some drugs (such as phenytoin and carbamazepine), and therefore the GGT level can be used to assess abstinence in alcoholics.
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