Liver Diseases: Viral Hepatitis, Cirrhosis and Complications
Liver questions are the highest-yield block in this exam. Expect hepatitis C and B treatment decisions, cirrhosis staging, and protocol-driven management of ascites, varices, encephalopathy and hepatocellular carcinoma.
Viral hepatitis
- Hepatitis C: diagnose with anti-HCV antibody then HCV RNA. Treat with direct-acting antivirals (for example sofosbuvir plus daclatasvir, or glecaprevir/pibrentasvir) for 8-12 weeks; cure is sustained virologic response at 12 weeks after treatment. Check for cirrhosis before choosing regimens, since decompensated disease excludes protease inhibitors.
- Hepatitis B: determine phase from HBeAg, HBV DNA and ALT. Treat when HBV DNA is elevated with ALT above the upper limit, significant fibrosis, cirrhosis, or immunosuppression risk. First-line agents are entecavir, tenofovir disoproxil or tenofovir alafenamide.
- Vaccinate against hepatitis A and B; screen contacts.
Cirrhosis and its complications
- Stage with Child-Pugh and MELD 3.0. Decompensation means ascites, variceal bleeding, encephalopathy or jaundice.
- Ascites: diagnostic paracentesis with serum-ascites albumin gradient of 1.1 g/dL or more indicates portal hypertension. Spontaneous bacterial peritonitis is diagnosed at 250 or more polymorphonuclear cells per microliter; treat with IV cefotaxime plus albumin 1.5 g/kg on day 1 and 1 g/kg on day 3, then secondary prophylaxis.
- Varices: nonselective beta blockers or endoscopic variceal ligation for prevention; acute bleeding needs vasoactive drug, antibiotics and ligation within 12 hours.
- Hepatic encephalopathy: exclude precipitants, treat with lactulose, add rifaximin for recurrent episodes.
- Hepatorenal syndrome-AKI: terlipressin plus albumin.
- Hepatocellular carcinoma surveillance: ultrasound with or without AFP every 6 months in cirrhosis.
Other liver disease
- Autoimmune hepatitis: elevated IgG, ANA or anti-smooth muscle antibody, interface hepatitis; treat with prednisolone plus azathioprine.
- Primary biliary cholangitis: antimitochondrial antibody, cholestatic pattern; ursodeoxycholic acid.
- Schistosomal periportal (Symmers pipestem) fibrosis remains relevant in Egypt and causes presinusoidal portal hypertension with relatively preserved synthetic function.
Worked example
A 54-year-old with cirrhosis and ascites has a diagnostic tap showing 480 PMN cells per microliter. This is spontaneous bacterial peritonitis even without fever: start IV cefotaxime, give albumin on days 1 and 3, and plan norfloxacin prophylaxis after treatment.
Traps
- Using the ascitic fluid neutrophil count from a traumatic tap without correction.
- Missing that SAAG below 1.1 suggests peritoneal tuberculosis or malignancy.
- Starting a protease inhibitor in decompensated cirrhosis.
- Forgetting 6-monthly HCC surveillance.