Cirrhosis

Q: A patient with hepatic cirrhosis requires a drug with high first-pass metabolism. Which pharmacokinetic parameter change would you most expect?

Increased bioavailability. Hepatic cirrhosis reduces first-pass metabolism, so less drug is metabolized before reaching systemic circulation, resulting in increased bioavailability and risk of toxicity. ---

Q: A 62-year-old male with chronic Hepatitis C and cirrhosis has a solitary liver mass. Which tumor marker, if >1000 ng/ml, is highly suggestive of HCC?

Alpha-fetoprotein (AFP). Markedly elevated levels of Alpha-fetoprotein (AFP) are highly specific for HCC in the setting of chronic liver disease (though its sensitivity varies). ---

Cirrhosis causes peripheral vasodilatation, SAAG is above 1.1, and SBP is caused mainly by gut aerobes (E. coli).

What our notes say

Cirrhosis causes peripheral vasodilatation, SAAG is above 1.1, and SBP is caused mainly by gut aerobes (E. coli). (Internal Medicine CAT 1 (MBIM 6112), 2019/2020: gastroenterology and hepatology,)
Liver transplantation is the recommended treatment of choice in decompensated cirrhosis (Internal Medicine CAT 1 (MBChB 4), 2022: liver, pancreas and bone marrow, 30 MCQ)
The reasoning chain: what is the pattern of liver injury → what is the cause (virus, drug, autoimmune, alcohol) → which virus and which phase → does this patient need treatment → what could go wrong later (cirrhosis, liver cancer). (Hepatitis B and the approach to hepatitis)
Likely causes: transudates: heart failure, cirrhosis, nephrotic syndrome. (Internal Medicine Respiratory CAT 1: 30 MCQs and 5 short answer questions)
Topics tested: HIV and the gut, diarrhoea (infectious and non-infectious), alcoholic liver disease, hepatitis A, B and C, cirrhosis, liver tumours, cholera, shigella, gallstones and pancreatitis. (Internal Medicine CAT 1 (MBIM 6112), 2019/2020: gastroenterology and hepatology,)
Topics tested: jaundice and liver tests, alcoholic liver disease, hepatitis B and C, primary biliary cirrhosis, NASH, Child-Pugh score, GI bleeding, acute pancreatitis, bone marrow failure, haemophilia and myelodysplasia. (Internal Medicine CAT 1 (MBChB 4), 2022: liver, pancreas and bone marrow, 30 MCQ)

Study material on Cirrhosis

Images

Practice questions on Cirrhosis

A patient with hepatic cirrhosis requires a drug with high first-pass metabolism. Which pharmacokinetic parameter change would you most expect?

Decreased bioavailability
Decreased volume of distribution
No change in bioavailability
Increased bioavailability

Answer: D. Hepatic cirrhosis reduces first-pass metabolism, so less drug is metabolized before reaching systemic circulation, resulting in increased bioavailability and risk of toxicity. ---

A 62-year-old male with chronic Hepatitis C and cirrhosis has a solitary liver mass. Which tumor marker, if >1000 ng/ml, is highly suggestive of HCC?

CA 19-9
CEA
Alpha-fetoprotein (AFP)
CA-125

Answer: C. Markedly elevated levels of Alpha-fetoprotein (AFP) are highly specific for HCC in the setting of chronic liver disease (though its sensitivity varies). ---

Gynecomastia in a patient with liver cirrhosis occurs because of

Direct oestrogen secretion by hepatocellular carcinoma cells
Impaired hepatic metabolism of oestrogens causing relative excess
Increased androgen production stimulating breast ductal growth
Portal hypertension causing direct hormonal effects on breast tissue

Answer: B. Cirrhosis impairs hepatic oestrogen metabolism, leading to relative oestrogen excess over androgens. This oestrogen-androgen imbalance drives ductal proliferation causing gynecomastia. ---

A patient with advanced alcoholic cirrhosis develops sudden massive haematemesis. Emergency endoscopy reveals ruptured oesophageal varices. What is the mortality rate from this first bleeding episode?

Approximately 70–80% without surgical ligation
Approximately 25–30% with optimal medical management
Approximately 50% despite intervention
Approximately 10–15% even without treatment

Answer: C. Approximately 50% of patients die from the first variceal bleeding episode from direct haemorrhage or hepatic coma from the protein load combined with hypovolaemic shock. ---

A 50-year-old female with a history of chronic hepatitis C develops ascites and esophageal varices. Liver biopsy shows micronodular cirrhosis. What is the most likely complication leading to this advanced liver disease?

Hepatitis B co-infection
Alcoholic liver disease
Non-alcoholic fatty liver disease (NAFLD)
Hepatocellular carcinoma

Answer: A. While chronic Hepatitis C is a direct cause of cirrhosis, co-infection with Hepatitis B can accelerate the progression to cirrhosis and hepatocellular carcinoma. In the context of already advanced disease, it's a significant factor that would have contributed to the severity and progression. ---

A 60-year-old male with known cirrhosis develops altered mental status, asterixis, and a musty odor to his breath. Lab results show elevated ammonia. What is the most likely diagnosis?

Hepatic encephalopathy
Intracranial hemorrhage
Uremic encephalopathy
Wernicke's encephalopathy

Answer: A. Hepatic encephalopathy is a complication of advanced liver disease characterized by neurological dysfunction due to the accumulation of toxins, such as ammonia, in the brain. Asterixis (flapping tremor) and a musty breath odor are classic signs. ---