Benign Lesions/Abscesses
A 34-year-old asymptomatic woman has a 2-cm smooth, thin-walled, anechoic hepatic lesion found incidentally on ultrasound with no septations or solid components. appopriate next step??
Answer: What is no further workup or follow-up imaging?
Why: Classic imaging features of a simple hepatic cyst (thin wall, anechoic, no septations) are diagnostic on their own; so no need to do biopsy or a repeat imaging when asymptomatic
A patient with compensated cirrhosis undergoes routine surveillance and is found to have a new 1.2-cm hepatic nodule on ultrasound. Next most appropriate step?
Answer: What is multiphasic (contrast-enhanced) CT or MRI?
Why: Nodules ≥1 cm found on surveillance US require CT/MRI
32F at 32 weeks' gestation reports severe pruritus, worse on the palms and soles, with normal bilirubin but a serum bile acid level of 18 Dx & first-line tx?
Answer: Intrahepatic cholestasis of pregnancy & ursodeoxycholic acid?
Why: Elevated bile acids (>10 ) with pruritus ursodeoxycholic acid improves pruritus/may reduce fetal risk
This intern was born with dirty blonde hair that turned dark after they were 4 years old
Who is Rashib
A 29-year-old woman on oral contraceptives for 6 years has a 6-cm well-circumscribed liver mass on MRI with washout on delayed phase. Next step??
surgical resection (given size ≥5 cm)
Why: Hepatic adenoma; OCP use is the classic risk factor; also ≥5 cm carry of hemorrhage and malignant transformation so need to do resection
A patient with HCC has a single 4-cm lesion, no vascular invasion, no extrahepatic spread, and decompensated cirrhosis (Child-Pugh C). Preferred treatment??
Answer: What is liver transplantation (meets Milan criteria; decompensation precludes resection)?
Why: Decompensated cirrhosis makes resection unsafe/also meets milan criteria--> the one lesion <5cm/no spread/no vascular invasion
31F 35 weeks' gestation with preeclampsia develops RUQ pain; labs show a hgb drop, schistocytes on smear, AST 300 and platelets of 80,000. tx?
Answer: Delivery?
Why: HELLP syndrome (hemolysis with schistocytes, elevated liver enzymes, low platelets); delivery is the only definitive treatment.
This intern has visited over 22 countries
Who is Sam? (he has visited 23 countries)
A 45-year-old man is found to have a 4-cm hepatic adenoma. Pt is asymptomatic. Next step??
Answer: surgical resection
Why: Adenomas in men; resected regardless of size bc increase risk for malignant transformation/rupture
Pt with solitary 2.5-cm HCC lesion and well-compensated cirrhosis without significant portal hypertension is being evaluated for definitive local therapy. Tx?
Answer: surgical resection?
Why: With good liver function and no portal hypertension, pt can tolerate resection safely
A woman at 34 weeks' gestation develops nausea, jaundice, hypoglycemia, and coagulopathy with a normal platelet count and no hemolysis on smear (distinguishing this from HELLP). This is the diagnosis, and this metabolic condition should be screened for in mother and infant.
Answer: What is acute fatty liver of pregnancy, with screening for LCHAD deficiency?
Why: Hypoglycemia and coagulopathy signal true liver failure, distinguishing AFLP from HELLP. LCHAD deficiency (a fatty acid oxidation disorder) is a known genetic association affecting both mother and fetus.
This intern has a twin sister
Who is Mutaz? (also played semi-pro soccer back home)
Pt from south america presents with fever and RUQ pain; imaging shows a solitary hepatic lesion, and serologic testing is positive. Aspiration is not performed. what is the appropriate treatment regimen??
Answer: Metronidazole (or tinidazole)
- followed by a luminal agent such as paromomycin?
Why: Amebic abscess is diagnosed serologically Metronidazole/tinidazole treats invasive tissue infection and then paromomycin is for the erdication of the intestinal colonization
A patient with a 2-cm HCC lesion is not a surgical candidate due to comorbidities, and the tumor is ≤3 cm. Tx?
Answer: What is ablation?
-radiofrequency/microwave ablation
Why: For small tumors (≤3 cm), thermal ablation; radioembolization for larger lesions (>3 cm)
A pregnant woman in her third trimester has a hepatitis B DNA level of 300,000. Tx to reduces the risk of vertical transmission? not counting beyond neonatal immunoprophylaxis
Answer: Starting tenofovir
Why: High maternal HBV DNA ( >200,000 ) associated with increased risk of transmission despite standard neonatal vaccination/HBIG; antiviral therapy in the third trimester further reduces viral load and transmission risk
This intern always checks the price of gold everyday
Who is Mushammar?
This resident once took the test to be on Jeopardy. This resident once rolled both a horse and a car in nearly fatal accidents. This resident loves Digimon. (2 truths and a lie)
Cam
Google: Digimon, short for "Digital Monsters", is a Japanese media franchise, which encompasses virtual pet toys, anime, manga, video games, films, and a trading card game.