Serum-ascites Albumin Gradient Research Articles

B-Type Natriuretic Peptide Levels in New-Onset Ascites

Cirrhosis and heart failure are common causes of ascites. The serum-ascites albumin gradient (SAAG) is usually ≥1.1 g/dL in both conditions, and the

84-Year-Old Man With Night Sweats, Weight Loss, and Diarrhea

An 84-year-old man with a history of coronary artery disease, hypertension, hyperlipidemia, ischemic stroke, and gastroesophageal reflux disease presented to the outpatient gastroenterology clinic with a 3-month history of night sweats, generalized weakness, nausea, vomiting, nonbloody postprandial diarrhea, and an 18-kg weight loss. He also reported a recent rash and daily morning stiffness in his fingers and knees lasting up to about 30 minutes. He denied alcohol or intravenous drug abuse. Previously, he had been taking several medications, but all had been recently discontinued because of the persistent diarrhea. On examination, the patient had normal vital signs. He appeared cachectic, with a distended abdomen with flank dullness but no pain on palpation. The joints of his fingers and knees were tender to palpation, and soft tissue swelling was evident. No other abnormalities were found on examination of the head, ears, eyes, nose and throat, skin, and lymphatic, cardiac, respiratory, and thyroid systems. A computed tomographic (CT) scan of the abdomen and pelvis obtained 1 month previously at another institution revealed abdominal and pelvic ascites and mildly prominent aortocaval and periportal lymph nodes. A positron emission tomographic/CT scan also obtained at another facility did not suggest malignancy.

Ascitic Fluid Analysis in the Differential Diagnosis of Ascites: Focus on Cirrhotic Ascites

Ascites is the pathologic accumulation of fluid within the peritoneal cavity. Because many diseases can cause ascites, in particular cirrhosis, samples of ascitic fluid are commonly analyzed in order to develop a differential diagnosis. The concept of transudate versus exudate, as determined by total protein measurements, is outdated and the use of serum-ascites albumin gradient as an indicator of portal hypertension is more accurate. Lactate dehydrogenase (LDH), vascular endothelial growth factor (VEGF), and other tumor markers can be helpful in distinguishing between malignant and benign conditions. Glucose and adenosine deaminase levels may support a diagnosis of tuberculous disease, and amylase level may indicate a diagnosis of pancreatitis. Given the specificity and sensitivity of laboratory results, accurate diagnosis should be based on both laboratory data and clinical judgment.

Serum B-type natriuretic peptide in the initial workup of patients with new onset ascites: A diagnostic accuracy study

Heart failure (HF) is, after cirrhosis, the second-most common cause of ascites. Serum B-type natriuretic peptide (BNP) plays an important role in the diagnosis of HF. Therefore, we hypothesized that BNP would be useful in the differential diagnosis of ascites. Consecutive patients with new onset ascites were prospectively enrolled in this cross-sectional study. All patients had measurements of serum-ascites albumin gradient (SAAG), total protein concentration in ascitic fluid, serum, and ascites BNP. We enrolled 218 consecutive patients with ascites resulting from HF (n = 44), cirrhosis (n = 162), peritoneal disease (n = 10), and constrictive pericarditis (n = 2). Compared to SAAG and/or total protein concentration in ascites, the test that best discriminated HF-related ascites from other causes of ascites was serum BNP. A cutoff of >364 pg/mL (sensitivity 98%, specificity 99%, and diagnostic accuracy 99%) had the highest positive likelihood ratio (168.1); that is, it was the best to rule in HF-related ascites. Conversely, a cutoff ≤ 182 pg/mL had the lowest negative likelihood ratio (0.0) and was the best to rule out HF-related ascites. These findings were confirmed in a 60-patient validation cohort. Serum BNP is more accurate than ascites analyses in the diagnosis of HF-related ascites. The workup of patients with new onset ascites could be streamlined by obtaining serum BNP as an initial test and could forego the need for diagnostic paracentesis, particularly in cases where the cause of ascites is uncertain and/or could be the result of HF.

Clinical study of ascites with special reference to Serum-Ascitic Albumin Gradient

Background: The Serum – Ascites Albumin Gradient (SAAG) defined as serum albumin concentration minus ascitic fluid albumin concentration. SAAG has been proposed a physiologically based alternative criterion in the classification of ascites. Aims & Objective: The present study was designed to differentiate ascites based on serum/ascites albumin gradient and comparing transudate and exudate concept using biochemical parameters. The study also designed to know various aetiologies of ascites. Material and Methods: This cross sectional study was done among 60 patients with ascites in Kasturba Medical College Mangalore from September 2006 to September 2008. Ascitic fluid and blood samples were sent for various investigations depending on the presentation of the patient to hospital. Results: In our study Cirrhosis of liver was the most common cause of ascites (78%) followed by Tubercular peritonitis (8%) and alcohol was the commonest cause for cirrhosis of liver (85%) followed by Hepatitis B virus infection. Cirrhosis of liver showed high SAAG compared with tubercular peritonitis and malignant ascites which showed low SAAG. Among High SAAG patients 96% had portal hypertension. Transudative ascites observed in 72.5% of cirrhosis patients whereas tubercular peritonitis showed exudative type in60% of cases. Conclusion: Cirrhosis liver was the most common cause of Ascites and alcohol was the commonest cause for cirrhosis. SAAG is superior to transudate exudate concept in differentiating the causes of ascites. High SAAG indicates presence of portal hypertension and low SAAG indicates absence of portal hypertension.

Diagnostic Value of Serum Ascites Lipid Gradients in Patients with Ascites

Introduction: Differential diagnosis of ascites is a common clinical problem. Aim of the work: To study the value of Serum Ascites Lipid Gradients (SALG) of total cholesterol, triglyceride, HDL cholesterol, and LDL cholesterol in the diagnosis of ascites. Materials and methods: The study was conducted on patients with ascites admitted to Tropical Medicine and Gastroenterology Department, Assiut University. The study included 115 patients with ascites of different etiologies (liver cirrhosis, tuberculosis, and malignant ascites). Clinical evaluation, abdominal ultrasonography, and laboratory investigations were conducted as follows: Serum Ascites Albumin Gradient (SAAG), serum lipid profile, and SALG of total cholesterol, triglyceride, HDL cholesterol, and LDL cholesterol. Results: SAAG values were 1.87 ± 0.537 (>1.1), 0.58 ± 0.112 (<1.1), and 0.69 ± 0.201 (<1.1) gm/dL respectively for patients with liver cirrhosis, tuberculosis, and malignancy. The SALG levels for differentiating high SAAG (cirrhosis) from low SAAG (tuberculosis and malignancy) were 97.9 ± 28.6 versus 52.7 ± 32.35 and 49.4 ± 28.64 for SALG- total cholesterol, 74.7 ± 28.2 versus 56.9 ± 48.0 and 48.3 ± 29.23 for SALG- triglyceride, 28.67 ± 9.11 versus 18.53 ± 15.7 and 14.7 ± 14.8 for SALG- HDL cholesterol, 55.7 ± 26.1 versus 17.93 ± 38.5 and 28.5 ± 13.65 for SALGLDL cholesterol respectively. These values are significantly higher in cirrhosis than tuberculosis or malignancy. The cut-off SALG values being 67 mg%, 66 mg%, 26 and 49 mg% in cholesterol, triglyceride, HDL cholesterol, LDL cholesterol respectively in differentiating cirrhotic ascites from tuberculosis or malignant ascites A close relationship between the levels of SALG and severity of cirrhosis is found but it is not significant. Conclusion: SALG has important value in differentiation cirrhotic ascites from tuberculosis or malignant ascites but cannot differentiate tuberculosis ascites from malignant ascites.

Traditional Chinese medicine compound for patients with liver cirrhosis and ascites: Efficacy and effect on serum lactate dehydrogenase, glucose, and serum ascites albumin gradient

Traditional Chinese medicine compound for patients with liver cirrhosis and ascites: Efficacy and effect on serum lactate dehydrogenase, glucose, and serum ascites albumin gradient

Bacteriologic study of cirrhotic patients with non-neutrocytic ascites.

We aimed for detection of bacterial DNA (bactDNA) in spontaneous bacterial peritonitis (SBP) by polymerase chain reaction (PCR) and its prognostic relevance in cirrhotic patients with culture-negative non-neutrocytic ascites (CNNNA). approximately 60% of patients with spontaneous bacterial peritonitis (SBP) are ascites culture negative. Of each 77 patients with cirrhosis and ascites, two samples including blood and ascitic fluid (AF) were taken. Blood samples were obtained for routine biochemical study and PMN count. AF samples were used for biochemical analysis and aerobic and anaerobic culture. BactDNA was detected by polymerase chain reaction (PCR) using bacterial universal 16srRNA gene primer. Of all AF samples, 3 (3.9%) were positive for bacterial culture (one streptococcus α hemolytic and two E.coli). The mean number of PMN in AF was 63. BactDNA was detected in 33 (42.9%) of 77 of samples (group A) and bactDNA was absent in 41 (53.2%) of samples (group B). Blood WBC, prothrombin time, LDH, serum total protein, AF WBC, serum albumin, AF albumin, AF total protein, serum total bilirubin, AST, ALT and BUN were not statically different among group A and B. Hepatitis B, 41(45%), was the most frequent cause of cirrhosis. Hepatitis B is the common cause of cirrhosis in Iranian cirrhotic patients. Also, current study showed that high number of Iranian cirrhotic patients with CNNNA carries bactDNA in their AF. The clinical findings as well as clinical laboratory data in patients with CNNNA are independent to bactDNA status in their ascitic fluid.

Peritoneal Tuberculosis Mimicking Peritoneal Carcinomatosis

A 67-year-old male presented with fatigue, abdominal pain , and 30-pound weight loss over 3 months. Computerized tomography (CT) abdomen displayed ascites with thickening and enhancement of the peritoneum and mottled nodular appearing as soft tissue consistent with omental caking worrisome for peritoneal carcinomatosis. A paracentesis revealed white blood cell count of 2,500 with 98% lymphocytes and serum ascites albumin gradient of 0.9 g/L. No acid-fast bacilli were seen by microscopic exam and culture was negative. Purified protein derivative skin test (PPD) was negative and CXR did not reveal any infiltrates. Esophagogastroduodenoscopy (EGD) and colonoscopy were unrevealing. The patient underwent exploratory laparotomy with round ligament and peritoneal biopsies that revealed numerous necrotizing granulomas. Acid-fast bacteria Ziehl-Neelsen stain (AFB) of the biopsy specimen revealed single acid-fast bacilli. Treatment for M. tuberculosis was initiated and final culture revealed that mycobacterium tuberculosis was sensitive to Isoniazid, Rifampin, Ethambutol, and Pyrazinamide. After 6 months of treatment, the ascites and peritoneal carcinomatosis resolved.

An Abnormal Presentation of Ascites

Purpose: A 73-year-old female patient with a history of hypertension, gastro-esophageal reflux disease, and hemorrhoids presented with abdominal distention, pain, and alternating constipation and diarrhea. On exam, she was hypotensive, and her abdomen was distended with a positive fluid wave. Computer tomography (CT) imaging of the abdomen showed minimal to moderate bilateral pleural effusions, and moderate abdominal pelvic ascites. Diagnostic paracentesis demonstrated a serum ascites-albumin gradient (SAAG) of greater than 1.1, with cytology revealing cells of malignant adenocarinoma, mullerian in origin. While the majority of patients who present with ascites have underlying liver disease, 20% demonstrate an extrahepatic etiology, half of which are malignancy-related ascites.1 Malignant ascites is a sign of peritoneal carcinomatosis,2 diagnosed when paracentesis demonstrates positive cytology, elevated protein concentrations, and a low SAAG.3 Accurate characterization of the malignancy is vital, as proper treatment can result in positive responses in a majority of patients, with a minority making complete recovery.4 Though surgical debulking with adjuvant chemotherapy is the preferred treatment,5 chemotherapy alone was initiated, as our patient was a poor surgical candidate. She responded to carboplatin and paclitaxel, with CA-125 decreasing from 15,000 to 600 over 5 months, but chemotherapy was stopped due to an illness, and her CA-125 increased to 7,000 over two months. A follow-up CT showed an increase in peritoneal carcinomatosis with upper abdominal lymphadenopathy and omental disease. She has since restarted chemotherapy. Common presentations of rare diseases are difficult to diagnose. This patient's rare cause of ascites, mullerian adenocarcinoma, is a prime example of this scenario. As ascites can signify a multitude of different diseases and pathologies, maintaining a broad differential when faced with ascites is important to decrease unnecessary treatment, reduce hospitalizations, and improve patient care.

Erosional response to northward-propagating crustal thickening in the coastal ranges of the U.S. Pacific Northwest

<h3>Background</h3> Spontaneous bacterial peritonitis is an infection of high serum-ascites albumin gradient (SAAG) ascites which usually occurs with cirrhosis. Various antibiotics are used for primary and secondary prevention of spontaneous bacterial peritonitis (SBP). We planned this study to systematically review the evidence from randomised studies comparing various antibiotics with placebo or one another for primary and secondary prevention of SBP. <h3>Methods</h3> We did a comprehensive literature search using various databases (i.e. MEDLINE via Ovid and PubMed, Embase, Scopus, Web of science, LILIAC, Cochrane Central Register of Controlled Trials and clinicaltrials.gov from inception to 6^th September 2018. The search strategy contained no language restrictions and used following keywords ‘Liver cirrhosis’, ‘Chronic liver disease’, ‘Chronic Liver Failure’, ‘Primary prevention’, ‘Secondary prevention’, Antibiotic, Norfloxacin, Rifaximin, Ciprofloxacin and TMP-SMX. Only those randomised studies were included which evaluated the role of antibiotics in high-risk cirrhosis patients of more than 18 years of age for primary or secondary prophylaxis of spontaneous bacterial peritonitis. Our outcomes were occurrence/recurrence of SBP episode, extra-peritoneal infections, any adverse effects and reduction in mortality. We did random-effects network meta-analysis using a Bayesian approach, and calculated odds ratios (ORs) and 95% CrI; agents were ranked using rank probabilities. <h3>Results</h3> We found total 1211 records in our systematic database search and out of these 17 randomised trials were found eligible for network meta-analysis. In aggregate group of both primary and secondary SBP, for the outcome of SBP occurrence/recurrence Rifaximin daily, Norfloxacin daily, Rifaximin Norfloxacin daily, Ciprofloxacin intermittent and Trimethoprim-sulfamethoxazole daily were found to be having an odds of 0.050(0.0049–0.21), 0.17 (0.048–0.41), 0.053(0.0036–0.35), 0.17(0.028–0.76) and 0.16(0.027–0.62) as compared to that of placebo. The rank probability showed that Rifaximin Norfloxacin daily and Rifaximin daily has a probability of 0.42 and 0.41 respectively for getting ranked as one. <h3>Conclusions</h3> CIprofloxacin, Norfloxacin, Trimethoprim-sulfamethoxazole and Rifaximin are useful in prophylaxis of SBP in patients with cirrhosis.

RETRACTED ARTICLE: New proposal for the serum ascites albumin gradient cut-off value in Chinese ascitic patients

BackgroundSerum ascites albumin gradient (SAAG) has been recognized as a reliable marker in the differential diagnosis of ascites. The etiological background of cirrhosis is rather different between western countries and eastern countries. The threshold of SAAG in Chinese ascitic patients has not been evaluated yet. The aim of this study was to define a new reasonable threshold of SAAG in Chinese ascitic patients.MethodsAdult patients with ascites admitted to the Shanghai Changzheng Hospital from Jan 2004 to Jun 2010 were retrospectively analyzed. The diagnostic criteria for cirrhotic ascites are clinical manifestations, radiological features and esophageal-gastric varicosis, or histopathology. Serum was detected by chemical method using a commercial kit. We used receiver operating characteristic (ROC) analysis to achieve maximal sensitivity and specificity of SAAG.ResultsThe mean value of SAAG in portal-hypertension-related ascites was significantly higher than that in the non-portal-hypertension-related ascites (21.15 ± 4.38 g/L vs 7.48 ± 3.64 g/L, P = 0.002). The SAAG cut-off value under 12.50 g/L predicted portal hypertension ascites with the sensitivity of 99.20%, specificity of 95.10% and accuracy of 97.65%.ConclusionsSAAG is useful to distinguish portal-hypertension-related ascites and non-portal-hypertension-related ascites, and 12.50 g/L might present as a more reasonable threshold in Chinese ascitic patients.Virtual slidesThe virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/1602582638991860.

Serum B-type natriuretic peptide is more accurate than ascites analyses in the diagnosis of ascites related to heart failure

Purpose: Heart failure (HF) is, after cirrhosis, the second most common cause of ascites. Serum B-type natriuretic peptide (BNP) plays an important role in the diagnosis of HF. We therefore hypothesized that BNP would be useful in the differential diagnosis of ascites. Methods: Consecutive patients with new onset ascites were prospectively enrolled in this cross-sectional study. All patients had measurements of serum-ascites albumin gradient (SAAG), total protein concentration in ascitic fluid, serum and ascites BNP. We enrolled 218 consecutive patients with ascites due to HF (n=44), cirrhosis (n=162), peritoneal disease (n=10) and constrictive pericarditis (n=2). Results: Compared to SAAG and/or total protein concentration in ascitic fluid, the test that best discriminated HF-related ascites from other causes of ascites was serum BNP. A cutoff of >364 pg/mL (sensitivity 98%, specificity 99%, diagnostic accuracy 99%) had the highest positive likelihood ratio (168.1), that is, it was the best to rule-in HF-related ascites. Conversely, a cutoff ≤182 pg/mL had the lowest negative likelihood ratio (0.0) and was the best to rule-out HF-related ascites. These findings were confirmed in a 60-patient validation cohort. Conclusions: Serum BNP is more accurate than ascites analyses in the diagnosis of HF-related ascites. The workup of patients with new onset ascites could be streamlined by obtaining serum BNP as an initial test. A positive test would forego the need for a diagnostic paracentesis.

Diagnostic laparoscopy in the era of modern imaging—retrospective analysis from a single center

A retrospective analysis of utility and outcomes of diagnostic laparoscopy at our center in the last 5 years was done. In the last 5 years, we subjected 90 patients to diagnostic laparoscopy (DL) when final diagnosis could not be achieved after all necessary imaging methods and serological, cytological, and microbiological investigations. DL was performed under sedation and local anesthesia, and patients were discharged within 24 h. Video documentation along with guided biopsies/collection of the samples for culture and other tests was performed. The commonest indication was ascites (46/90), followed by diffuse liver disease (15), focal liver disease (9), intraabdominal malignancies (10), and miscellaneous (10). Overall accuracy of DL was 91 %. In 64 % of patients, laparoscopy confirmed the clinical diagnosis, and in 27 % of patients, laparoscopy was useful in correcting the diagnosis. DL was performed in 46 patients with low-serum ascitic fluid albumin gradient ascites and ascites of mixed etiology. DL confirmed the suspected diagnosis in 48 %, corrected in 38 %, and yielded unsuspected diagnosis in 15 % patients. In 6 % of patients, laparoscopy was inconclusive. In three patients, there were extensive intraperitoneal adhesions, and adequate examination was not possible. No serious complications were encountered. Minor complications of pain at the port site, ascitic fluid leakage, and port site infection were seen in three, two, and one patient, respectively. DL is useful in patients when diagnosis and extent of the disease were unclear especially in ascites of undetermined etiology.

DIAGNOSIS OF TUBERCULOUS ASCITIES;

Diagnosing Tuberculous ascites is a challenge. Polymerase chain reaction (PCR) and adenosine deaminase activity(ADA) have come up as promising modalities to aid diagnosis of tuberculosis in body fluids. Objective: To find and compare theusefulness of ADA and PCR in ascitic fluid in diagnosis of peritoneal tuberculosis. Study Design: A cross-sectional study. Place of Study:Medical Unit-I, Ghulam Mohammad Mahar Medical College Hospital, Sukkur. Duration of Study: From January 2010 to July 2011.Methods: Fifty five patients of exudative ascites, were diagnosed as peritoneal tuberculosis by following criteria- clinical suspicion, PPD(Skin Tuberculin test) positive, suggestive bacteriological and/or imaging findings and ascitic fluid showing lymphocytosis withdecreased glucose and SAAG (Serum- Ascites albumin gradient) of &lt;1.1 gm/ dL. PCR and ADA were performed in the ascitic fluid andpositivity rates determined and compared. Results: Out of 55 study subjects, 50 patients (90.9%) were PCR positive and 48 (87.3%)were ADA positive; both were equiefficacious (p=0.54). High agreement between PCR and ADA tests was noted. Conclusions: ADA andPCR are comparable as diagnostic modality for tuberculous peritonitis, however ADA scores over PCR because of easy availability, lowcost, less infrastructure requirement and less-time consuming.

Differentiation of exudate from transudate ascites based on the dipstick values of protein, glucose, and pH

The aim of present study was to determine the reliability of the dipstick values (protein, glucose, and pH) for differentiation of exudate from transudate ascites in comparison with the serum-ascites albumin gradient as criterion standard. A total of 100 patients with ascites (58 males and 42 females; mean age, 55.6 ± 16.1 years) were studied for the different causes of ascites. Peripheral blood samples were obtained, and at the same time, the patients underwent paracentesis. There were 62 cases (62.0%) of transudate ascites and 38 (38.0%) of exudates ascites, based on serum-ascites albumin gradient. Using logistic regression, we found a dipstick equation (K = 0.012Protein − 0.012Glucose − 3.329pH + 23.498) to differentiate transudate (K < 0) from exudate (K > 0) ascites. The sensitivity, specificity, positive predictive value, and negative predictive value of dipstick equation to diagnose ascites as transudate and exudate were 93.8%, 94.4%, 96.8%, and 89.5%, respectively, and 94.4%, 93.9%, 89.5%, and 96.9%, respectively. The area under the receiver operating characteristic curve was 0.915 (95% confidence interval, 0.848-0.982; P < .001). We concluded that the dipstick can be an inexpensive, rapid, and simple option for categorizing ascites into transudate and exudate and can be used routinely for this purpose in clinical practice.

Usefulness of serum ascites cholesterol gradient (SACG), total protein (TP) ratio and serum ascites albumin gradient (SAAG) in differentiating tuberculous ascites and cirrhotic ascites

Background: Differential diagnosis of ascites is a common clinical problem and is usually done by Serum Ascites Albumin Gradient (SAAG).However many other markers can also be utilized for the same. Aims & Objective: This study was carried out to evaluate the diagnostic efficiency of ascitic fluid cholesterol, serum ascites albumin gradient (SAAG) , Total protein Ratio and serum ascites cholesterol gradient (Chol gradient/ SACG) in differentiating cirrhotic and tuberculous ascites. Material and Methods: The study included 48 patients admitted in St John’s Medical Hospital, Bangalore, out of which 25 patients were diagnosed with tuberculous ascites and 23 patients were diagnosed with cirrhotic ascites. Serum and ascitic fluid (AF) albumin, Total protein (TP) and Cholesterol (Chol) were estimated. The SAAG, TP ratio, Serum ascites cholesterol gradient (SACG) were calculated. Significance was assessed at 5% level of significance. Cohen’s d effect size has been computed and discrimination function analysis is done to determine the percentage of correct classification between cirrhotic and tubercular ascites. Results: SAAG showed a sensitivity and specificity of 100% and 95.6% at cut off of >1.1g/dl TP ratio at a cut off > 0.5 showed sensitivity100% and specificity98% specificity. Ascitic fluid Cholesterol is high in the tuberculous group and showed sensitivity and specificity of at a cut off value of 100% and 95.5%. Ascitic fluid TP showed a sensitivity and specificity of 100% and 96% at a cut off value of

Hydatid cyst of liver complicated with Budd-Chiari syndrome and portal vein thrombosis

Hydatid cyst of liver complicated with Budd-Chiari syndrome and portal vein thrombosis

Peritoneal Tuberculosis in an Immunocompetent, Unknown Risk Patient

A 36-year-old man with no significant past medical history presented with two-month abdominal distention, night sweats, and weight loss of 15 Ib. He had no known exposure to tuberculosis. PPD test was negative prior to the hospital admission. Physical examination was notable for new onset ascites, but no superficial lymphadenopathy or stigmata of chronic liver disease was found. CT scan demonstrated enlarged mesenteric lymph nodes, and prominent retroperitoneal lymph nodes along with moderate ascites and omental infiltration. Diagnostic paracentesis yielded WBC of 295/mm3, lymphocytic predominance (70%), and serum ascitic albumin gradient of 0.1, consistent with exudate. Both the ascitic culture and AFB smear were negative, and ascitic cytology revealed nonmalignant cells. Exploratory laparoscopy for excisional biopsy of mesenteric lymph nodes was performed. Pathologic findings revealed caseous granulomas with scattered multinucleated giant cells. Mesenteric lymph node tissue culture subsequently grew Mycobacterium tuberculosis complex and the diagnosis of peritoneal tuberculosis was confirmed. The patient was started on quadruple therapy. A couple of days after the antibiotics were started, the small bowel obstruction started to resolve with resumption of bowel movements and tolerance of oral intake. A week later, ascites stopped accumulating and fever was no longer noted. He has been well and continues to be under observation.

Multiple Choice Questions

1.Regarding drug induced liver injury (DILI) the following are TRUE EXCEPT:1.Most common cause of drug induced acute liver failure in India is paracetamol.2.Most common cause of drug induced liver injury in India is antitubercular drugs.3.Degree of liver enzyme elevation correlates with severity of liver disease.4.Clinical jaundice is a predictor of mortality.5.Cholestatic pattern of DILI can be prolonged even on stopping the offending drug.2.Regarding surgery in patients with liver disease the following are TRUE:1.Child-Turcotte-Pugh (CTP) and model for end-stage liver disease (MELD) scores can reliably predict operative mortality in chronic liver disease.2.Acute viral hepatitis is not a contraindication for surgery.3.Laparoscopic cholecystectomy can be safely performed in compensated cirrhotics.4.Umbilical hernias have low risk of complications in cirrhotics and elective repair should not be attempted.5.Preferred anaesthetic agents include sevoflurane, desflurane and isoflurane.3.Regarding peri-operative monitoring after liver transplantation the following are TRUE:1.Cardiovascular events are the most common cause of readmission to intensive care and non-graft related deaths after liver transplantation.2.Conventional tests of coagulation like prothrombin time, activated partial thromboplastin time, platelet count and plasma fibrinogen levels are sufficient measure of coagulation intra-operatively.3.Hyperglycemia is an ominous sign of poor graft function.4.Serum potassium levels are independent predictors of death after liver transplantation.5.Commonest acid-base disorder in the immediate post-operative period is metabolic acidosis.4.Regarding tuberculosis (TB) in chronic liver disease the following are TRUE EXCEPT:1.Cirrhotic patients have a higher chance of developing extra-pulmonary tuberculosis than those without cirrhosis.2.Adenosine deaminase for diagnosis of TB in cirrhosis with ascites has high sensitivity.3.Tuberculin skin testing is sensitive for the diagnosis of TB in cirrhotic patients.4.Likelihood of anti-tubercular drug induced hepatotoxicity is higher in pre-existing liver disease patients.5.Isoniazid induced hepatotoxicity is more common in slow acetylators.5.Regarding hepatotoxicity of anti-tubercular therapy (ATT) the following are TRUE:1.Rechallenge with isoniazid is contraindicated if patient has history of isoniazid induced hepatotoxicity.2.Isoniazid induced transaminitis is self limited and asymptomatic in majority of patients.3.Isolated conjugated hyperbilirubinemia is seen with rifampicin.4.Pyrazinamide mainly causes idiosyncratic hepatotoxicity.5.Inactive carriers of hepatitis B do not have increased risk of ATT induced hepatotoxicity.6.Regarding Budd-Chiari syndrome (BCS) the following are TRUE EXCEPT:1.Most common cause of BCS in India is membranous obstruction of inferior vena cava.2.Ascites with high protein and high serum ascitic albumin gradient is suggestive of BCS.3.Initial imaging modality of choice to diagnose BCS is magnetic resonance venogram.4.Failure to visualize the hepatic veins on Doppler is diagnostic of BCS.5.Direct intrahepatic portosystemic shunt can be done even if all hepatic vein ostia are blocked.7.Regarding the role of gut microbiota in hepatic encephalopathy (HE) the following are TRUE:1.Markers of systemic inflammation are better correlated with HE than the severity of liver disease.2.Pathogen associated molecular patterns (PAMPs) are microbial components that initiate inflammatory cascade.3.Gut microbiota of patients with cirrhosis and normal controls is similar.4.Lactulose exerts its actions in HE predominantly by altering the composition of gut microbiota.5.Stool microbiota is an accurate estimate of intestinal microbiota.8.Regarding primary sclerosing cholangitis (PSC) the following are TRUE:1.Majority of patients with PSC have isolated extrahepatic disease.2.Magnetic resonance cholangiography is the diagnostic modality of choice.3.Dominant stricture is a stenosis with a diameter of <1.5 mm in the hepatic duct or of <1 mm in the common bile duct.4.Inflammatory bowel disease is usually diagnosed after diagnosis of PSC.5.Cholecystectomy is recommended in a patient with PSC with a gallbladder mass lesion, irrespective of its size.9.Regarding primary biliary cirrhosis (PBC) the following are TRUE EXCEPT:1.Antimitochondrial antibodies (AMA) are highly sensitive and specific for the diagnosis of PBC.2.AMA negative cases of PBC have less aggressive disease and better prognosis.3.Ursodeoxycholic acid improves symptoms but does not alter natural course of PBC.4.Modafinil may improve fatigue in patients with PBC.5.Sjogren's syndrome occurs more frequently in PBC than matched controls.10.Regarding overlap syndromes the following are TRUE:1.Overlap of autoimmune hepatitis (AIH) and PBC is the most common variant.2.Overlap of PSC and PBC is common.3.Autoimmune sclerosing cholangitis refers to features of PSC in children with AIH.4.The components of the overlap syndrome may develop sequentially with one appearing years after the first.5.UDCA does not have a beneficial role in overlap syndromes.