60-year-old male with history of HCV cirrhosis s/p deceased donor liver transplant with duct-to-duct biliary anastomosis six months ago presents with jaundice, dark urine, pruritus, and pale stools. Exam is notable for icterus. Labs revealed a total bilirubin of 10 mg/dL, direct bilirubin 5 mg/dL, ALP 538 u/L, AST 36 u/L, and ALT 41 u/L. INR is 1.0. Labs from three weeks prior were notable for a normal bilirubin and mildly elevated ALP to 181 u/L which has been rising. Doppler ultrasound reveals coarsened hepatic echotexture, patent vessels, and intrahepatic biliary dilatation to 1cm.

What is the next best step?

A 66 year old male with a history of compensated alcohol-related cirrhosis presents with abdominal swelling and a ten pound weight gain but denies any other symptoms. His exam is notable for normal vital signs and abdominal distension, and labs show an increase in his MELD-Na from 11 to 17, primarily due to an increased bilirubin and INR. AST and ALT are 17 and 13, respectively. What is the most likely cause of his acute decompensation?

A 44 year-old female with a past medical history of hypothyroidism and obesity presents with acute onset right upper quadrant abdominal pain radiating to the back and sternum. Associated symptoms include nausea and lightheadedness with standing. Her medications include Levothyroxine and an oral contraceptive pill (OCP).

Lab work-up reveals total bilirubin 0.2 mg/dL, alkaline phosphatase 150 U/L, ALT 113 U/L, AST 104 U/L, INR 0.9, WBC 14.3 K/uL, hemoglobin 9.3 g/dL, platelet count 488, Lactate 4.5 mmol/L.

On physical exam hepatomegaly is palpable and she is significantly tender to palpation in the epigastrium and right upper quadrant.

What is the next best step?

65 year old female with a history of steroid dependent pemphigus vulgaris would like a second opinion on treatment options. Upon review of her medical records, the rheumatologist discovers she has a history of positive hepatitis B core antibody and refers her to hepatology clinic for further workup. 

Her rheumatologist would like to start her on rituximab and would like to know if this can be initiated immediately. What do you do next?

A 39 year-old female was referred for an abnormal liver profile after she noted scleral icterus, fatigue, and pruritus. She denies alcohol, substance, herbal supplement, or recent antibiotic use. Labs demonstrate an alkaline phosphatase of 462 u/l, AST 277 u/l, ALT 281 u/l, total bilirubin 1.9 mg/dl, direct bilirubin 1.0 mg/dl, INR is normal. Viral serologies were notable for immunity to HAV and HBV and negative HCV antibody. Ultrasonography revealed hepatomegaly and coarsened echotexture. Her primary care provider obtained an ANA in evaluation of a silvery plaque which was elevated to >1:2560 titer. You order several studies which are remarkable for significantly elevated IgG level, positive anti-mitochondrial antibody, and positive anti-smooth muscle antibody.

A 19-year-old male with past medical history of hypoplastic left heart syndrome s/p Fontan surgery 15 years ago is referred to be seen in hepatology clinic for screening for Fontan associated liver disease (FALD). Which of the following is the best clinical predictor of FALD?

61 year old male with alcohol-related cirrhosis presents with severe ascites. He had a therapeutic paracentesis with improvement in his ascites and underwent a surveillance EGD which showed large varices that were then banded. The following day, he developed tachycardia, hypotension, and hematochezia. A nasogastric tube was placed to suction without blood return.

What is the most likely etiology of the bleed?

A 40 year-old female with a past medical history of dermatomyositis, interstitial lung disease (ILD) and hypothyroidism is referred to the hepatology clinic for elevated liver enzymes. Labs reveal total bilirubin 0.3 mg/dL, alkaline phosphatase 177 U/L, ALT 237 U/L, AST 156 U/L, INR 1.0, platelet count 250. Medications include Rituximab Q4 weeks, Mycophenolate sodium 720 mg BID, Prednisone 10 mg daily, Bactrim 800-160 QMWF and Synthroid 88 mcg daily. Serologic workup reveals positive Hep E RNA PCR. What is the next best step?

A 57-year-old woman presents with an acute history of fevers to 101°F, RUQ abdominal pain, fatigue, arthralgias, and elevated liver enzymes. Her symptoms first started two weeks prior to presentation. She does not drink alcohol or use illicit drugs. She has not had any recent travel. She does not take NSAIDs or Tylenol. Her labs on admission are WBC 6.5, Hct 42, Plts 222, ALT 348, AST 225, ALP 185, Tbili 4.5, INR 1.1. A Tylenol level is undetectable. Hepatitis A, B, and C testing are negative. COVID-19 testing and tickborne panel are negative. A doppler ultrasound of the liver is normal. Additional lab testing revealed a positive antinuclear antibody, an elevated anti-smooth muscle antibody at a titer of 1:320 and an elevated IgG at 2052. What is the next best step in evaluation and/or management? 

A 45-year-old female underwent colonoscopy for iron deficiency and chronic diarrhea with associated flushing and was found to have an erythematous region in her terminal ileum. Biopsies revealed a neuroendocrine tumor. She undergoes an abdominal MRI showing multiple hepatic lesions and a mass near the terminal ileum. She was referred to oncology and started on octreotide depot injections for symptom control. Liver biopsy confirmed metastatic well-differentiated neuroendocrine tumor with synaptophysin and chromogranin stains positive. An octreotide scan demonstrated multiple avid foci in the liver but no extrahepatic lesions. An echocardiogram showed normal LV and RV function without valvulopathies.  She now presents to Hepatology clinic for assessment.

What is the next best step?