Hepatology
Expert perspectives on liver disease, viral hepatitis, cirrhosis management, and liver transplantation.
Recent Discussions
How do you approach a patient who has incidentally found liver and renal cysts?
If has many cysts in both organs, then consider polycystic syndromes and should see a nephrologist and hepatologist. For liver cysts - determine if simple or complicated (irregular borders, thick septations) - if the latter then likely need sampling. regardless hepatic simple cysts not causing sympt...
What is your approach to a patient with an elevated alkaline phosphatase level, but negative PBC serologies and normal biliary imaging?
Look for non-biliary or non-liver causes of raised alkaline phosphatase. For example, nodular regenerative hyperplasia, bony causes, congestive cardiac failure.
In Fontan-associated liver disease (FALD), what clinical scenario would lead you to pursue an evaluation for simultaneous liver-heart transplant as opposed to heart alone if there is evidence of fibrosis on a liver biopsy?
Certainly, the stage of fibrosis (F3-F4) in a good quality biopsy indicates to pursue further evaluation. The presence of varices in the esophagus (distal), thrombocytopenia, and other signs of portal hypertension on cross imaging (abdominal collaterals, splenomegaly, low protein ascites) are import...
How would you differentiate neurologic manifestations of a patient with Wilson's disease versus manifestations of hepatic encephalopathy due to end-stage liver disease?
The neurological manifestations of Wilson's include movement disorders (tremor, dystonia, parkinsonian rigidity, dysarthria, gait abnormalities, pseudobulbar signs) and neuropsychiatric symptoms (impaired executive function, cognitive disorders, depression), ophthalmologic Kayser Fleischer rings. He...
How do you balance infection risk in patients with immune-mediated liver disease on chronic immunosuppression (ex: prednisone, AZA, MMF, etc)?
The risk of infection depends on patient-related factors (some related to liver disease, others due to other conditions) as well as the degree of immunosuppression. Patient-related risk factors include the presence of cirrhosis, age, diabetes, CKD, and others, which can increase the risk of infectio...
In what clinical scenario would you consider the use of budesonide over prednisone as part of the pharmacologic management of autoimmune hepatitis?
Primarily in patients where the side effects of prednisone will or are too difficult to tolerate (diabetics, weight gain, metabolic syndrome, psychiatric disease, etc). I like to try prednisone first because of its ability to elucidate a biochemical response, fairly rapidly, so we know what we are d...
How do you approach the surveillance and serologic evaluation of a patient in whom you suspect has a hepatitis B pre-core mutant?
HBeAg- HBeAb+/- with HBV DNA > 2 log likely precore mutant. Surveillance similar to wild-type with ALT and HBV DNA q6mos to assess for reactivation (abnormal ALT, DNA > 2000IU) that you would consider treating. If considering treatment, qHBsAg might be useful to identify patients who might be able t...
What role is there for the assessment of hepatitis B virus genotype as it pertains to pharmacologic therapy and HCC screening?
We always get genotype before treatment of HBV. It supplies a lot of valuable information.A-G not so much but resistance testing is important in case they took Chinese herbs with lamivudine in them unknowingly. What is really important though for risk of HCC is the presence of the Basal Core Promote...
When would you consider quantification of hepatitis B surface antigen as part of the treatment decision making process?
It is not absolutely necessary. Treatment initiation decisions primarily hinge on expected benefit for reduction of inflammation, injury and fibrosis. qHBsAg is primarily a predictor of treatment duration, the likelihood of HBsAg loss during treatment.
What clinical evidence do you find most favorable of a positive response post-liver transplant for patients with portopulmonary hypertension?
In our Mayo Clinic experience, POPH patients who normalize the PVR with therapy (measured by right heart catheterization pre-transplant) are most likely to resolve POPH post-transplant and come off of all pulmonary artery hypertension medications. Normalization of right ventricular function by echoc...