Case 1: A 19-year-old girl has presented to the ED, 5 days after deliberate ingestion of rat killer paste

(Ratol paste, 15g) with mild right upper quadrant abdominal pain, nausea and vomiting. She is
awake and alert, has mild icterus and hemodynamically stable. Her laboratory tests reveal: Na+ 126
(135-145 mEq/L) , K+ 3.3 (3.3 – 4.8 mEq/L), ser. creatinine 1.9 (0.7 - 1.5 mg/dL), Glucose 70 (70 – 110
mg/dL) , T. Bilirubin 2.8 (0.2 – 1.2 mg/dL ), AST 468 (4 – 40 U/L), ALT 420 (4-40 U/L), ALP 100 (4 – 110
U/L) , PT 21.7s (11.8-14.5 sec) ; INR 2.0.

a) What is the most probable diagnosis and what are the stages of rat killer paste poisoning?

b) Interpret the investigations?

c) How will you manage this patient?

d) List some other toxins which can cause similar manifestations.

Case 2: A 48-year-old man has presented with history of chronic hepatitis B and treatment with
entecavir for the past two years. He has stopped entecavir treatment for past five months. Two
weeks ago, the patient started experiencing fatigue, abdominal distension, yellow urine, and day
time somnolence and was evaluated in the local hospital. Liver function tests before hospitalization
showed alanine aminotransferase (ALT) 1007 U/L, aspartate transaminase (AST) 864 U/L, total
bilirubin (TBIL) 10mg/dl, and direct bilirubin (DBIL) 7mg/dl, while hepatitis B virus markers showed
HBsAg+, HBeAg+, Anti HBc IgG Ab+, and HBV-DNA 3.21 × 10 6 IU/L.

A. What should be the diagnostic considerations in this patient?

B. How will you further evaluate and manage this patient?

Case 3: A 22-year-old lady has presented with two-week history of right upper quadrant abdominal
pain, deepening jaundice, abdominal distension and fatigue. She was otherwise healthy previously,
apart from a diagnosis of acne vulgaris. She was prescribed some medications for postponement of
her periods 3 weeks back, during her brother’s marriage. She denied high-risk behaviours and had
no family history of liver disease. On examination, the patient was afebrile, her blood pressure was
119/79 mmHg, heart rate was 105 beats per minute, respiratory rate was 20 breaths per minute,
and her oxygen saturation was 99% on room air. She was alert and oriented with icteric sclera,
distended abdomen with shifting dullness and 1+ pitting edema of the lower extremities. Clinical
deterioration ensued with increasing abdominal distention and development of hepatic
encephalopathy. Further testing revealed negative results for hepatitis A and E (anti HAV and anti
HEV IgM Abs), hepatitis B (surface antigen, e antigen, and anti Hbc IgM), hepatitis C (anti HCV IgM
and IgG), anti-nuclear antibody and anti-smooth muscle antibody.

a) What are the diagnostic possibilities in this lady?

a) Which investigations will confirm your diagnosis?

b) How will you treat this patient?

Case 4: A 58-year-old man with history of diabetes and hypertension for the past 15 years has
presented to the hospital with fatigue, nausea, reduced appetite and yellowish urine for 7 days. He is
not an alcohol consumer and gives history of recent travel to attend a fair in his native village, 4
weeks prior to the onset of these symptoms. Initial physical examination showed scleral icterus and
tender liver palpable 3 cm below right costal margin. Lab investigations revealed elevated liver
enzymes (aspartate transaminase [AST] 4086 U/L and alanine Aminotransferase [ALT] 6798 U/L),
elevated total bilirubin (5.6 mg/dL) and elevated INR (2.5). He worsens overnight with marked
confusion and lethargy and subsequently becomes unconscious, requiring intubation.

a) What is the most likely diagnosis?

a) Interpret the investigations, what other investigations will you order?

b) How will you treat?

c) what is MELD Score?

d) What are the King’s college criteria for liver transplantation?