(a) Discuss in short the etiology, diagnosis, treatment and complications of cirrhosis of liver. (5+5+5+5=20 marks) (b) A…

(a) Cirrhosis of the liver

Cirrhosis is diffuse hepatic fibrosis with regenerative nodules and distorted architecture.

Aetiology: alcohol; chronic hepatitis B and C; metabolic dysfunction-associated fatty liver disease; autoimmune hepatitis; biliary diseases (primary biliary cholangitis, primary sclerosing cholangitis); Wilson disease, haemochromatosis and alpha-1 antitrypsin deficiency; vascular causes (Budd–Chiari syndrome, chronic right heart failure); drugs and cryptogenic causes.

Diagnosis:

• Clinical: jaundice, spider naevi, palmar erythema, gynaecomastia, ascites, splenomegaly and collaterals.
• Laboratory: thrombocytopenia, low albumin, prolonged INR, raised bilirubin, AST above ALT in alcohol-related disease.
• Imaging: ultrasound shows nodular surface, coarse echotexture and portal hypertension; elastography shows stiffness.
• Upper endoscopy for varices; ascitic fluid analysis; liver biopsy if the cause is uncertain.
• Severity by Child–Pugh and MELD scores.

Treatment:

• Treat the cause: alcohol abstinence, antivirals for hepatitis B and C, weight loss, copper chelation in Wilson disease; vaccinate against hepatitis A and B.
• Varices: non-selective beta-blocker (propranolol or carvedilol) and endoscopic band ligation.
• Ascites: sodium restriction, spironolactone with furosemide, paracentesis with albumin; norfloxacin or ciprofloxacin prophylaxis after spontaneous bacterial peritonitis.
• Encephalopathy: lactulose and rifaximin.
• Hepatorenal syndrome: terlipressin with albumin; TIPS in selected patients.
• Liver transplantation for decompensated disease; ultrasound every 6 months for hepatocellular carcinoma.

Complications: variceal bleeding, ascites, spontaneous bacterial peritonitis, hepatic encephalopathy, hepatorenal syndrome, hepatopulmonary syndrome, coagulopathy, hypersplenism, malnutrition and hepatocellular carcinoma.

(b)(i) Severity of illness

Using the WHO/IMCI assessment: look at general condition, eyes, thirst or ability to drink, and skin pinch. This child is lethargic and unable to drink, which are two signs of severe dehydration (Plan C). Estimated deficit is above 10% of body weight, over 1 kg of the usual 10 kg. Also check for shock (cold extremities, weak pulse, delayed capillary refill).

(b)(ii) Fluids in the first 3 hours

Give intravenous Ringer's lactate (or normal saline) 100 mL/kg (1,000 mL): 30 mL/kg (300 mL) over the first 30 minutes, then 70 mL/kg (700 mL) over the next 2.5 hours (the faster schedule applies to children over 12 months; infants take 1 hour and 5 hours). Offer ORS 5 mL/kg/hour as soon as the child can drink. Reassess every 15–30 minutes.

(b)(iii) After 3 hours

Reassess. If severe dehydration persists, repeat the IV regimen. If some dehydration remains, switch to Plan B (ORS 75 mL/kg over 4 hours); if none, use Plan A, with continued feeding and ORS after each loose stool. Give zinc 20 mg daily for 14 days, continue breastfeeding and normal feeds, and counsel on danger signs and follow-up.

(b)(iv) WHO ORS (reduced osmolarity, 245 mOsm/L)

Per litre: sodium chloride 2.6 g (sodium 75 mmol/L, chloride 65 mmol/L), anhydrous glucose 13.5 g (75 mmol/L), potassium chloride 1.5 g (potassium 20 mmol/L) and trisodium citrate dihydrate 2.9 g (citrate 10 mmol/L).

Preparation: dissolve one full packet in 1 litre of clean (boiled and cooled) water, stir well, do not add sugar or milk, and discard unused solution after 24 hours.

(c)(i) Differential diagnosis of psoriatic arthritis

• Rheumatoid arthritis: symmetric small-joint polyarthritis sparing the DIP joints, positive rheumatoid factor and anti-CCP, nodules; psoriatic arthritis is usually seronegative, often asymmetric, with DIP disease, dactylitis, enthesitis and nail changes.
• Axial spondyloarthritis: symmetric sacroiliitis and marginal syndesmophytes; in psoriatic arthritis sacroiliitis is often asymmetric with non-marginal syndesmophytes.
• Osteoarthritis: Heberden's nodes, no inflammatory features.
• Gout: acute monoarthritis with urate crystals.
• Reactive arthritis: follows genitourinary or enteric infection.
• Enteropathic arthritis (IBD).

Pointers: psoriasis, nail pitting, dactylitis, pencil-in-cup deformity, periostitis, and negative rheumatoid factor; CASPAR criteria (3 points or more) support the diagnosis.

(c)(ii) Management of psoriatic arthritis

Treat to target with a rheumatology–dermatology team.

• Mild peripheral disease: NSAIDs and intra-articular steroid injections.
• Persistent arthritis: conventional DMARDs (methotrexate, leflunomide, sulfasalazine).
• Inadequate response, axial disease or severe skin disease: biologics (TNF inhibitors, IL-17 inhibitors, IL-12/23 or IL-23 inhibitors), or tofacitinib or apremilast.
• Avoid systemic steroids (psoriasis flare on withdrawal); treat skin disease; physiotherapy, weight loss and smoking cessation; screen for cardiovascular and metabolic comorbidity.