CCE-CBD-159

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What is your provisional diagnosis, and what differentials would you consider?

• Prompt: Discuss NAFLD/NASH and alcoholic liver disease.
• Prompt: Discuss other causes of raised LFTs (viral hepatitis, haemochromatosis, autoimmune liver disease).

Q2. What further investigations and assessments are required?

• Prompt: Non-invasive assessment for fibrosis (FibroScan, Fibrosis-4 score).
• Prompt: Discuss need for hepatitis serology, autoimmune markers, iron studies already done.

Q3. How would you manage Daniel in the rural setting?

• Prompt: Lifestyle modification: weight loss, alcohol reduction/cessation, diabetes control.
• Prompt: Referral options—telehealth hepatology, allied health.

Q4. How would you address his concerns about liver cancer?

• Prompt: Discuss risk of hepatocellular carcinoma with advanced fibrosis/cirrhosis.
• Prompt: Outline surveillance strategies (ultrasound + AFP every 6 months if indicated).

Q5. What preventive health measures should you consider for Daniel?

• Prompt: Vaccination updates, healthy lifestyle promotion.
• Prompt: Hepatitis B vaccination, alcohol use counselling, cardiovascular risk assessment, cancer screening.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What is your provisional diagnosis, and what differentials would you consider?

Provisional Diagnosis:

• The most likely diagnosis is Non-Alcoholic Fatty Liver Disease (NAFLD) with possible progression to Non-Alcoholic Steatohepatitis (NASH). This is suggested by Daniel’s metabolic risk factors (T2DM, obesity, dyslipidaemia) and the ultrasound showing fatty liver. The elevated liver enzymes, particularly ALT and AST, are consistent with this diagnosis.

Differential Diagnoses:

1. Alcoholic Liver Disease (ALD):
   • Significant alcohol consumption (40+ standard drinks per week) increases this risk.
   • Pattern of LFTs (AST > ALT) typically suggests ALD, but in Daniel’s case, ALT is higher, which may suggest a mixed pattern.
2. Chronic Viral Hepatitis:
   • Hepatitis B and C have been excluded through serology, but it’s essential to verify that these results are up to date.
3. Haemochromatosis:
   • Iron studies and ferritin levels are within normal limits, making this less likely.
4. Autoimmune Hepatitis:
   • Should be considered, especially in unexplained raised transaminases. Autoimmune markers (ANA, SMA, LKM) may be warranted if unexplained.
5. Drug-Induced Liver Injury (DILI):
   • His current medications (atorvastatin, metformin, ramipril) can rarely cause liver enzyme elevations. Atorvastatin is the most common culprit, but the benefit outweighs the risk in Daniel’s context.
6. Wilson’s Disease / Alpha-1 Antitrypsin Deficiency:
   • Less likely given his age, but consideration can be made if diagnosis remains unclear.

Key Points:

• Both NAFLD/NASH and ALD can co-exist.
• Further evaluation is required to assess the extent of fibrosis and risk of cirrhosis.

Q2: What further investigations and assessments are required?

Non-Invasive Fibrosis Assessment:

• Fibrosis-4 (FIB-4) score: Utilises age, AST, ALT, and platelets. This can stratify Daniel’s fibrosis risk.
• Transient Elastography (FibroScan): If available, to assess liver stiffness and steatosis.

Further Blood Tests:

• Autoimmune screen: ANA, SMA, LKM antibodies.
• Alpha-1 antitrypsin and ceruloplasmin levels: In atypical cases.
• Repeat LFTs after alcohol reduction, if applicable.

Other Assessments:

• Abdominal Ultrasound (already done): No focal lesions or portal hypertension signs.
• Screening for hepatocellular carcinoma (HCC): Consider in the presence of cirrhosis (Ultrasound +/- AFP every 6 months).

Lifestyle and Alcohol Use Assessment:

• Detailed assessment of alcohol intake using AUDIT-C tool.
• Motivational interviewing to discuss alcohol reduction.

Q3: How would you manage Daniel in the rural setting?

Lifestyle Management:

• Weight Loss: Aim for at least 7-10% body weight loss through dietary changes and increased physical activity.
• Alcohol Reduction: Strongly advise reduction to low-risk levels (≤10 standard drinks/week) or ideally abstinence to minimise progression.
• Diabetes Management: Optimise glycaemic control (target HbA1c <7%) and consider adding GLP-1 receptor agonists for weight loss and NASH benefits.

Pharmacotherapy:

• Continue statin (atorvastatin), given cardiovascular risk, unless contraindicated.
• Consider vitamin E (in non-diabetic NASH patients), but caution with potential risks.

Referral and Collaboration:

• Telehealth hepatology consult if FibroScan is concerning or advanced fibrosis suspected.
• Referral to dietitian and alcohol counselling services (e.g., drug and alcohol counsellor).

Monitoring:

• Regular LFTs (every 3-6 months).
• Monitor for signs of cirrhosis and complications (ascites, encephalopathy).

Q4: How would you address his concerns about liver cancer?

• Acknowledge his concern compassionately and provide clear education on the risk factors.
• Explain that HCC risk increases with cirrhosis, regardless of cause (NAFLD, ALD, viral hepatitis).
• Based on current assessment, there is no evidence of cirrhosis, but this requires ongoing surveillance.
• If cirrhosis or advanced fibrosis is identified (via FibroScan/FIB-4), institute six-monthly ultrasound and AFP testing for HCC surveillance.
• Emphasise lifestyle modification and alcohol cessation to reduce risk.

Q5: What preventive health measures should you consider for Daniel?

• Vaccination:
  • Hepatitis B vaccination (he is not immune).
  • Annual influenza and updated pneumococcal vaccines.
  • COVID-19 vaccine booster if indicated.
• Cardiovascular Risk Assessment:
  • Absolute cardiovascular risk assessment and management (lipids, BP, smoking history).
  • Encourage exercise and dietary improvements.
• Cancer Screening:
  • Bowel cancer screening (iFOBT or colonoscopy if indicated).
  • Prostate health discussion (PSA testing) as per shared decision-making.
• Lifestyle and Behavioural Interventions:
  • Alcohol counselling.
  • Smoking abstinence reinforcement.
  • Sleep and mental health screening.

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SUMMARY OF A COMPETENT ANSWER

• Identifies NAFLD/NASH with consideration of ALD as key differentials.
• Appropriately selects investigations to assess fibrosis and exclude other causes.
• Develops a clear, practical rural management plan with lifestyle interventions and referral pathways.
• Addresses cancer concerns empathetically and explains surveillance strategies.
• Implements preventive health measures, including vaccinations and cardiovascular screening.

PITFALLS

• Failing to assess alcohol intake comprehensively and ignoring ALD possibility.
• Not performing fibrosis risk stratification.
• Delaying or omitting referral for hepatology advice in a rural context.
• Inadequate explanation of liver cancer risk and surveillance need.
• Neglecting preventive health interventions such as hepatitis B vaccination.

REFERENCES

• RACGP Guidelines for preventive activities in general practice (Red Book)
• EASL Clinical Practice Guidelines on NAFLD
• Australian Government Department of Health on National Hepatitis B Strategy

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MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Communication is appropriate to the person and the sociocultural context.
1.2 Engages the patient to gather information about their symptoms, ideas, concerns, expectations of healthcare and the full impact of their illness experience on their lives.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Elicits a full and accurate history and performs relevant physical examinations.
2.2 Selects and interprets appropriate investigations.

3. Diagnosis, Decision-Making and Reasoning

3.1 Makes diagnoses based on sound clinical reasoning.
3.2 Prioritises issues to be addressed in patient care.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops and implements management plans.
4.2 Safely prescribes and monitors therapies.

5. Preventive and Population Health

5.1 Provides care that addresses prevention, early detection, and health promotion.

6. Professionalism

6.1 Demonstrates respectful, reflective, and responsible behaviour.

7. General Practice Systems and Regulatory Requirements

7.1 Practices in accordance with legal, regulatory, and ethical standards.

9. Managing Uncertainty

9.1 Manages diagnostic uncertainty and patient safety.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies and manages patients with potentially serious illness.

12. Rural Health Context (RH)

RH1.1 Provides care considering rural practice limitations.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD