[vc_row row_type=”row” use_row_as_full_screen_section=”no” type=”full_width” oblique_section=”no” text_align=”left” css_animation=””][vc_column][ultimate_heading main_heading=”Candidate brief” main_heading_color=”#000000″ sub_heading_color=”#000000″ main_heading_style=”font-weight:bold;” main_heading_font_size=”desktop:36px;”]

“This patient has presented for routine follow-up after a recent operation, please examination their gastrointestinal system and present your findings to the examiners”

[/ultimate_heading][vc_empty_space image_repeat=”no-repeat”][vc_video link=”https://vimeo.com/218854838″][vc_empty_space image_repeat=”no-repeat”][vc_row_inner row_type=”row” type=”full_width” use_row_as_full_screen_section_slide=”no” text_align=”left” css_animation=””][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Station Time” counter_value=”20″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Time for this encounter” counter_value=”10″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Maximum time to examine your patient” counter_value=”6″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][vc_column_inner width=”1/4″][stat_counter icon_size=”32″ counter_title=”Minimum time for discussion and questions” counter_value=”4″ counter_suffix=” minutes” speed=”3″][/vc_column_inner][/vc_row_inner][vc_empty_space image_repeat=”no-repeat”][/vc_column][/vc_row][vc_row row_type=”row” use_row_as_full_screen_section=”no” type=”full_width” oblique_section=”no” text_align=”left” css_animation=””][vc_column][vc_accordion style=”accordion”][vc_accordion_tab title=”Common examiner questions”][vc_column_text]Common examiner questions include the following:

  1. What do you think this patient has?
  2. How would you like to investigate this patient next?
  3. What do you think the underlying cause of this patient’s signs is?

[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Diagnosis and clinical signs”][vc_column_text]This patient has recently undergone a liver transplant

The clinical signs exhibited in this video include a right upper horizontal scar with a slight mid-line vertical portion. This is indicative of a partial Mercedes-Benz scar of a recent transplant, differentiating it from an older one.[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Discussion”][vc_column_text]The first liver transplant was conducted in 1963, and is one of the most successful organs transplanted since (second only to renal).

The scar normally associated with liver transplantation is well known as the “Mercedes Benz” scar due to the similarity with the car’s motif. However, in recent years, due to improved surgical techniques, this is no longer the case and now a half-Mercedes Benz scar is now used, thereby reducing further risks of post-operative complications.

Liver transplantation has become a well tolerated procedure with good outcomes for patients with end stage liver disease. The first liver transplant was in 1963, and in elective transplants, 1-year survival rates now go beyond 80-90%.

Indications for liver transplantation include:

  • acute liver failure e.g. paracetamol toxicity or fulminant Wilson’s disease
  • primary biliary cirrhosis
  • primary sclerosing cholangitis
  • autoimmune hepatitis
  • alcohol liver disease (with guidelines on abstinence except maybe on younger, acute liver failure patients
  • hepatitis B and C
  • neuroendocrine tumours (only malignancy where transplantation occurs for palliation)
  • small hepatocellular carcinomas

This patient demonstrates the classic scar of a liver transplant, termed the Mercedes-Benz scar due to its resemblance to the car’s symbol. However, newer patients due to advances in surgical techniques now have a reduced scar, which can be found here.

Poorer outcomes are associated with:

  • extremes of age (young and elderly)
  • black and oriental ethnicity
  • initial liver disease

In acute liver failure, the King’s College Hospital criteria is used as a marker:

Paracetamol toxicity:

  • pH < 7.30
  • prothrombin time >100 seconds
  • serum creatinine >300 μmol/l – if grade III/IV encephalopathy

Non-paracetamol acute liver failure:

  • cause – indeterminate hepatitis, halothane hepatitis or an idiosyncratic drug reaction
  • <10- or >40- years of age
  • jaundice to encephalopathy time > 7-days
  • prothrombin time >50 seconds
  • serum bilirubin >300 μmol/l

The best outcomes for transplantation have been found in primary biliary cirrhosis.

The reasons there are poor transplant rates among patients with alcohol induced liver disease relates to the possible reversibility were the patient to cease drinking alcohol; associated alcohol dependence and risks of relapse after abstinence and finally associated co-morbidities (e.g. alcohol induced cardiomyopathy).

References:

British Society of Gastroenterology guidelines for liver transplantation.

2013 Practice Guideline by the American Association for the Study of Liver Diseases and the American Society of Transplantation.[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Specimen case presentation”][vc_column_text]”This patient has a partial Merced-Benz scar, indicating a recent liver transplant. I would like to take a full history and complete my examination before conducting baseline blood tests including clotting and liver function tests and ultrasound doppler imaging of the liver to ensure it is functioning well”[/vc_column_text][/vc_accordion_tab][/vc_accordion][/vc_column][/vc_row]