1.b Hepatic vein do not form part of the portal triad. It forms the central vein around which the hepatocytes are arranged and on the periphery is the portal triad consisting of Portal Vein posteriorly, the bile duct on the right and Hepatic artery on the left

2. c Hepatitis B and Hepatitis C have known association with cirrhosis and Hepatocellular Carcinoma. Other significant risk factors are Chronic alcohol abuse Smoking Aflatoxins Nitrates, Nitrites Haemochromatosis, Wilson, Aplpha 1 Antitrypsin deficiemcy Throrotrast Associations with hormonal manipulations such as the use of oral contraceptive agents and anabolic steroids have been suggested but are weak Hepatitis B and Hepatitis C are well-established major risk factors for Hepatocellular Carcinoma due to their chronic inflammatory and fibrotic effects on the liver. Smoking is also associated with an increased risk, likely due to the carcinogenic compounds that can promote hepatic tumorigenesis. In contrast, while early studies suggested a possible link between long-term OCP use and liver tumors (especially benign hepatic adenomas), there is no strong evidence to support a significant association between OCPs and HCC.

3. d Less than 1% of cases of HCC present as a paraneoplastic syndrome Paraneoplastic syndromes such as diarrhea, hypoglycemia, erythrocytosis, and hypercalcemia may also be present and are generally associated with poor prognosis Hepatocellular carcinoma can be associated with several paraneoplastic syndromes, including: Hypercalcemia – due to ectopic production of parathyroid hormone-related peptide (PTHrP) Hypoglycemia – often seen in advanced tumors due to increased glucose consumption by the tumor or decreased hepatic gluconeogenesis Polycythemia – due to ectopic erythropoietin production These paraneoplastic features may be the first clinical clue in a patient with underlying liver disease developing HCC.

4.b This patient presents with Quincke’s triad (right upper quadrant pain, jaundice, and GI bleeding), which is characteristic of hemobilia. Given his recent liver biopsy, the most likely cause is iatrogenic trauma, which is the leading cause of hemobilia in modern clinical practice. Earlier Blunt Abdominal trauma was the most common cause of Hemobilia. But recently with the advent of more interventional procedures like PTBD (Percutaneous Transhepatic Biliary Drainage), hemobilia has become more common.

5.d Hepatic epithelioid hemangioendothelioma (HEHE) is a rare, low- to intermediate-grade vascular tumor. It often presents with multifocal liver involvement in young to middle-aged adults. The diagnosis is confirmed via histopathology and immunohistochemistry (positive for endothelial markers like CD31, CD34, and CAMTA1). Due to its unpredictable behavior and resistance to chemotherapy, liver transplantation is considered the treatment of choice, especially in multifocal disease without extrahepatic spread. Extra hepatic spread is seen in 25% only Death is usually due to liver failure. All other options are correct

c Key to the management of encephalopathy is identifying and then eliminating whatever precipitating factors are responsible. All infections should be treated, all sedatives should be discontinued, and intestinal catharsis should be accomplished. Pharmacologic treatment of encephalopathy is indicated for patients with chronic, intermittent symptoms and for those with persistent, acute psychoneurologic disturbances despite elimination of precipitating factors. The only drugs with proven effectiveness are neomycin, a poorly absorbed antibiotic that suppresses urease containing bacteria, and lactulose, a nonabsorbable disaccharide that acidifies colonic contents and also has a cathartic effect Unproven therapies for encephalopathy include the enteral or parenteral administration of branched-chain amino acids and the drug flumazenil, a selective antagonist of benzodiazepine receptors

a Cryotherapy is a good ablation for unresectable liver cancer. It has a 2 year survival of 60% in unresectable group. Big sized blood vessels are relatively not affected much because of the rapid blood flow which prevents injury but larger bile ducts are at risk of injury. Cryotherapy is generally avoided at sites near major bile ducts. Bleeding from the probe tract is never a major problem as it can easily be embolized

a In shock liver, liver enzymes (AST, ALT) rise rapidly, often within hours, and LDH levels are markedly elevated, not mildly. The condition usually resolves with correction of the underlying cause, and liver failure is rare. Histologically, it is characterized by centrilobular (zone 3) necrosis, as this region is most susceptible to hypoxia. Recovery is usually possible if the underlying cause is reversed.

d Contrast Enhanced Ultrasound is a new modality which consists of injecting contrast bubbles in the circulatuion and as these contrast get adherent to the Kupffer cells of liver, they emit acoustic signals which are then picked up by the USG probe. Now 2nd generation contrast bubbles are available that emit acoustic signals as they contract and expand. These bubbles remian in circulation and detection of arterial and portal phase becomes easier Advantages over CT scan are 1 the microbubble contrast agents are real blood-pool agents not leaving the intravascular space 2 A continuous imaging over the whole enhancement period with high temporal resolution is possible, not limited to distinct, pre-defined time points Other advantages are no exposure to radiation, absence of nephrotoxic contrast agents and large availability of machines. In comparison with CT and/or dynamic MRI, SonoVue®-enhanced sonography applied for characterization of focal liver lesions was 30.2% more sensitive in the recognition of malignancy and 16.1% more specific in the exclusion of malignancy and overall 22.9% more accurate.

Ans ) a Despite a long list of functional, biochemical tests and imaging studies, the clinical examination by an experienced hepatic surgeon remains the most important issue in major hepatic resections. With improvements in surgical technique, anesthesia and ICU care liver resection now has a mortality of less than 3% Child Pugh System was initially developed for patients of Postal Hypertension who underwent a shunt procedure. It has three objective (Bilirubin, Ascites, INR) and two subjective (Ascites, Encephalopathy) criteria