✅ Model Answer:
• Diagnosis: Cirrhosis / chronic liver failure – hypoalbuminemia (2.2 g/dL), jaundice (bilirubin 5.5), elevated INR (2.0), ascites, nodular liver on ultrasound.
• Any other test: Abdominal Ultrasound, Viral hepatitis panel (A, B, C), autoimmune markers (ANA, ASMA, anti-LKM), alpha-1 antitrypsin level, ceruloplasmin (Wilson disease), serum copper, 24-hour urine copper, abdominal Doppler (portal vein patency), liver biopsy (gold standard).
• What to do next: Sodium restriction, diuretics (spironolactone 1-3 mg/kg/day + furosemide 1-2 mg/kg/dose) for ascites. IV albumin if severe hypoalbuminemia. Vitamin K for coagulopathy. Start ursodeoxycholic acid (10-15 mg/kg/day).
• Follow-up plan: Monitor LFTs, INR, albumin, ascites (weight, abdominal girth). Assess for complications: spontaneous bacterial peritonitis (SBP), variceal bleeding, hepatic encephalopathy. Evaluate for liver transplantation.

✅ Model Answer:
• Biliary causes: Biliary atresia (most common cause of neonatal cholestasis), Alagille syndrome, primary sclerosing cholangitis, cystic fibrosis liver disease
• Metabolic causes: Wilson disease (copper accumulation), alpha-1 antitrypsin deficiency, tyrosinemia, galactosemia, glycogen storage diseases, Niemann-Pick disease
• Infectious causes: Chronic viral hepatitis (Hepatitis B, C), congenital infections (CMV, rubella, toxoplasmosis)
• Autoimmune: Autoimmune hepatitis
• Vascular: Budd-Chiari syndrome, veno-occlusive disease
• Other: Nonalcoholic fatty liver disease (NAFLD), drug-induced liver injury, cryptogenic cirrhosis

✅ Model Answer:
• Synthetic function:
- Albumin: Low (due to decreased synthesis, normal 3.5-5.0 g/dL)
- INR/PT: Elevated (prolonged clotting time due to decreased synthesis of clotting factors)
- Total protein: Low (decreased synthesis)
• Hepatocellular injury:
- AST/ALT: Elevated (hepatocyte damage), may be normal in end-stage cirrhosis
- GGT: Elevated (cholestasis)
• Cholestasis:
- Total and Direct Bilirubin: Elevated (impaired excretion)
- Alkaline phosphatase: Elevated (bile duct obstruction)
• Severity scoring: Child-Pugh and MELD scores use albumin, INR, bilirubin, ascites, encephalopathy

✅ Model Answer:
• Dietary management: Sodium restriction (<2 mEq/kg/day, or <2 g/day)
• Fluid restriction: If hyponatremia (Na <125 mEq/L)
• Diuretics:
- Spironolactone: First-line (1-3 mg/kg/day) – potassium-sparing diuretic
- Furosemide: Add if inadequate response (1-2 mg/kg/dose)
- Monitor: Weight, urine output, electrolytes (K+, Na+)
• Paracentesis: For tense ascites causing respiratory distress
• IV Albumin: If severe hypoalbuminemia (albumin <2.0 g/dL) after large-volume paracentesis
• Treat underlying cause: Liver transplantation if refractory ascites

✅ Model Answer:
• Portal hypertension: Variceal bleeding (esophageal/gastric varices), splenomegaly, hypersplenism
• Ascites: Fluid accumulation in peritoneal cavity
• Spontaneous Bacterial Peritonitis (SBP): Infection of ascitic fluid (fever, abdominal pain, leukocytosis)
• Hepatic encephalopathy: Confusion, asterixis, somnolence (due to ammonia accumulation)
• Coagulopathy: Bleeding tendency (elevated INR)
• Malnutrition: Poor weight gain, muscle wasting (due to poor intake, malabsorption)
• Jaundice: Hyperbilirubinemia
• Hepatopulmonary syndrome: Hypoxemia due to intrapulmonary shunting
• Portopulmonary hypertension: Pulmonary hypertension
• Hepatocellular carcinoma (HCC): Rare in children but possible

✅ Model Answer:
• Indications:
- Confirming diagnosis (autoimmune hepatitis, Wilson disease, biliary atresia)
- Assessing severity (grade of fibrosis, stage of cirrhosis)
- Monitoring treatment response
- Evaluating for hepatocellular carcinoma
• Contraindications: Coagulopathy (INR >1.5, platelets <50,000), ascites (do transjugular biopsy)
• Findings:
- Cirrhosis: Bridging fibrosis, nodular regeneration
- Autoimmune hepatitis: Interface hepatitis, plasma cell infiltration
- Wilson disease: Copper accumulation (rhodanine stain)
- Alpha-1 antitrypsin: PAS-positive diastase-resistant globules

✅ Model Answer:
• Acute bleeding management:
- ABCs: Airway, breathing, circulation, IV access
- Fluid resuscitation: Blood products (PRBCs, platelets, FFP), IV fluids
- Somatostatin/Octreotide: Reduce portal pressure (bolus + infusion)
- Proton pump inhibitors (PPI): To reduce gastric acid
- Endoscopy: Diagnostic and therapeutic (band ligation or sclerotherapy)
- Antibiotics: Prophylactic (ceftriaxone) to prevent SBP
• Secondary prophylaxis: Non-selective beta-blockers (propranolol), repeated variceal banding
• Refractory bleeding: TIPS (transjugular intrahepatic portosystemic shunt) or liver transplantation

✅ Model Answer:
• Prognosis: Depends on underlying cause and complications
- Biliary atresia: 80-90% survival at 5 years with successful Kasai procedure; otherwise liver transplant
- Autoimmune hepatitis: Good response to immunosuppression
- Wilson disease: Good with chelation therapy
- Alpha-1 antitrypsin: Variable, often requires transplant
• Indications for liver transplantation:
- End-stage liver disease (Child-Pugh class C, MELD score >15)
- Refractory ascites, variceal bleeding
- Hepatic encephalopathy
- Hepatopulmonary syndrome
- Hepatocellular carcinoma (within Milan criteria)
- Metabolic liver disease with systemic effects
• Prognosis after transplant: 85-90% 5-year survival in children
• Post-transplant: Immunosuppression, regular follow-up, monitoring for rejection and complications