Scope It Out Case Answers 
Spring 2026

The most likely cause is: 
C. Autoimmune Hepatitis 

Why? 

This patient has several classic features of autoimmune hepatitis (AIH): 

• Marked hepatocellular injury with very high AST/ALT 

• Positive ANA 

• Liver biopsy showing interface hepatitis with plasma cell infiltrate — this is highly characteristic of AIH 

• Initial improvement followed by relapse/worsening after discharge, which is common in untreated autoimmune hepatitis 

Although he initially reported taking an online “men’s vitality supplement,” which raises concern for drug-induced liver injury (DILI), some drugs/supplements can actually trigger autoimmune hepatitis or an AIH-like syndrome. The biopsy findings strongly favor true autoimmune hepatitis. 

Why not the others? 

• A. Drug induced liver injury 

  • Supplements commonly cause DILI, but classic histology for DILI is variable. 

  • The presence of interface hepatitis with plasma cells and positive ANA strongly points toward AIH. 

  • The relapse despite stopping the supplement also argues against a simple toxic DILI. 

• B. Alcohol associated hepatitis 

  • Typically AST and ALT are much lower (<500), with AST:ALT ratio >2. 

  • Plasma cell/interface hepatitis pattern is not typical. 

• D. Hepatic lymphoma 

  • Would not classically present with this biopsy pattern or marked transaminase elevation. 

Winter 2026

Part 1:

2) Titrate spironolactone up to 400 mg/day and furosemide up to 160 mg/day.

Part 2:

(3) refer to TIPS

 

​​Fall 2025

B. Both FDA and EASL recommend withholding terlipressin and decreasing albumin if there is hypoxemia (SpO2<90%) or evidence of volume overload or ischemia, regardless of renal response due to the risk of respiratory and cardiac complications. 

 

Summer 2025

​B. LES Botulinum toxin injection

Botox is the best option even though it may only provide short-term relief. Patient is not a candidate for Heller myotomy because severe comorbidities. Pneumatic dilation is not a reasonable option due to risk of perforation which would require surgery to correct. POEM would not be considered a safer alternative to Heller myotomy or pneumatic dilation. Sildenafil is not a treatment for type II achalasia and heart failure would be a contraindication. Nitrates and calcium channel blockers are less effective.