Internal medicine - Liver disease (78) Flashcards
INT - 7.1
Male patient with liver cirrhosis is admitted to the hospital with massive hematemesis, with the possibility of variceal rupture. The followings should be done, except:
A) ensuring venous access with cannulation of 2 peripheral vein
B) determining blood group, INR, blood count
C) administration of iv. terlipressin
D) oesophagogastroscopy and ligation or sclerotherapy of esophageal varices after hemodynamic stability is reached
E) blood transfusion to increase hemoglobin level above 100 g/l
ANSWER
E) blood transfusion to increase hemoglobin level above 100 g/l
EXPLANATION
One of the most severe complications of liver cirrhosis is bleeding caused by variceal rupture. In such cases, the first measures of treatment include the assurance of venous access including the canulation of two peripheral veins, blood group determination, complete blood count (CBC), INR determination, commencement of intravenous terlipressin, emergency endoscopy, or hemostasis, performed with sclerotherapy or endoscopic ligation, if required. Transfusion is required in the case of attaining a restrictive hemoglobin level < 75 g/L, however, a higher level leads to an increased risk of additional bleeding in variceal bleeders, therefore, a hemoglobin level above 100 g/l is not recommended.
INT - 7.2
The extrahepatic complication of chronic hepatitis B might be:
A) periarteritis nodosa, immuncomplex vasculitis
B) glomerulonephritis
C) cryoglobulinaemia
D) arthritis
E) all of the above
ANSWER
E) all of the above
EXPLANATION
Extrahepatic manifestations of chronic hepatitis B virus (HBV) infection may be subject to all of the following four diseases: immune complex vasculitis, nephritis, cryoglobulinaemia or arthritis.
INT - 7.3
Characteristics of drug-induced liver injury, except:
A) it is always dose-dependent
B) idiosyncratic reaction is also possible
C) it can manifest few days or several weeks after drug intake
D) it is forbidden to readminister the drug which caused liver injury
E) cholestasis can be present
ANSWER
A) it is always dose-dependent
EXPLANATION
Drug-induced liver injury may be dose-dependent or dose-independent, and sometimes referred to as an idiosyncratic reaction. It can manifest itself within several days or over a period of weeks following the administered and recommended medication. It is forbidden to re-administer the medication, which resulted in the original injury to the liver. It can manifest as GOT and GPT or in the form of cholestasis.
INT - 7.4
A 65-year-old male patient presented with jaundice started 3 weeks before. What is the first step?
A) abdominal ultrasound
B) computer tomography (CT)
C) endoscopic retrograde cholangiopancreatography (ERCP)
D) percutaneous transhepatic cholangiography (PTC)
E) MR cholangio-pancreatography (MRCP)
ANSWER
A) abdominal ultrasound
EXPLANATION
In the differential diagnosis of jaundice, the first non-invasive imaging is abdominal ultrasound. It can reveal the presence of gallstones, the dilation of the ductus choledochus (common bile duct), including the space-occupying processes in the pancreatic head or the liver. Further examinations are generally conducted, if deemed medically necessary.
INT - 7.5
The most frequent cause of liver cirrhosis nowadays, which was earlier labeled as “cryptogen” cirrhosis:
A) Wilson’s disease
B) Hepatitis E virus (HEV) infection
C) Non alcoholic steatohepatitis (NASH)
D) Hemochromatosis
E) Drugs and other toxic agents
ANSWER
C) Non alcoholic steatohepatitis (NASH)
EXPLANATION
Today, liver cirrhosis, formerly referred to as cryptogen cirrhosis, is most frequently (in 70 percent of the cases) aligned with nonalcoholic steatohepatitis (NASH), and is directly correlated with insulin resistance.
INT - 7.6
Select the tumor where serum alpha-fetoprotein (AFP) is mostly pathognomic.
A) prostate cancer
B) osteogenic carcinoma
C) gastric cancer
D) colon cancer
E) hepatocellular cancer (HCC)
ANSWER
E) hepatocellular cancer (HCC)
EXPLANATION
Serum-α-fetoprotein (AFP) is a tumor marker and an oncofoetal antigen, characteristic of hepatocellular carcinoma (HCC). This tumor is particularly typical of increased concentration in the serum (20 ng/ml level may elevate to several thousand ng/ml). Otherwise, a moderate AFP increase can be observed in disease processes related to hepatocyte regeneration, such as hepatitis and cirrhosis. A higher AFP level can also occur atypically in other tumors. AFP is not suitable for HCC surveillance, while normal AFP-levels do not rule out liver cancer.
INT - 7.7
Characteristics of alcoholic hepatitis, except:
A) excessive alcohol consumption recently
B) corticosteroid administration is always necessary
C) elevated bilirubin, high INR, leukocytosis can be present
D) high mortality in severe cases
E) alcohol abstinence is essential during treatment
ANSWER
B) corticosteroid administration is always necessary
EXPLANATION
Alcoholic hepatitis is typically preceded by massive alcohol consumption. During treatment, reaching abstinence is generally based on an elevated serum bilirubin level, high INR, and leukocytosis. In severe cases, it results in a high mortality rate. Corticosteroid administration should be considered only if there is no contraindication (e.g., SBP, other infection, peptic or duodenal ulcer) and in the most severe cases. Its administration does not have a long-term mortality-reducing effect, but can increase the risk of infectious complications (e.g., sepsis and pneumonia).
INT - 7.9
Characteristics of primary biliary cholangitis (PBC), except:
A) antimitochondrial antibody (AMA) is present
B) serum-IgM is frequently elevated
C) female dominance
D) corticosteroid is indicated for treatment
E) it might be associated with scleroderma
ANSWER
D) corticosteroid is indicated for treatment
EXPLANATION
Primary biliary cholangitis (PBC) is an idiopathic cholestatic liver disease, presumably autoimmune in nature. It is predominant in women, and may be associated with scleroderma, the antimitochondrial antibody (AMA), is a typical serological marker of the disease, and may result in elevated levels of serum-IgM. Its treatment is not completely developed, and corticosteroid is not indicated. In its early phase, ursodeoxycholic acid is the most useful medication.
INT - 7.10
Which of the following medication can dose-dependently cause liver failure?
A) halothane
B) paracetamol (acetaminophen)
C) chlorpromazine
D) methyldopa
E) erythromycin
ANSWER
B) paracetamol (acetaminophen)
EXPLANATION
Paracetamol (acetaminophen) may cause liver failure, dose-dependently. Alcoholics and malnutritioned, starving individuals suffering from low protein intake are particularly at risk in this respect, whose reduced hepatic glutathione reserve and antioxidant defense system is notably decreased. In such cases, the neutralization of the toxic metabolite of paracetamol fails, which results in hepatocyte necrosis. The same premise also applies to the healthy organism, if the excessive dose of paracetamol (e.g. 12–16 g/day) exceeds the capacity of the level of antioxidant defense. In the above-mentioned alcoholic and malnutritioned patients, 4–6 g can qualify a toxic dose.) In the case of paracetamol overdose, the administration of N-acetylcystein can result in the restoration of the endogenous glutathione reserve and recovery. Additional use of medications and drugs, including, halothane, chlorpromazine, methyldopa and erythromycin, may cause liver failure, dose-independently, through an immunoallergic idiosyncratic mechanism.
INT - 7.11
It can trigger hepatic encephalopathy in severe liver cirrhosis, except:
A) gastrointestinal bleeding
B) metabolic acidosis
C) aggressive diuretic therapy
D) enteral infection
E) high amount of oral protein intake
ANSWER
B) metabolic acidosis
EXPLANATION
In severe liver cirrhosis patients, hepatic encephalopathy may be caused by gastrointestinal bleeding, aggressive diuretic therapy, enteral infection, or a large amount of per os protein intake, but not by metabolic acidosis.
INT - 7.12
Jaundice appears on the 3rd postoperative day after aortic aneurysms surgery in a female patient, who is afebrile, otherwise asymptomatic. Lab results: SeBi: direct 220 μmol/l, indirect 80 μmol/l, ALP 500 IU, AST, ALT, LDH are normal. What is the most likely diagnosis?
A) biliary tract obstruction
B) halothane-induced hepatitis
C) portal vein thrombosis
D) haemolysis
E) benign postoperative cholestasis
ANSWER
E) benign postoperative cholestasis
EXPLANATION
Benign postoperative cholestasis syndrome occurring during the postoperative days following a protracted cardiac surgery is primarily due to hypoxia and hypothermia. Halothane-induced hepatitis occurs only within one or two weeks, especially in case of repeated halothane narcosis. The latter involves high temperatures and significant elevated levels of transaminase. Haemolysis can be ruled out in this case, based on normal LDH and direct hyperbilirubinaemia jaundice.
INT - 7.14
Predisposing factor(s) for gallstone formation:
A) obesity
B) chronic hemolysis
C) octreotide therapy
D) bowel resection
E) all of the above
ANSWER
E) all of the above
EXPLANATION
All of the four mentioned cases (obesity, chronic haemolysis, octreotide treatment and bowel resection) are predisposing factors for gallstone formation.
Octreotide, a nonspecific somatostatin analogue
decrease GH level in acromegaly
treat severe diarrhea and other symptoms that occur with certain intestinal tumors (eg, vasoactive intestinal peptide tumors or VIPomas) or metastatic carcinoid tumors
Chronic hemolysis leads to increased bilirubin excretion and pigment gallstones formation
bowel resection: alteration of the concentration of bile salts in the enterohepatic circulation leading to the possible formation of gallbladder stones.
INT - 7.16
67-year-old patient sees a doctor with dull right hypochondriac pain, fever, weight loss. Lab findings: GGT 600 E, ALP 740 E, LDH: 900 E. What additional lab tests would be helpful to confirm the diagnosis?
A) antinuclear antibody (ANA)
B) serum α-fetoprotein (AFP)
C) antimitochondrial antibody (AMA)
D) anti smooth muscle antibody (SMA)
E) prostate specific antigen (PSA)
NSWER
B) serum α-fetoprotein (AFP)
EXPLANATION
The described syndrome raises the suspicion of hepatic cancer based on cirrhosis, which can further be substantiated by an increased serum-α-foetoprotein (AFP) level. However, normal AFP does not rule out hepatic cancer!
INT - 7.17
True for esophageal variceal bleeding, except:
A) sclerotherapy is needed only when recurrent bleeding occurs after portocaval shunt operation
B) iv. terlipressin is important to stop bleeding
C) deep jaundice and ascites increase the risk of mortality
D) per os propranolol or carvediol are useful in prevention of bleeding
E) portocavalis shunt increases the risk of hepatic encephalopathy
NSWER
A) sclerotherapy is needed only when recurrent bleeding occurs after portocaval shunt operation
EXPLANATION
Among the listed statements, it is not true that sclerotherapy is needed only when recurrent variceal bleeding occurs following portocaval shunt operative procedures. It is true, in the case of variceal bleeding, i.v. terlipressin is important in controlling excessive bleeding. Deep jaundice and ascites increase the mortality risk. Per os propranolol or carvediol are useful in the prevention of bleeding. Portocaval shunt increases the risk of hepatic encephalopathy, therefore, TIPS is contraindicated in the case of hepatic encephalopathy.
INT - 7.18
Liver biopsy is indicated, except:
A) suspected liver adenoma
B) unexplained abnormal liver function tests
C) for diagnosis of NASH
D) for diagnosis of autoimmune hepatitis
E) suspected hemangioma
ANSWER
E) suspected hemangioma
EXPLANATION
In the case of suspected haemangioma, liver biopsy is contraindicated due to high risk of bleeding complications.
INT - 7.19
The risk of following disorders is increased in female patients who are taking oral contraceptive pills, except:
A) liver adenoma
B) peliosis hepatis
C) focal nodular hyperplasia
D) angiosarcoma
E) thromboembolism
ANSWER
D) angiosarcoma
EXPLANATION
In female patients who are taking oral contraceptives, the risk of hepatic adenoma, focal nodular hyperplasia, peliosis hepatis associated with sinusoidal dilatation, and complications of thromboembolism increases. This is not applicable to angiosarcoma.
INT - 7.20
The effect of acetaldehyde produced in the metabolism of alcohol:
A) induces immunoreaction through neoantigen formation
B) damage of microtubular functions in hepatocytes
C) decrease of the glutathione reserve of liver
D) increase of superoxide formation
E) all of the above
ANSWER
E) all of the above
EXPLANATION
Acetaldehyde produced in the metabolism of alcohol has all the afore mentioned effects.
INT - 7.21
Characteristic laboratory values in chronic heavy drinkers, except:
A) high MCV, usually above 100 fl
B) elevated GGT
C) elevated triglyceride
D) AST/ALT ratio > 1
E) AST/ALT ratio < 1
ANSWER
E) AST/ALT ratio < 1
EXPLANATION
Characteristic laboratory values in chronic heavy drinkers include high levels of MCV, usually above 100 fl, elevated GGT and triglyceride, including AST/ALT ratio >1.
INT - 7.22
Characteristics of HCV infection, except:
A) infection can cause cirrhosis for decades
B) only the IFN-based therapy can lead to total recovery
C) it was transmitted through blood transfusion before 1992
D) infection spreads among intravenous drug users nowadays
E) it increases the risk of hepatocellular carcinoma
ANSWER
B) only the IFN-based therapy can lead to total recovery
EXPLANATION
It is a characteristic of HCV infection, in which cirrhosis is induced over a period of decades. Today, the therapy based on IFN-free, direct-acting antiviral medicine leads to healing in 90 percent of the cases, and the administration of IFN is no longer needed. Prior to 1992, the virus was also transmitted via blood transfusion. Today, it is primarily transmitted by intravenous narcotic users. It may increase the risk of hepatocellular carcinoma (HCC).
INT - 7.23
True for paracetamol- (acetaminophen) toxicity:
A) toxicity is dose-dependent
B) it is based on immune-allergy
C) it never results in severe toxicity
D) antidote is not known
E) it can safely be administered to alcoholics
ANSWER
A) toxicity is dose-dependent
EXPLANATION
Paracetamol causes hepatotoxicity dose-dependently. Its overdose might lead to severe liver failure. Its “antidote” is N-acetylcystein. Alcoholics are especially at risk of paracetamol-toxicity
INT - 7.24
Septic complications mostly occur in obstructive jaundice caused by Klatskin tumor:
A) after percutaneous transhepatic cholangiography
B) after MRCP
C) after duodenoscopy
D) after ERCP
E) none of the above
ANSWER
D) after ERCP
EXPLANATION
Septic complications mostly occur following ERCP.
INT - 7.25
Characteristics of ursodeoxycholic acid, except:
A) it has hydrophilic property
B) it is used in treatment of primary biliary cholangitis
C) it increases the risk of colorectal cancer in patients with primary sclerosing cholangitis
D) it takes part in the enterohepatic cycle
E) it is non-toxic bile acid
ANSWER
C) it increases the risk of colorectal cancer in patients with primary sclerosing cholangitis
EXPLANATION
Ursodeoxcholic acid is characteristic for its hydrophilic property. It is a non-toxic bile acid which takes part in the enterohepatic cycle. It is used in the treatment of primary biliary cholangitis. It reduces the risk of colorectal cancer in patients with primary sclerosing cholangitis.
INT - 7.26
True for hepatocellular carcinoma (HCC), except:
A) metastasis always occurs in the early phase
B) it has bad prognosis
C) it often develops in cirrhotic liver
D) serum-α-fetoprotein (AFP) level increases in half of the cases
E) it develops more frequently in males than in females
ANSWER
A) metastasis always occurs in the early phase
EXPLANATION
Hepatocellular carcinoma is not characteristic of metastasis-formation occurring in the early phase.
INT - 7.27
True for the ascites in liver cirrhosis without further cirrhotic complications:
A) it is bloody
B) protein content is always above 30 g/l
C) malignant cells are found in the sediment
D) serum albumin - ascites albumin gradient >11 g/l
E) neutrophil granulocyte count is above 1000/mm3
ANSWER
D) serum albumin - ascites albumin gradient >11 g/l
EXPLANATION
In cirrhosis, in which there are no additional complications, ascites develops as the consequence of portal hypertension, and, in such cases, it is typically characteristic of serum albumin - ascites albumin gradient is more than 11 g/l.
INT - 7.28
Characteristics of cholestatic jaundice, except:
A) level of conjugated bilirubin is high in serum
B) it can be accompanied by pruritus
C) it is associated with elevated level of ALP
D) it is always accompanied by increased level of AST
E) it is associated with elevated GGT
ANSWER
D) it is always accompanied by increased level of AST
EXPLANATION
Cholestasis is not associated with an increased level of AST.
INT - 7.29
Characteristics of Wilson’s disease, except:
A) biliary secretion of copper is damaged
B) level of serum ceruloplasmin decreases
C) Kayser–Fleischer-ring is visible with slit lamp examination in half of the cases
D) fulminant hepatitis can occur as acute liver failure
E) it always leads to development of HCC
ANSWER
E) it always leads to development of HCC
EXPLANATION
Wilson’s disease does not always lead to hepatocellular carcinoma.
INT - 7.30
Duration of development of hepatocellular carcinoma (HCC) after infection with hepatitis B virus (HBV) or hepatitis C virus (HCV):
A) 1–2 years
B) 5–10 years
C) 10–15 years
D) 20–25 years
E) few months
ANSWER
D) 20–25 years
EXPLANATION
Hepatocellular carcinoma develops 20-25 years following the chronic hepatitis B or C virus.
INT - 7.31
The earliest sign of primary biliary cholangitis (PBC) can be:
A) spider nevi
B) dilated abdominal wall veins
C) skin hematomas
D) jaundice
E) pruritus
ANSWER
E) pruritus
EXPLANATION
Itchiness may be the primary, early symptom in primary biliary cirrhosis
INT - 7.32
45-year-old alcoholic male patient is admitted to the hospital with ascites, restlessness, bizarre behavior. In his sudden deterioration provoking factors might be, except:
A) asymptomatic duodenal bleeding
B) aggressive diuretic therapy
C) he discontinued lactulose, consumed large amount of protein
D) his protein intake was insufficient
E) spontaneous bacterial peritonitis developed
ANSWER
D) his protein intake was insufficient
EXPLANATION
Except in the event of low or diminished protein intake! This does not cause hepatic encephalopathy!
INT - 7.33
Hepatic encephalopathy can be provoked by:
A) after TIPS procedure
B) gastrointestinal bleeding
C) aggressive diuretic therapy
D) spontaneous bacterial peritonitis
E) all of the above
ANSWER
E) all of the above
EXPLANATION
Hepatic encephalopathy may be induced by all of the listed circumstances.
INT - 7.34
Characteristics of autoimmune hepatitis, except:
A) mostly younger females are affected
B) high IgG level
C) it does not require liver biopsy to make diagnosis
D) good response to corticosteroid therapy
E) it leads to liver cirrhosis at a young age without treatment
ANSWER
C) it does not require liver biopsy to make diagnosis
EXPLANATION
It is characteristic for autoimmune hepatitis that primarily younger females are affected, implies a high IgG level, responds well to corticosteroid therapy, and leads to liver cirrhosis in young age if no therapy is administered. Liver biopsy is required to establish the diagnosis.
