Liver disease

Liver disease US Medical PG Question 1: A 60-year-old rock musician presents to the office because he has been feeling increasingly tired for the past 6 months. He has a history of intravenous drug use and alcohol abuse. He states that he feels quite tired, but he otherwise has no complaints. Physical examination is noncontributory. His laboratory values are normal other than moderately elevated liver enzymes. Which of the following additional tests should you order first?

• A. Hepatitis C virus antibodies (Correct Answer)
• B. Hepatitis B surface antigen
• C. Hepatitis E virus-specific IgM antibodies
• D. Hepatitis D virus-specific IgG antibody
• E. Hepatitis A virus-specific IgM antibodies

Liver disease Explanation: ***Hepatitis C virus antibodies*** - The patient's history of **intravenous drug use** and **chronic fatigue** with **elevated liver enzymes** strongly suggests chronic viral hepatitis, with hepatitis C being the most common blood-borne infection in persons with IVDU history. - **Hepatitis C** is the **most prevalent chronic viral hepatitis** in the United States among persons with history of injection drug use, with transmission efficiency via needle sharing being very high. - Hepatitis C often has a **long asymptomatic phase** (decades) before symptoms like fatigue and liver damage become apparent, making antibody testing the appropriate initial screen. - While both HBV and HCV should ultimately be screened in this patient, **HCV prevalence is significantly higher** in the IVDU population, making it the priority initial test. *Hepatitis B surface antigen* - While **hepatitis B** can also be transmitted via intravenous drug use and cause chronic liver disease, **hepatitis C is more prevalent** in persons with IVDU history in the United States. - **HBsAg** is used to detect active hepatitis B infection and should also be ordered, but given resource constraints and the clinical context, **anti-HCV is the higher-yield initial test**. - Many IVDU patients have been vaccinated against HBV, further reducing its likelihood compared to HCV (for which no vaccine exists). *Hepatitis E virus-specific IgM antibodies* - **Hepatitis E** is typically transmitted via the **fecal-oral route** (contaminated water) and usually causes **acute, self-limiting hepatitis**, not chronic insidious fatigue and liver enzyme elevation in a Western patient. - **IgM antibodies** would indicate an acute infection, which is less likely given the 6-month duration of symptoms. - HEV rarely causes chronic infection except in immunocompromised patients. *Hepatitis D virus-specific IgG antibody* - **Hepatitis D** requires an existing **hepatitis B infection** to replicate (it's a satellite virus), meaning you would first need to confirm chronic hepatitis B before testing for HDV. - While HDV can cause severe liver disease and is transmitted via blood exposure, it's not the initial test to pursue without evidence of HBV co-infection. *Hepatitis A virus-specific IgM antibodies* - **Hepatitis A** is transmitted via the **fecal-oral route** and causes an **acute, self-limiting infection** with complete resolution, rarely leading to chronic liver disease or persistent fatigue over 6 months. - **IgM antibodies** are indicative of acute infection, which contradicts the chronic nature of the patient's symptoms. - HAV does not cause chronic hepatitis.

Liver disease US Medical PG Question 2: A 59-year-old woman comes to the physician for a routine health maintenance examination. She feels well. She has systemic lupus erythematosus and hypertension. She does not drink alcohol. Her current medications include lisinopril and hydroxychloroquine. She appears malnourished. Her vital signs are within normal limits. Examination shows a soft, nontender abdomen. There is no ascites or hepatosplenomegaly. Serum studies show: Total bilirubin 1.2 mg/dL Alkaline phosphatase 60 U/L Alanine aminotransferase 456 U/L Aspartate aminotransferase 145 U/L Hepatitis A IgM antibody negative Hepatitis A IgG antibody positive Hepatitis B surface antigen positive Hepatitis B surface antibody negative Hepatitis B envelope antigen positive Hepatitis B envelope antibody negative Hepatitis B core antigen IgM antibody negative Hepatitis B core antigen IgG antibody positive Hepatitis C antibody negative Which of the following is the most appropriate treatment for this patient?

• A. Pegylated interferon alpha therapy
• B. Tenofovir therapy (Correct Answer)
• C. Referral to a liver transplantation center
• D. Reassurance and follow-up
• E. Lamivudine therapy

Liver disease Explanation: ***Tenofovir therapy*** - This patient has **chronic hepatitis B** with evidence of **active viral replication** (positive HBsAg, HBeAg, and elevated liver enzymes), indicating a need for antiviral treatment. - **Tenofovir** is a highly effective and well-tolerated oral antiviral agent for chronic hepatitis B, suitable for initial therapy. *Pegylated interferon alpha therapy* - While an option for chronic hepatitis B, **pegylated interferon alpha** has more significant side effects and is generally avoided in patients with **systemic lupus erythematosus (SLE)** due to the risk of exacerbating the autoimmune condition. - It also requires subcutaneous injections and has a lower rate of HBeAg seroconversion compared to nucleos(t)ide analogs in many patient populations. *Referral to a liver transplantation center* - This patient currently shows **elevated liver enzymes** but no immediate signs of **decompensated liver disease** (e.g., ascites, encephalopathy, variceal bleeding) or severe liver failure that would warrant urgent transplantation. - Treatment with antiviral medication is the first step to prevent progression to end-stage liver disease. *Reassurance and follow-up* - The patient has **elevated transaminases** and markers of **active viral replication** (positive HBeAg), indicating ongoing liver injury and potential progression to cirrhosis. - Simply observing the patient without treatment would be inappropriate and could lead to irreversible liver damage. *Lamivudine therapy* - **Lamivudine** is an older nucleos(t)ide analog for hepatitis B that has a significantly **higher rate of drug resistance** compared to newer agents like tenofovir. - It is generally not recommended as a first-line treatment due to its resistance profile.

Liver disease US Medical PG Question 3: A 27-year-old man presents to the emergency department with loss of consciousness. The patient was brought in 20 minutes ago by the supervisor at a homeless shelter who found him passed out next to a bottle of acetaminophen. The patient has a past medical history of HIV, hepatitis C, IV drug abuse, alcohol abuse, suicide attempt, and constipation. He takes methadone daily but is notably non-compliant with his anti-retroviral therapy. His temperature is 104°F (40°C), blood pressure is 85/40 mmHg, pulse is 180/min, respirations are 18/min, and oxygen saturation is 90% on room air. The patient is started on IV fluids, N-acetylcysteine, and 100% oxygen. Blood cultures are obtained, and lab work is sent off. The patient is then started on broad spectrum antibiotics and given norepinephrine. Repeat vitals demonstrate hypotension and tachycardia. Serum toxicology returns and is positive for alcohol. The patient is transferred to the medicine floor and managed further. Two days later, the patient's vitals have improved. Repeat lab values are ordered and return as follows: Hemoglobin: 11 g/dL Hematocrit: 30% Leukocyte count: 6,500 cells/mm^3 with normal differential Platelet count: 245,000/mm^3 Serum: Na+: 138 mEq/L Cl-: 100 mEq/L K+: 4.1 mEq/L HCO3-: 22 mEq/L BUN: 30 mg/dL Glucose: 145 mg/dL Creatinine: 1.4 mg/dL Ca2+: 9.6 mg/dL AST: 1,440 U/L ALT: 1,350 U/L Which of the following is the best explanation for this patient’s laboratory abnormalities?

• A. Antibiotic use
• B. Chronic viral infection
• C. Alcohol abuse
• D. Previous hypotension
• E. Toxic liver metabolite (Correct Answer)

Liver disease Explanation: ***Toxic liver metabolite*** - The patient experienced an **acetaminophen overdose**, which leads to the production of **NAPQI**, a toxic metabolite. This causes significant **hepatocellular injury**, reflected by the extremely elevated AST and ALT levels. - The elevated AST and ALT indicate severe **acute liver damage**, which is characteristic of acetaminophen toxicity. The initial presentation with **loss of consciousness**, subsequent **hypotension**, and a history of **suicide attempt** (with a bottle of acetaminophen found nearby) strongly support this etiology. *Antibiotic use* - While some antibiotics can cause **drug-induced liver injury**, the exceptionally high AST and ALT levels (over 1000 U/L) are more indicative of a **massive hepatocellular insult** like acetaminophen toxicity, rather than a typical antibiotic reaction. - Antibiotic-induced liver damage is usually less severe and often presents with a more **cholestatic pattern** or a different enzyme elevation profile. *Chronic viral infection* - The patient has a history of **hepatitis C** and **HIV**, which can cause chronic liver inflammation and elevated transaminases. However, these conditions typically result in **persistently elevated but less dramatically high** AST and ALT levels. - The acute presentation with **loss of consciousness** and the finding of an acetaminophen bottle point to an acute event rather than a chronic viral exacerbation. *Alcohol abuse* - Chronic alcohol abuse can cause **alcoholic hepatitis** and elevated liver enzymes. However, alcoholic hepatitis typically results in an **AST:ALT ratio of 2:1 or greater**, and the values are usually in the hundreds, not in the thousands as seen here. - While serum toxicology was positive for alcohol, the **extreme transaminase elevation** is more consistent with a acute toxic injury, such as acetaminophen overdose, rather than acute on chronic alcoholic liver disease. *Previous hypotension* - **Ischemic hepatitis**, or "shock liver," can occur due to severe hypotension, leading to a rise in transaminases. However, the AST and ALT levels in ischemic hepatitis often **peak within 24-48 hours** and then fall rapidly. - While the patient was hypotensive, the context of the acetaminophen overdose provides a more specific and potent cause for the observed **massive and sustained liver enzyme elevation**.

Liver disease US Medical PG Question 4: A 56-year-old woman is brought to the emergency department by her family with altered mental status. Her husband says that she complained of fever, vomiting, and abdominal pain 2 days ago. She has a history of long-standing alcoholism and previous episodes of hepatic encephalopathy. Current vital signs include a temperature of 38.3°C (101°F), blood pressure of 85/60 mm Hg, pulse of 95/min, and a respiratory rate 30/min. On physical examination, the patient appears ill and obtunded. She is noted to have jaundice, a palpable firm liver, and massive abdominal distension with shifting dullness. Which of the following is the best initial step in management of this patient's condition?

• A. Empiric antibiotics (Correct Answer)
• B. Diagnostic paracentesis
• C. Large volume paracentesis
• D. Intravenous albumin
• E. Non-selective beta-blockers

Liver disease Explanation: ***Empiric antibiotics*** - This patient presents with **altered mental status**, **fever**, **hypotension (85/60 mm Hg)**, **tachypnea**, and **massive ascites** in the setting of **cirrhosis**, indicating **suspected spontaneous bacterial peritonitis (SBP) with septic shock**. - In a **hemodynamically unstable patient** with suspected SBP, **empiric antibiotics** (typically a third-generation cephalosporin like ceftriaxone or cefotaxime) should be initiated **immediately** without waiting for diagnostic paracentesis results. - Current **AASLD and EASL guidelines** emphasize that antibiotic therapy should not be delayed in critically ill patients, as early treatment significantly reduces mortality in SBP. - Diagnostic paracentesis should still be performed urgently but should **not delay antibiotic administration** in this unstable patient. *Diagnostic paracentesis* - While **diagnostic paracentesis** is the gold standard for confirming SBP and should be performed promptly, it is not the **best initial step** in a hemodynamically unstable patient. - In this critically ill patient with septic shock, obtaining ascitic fluid can be done **simultaneously with** or **immediately after** starting antibiotics, but antibiotics take priority. - If the patient were stable, diagnostic paracentesis before antibiotics would be appropriate to guide therapy. *Large volume paracentesis* - **Large volume paracentesis** is indicated for symptomatic relief of tense ascites causing respiratory compromise, not as an initial step in suspected infection. - In the setting of suspected SBP, only diagnostic paracentesis (50-100 mL) is needed initially, not large volume removal. *Intravenous albumin* - **Intravenous albumin** is given as adjunctive therapy in SBP patients with **renal dysfunction** (creatinine >1 mg/dL, BUN >30 mg/dL) or **hypotension** to prevent hepatorenal syndrome. - While this patient may benefit from albumin, it is not the **initial step**—antibiotics and fluid resuscitation take priority. - Albumin is typically given at 1.5 g/kg within 6 hours and 1 g/kg on day 3. *Non-selective beta-blockers* - **Non-selective beta-blockers** (propranolol, nadolol) are used for **primary and secondary prophylaxis of variceal bleeding** in portal hypertension. - They are **contraindicated** in patients with **hypotension** (BP 85/60 mm Hg), **sepsis**, or **SBP**, as they can worsen hemodynamic instability. - Recent studies suggest beta-blockers may be harmful in patients with refractory ascites or SBP.

Liver disease US Medical PG Question 5: A 55-year-old patient who immigrated from the Middle East to the United States 10 years ago presents to the emergency department because of excessive weakness, abdominal discomfort, and weight loss for the past 10 months. He has had type 2 diabetes mellitus for 10 years for which he takes metformin. He had an appendectomy 12 years ago in his home country, and his postoperative course was not complicated. He denies smoking and drinks alcohol socially. His blood pressure is 110/70 mm Hg, pulse is 75/min, and temperature is 37.1°C (98.7°F). On physical examination, the patient appears exhausted, and his sclerae are yellowish. A firm mass is palpated in the right upper abdominal quadrant. Abdominal ultrasonography shows liver surface nodularity, splenomegaly, and increased diameter of the portal vein. Which of the following is the most common complication of this patient condition?

• A. Hepatopulmonary syndrome
• B. Ascites (Correct Answer)
• C. Hepatic encephalopathy
• D. Hepatorenal syndrome
• E. Hepatic osteodystrophy

Liver disease Explanation: ***Ascites*** - The patient presents with classic signs of **portal hypertension** (splenomegaly, increased portal vein diameter, liver surface nodularity suggesting cirrhosis), and **ascites** is the most common and often the earliest major complication. - The presence of **abdominal discomfort** and an **RUQ mass** could be related to severe liver disease and its complications, including fluid accumulation or an underlying liver malignancy often associated with cirrhosis. *Hepatopulmonary syndrome* - This involves **intrapulmonary vascular dilatations** in the setting of liver disease leading to oxygenation defects, typically marked by platypnea and orthodeoxia, which are not described here. - While a complication of **cirrhosis**, it is less common than ascites and typically presents with respiratory symptoms not highlighted in this case. *Hepatic encephalopathy* - Characterized by **neuropsychiatric symptoms** due to the accumulation of toxins (e.g., ammonia) that the liver cannot detoxify. - The patient's presentation mainly focuses on physical weakness, abdominal issues, and jaundice, without mention of confusion, asterixis, or altered mental status. *Hepatorenal syndrome* - This is a form of **functional renal failure** that occurs in patients with advanced liver disease, presenting with rapidly progressive azotemia due to severe splanchnic vasodilation. - It is a **later and more severe complication** of liver failure, and while possible, ascites is typically seen much earlier and more frequently. *Hepatic osteodystrophy* - This refers to a group of **metabolic bone disorders** (osteoporosis, osteomalacia) that can occur in chronic liver disease. - While it can manifest as bone pain, it is not a direct or immediate complication of portal hypertension and would not explain the acute abdominal findings.

Liver disease US Medical PG Question 6: A 48-year-old man presents to the emergency department with shortness of breath. He reports that 6 months ago he was able to walk several miles without stopping. Yesterday, he became short of breath walking from his bed to the bathroom. He also endorses worsening abdominal distension and leg swelling, which he reports is new from several months ago. The patient has a past medical history of hypertension and hyperlipidemia. He admits to drinking 6-8 beers daily for the past 10 years. On physical exam, the patient has moderate abdominal distension and pitting edema to the knee. Crackles are present at the bilateral bases. Laboratory testing reveals the following: Hemoglobin: 13.4 g/dL Mean corpuscular volume (MCV): 102 μm³ Leukocyte count: 11,200/mm³ with normal differential Platelet count: 256,000/mm³ Serum: Na+: 137 mEq/L Cl-: 100 mEq/L K+: 4.2 mEq/L HCO3-: 25 mEq/L BUN: 18 mg/dL Glucose: 126 mg/dL Creatinine: 0.9 mg/dL Alkaline phosphatase: 88 U/L Aspartate aminotransferase (AST): 212 U/L Alanine aminotransferase (ALT): 104 U/L Which of the following is the best next step in management?

• A. Antiviral therapy
• B. Alcohol cessation (Correct Answer)
• C. Immunosuppressive therapy
• D. Hormone replacement
• E. Vitamin repletion

Liver disease Explanation: ***Alcohol cessation*** - The patient exhibits clear signs of **decompensated cirrhosis** due to chronic alcohol use, including **abdominal distension** (ascites), **leg swelling** (peripheral edema), and **shortness of breath** (likely due to fluid overload or hepatopulmonary syndrome). The elevated AST/ALT with an AST:ALT ratio > 2:1 is also suggestive of **alcoholic liver disease**. - **Alcohol cessation** is the most critical intervention to halt the progression of liver damage and improve outcomes in alcoholic liver disease. *Antiviral therapy* - Antiviral therapy is indicated for **viral hepatitis (e.g., hepatitis B or C)**, but the patient's history of heavy alcohol consumption and the AST:ALT ratio > 2:1 specifically point towards **alcoholic liver disease**, not viral hepatitis. - There is no lab or clinical evidence (e.g., positive hepatitis serologies) presented that would suggest a viral etiology requiring antiviral treatment. *Immunosuppressive therapy* - Immunosuppressive therapy is used for **autoimmune liver diseases** (e.g., autoimmune hepatitis) or conditions requiring immune modulation. - The patient's history and lab findings are not consistent with an autoimmune liver disease, and there is no indication for immunosuppression in uncomplicated alcoholic liver disease. *Hormone replacement* - Hormone replacement is typically considered for **endocrine disorders** or **menopause**. - There is no clinical or laboratory evidence to suggest any hormonal imbalance or deficiency in this male patient. *Vitamin repletion* - While patients with chronic alcoholism often have **vitamin deficiencies** (e.g., thiamine, folate), **vitamin repletion** alone will not address the underlying liver damage and decompensation this patient is experiencing. - While it may be a supportive measure, it is not the most crucial next step for immediate management and preventing further progression of severe liver disease.

Liver disease US Medical PG Question 7: A 27-year-old woman presents to the emergency department complaining of a left-sided headache and right-sided blurry vision. She states that 2 weeks ago she developed dark urine and abdominal pain. She thought it was a urinary tract infection so she took trimethoprim-sulfamethoxazole that she had left over. She planned on going to her primary care physician today but then she developed headache and blurry vision so she came to the emergency department. The patient states she is otherwise healthy. Her family history is significant for a brother with sickle cell trait. On physical examination, there is mild abdominal tenderness, and the liver edge is felt 4 cm below the right costal margin. Labs are drawn as below: Hemoglobin: 7.0 g/dL Platelets: 149,000/mm^3 Reticulocyte count: 5.4% Lactate dehydrogenase: 3128 U/L Total bilirubin: 2.1 mg/dL Indirect bilirubin: 1.4 mg/dL Aspartate aminotransferase: 78 U/L Alanine aminotransferase: 64 U/L A peripheral smear shows polychromasia. A Doppler ultrasound of the liver shows decreased flow in the right hepatic vein. Magnetic resonance imaging of the brain is pending. Which of the following tests, if performed, would most likely identify the patient’s diagnosis?

• A. Flow cytometry (Correct Answer)
• B. Glucose-6-phosphate-dehydrogenase levels
• C. Anti-histone antibodies
• D. Bone marrow biopsy
• E. Hemoglobin electrophoresis

Liver disease Explanation: ***Flow cytometry*** - The patient's symptoms (headache, blurry vision, dark urine, abdominal pain, hepatomegaly) along with laboratory findings of **hemolytic anemia** (low hemoglobin, elevated reticulocyte count, high LDH, elevated indirect bilirubin) and signs of **thrombosis** (decreased hepatic vein flow, neurological symptoms) are highly suggestive of **paroxysmal nocturnal hemoglobinuria (PNH)**. - **Flow cytometry** is the gold standard for diagnosing PNH by detecting the absence of **CD55** and **CD59** on red blood cells, granulocytes, and monocytes, indicating a deficiency in the **GPI anchor protein**. *Glucose-6-phosphate-dehydrogenase levels* - **G6PD deficiency** typically presents with hemolytic anemia triggered by **oxidant stressors** (like trimethoprim-sulfamethoxazole) but does not typically cause **thrombosis** or widespread organ involvement (e.g., hepatic vein thrombosis, neurological symptoms) as seen in this patient. - Measuring G6PD levels would be appropriate if G6PD deficiency was suspected, but the clinical picture points more strongly to PNH due to the thrombotic events. *Anti-histone antibodies* - **Anti-histone antibodies** are primarily associated with drug-induced **lupus erythematosus**, which can manifest with various systemic symptoms, but not typically with severe hemolytic anemia and thrombotic microangiopathy in this specific pattern. - While drug exposure is present (trimethoprim-sulfamethoxazole), the overall clinical and lab findings (especially the severe hemolytic picture and thrombosis) are not characteristic of drug-induced lupus in this context. *Bone marrow biopsy* - A **bone marrow biopsy** might show findings consistent with increased erythropoiesis due to hemolysis but is not a primary diagnostic test for PNH or its associated thrombotic complications. - While it could be part of an evaluation for underlying bone marrow disorders, it would not directly confirm a diagnosis of PNH, which requires specific surface marker detection. *Hemoglobin electrophoresis* - **Hemoglobin electrophoresis** is used to diagnose **hemoglobinopathies** such as **sickle cell disease** or **thalassemia**. The patient's brother has sickle cell trait, but the patient's symptoms, particularly the prominent hemolytic anemia and thrombotic events, are not typical of a hemoglobinopathy in this acute presentation. - While it could rule out a hemoglobinopathy, it wouldn't explain the full spectrum of symptoms, especially the thrombosis and the specific pattern of hemolysis (e.g., elevated LDH, indirect bilirubin).

Liver disease US Medical PG Question 8: A 32-year-old woman presents to her family physician with a long history of depression, irritability, and, more recently, personality changes. As her partner comments, she has stopped engaging in activities she used to enjoy like dancing, drumming lessons, and yoga. The patient denies changes in skin pigmentation and assures she keeps a balanced diet low in fat and carbohydrates. During the physical examination, jaundice and dark rings encircling the iris of the eye are noted, as well as hepatomegaly and gait disturbances. For a follow-up visit, the patient brings a battery of laboratory tests that includes a complete blood count showing normocytic normochromic anemia, a negative Coombs, normal iron levels, normal fasting glucose levels, elevated aminotransferases from the liver biochemical tests, bilirubin, and decreased serum ceruloplasmin levels. Antinuclear antibodies are negative. What is the most likely diagnosis?

• A. Primary sclerosing cholangitis
• B. Wilson disease (Correct Answer)
• C. Hemochromatosis
• D. Nonalcoholic fatty liver disease
• E. Autoimmune hepatitis

Liver disease Explanation: ***Wilson disease*** - The combination of **neuropsychiatric symptoms** (depression, irritability, personality changes, gait disturbances), **liver disease** (jaundice, hepatomegaly, elevated aminotransferases, hyperbilirubinemia), and **Kayser-Fleischer rings** in the eyes is pathognomonic for Wilson disease. - **Decreased serum ceruloplasmin** levels further confirm the diagnosis, as ceruloplasmin is the main copper-carrying protein in the blood, and its deficiency leads to copper accumulation. *Primary sclerosing cholangitis* - Characterized by inflammation and fibrosis of the **bile ducts**, leading to cholestasis and can be associated with inflammatory bowel disease, which is not mentioned here. - While it causes jaundice and elevated liver enzymes, it does not typically present with the neurological or psychiatric symptoms, or **Kayser-Fleischer rings** seen in Wilson disease. *Hemochromatosis* - This disorder involves excessive **iron accumulation** in the body, leading to symptoms like fatigue, joint pain, impotence, and liver damage (cirrhosis, hepatomegaly). - The patient's **normal iron levels** and the absence of classic bronze skin pigmentation, along with the presence of Kayser-Fleischer rings and neuropsychiatric symptoms, rule out hemochromatosis. *Nonalcoholic fatty liver disease* - Primarily associated with **metabolic syndrome** (obesity, diabetes, hyperlipidemia) and is characterized by fat accumulation in the liver. - While it can cause hepatomegaly and elevated liver enzymes, it does not typically manifest with neurological or psychiatric symptoms, nor **Kayser-Fleischer rings**, and the patient describes a balanced diet. *Autoimmune hepatitis* - Involves **immune-mediated inflammation of the liver** and can present with elevated aminotransferases, hyperbilirubinemia, and hepatomegaly, often with positive autoantibodies (e.g., ANA, anti-smooth muscle antibodies). - The patient's **negative ANA** and the presence of **Kayser-Fleischer rings** and prominent neuropsychiatric symptoms are not characteristic of autoimmune hepatitis.

Liver disease US Medical PG Question 9: A 44-year-old man comes to the physician for a routine health maintenance examination. He had not seen his primary care physician for 7 years. He has no complaints other than feeling easily fatigued. He has no significant medical history. He reports drinking half a pint of liquor a day. His temperature is 98.7°F (37.1°C), pulse is 65/min, respiratory rate is 15/min, and blood pressure is 120/70 mm Hg. Physical examination shows reddish color to both of his palms. His abdomen has no focal tenderness but is difficult to assess due to distention. Laboratory studies show: Hemoglobin 11.0 g/dL Hematocrit 33% Leukocyte count 5,000/mm3 Platelet count 60,000/mm3 Serum Na+ 135 mEq/L K+ 4.5 mEq/L Cl- 100 mEq/L HCO3- 24 mEq/L Urea nitrogen 15 mg/dL Creatinine 1.3 mg/dL Total bilirubin 3.0 mg/dL AST 112 U/L ALT 80 U/L Alkaline phosphatase 130 U/L Which of the following is the most likely explanation for this patient's thrombocytopenia?

• A. Uremia
• B. Hypersplenism (Correct Answer)
• C. Autoimmune antibodies
• D. Bone marrow infiltration
• E. Decreased protein synthesis

Liver disease Explanation: ***Hypersplenism*** - This patient presents with **severe alcohol use**, signs of **liver disease** (fatigue, palmar erythema, abdominal distention suggestive of ascites, elevated bilirubin, AST, ALT), and **thrombocytopenia**. **Cirrhosis** from heavy alcohol use can lead to **portal hypertension**, causing **splenomegaly** and subsequent **hypersplenism**, where the spleen sequesters and destroys platelets at an accelerated rate. - The combination of **liver dysfunction** and **low platelet count** in the context of chronic alcohol abuse strongly points to hypersplenism as the cause for thrombocytopenia. *Uremia* - **Uremia** refers to a buildup of waste products in the blood due to **kidney dysfunction**, which can cause platelet dysfunction but typically does not cause a significant decrease in platelet count (thrombocytopenia) itself. - While the patient's **creatinine is slightly elevated** (1.3 mg/dL), it is not indicative of severe renal failure that would typically lead to uremia-induced bleeding diathesis, and his platelet count is significantly low rather than merely dysfunctional. *Autoimmune antibodies* - **Immune thrombocytopenia (ITP)** is caused by **autoantibodies** against platelets, leading to their premature destruction. While it causes severe thrombocytopenia, it is typically a diagnosis of exclusion and less likely given the clear evidence of advanced **liver disease** and **portal hypertension** in this patient. - There is no specific evidence or clinical context suggesting an autoimmune process is at play rather than a direct complication of chronic liver disease. *Bone marrow infiltration* - **Bone marrow infiltration** (e.g., by malignancy or fibrosis) can lead to **myelophthisic anemia** and thrombocytopenia due to the displacement of megakaryocytes. - This patient's presentation with prominent signs of **liver disease** and **chronic alcohol abuse** does not suggest bone marrow pathology as the primary cause for his thrombocytopenia. No other cytopenias (beyond mild anemia, which can be multifactorial in liver disease) are profoundly out of proportion to suggest a primary marrow disorder. *Decreased protein synthesis* - **Decreased protein synthesis** is a hallmark of severe **liver failure**, affecting the production of many proteins, including clotting factors. However, the liver primarily produces factors involved in coagulation, not platelets themselves. - While liver failure can impair thrombopoietin production, which stimulates platelet production, **hypersplenism** is a more direct and common cause of significant thrombocytopenia in the context of advanced liver disease with portal hypertension.

Liver disease US Medical PG Question 10: A 52-year-old man comes to the physician because his skin has been progressively yellowing for the past 4 weeks. He also reports low appetite and difficulty fitting into his pants because of his swollen legs over the past several months. There is no personal or family history of serious illness. He does not smoke and drinks 1 to 2 beers on special occasions. He used to be sexually active with multiple female partners but has lost interest in sexual intercourse recently. He is 178 cm (5 ft 10 in) tall and weighs 68 kg (150 lb); his BMI is 22 kg/m2. Vital signs are within normal limits. Physical examination shows yellowing of the skin and sclera as well as erythema of the palms. There is bilateral enlargement of breast tissue. Cardiopulmonary examinations show no abnormalities. The abdomen is distended. The liver is palpated 2 to 3 cm below the right costal margin. On percussion of the left abdomen, a thrill can be felt on the right side. Hepatojugular reflux is absent. There is bilateral edema below the knees. Which of the following is the most likely underlying cause of this patient's condition?

• A. Autoimmune hepatitis
• B. Congestive hepatopathy
• C. Primary biliary cirrhosis
• D. Chronic viral hepatitis (Correct Answer)
• E. Non-alcoholic steatohepatitis

Liver disease Explanation: ***Chronic viral hepatitis*** - The patient's history of **multiple sexual partners** and subsequent development of **jaundice**, **ascites** (distended abdomen with thrill on percussion), **palmar erythema**, **gynecomastia** (bilateral enlarged breast tissue), and **peripheral edema** are highly suggestive of **decompensated chronic liver disease**, such as **cirrhosis**. - **Chronic viral hepatitis** (e.g., Hepatitis B or C) is a very common cause of cirrhosis, especially in patients with a history of risky behaviors like unprotected sexual intercourse. *Autoimmune hepatitis* - While it can cause cirrhosis, **autoimmune hepatitis** typically presents with elevated **liver enzymes** (AST, ALT) and specific **autoantibodies** (e.g., ANA, anti-smooth muscle antibodies), which are not mentioned here. - There is no specific risk factor for autoimmune disease in this patient's history. *Congestive hepatopathy* - This condition results from **right-sided heart failure**, causing engorgement of the liver and potentially cirrhosis. The absence of **hepatojugular reflux** makes this diagnosis less likely. - Symptoms like **jugular venous distention** and **cardiac murmurs** associated with heart failure would typically be present. *Primary biliary cirrhosis* - This is a **cholestatic liver disease** primarily affecting **middle-aged women** and is characterized by **pruritus**, **fatigue**, and elevated **alkaline phosphatase**. - The patient's gender and lack of specific cholestatic symptoms make this less probable. *Non-alcoholic steatohepatitis* - While **NASH** can progress to cirrhosis, the patient's **normal BMI**, lack of significant **alcohol intake**, and no history of **diabetes** or **dyslipidemia** make this diagnosis less likely. - NASH is strongly associated with **metabolic syndrome**.

Liver disease Flashcard 1 of 10

Question: What is the result of hepatic failure on a T3 resin uptake test?_____

Answer: Resin uptake is increased

Liver disease Flashcard 2 of 10

Question: Hepatic encephalopathy may be triggered by decreased NH3 removal, such as _____ failure

Answer: renal

Liver disease Flashcard 3 of 10

Question: Loop diuretics may be used to treat _____ in liver failure (e.g. cirrhosis)

Answer: ascites

Liver disease Flashcard 4 of 10

Question: The acute phase of HCV infection is marked by a rise and fall of _____ in 6 months (liver enzyme)

Answer: ALT

Liver disease Flashcard 5 of 10

Question: Hepatic encephalopathy may be triggered by increased NH3 production or absorption, such as increased dietary _____

Answer: protein

Liver disease Flashcard 6 of 10

Question: AST _____ ALT in nonalcoholic liver disease suggests progression to advanced fibrosis or cirrhosis

Answer: >

Liver disease Flashcard 7 of 10

Question: _____ liver disease is associated with obesity and metabolic syndrome

Answer: Non-alcoholic fatty

Liver disease Flashcard 8 of 10

Question: Wilson disease is characterized by accumulation of copper, especially in the _____, brain, cornea, and kidneys

Answer: liver

Liver disease Flashcard 9 of 10

Question: Meigs' syndrome

Answer:

Extra Information: ovarian fibroma, ascites, hydrothorax

Liver disease Flashcard 10 of 10

Question: What conditions are associated with myoclonus?

Answer: metabolic abnormalities e.g. renal or liver failure