A person with a history of chronic alcohol consumption who indulged in binge drinking 10 days ago is brought to the emergency department in an unconscious state. A non-contrast CT scan was normal, and his blood glucose level is 45 mg/dL. What is the most appropriate treatment?
Q2
A 40-year-old farmer presents with fever, calf tenderness, conjunctival suffusion, retro-orbital pain, and hypokalemia. What is the diagnosis?
Q3
A 51-year-old man presents to the office with complaints of a gradual swelling of his face and frothy urine, which was first noticed by his wife 4 days ago. He also noticed that his limbs appear swollen. His past medical history includes diabetes mellitus for the past 10 years. He is currently on metformin and has well-controlled blood sugar and HbA1c levels. He does not smoke and drinks alcohol occasionally. His laboratory results during his last visit 6 months ago were normal. On physical examination, there is pitting edema in the lower extremities and on his face. His vital signs include: blood pressure 121/78 mm Hg, pulse 77/min, temperature 36.7°C (98.1°F), and respiratory rate 10/min.
The urinalysis shows:
pH 6.2
Color light yellow
RBC none
WBC 3–4/HPF
Protein 4+
Cast fat globules
Glucose absent
Crystal none
Ketone absent
Nitrite absent
24-hour urine protein excretion 5.1 g
Which of the following is the most likely cause of the generalized edema in this patient?
Q4
A 27-year-old man with a history of intravenous drug use comes to the physician because of anorexia, nausea, dark urine, and abdominal pain for 2 weeks. Physical examination shows scleral icterus and right upper quadrant tenderness. Serum studies show:
Alanine aminotransferase 1248 U/L
Aspartate aminotransferase 980 U/L
Hepatitis B surface antigen negative
Anti-hepatitis B surface antibody positive
Anti-hepatitis C antibody negative
Further evaluation shows hepatitis C virus RNA detected by PCR. Without appropriate treatment, which of the following is the most likely outcome of this patient's current condition?
Q5
A 40-year-old man visits the office with complaints of fever and abdominal pain for the past 6 days. He is also concerned about his weight loss as he weighs 3.6 kg (8 lb) less, today, than he did 2 months ago. He has a previous history of being admitted to the hospital for recurrent cholangitis. The vital signs include: heart rate 97/min, respiratory rate 17/min, temperature 39.0°C (102.2°F), and blood pressure 114/70 mm Hg. On physical examination, there is tenderness on palpation of the right upper quadrant. The laboratory results are as follows:
Hemoglobin 16 g/dL
Hematocrit 44%
Leukocyte count 18,000/mm3
Neutrophils 60%
Bands 4%
Eosinophils 2%
Basophils 1%
Lymphocytes 27%
Monocytes 6%
Platelet count 345,000/mm3
Aspartate aminotransferase (AST) 57 IU/L
Alanine aminotransferase (ALT) 70 IU/L
Alkaline phosphatase 140 U/L
Total bilirubin 8 mg/dL
Direct bilirubin 5 mg/dL
An ultrasound is also done to the patient which is shown in the picture. What is the most likely diagnosis?
Q6
A 36-year-old female presents to the emergency department with right upper quadrant (RUQ) pain. She describes the pain as dull and getting progressively worse over the last several weeks. She denies any relationship to eating. Her past medical history is significant for endometriosis, which she manages with oral contraceptive pills, and follicular thyroid cancer, for which she underwent total thyroidectomy and now takes levothyroxine. The patient drinks a six pack of beer most nights of the week, and she has a 20 pack-year smoking history. She recently returned from visiting cousins in Mexico who have several dogs. Her temperature is 98.2°F (36.8°C), blood pressure is 132/87 mmHg, pulse is 76/min, and respirations are 14/min. On physical exam, her abdomen is soft and non-distended with tenderness in the right upper quadrant and palpable hepatomegaly. Laboratory testing is performed and reveals the following:
Aspartate aminotransferase (AST, GOT): 38 U/L
Alanine aminotransferase (ALT, GPT): 32 U/L
Alkaline phosphatase: 196 U/L
gamma-Glutamyltransferase (GGT): 107 U/L
Total bilirubin: 0.8 mg/dL
RUQ ultrasound demonstrates a solitary, well-demarcated, heterogeneous 6 cm mass in the right lobe of the liver. CT scan with contrast reveals peripheral enhancement during the early phase with centripetal flow during the portal venous phase. Which of the following is a risk factor for this condition?
Q7
A 30-year-old woman presents with a history of progressive forgetfulness, fatigue, unsteady gait, and tremor. Family members also report that not only has her speech become slurred, but her behavior has significantly changed over the past few years. On physical examination, there is significant hepatomegaly with a positive fluid wave. There is also distended and engorged veins present radiating from the umbilicus and 2+ lower extremity pitting edema worst in the ankles. There are corneal deposits noted on slit lamp examination. Which of the following conditions present with a similar type of edema?
I. Hypothyroidism
II. Kwashiorkor
III. Mastectomy surgery
IV. Heart failure
V. Trauma
VI. Chronic viral hepatitis
VII. Hemochromatosis
Q8
A 57-year-old woman comes to the physician because of a 1-month history of lesions on her eyelids. A photograph of the lesions is shown. This patient's eye condition is most likely associated with which of the following processes?
Q9
A 37-year-old woman comes to the office complaining of fatigue and itchiness for the past 2 months. She tried applying body lotion with limited improvement. Her symptoms have worsened over the past month, and she is unable to sleep at night due to intense itching. She feels very tired throughout the day and complains of decreased appetite. She does not smoke cigarettes or drink alcohol. Her past medical history is noncontributory. Her father has diabetes and is on medications, and her mother has hypothyroidism for which she is on thyroid supplementation. Temperature is 36.1°C (97°F), blood pressure is 125/75 mm Hg, pulse is 80/min, respiratory rate is 16/min, and BMI is 25 kg/m2. On examination, her sclera appears icteric. There are excoriations all over her body. Abdominal and cardiopulmonary examinations are negative.
Laboratory test
Complete blood count
Hemoglobin 11.5 g/dL
Leukocytes 9,000/mm3
Platelets 150,000/mm3
Serum cholesterol 503 mg/dL
Liver function test
Serum bilirubin 1.7 mg/dL
AST 45 U/L
ALT 50 U/L
ALP 130 U/L (20–70 U/L)
Which of the following findings will favor primary biliary cirrhosis over primary sclerosing cholangitis?
Q10
A 54-year-old man presents to the emergency department for fatigue and weight loss. He reports feeling increasingly tired over the last several weeks and has lost seven pounds over the last month. His wife has also noticed a yellowing of the eyes. He endorses mild nausea but denies vomiting, abdominal pain, or changes in his stools. Ten years ago, he was hospitalized for an episode of acute pancreatitis. His past medical history is otherwise significant for hyperlipidemia, diabetes mellitus, and obesity. He has two glasses of wine most nights with dinner and has a 30-pack-year smoking history. On physical exam, the patient has icteric sclera and his abdomen is soft, non-distended, and without tenderness to palpation. Bowel sounds are present. Laboratory studies reveal the following:
Alanine aminotransferase (ALT): 67 U/L
Aspartate aminotransferase (AST): 54 U/L
Alkaline phosphatase: 771 U/L
Total bilirubin: 12.1 mg/dL
Direct bilirubin: 9.4 mg/dL
Which of the following would most likely be seen on abdominal imaging?
Liver disease US Medical PG Practice Questions and MCQs
Question 1: A person with a history of chronic alcohol consumption who indulged in binge drinking 10 days ago is brought to the emergency department in an unconscious state. A non-contrast CT scan was normal, and his blood glucose level is 45 mg/dL. What is the most appropriate treatment?
A. Normal saline
B. IM thiamine followed by dextrose (Correct Answer)
C. 5% dextrose/vitamin K
D. 25% dextrose
E. IV dextrose followed by thiamine
Explanation: **IM thiamine followed by dextrose**
- Administering **thiamine** prior to **dextrose** is crucial in patients with chronic alcohol use to prevent **Wernicke-Korsakoff syndrome**, as glucose administration can precipitate or worsen Wernicke encephalopathy in thiamine-deficient individuals.
- The patient's **hypoglycemia** (45 mg/dL) requires immediate correction with **dextrose**, but **thiamine** must be given first due to the patient's history of chronic alcohol consumption.
*Normal saline*
- While **normal saline** is used for rehydration and volume expansion, it does not address the patient's immediate and life-threatening **hypoglycemia** or **thiamine deficiency**.
- Without addressing **hypoglycemia**, the patient's unconscious state will persist and lead to further neurological damage.
*5% dextrose/vitamin K*
- **5% dextrose** alone might correct **hypoglycemia**, but administering it without prior **thiamine** in a chronic alcoholic can precipitate **Wernicke encephalopathy**.
- **Vitamin K** is typically given for coagulopathies or bleeding disorders, not as a primary treatment for **hypoglycemia** or **alcohol-related neurological emergencies** unless specific indications are present.
*25% dextrose*
- **25% dextrose** would rapidly correct **hypoglycemia**, but as with 5% dextrose, administering it without prior **thiamine** in a chronic alcoholic can precipitate or worsen **Wernicke encephalopathy**.
- The primary concern in this context for an alcoholic patient with hypoglycemia is the potential for **thiamine deficiency**.
*IV dextrose followed by thiamine*
- While this option includes both necessary treatments, the **incorrect sequence** is critical—administering **dextrose before thiamine** in a chronic alcoholic can precipitate **Wernicke encephalopathy**.
- The correct protocol requires **thiamine first** to replenish stores before glucose metabolism is accelerated by dextrose administration.
Question 2: A 40-year-old farmer presents with fever, calf tenderness, conjunctival suffusion, retro-orbital pain, and hypokalemia. What is the diagnosis?
A. Malaria
B. Dengue
C. Leptospira (Correct Answer)
D. Influenza
E. Typhoid fever
Explanation: ***Leptospira***
- The combination of **fever**, **calf tenderness**, **conjunctival suffusion** (red eyes without purulent discharge), **retro-orbital pain**, and **hypokalemia** is highly suggestive of **leptospirosis**.
- A farmer's occupation increases the risk of exposure to contaminated water or soil, which is a common transmission route for Leptospira.
- **Calf tenderness** and **conjunctival suffusion** are particularly characteristic features.
*Malaria*
- Characterized by **cyclic fevers**, **chills**, and **sweats**, often with **splenomegaly** and **anemia**.
- **Calf tenderness**, **conjunctival suffusion**, and **retro-orbital pain** are not typical primary symptoms of malaria.
*Dengue*
- Often presents with **high fever**, **severe headache** (especially retro-orbital), **muscle and joint pain** ("breakbone fever"), and **rash**.
- **Conjunctival suffusion** and significant **calf tenderness** are not classic features, and hypokalemia is less common than with leptospirosis.
*Influenza*
- Acute respiratory illness with **fever**, **cough**, **sore throat**, **muscle aches**, and **fatigue**.
- While muscle aches can occur, **calf tenderness**, **conjunctival suffusion**, and **hypokalemia** are not characteristic of influenza.
*Typhoid fever*
- Presents with **sustained fever**, **relative bradycardia**, **rose spots**, and **hepatosplenomegaly**.
- **Conjunctival suffusion**, **calf tenderness**, and **retro-orbital pain** are not typical features of typhoid fever.
Question 3: A 51-year-old man presents to the office with complaints of a gradual swelling of his face and frothy urine, which was first noticed by his wife 4 days ago. He also noticed that his limbs appear swollen. His past medical history includes diabetes mellitus for the past 10 years. He is currently on metformin and has well-controlled blood sugar and HbA1c levels. He does not smoke and drinks alcohol occasionally. His laboratory results during his last visit 6 months ago were normal. On physical examination, there is pitting edema in the lower extremities and on his face. His vital signs include: blood pressure 121/78 mm Hg, pulse 77/min, temperature 36.7°C (98.1°F), and respiratory rate 10/min.
The urinalysis shows:
pH 6.2
Color light yellow
RBC none
WBC 3–4/HPF
Protein 4+
Cast fat globules
Glucose absent
Crystal none
Ketone absent
Nitrite absent
24-hour urine protein excretion 5.1 g
Which of the following is the most likely cause of the generalized edema in this patient?
A. Loss of antithrombin III in the urine
B. Hypoalbuminemia (Correct Answer)
C. Hypertension
D. Loss of globulin in the urine
E. Hyperlipidemia
Explanation: ***Hypoalbuminemia***
- **Hypoalbuminemia** significantly reduces **plasma oncotic pressure**, leading to fluid extravasation into the interstitial space and causing generalized edema.
- The patient's **frothy urine** and **5.1 g/24-hour urine protein excretion** indicate significant **proteinuria**, resulting in substantial albumin loss.
*Loss of antithrombin III in the urine*
- While **nephrotic syndrome** can lead to urinary loss of **antithrombin III**, increasing the risk of thromboembolism, it is not the direct cause of the generalized edema.
- The loss of antithrombin III is a **complication** of extensive proteinuria, not its cause.
*Hypertension*
- **Hypertension** can contribute to edema in certain conditions, especially heart failure, but it is not the primary cause of the severe generalized edema in the setting of nephrotic range proteinuria.
- The patient's blood pressure is currently **well-controlled** at 121/78 mmHg, making it unlikely to be the sole or primary cause.
*Loss of globulin in the urine*
- While other proteins, including some globulins, may be lost in significant proteinuria, **albumin** is the most abundant and osmotically active plasma protein, making its loss the primary driver of reduced oncotic pressure and edema.
- The term "frothy urine" specifically signifies a high concentration of **albumin**, not typically globulins.
*Hyperlipidemia*
- **Hyperlipidemia** is a common finding in nephrotic syndrome due to increased hepatic synthesis of VLDL and LDL, along with reduced catabolism.
- However, **hyperlipidemia** itself does not directly cause edema; it is a metabolic consequence of the syndrome.
Question 4: A 27-year-old man with a history of intravenous drug use comes to the physician because of anorexia, nausea, dark urine, and abdominal pain for 2 weeks. Physical examination shows scleral icterus and right upper quadrant tenderness. Serum studies show:
Alanine aminotransferase 1248 U/L
Aspartate aminotransferase 980 U/L
Hepatitis B surface antigen negative
Anti-hepatitis B surface antibody positive
Anti-hepatitis C antibody negative
Further evaluation shows hepatitis C virus RNA detected by PCR. Without appropriate treatment, which of the following is the most likely outcome of this patient's current condition?
A. Liver cirrhosis
B. Hepatocellular carcinoma
C. Transient infection
D. Fulminant hepatitis
E. Slowly progressive hepatitis (Correct Answer)
Explanation: ***Slowly progressive hepatitis***
- This patient has **acute hepatitis C infection** (HCV RNA positive by PCR but anti-HCV antibody still negative, indicating early infection within the 8-12 week window period before antibody seroconversion).
- Without treatment, **75-85% of acute HCV infections progress to chronic infection**, characterized by **slowly progressive hepatitis** with ongoing liver inflammation and gradual fibrosis development over years to decades.
- This chronic progression is the most statistically likely outcome of the current acute infection, making it the correct answer.
*Transient infection*
- **Spontaneous viral clearance** occurs in only **15-25% of acute hepatitis C cases**, making it less likely than progression to chronicity.
- While possible, this is the minority outcome and therefore not the "most likely" result without treatment.
- Spontaneous clearance typically occurs within the first 6 months of infection.
*Liver cirrhosis*
- While **liver cirrhosis** is a potential long-term complication of chronic hepatitis C, it represents an advanced stage of liver fibrosis that develops over **20-30 years** of chronic infection.
- It is not the immediate or direct outcome of the current acute infection, but rather a late-stage sequela that may develop after years of slowly progressive hepatitis.
*Hepatocellular carcinoma*
- **Hepatocellular carcinoma** (HCC) is a complication that typically arises in the setting of established cirrhosis from chronic HCV.
- It represents an even later-stage complication than cirrhosis (often decades after initial infection) and does not represent the most likely immediate outcome of acute infection.
*Fulminant hepatitis*
- **Fulminant hepatitis**, characterized by rapid onset of severe liver failure with encephalopathy within 8 weeks of symptom onset, is extremely rare with hepatitis C (**<0.1% of cases**).
- The patient's presentation shows acute hepatitis with elevated transaminases but no signs of hepatic encephalopathy or coagulopathy that would suggest fulminant liver failure.
Question 5: A 40-year-old man visits the office with complaints of fever and abdominal pain for the past 6 days. He is also concerned about his weight loss as he weighs 3.6 kg (8 lb) less, today, than he did 2 months ago. He has a previous history of being admitted to the hospital for recurrent cholangitis. The vital signs include: heart rate 97/min, respiratory rate 17/min, temperature 39.0°C (102.2°F), and blood pressure 114/70 mm Hg. On physical examination, there is tenderness on palpation of the right upper quadrant. The laboratory results are as follows:
Hemoglobin 16 g/dL
Hematocrit 44%
Leukocyte count 18,000/mm3
Neutrophils 60%
Bands 4%
Eosinophils 2%
Basophils 1%
Lymphocytes 27%
Monocytes 6%
Platelet count 345,000/mm3
Aspartate aminotransferase (AST) 57 IU/L
Alanine aminotransferase (ALT) 70 IU/L
Alkaline phosphatase 140 U/L
Total bilirubin 8 mg/dL
Direct bilirubin 5 mg/dL
An ultrasound is also done to the patient which is shown in the picture. What is the most likely diagnosis?
A. Hepatitis B
B. Acute cholecystitis
C. Cholangitis
D. Hepatocarcinoma
E. Liver abscess (Correct Answer)
Explanation: ***Liver abscess***
- The patient presents with **fever**, **RUQ tenderness**, **leukocytosis**, and a **history of recurrent cholangitis**, which increases the risk of pyogenic liver abscess formation.
- The ultrasound would likely show a **fluid-filled lesion** in the liver, consistent with an abscess.
*Hepatitis B*
- While hepatitis B can cause **fever, abdominal pain, and liver enzyme elevation**, it typically does not present with a discrete mass or recurrent cholangitis.
- The provided symptoms and lab results are more indicative of an **infectious process with focal involvement**.
*Acute cholecystitis*
- This condition involves **inflammation of the gallbladder**, usually due to gallstones, presenting with RUQ pain, fever, and leukocytosis.
- However, the patient's **recurrent cholangitis history** and the high bilirubin levels suggest obstruction or infection within the bile ducts or liver parenchyma, rather than just gallbladder inflammation.
*Cholangitis*
- Cholangitis is an **infection of the bile ducts**, characterized by **fever, RUQ pain, and jaundice** (**Charcot's triad**), which matches many of the patient's symptoms.
- However, the question states a history of recurrent cholangitis, and the current presentation, especially with the high leukocytosis and potential for a focal lesion on ultrasound, points towards a **complication of chronic cholangitis**, such as a liver abscess.
*Hepatocarcinoma*
- Hepatocarcinoma typically presents with **weight loss, abdominal pain, and an elevated alpha-fetoprotein level**, but fever is usually not as prominent unless there's tumor necrosis or infection.
- The **acute febrile presentation** and marked leukocytosis are more consistent with an infectious process rather than a malignancy.
Question 6: A 36-year-old female presents to the emergency department with right upper quadrant (RUQ) pain. She describes the pain as dull and getting progressively worse over the last several weeks. She denies any relationship to eating. Her past medical history is significant for endometriosis, which she manages with oral contraceptive pills, and follicular thyroid cancer, for which she underwent total thyroidectomy and now takes levothyroxine. The patient drinks a six pack of beer most nights of the week, and she has a 20 pack-year smoking history. She recently returned from visiting cousins in Mexico who have several dogs. Her temperature is 98.2°F (36.8°C), blood pressure is 132/87 mmHg, pulse is 76/min, and respirations are 14/min. On physical exam, her abdomen is soft and non-distended with tenderness in the right upper quadrant and palpable hepatomegaly. Laboratory testing is performed and reveals the following:
Aspartate aminotransferase (AST, GOT): 38 U/L
Alanine aminotransferase (ALT, GPT): 32 U/L
Alkaline phosphatase: 196 U/L
gamma-Glutamyltransferase (GGT): 107 U/L
Total bilirubin: 0.8 mg/dL
RUQ ultrasound demonstrates a solitary, well-demarcated, heterogeneous 6 cm mass in the right lobe of the liver. CT scan with contrast reveals peripheral enhancement during the early phase with centripetal flow during the portal venous phase. Which of the following is a risk factor for this condition?
A. Recent contact with dogs
B. Extrahepatic malignancy
C. Chronic alcohol abuse
D. Recent travel to Mexico
E. Oral contraceptive pill use (Correct Answer)
Explanation: ***Oral contraceptive pill use***
- The patient's presentation with a solitary, well-demarcated hepatic mass showing **peripheral enhancement with centripetal filling** on CT scan is pathognomonic for a **hepatic hemangioma**.
- Hepatic hemangiomas are the most common benign liver tumors and are typically asymptomatic, though large lesions (>4 cm) can cause symptoms.
- While hemangiomas have no clearly established risk factors, they are more common in women and may have an association with **oral contraceptive pill (OCP) use**, though this relationship is less definitive than with hepatic adenomas.
- Some studies suggest OCPs may influence hemangioma growth, making this the most relevant risk factor among the options provided.
*Recent contact with dogs*
- Contact with dogs, especially in endemic areas, is a risk factor for **echinococcal cysts** (hydatid disease).
- Echinococcal cysts appear as multiloculated, cystic lesions with daughter cysts or calcifications on imaging, not as a solid mass with the described enhancement pattern.
*Extrahepatic malignancy*
- An extrahepatic malignancy could lead to **metastatic liver disease**, which typically presents as multiple lesions with different enhancement characteristics (e.g., rim enhancement or rapid washout).
- While the patient has a history of follicular thyroid cancer, the characteristic centripetal filling pattern is specific for hemangioma, not metastases.
*Chronic alcohol abuse*
- **Chronic alcohol abuse** is a major risk factor for alcoholic liver disease, cirrhosis, and **hepatocellular carcinoma (HCC)**.
- HCC typically shows arterial hyperenhancement with portal venous washout (not centripetal filling), and is usually associated with cirrhosis.
- The patient's imaging findings and clinical presentation are not consistent with HCC.
*Recent travel to Mexico*
- Travel to Mexico with potential exposure to contaminated food or water could be a risk factor for **parasitic infections** or **amebic liver abscess**.
- However, the imaging findings of a well-demarcated solid mass with classic hemangioma enhancement pattern are inconsistent with infectious or abscess formations, which would show rim enhancement and internal heterogeneity.
Question 7: A 30-year-old woman presents with a history of progressive forgetfulness, fatigue, unsteady gait, and tremor. Family members also report that not only has her speech become slurred, but her behavior has significantly changed over the past few years. On physical examination, there is significant hepatomegaly with a positive fluid wave. There is also distended and engorged veins present radiating from the umbilicus and 2+ lower extremity pitting edema worst in the ankles. There are corneal deposits noted on slit lamp examination. Which of the following conditions present with a similar type of edema?
I. Hypothyroidism
II. Kwashiorkor
III. Mastectomy surgery
IV. Heart failure
V. Trauma
VI. Chronic viral hepatitis
VII. Hemochromatosis
A. I, II, IV, VI
B. I, IV, VI, VII (Correct Answer)
C. I, II, IV, VII
D. II, IV, VI, VII
E. II, IV, V, VI
Explanation: ***I, IV, VI, VII***
- The patient's symptoms (forgetfulness, fatigue, unsteady gait, tremor, slurred speech, behavioral changes, hepatomegaly, ascites, caput medusae, lower extremity edema, and **corneal deposits (Kayser-Fleischer rings)**) are highly suggestive of **Wilson's disease**. This condition leads to severe liver disease and neurological dysfunction due to copper accumulation, often resulting in **edema from hypoalbuminemia** due to liver failure.
- Conditions presenting with similar types of edema (non-inflammatory, often pitting, due to systemic causes like fluid overload, hypoalbuminemia, or impaired lymphatic/venous return) include **hypothyroidism** (myxedema, non-pitting but can have pitting features), **heart failure** (increased hydrostatic pressure), **chronic viral hepatitis** (leading to liver failure and hypoalbuminemia), and **hemochromatosis** (can cause heart failure or liver damage leading to edema).
*I, II, IV, VI*
- This option incorrectly includes **Kwashiorkor** while omitting **hemochromatosis**. While Kwashiorkor causes edema due to protein deficiency, hemochromatosis is a more relevant cause of systemic edema similar to the conditions presented.
- The presented conditions share a common mechanism of edema, typically **pitting edema secondary to systemic causes** like low albumin or increased hydrostatic pressure, whereas Kwashiorkor is specific to nutritional protein deficiency.
*I, II, IV, VII*
- This option incorrectly includes **Kwashiorkor** while accurately including hypothyroidism, heart failure, and hemochromatosis. Kwashiorkor is a specific nutritional deficiency not directly implied by the initial patient presentation beyond general hypoalbuminemia.
- The other conditions (hypothyroidism, heart failure, hemochromatosis) all have well-established mechanisms for systemic edema that align with the type described in the patient (e.g., fluid retention, altered osmotic pressure).
*II, IV, VI, VII*
- This option misses **hypothyroidism**, which is a significant cause of edema. While including Kwashiorkor, heart failure, chronic viral hepatitis, and hemochromatosis, the omission of hypothyroidism makes it a less comprehensive answer.
- **Myxedema** from hypothyroidism is a distinct form of edema (non-pitting but can sometimes present with pitting qualities due to underlying fluid retention) that should be considered alongside other systemic causes.
*II, IV, V, VI*
- This option incorrectly includes **Trauma** as a primary cause of generalized edema similar to the patient's presentation and omits **hypothyroidism** and **hemochromatosis**. Trauma typically causes localized edema, not the generalized systemic edema observed in the patient.
- The question refers to systemic edema often associated with **fluid imbalances or organ dysfunction**, which is not characteristic of trauma-induced edema, which is usually focal and inflammatory.
Question 8: A 57-year-old woman comes to the physician because of a 1-month history of lesions on her eyelids. A photograph of the lesions is shown. This patient's eye condition is most likely associated with which of the following processes?
A. Dietary protein-induced inflammation of duodenum
B. Autoimmune destruction of lobular bile ducts (Correct Answer)
C. Transmural inflammation of colonic mucosa
D. Deposition of immunoglobulin light chains
E. Infection with human herpesvirus 8
Explanation: ***Autoimmune destruction of lobular bile ducts***
- The image shows **xanthelasma**, which are **cholesterol-filled plaques** on the eyelids, a common manifestation of **dyslipidemia**.
- Xanthelasma are strongly associated with **primary biliary cholangitis (PBC)**, an autoimmune disease characterized by progressive **destruction of small intrahepatic bile ducts**, leading to impaired bile flow and **hypercholesterolemia**.
*Dietary protein-induced inflammation of duodenum*
- This description refers to **celiac disease**, which presents with gastrointestinal symptoms and malabsorption, not typically xanthelasma.
- While celiac disease can have cutaneous manifestations (dermatitis herpetiformis), xanthelasma is not one of them.
*Transmural inflammation of colonic mucosa*
- This describes **Crohn's disease**, an inflammatory bowel disease primarily affecting the gastrointestinal tract.
- Crohn's disease is not directly associated with xanthelasma or primary biliary cholangitis.
*Deposition of immunoglobulin light chains*
- This process is characteristic of **amyloidosis**, which can cause a wide range of systemic symptoms based on the organs involved.
- While amyloidosis can affect the skin, it does not typically present as xanthelasma, which is specifically related to lipid deposition.
*Infection with human herpesvirus 8*
- **Human herpesvirus 8 (HHV-8)** is associated with **Kaposi's sarcoma**, a vascular tumor that presents as purple, red, or brown lesions.
- The lesions shown in the image are yellowish, flat plaques consistent with xanthelasma, not Kaposi's sarcoma.
Question 9: A 37-year-old woman comes to the office complaining of fatigue and itchiness for the past 2 months. She tried applying body lotion with limited improvement. Her symptoms have worsened over the past month, and she is unable to sleep at night due to intense itching. She feels very tired throughout the day and complains of decreased appetite. She does not smoke cigarettes or drink alcohol. Her past medical history is noncontributory. Her father has diabetes and is on medications, and her mother has hypothyroidism for which she is on thyroid supplementation. Temperature is 36.1°C (97°F), blood pressure is 125/75 mm Hg, pulse is 80/min, respiratory rate is 16/min, and BMI is 25 kg/m2. On examination, her sclera appears icteric. There are excoriations all over her body. Abdominal and cardiopulmonary examinations are negative.
Laboratory test
Complete blood count
Hemoglobin 11.5 g/dL
Leukocytes 9,000/mm3
Platelets 150,000/mm3
Serum cholesterol 503 mg/dL
Liver function test
Serum bilirubin 1.7 mg/dL
AST 45 U/L
ALT 50 U/L
ALP 130 U/L (20–70 U/L)
Which of the following findings will favor primary biliary cirrhosis over primary sclerosing cholangitis?
A. ‘Beads-on-a-string’ appearance on MRCP
B. Anti-mitochondrial antibody (Correct Answer)
C. ‘Onion skin fibrosis’ on liver biopsy
D. Elevated alkaline phosphatase and gamma glutamyltransferase
E. P-ANCA staining
Explanation: **Anti-mitochondrial antibody**
- The presence of **anti-mitochondrial antibodies (AMA)** is a hallmark of primary biliary cirrhosis (PBC), being positive in about 90-95% of cases.
- This finding, combined with obstructive cholestasis symptoms like **pruritus**, **fatigue**, **elevated ALP**, and **hyperlipidemia**, strongly supports a diagnosis of PBC.
*‘Beads-on-a-string’ appearance on MRCP*
- This finding, characterized by **strictures** and **dilatations** of the bile ducts, is pathognomonic for **primary sclerosing cholangitis (PSC)**.
- In contrast, the bile ducts in PBC usually appear normal on imaging, differentiating it from PSC.
*‘Onion skin fibrosis’ on liver biopsy*
- **'Onion skin fibrosis'**, or periductal concentric fibrosis, is a characteristic histological feature seen on **liver biopsy** in **primary sclerosing cholangitis (PSC)**.
- PBC liver biopsies typically show **florid duct lesions** or non-suppurative destructive cholangitis rather than 'onion skin' fibrosis.
*Elevated alkaline phosphatase and gamma glutamyltransferase*
- While both **ALP** and **GGT** are typically elevated in **cholestatic liver diseases**, including both PBC and PSC, this finding is **non-specific** and cannot distinguish between them.
- This generalized elevation indicates **biliary obstruction** or injury, but does not point to a specific etiology in this context.
*P-ANCA staining*
- **Perinuclear anti-neutrophil cytoplasmic antibodies (P-ANCA)** are often positive in a significant proportion of patients with **primary sclerosing cholangitis (PSC)**, especially those with co-existing inflammatory bowel disease.
- P-ANCA is typically **negative** in primary biliary cirrhosis (PBC), making it a distinguishing serological marker between the two conditions.
Question 10: A 54-year-old man presents to the emergency department for fatigue and weight loss. He reports feeling increasingly tired over the last several weeks and has lost seven pounds over the last month. His wife has also noticed a yellowing of the eyes. He endorses mild nausea but denies vomiting, abdominal pain, or changes in his stools. Ten years ago, he was hospitalized for an episode of acute pancreatitis. His past medical history is otherwise significant for hyperlipidemia, diabetes mellitus, and obesity. He has two glasses of wine most nights with dinner and has a 30-pack-year smoking history. On physical exam, the patient has icteric sclera and his abdomen is soft, non-distended, and without tenderness to palpation. Bowel sounds are present. Laboratory studies reveal the following:
Alanine aminotransferase (ALT): 67 U/L
Aspartate aminotransferase (AST): 54 U/L
Alkaline phosphatase: 771 U/L
Total bilirubin: 12.1 mg/dL
Direct bilirubin: 9.4 mg/dL
Which of the following would most likely be seen on abdominal imaging?
A. Multifocal dilation and stricturing of intra- and extrahepatic ducts
B. Pancreatic pseudocyst
C. Distended gallbladder (Correct Answer)
D. Surface nodularity of the liver
E. Choledocholithiasis
Explanation: ***Distended gallbladder***
- The patient presents with **obstructive jaundice** (elevated total and direct bilirubin, significantly elevated alkaline phosphatase) and a history of chronic pancreatitis risk factors (alcohol use, diabetes, obesity, prior acute pancreatitis). The absence of abdominal pain or tenderness suggests a **painless obstruction** of the common bile duct.
- Given the history of pancreatitis and the painless obstructive pattern, a **pancreatic head mass** (e.g., adenocarcinoma) compressing the common bile duct is highly suspected. This compression, if distal enough, leads to Courvoisier's sign: a **distended, palpable, and non-tender gallbladder**.
*Multifocal dilation and stricturing of intra- and extrahepatic ducts*
- This imaging finding is characteristic of **primary sclerosing cholangitis (PSC)**, a chronic cholestatic liver disease commonly associated with inflammatory bowel disease.
- PSC typically presents with fatigue and pruritus, but the highly elevated alkaline phosphatase and bilirubin, along with the patient's risk factors and jaundice, point away from PSC as the primary diagnosis.
*Pancreatic pseudocyst*
- A **pancreatic pseudocyst** is a common complication of acute or chronic pancreatitis and can cause symptoms like abdominal pain and mass effect.
- While the patient has a history of acute pancreatitis and risk factors for chronic pancreatitis, a pseudocyst is less likely to cause painless, isolated obstructive jaundice without significant abdominal pain or a palpable mass.
*Surface nodularity of the liver*
- **Surface nodularity of the liver** is a classic finding in **cirrhosis**, which can lead to jaundice if decompensated.
- However, the patient's laboratory values show an extremely high alkaline phosphatase and direct bilirubin, indicating a predominant **obstructive cholestatic pattern** rather than diffuse hepatocellular injury from cirrhosis.
*Choledocholithiasis*
- **Choledocholithiasis** (gallstones in the common bile duct) typically presents with **biliary colic**, severe epigastric or right upper quadrant pain, and often fever if cholangitis develops.
- The patient denies abdominal pain and fever, making choledocholithiasis less likely, especially with the painless jaundice and underlying risk factors for pancreatic malignancy.
