Liver disease — MCQs

A 32-year-old woman comes to the physician with increasing jaundice and fatigue for the past week. She has no history of a serious illness. She takes no medications and denies use of recreational drugs. She does not drink alcohol. Her vital signs are within normal limits. Her body mass index is 21 kg/m2. On physical examination, she has icteric sclera. Otherwise, her heart and lung sounds are within normal limits. Hemoglobin 15 g/dL Leukocyte count 6,000/mm3 with a normal differential Serum bilirubin Total 6.5 mg/dL Direct 0.9 mg/dL Alkaline phosphatase 70 U/L Aspartate aminotransferase (AST, GOT) 430 U/L Alanine aminotransferase (ALT, GPT) 560 U/L γ-Glutamyltransferase (GGT) 43 U/L (N=5-50 U/L) Hepatitis A antibody Negative Hepatitis B surface antigen Negative Hepatitis C antibody Negative Rheumatoid factor 80 IU/mL (N=0-20 IU/mL) Antinuclear antibody (ANA) titer is 1:1280. Polyclonal immunoglobulin gamma is 5 g/dL. Which of the following antibodies is most likely to be positive in this patient?

A 61-year-old woman presents to the emergency department with bloody vomiting for the last hour. She had been vomiting for several hours. Additionally, she states she felt a sudden onset of chest and epigastric pain when she noted blood in her vomit. In the emergency room, she endorses feeling lightheaded and denies difficulty breathing or coughing, and the pain is not worse with swallowing. On review of systems, she notes that she has been bruising more easily than usual over the last 3 months. The patient has a long history of alcoholism with recent progression of liver disease to cirrhosis. She has known esophageal varices and is on propranolol for prophylaxis. In the emergency room, the patient’s temperature is 98.2°F (36.8°C), blood pressure is 94/60 mmHg, pulse is 103/min, and respirations are 16/min. On exam, she is in moderate distress, and there is frank blood in her emesis basin. Cardiovascular and lung exams are unremarkable, and there is pain on palpation of her epigastrium and chest without crepitus. Initial labs are shown below: Hemoglobin: 13.1 g/dL Leukocyte count: 6,200/mm^3 Platelet count: 220,000/mm^3 Creatinine: 0.9 mg/dL The patient is started on IV isotonic saline, pantoprazole, ceftriaxone, and octreotide. Which of the following is the best next step in management?

A 38-year-old man presents with pruritus and jaundice. Past medical history is significant for ulcerative colitis diagnosed 2 years ago, well managed medically. He is vaccinated against hepatitis A and B and denies any recent travel abroad. On physical examination, prominent hepatosplenomegaly is noted. Which of the following would confirm the most likely diagnosis in this patient?

A 44-year-old woman is brought to the emergency department by her husband because of increasing confusion for 3 days. Her husband states that he noticed a yellowish discoloration of her eyes for the past 6 days. She has osteoarthritis. Current medications include acetaminophen and a vitamin supplement. She does not drink alcohol. She uses intravenous cocaine occasionally. She appears ill. Her temperature is 37.2 °C (99.0 °F), pulse is 102/min, respirations are 20/min, and blood pressure is 128/82 mm Hg. She is confused and oriented only to person. Examination shows scleral icterus and jaundice of her skin. Flapping tremors of the hand when the wrist is extended are present. The liver edge is palpated 4 cm below the right costal margin and is tender; there is no splenomegaly. Hemoglobin 12.4 g/dL Leukocyte count 13,500/mm3 Platelet count 100,000/mm3 Prothrombin time 68 sec (INR=4.58) Serum Na+ 133 mEq/L Cl- 103 mEq/L K+ 3.6 mEq/L Urea nitrogen 37 mg/dL Glucose 109 mg/dL Creatinine 1.2 mg/dL Total bilirubin 19.6 mg/dL AST 1356 U/L ALT 1853 U/L Hepatitis B surface antigen positive Hepatitis B surface antibody negative Hepatitis C antibody negative Anti-hepatitis A virus IgM negative Acetaminophen level 12 mcg/mL (N < 20 mcg/mL) The patient is transferred to the intensive care unit and treatment with tenofovir is begun. Which of the following is the most appropriate next step in the management of this patient?

A 70-year-old man without recent travel history presents with a 2-week history of gradually worsening generalized pruritus. He is unsure if his skin has yellowed, and carries an identification card without a photograph for comparison. On physical examination, the liver morphology is normal. A basic chemistry panel reveals sodium 139 mmol/L, potassium 3.8 mmol/L, chloride 110 mmol/L, carbon dioxide 27, blood urea nitrogen 26 mg/dL, creatinine 0.84 mg/dL, and glucose 108 mg/dL. Which of the following is the least compatible with the patient's provided history?

A 73-year-old woman visits an urgent care clinic with a complaint of fever for the past 48 hours. She has been having frequent chills and increasing abdominal pain since her fever spiked to 39.4°C (103.0°F) at home. She states that abdominal pain is constant, non-radiating, and rates the pain as a 4/10. She also complains of malaise and fatigue. The past medical history is insignificant. The vital signs include: heart rate 110/min, respiratory rate 15/min, temperature 39.2°C (102.5°F), and blood pressure 120/86 mm Hg. On physical examination, she is icteric and there is severe tenderness on palpation of the right hypochondrium. The ultrasound of the abdomen shows a dilated bile duct and calculus in the bile duct. The blood cultures are pending, and the antibiotic therapy is started. What is the most likely cause of her symptoms?

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 22-year-old woman comes to the office with complaints of dark urine and low-grade fever for 3 months. She also expresses her concerns about feeling fatigued most of the time. She says that she thought her dark urine was from dehydration and started to drink more water, but it showed minimal improvement. She reports a recent decrease in her appetite, and also states that her bowel movements are pale appearing. She denies smoking and alcohol consumption. The vital signs include: heart rate 99/min, respiratory rate 18/min, temperature 38.5°C (101.3°F) and blood pressure 100/60 mm Hg. On physical examination, telangiectasias on the anterior thorax are noted. The liver is palpable 4 cm below the costal border in the right midclavicular line and is tender on palpation. The spleen is palpable 2 cm below the costal border. Liver function results show: Aspartate aminotransferase (AST) 50 U/L Alanine Aminotransferase (ALT) 780 U/L Total bilirubin 10 mg/dL Direct bilirubin 6 mg/dL Alkaline phosphatase (ALP) 150 U/L Serum albumin 2.5 g/dL Serum globulins 6.5 g/dL Prothrombin time 14 s Agglutinations negative Serology for hepatitis C and D negative Anti-smooth muscle antibodies positive What is the most likely cause?

A 50-year-old woman comes to the office complaining of fatigue over the last several months. She feels ‘drained out’ most of the time and she drinks coffee and takes other stimulants to make it through the day. She also complains of severe itching all over her body for about 3 months which worsens at night. Her past medical history is significant for celiac disease. Additionally, she uses eye drops for a foreign body sensation in her eyes with little relief. Her mother has some neck problem for which she takes medicine, but she could not provide with any further information. Vitals include temperature 37.0°C (98.6°F), blood pressure 120/85 mm Hg, pulse 87/min, and respiration 18/min. BMI 26 kg/m2. On physical examination, there are skin excoriations and scleral icterus. Her gums are also yellow. Laboratory values: Total bilirubin 2.8 mg/dL Direct bilirubin 2.0 mg/dL Albumin 4.5 g/dL AST 35 U/L ALT 40 U/L ALP 240 U/L Ultrasonogram of the right upper quadrant shows no abnormality. What is the next best step to do?

A 57-year-old man presents to the emergency department for feeling weak for the past week. He states that he has felt much more tired than usual and has had a subjective fever during this time. The patient has a past medical history of IV drug use, hepatitis C, atrial fibrillation, cirrhosis, alcohol dependence, obesity, and depression. His temperature is 102°F (38.9°C), blood pressure is 157/98 mmHg, pulse is 110/min, respirations are 17/min, and oxygen saturation is 98% on room air. On physical exam, you note a fatigued man with diffuse yellowing of his skin. Cardiopulmonary exam is notable for bibasilar crackles on auscultation. Abdominal exam is notable for abdominal distension, dullness to percussion, and a fluid wave. The patient complains of generalized tenderness on palpation of his abdomen. The patient is started on piperacillin-tazobactam and is admitted to the medical floor. On day 4 of his stay in the hospital the patient is afebrile and his pulse is 92/min. His abdominal tenderness is reduced but is still present. Diffuse yellowing of the patient's skin and sclera is still notable. The nurses notice bleeding from the patient's 2 peripheral IV sites that she has to control with pressure. A few new bruises are seen on the patient's arms and legs. Which of the following is the best explanation for this patient's condition?