A 32-year-old woman comes to the physician because of a 3-month history of fatigue and myalgia. Over the past month, she has had intermittent episodes of nausea. She has a history of intravenous drug use, but she has not used illicit drugs for the past five years. She has smoked one pack of cigarettes daily for 14 years and drinks one alcoholic beverage daily. She takes no medications. Her last visit to a physician was 4 years ago. Her temperature is 37°C (98.6°F), pulse is 90/min, respirations are 20/min, and blood pressure is 110/70 mm Hg. Physical examination shows jaundice and hepatosplenomegaly. There are also blisters and erosions on the dorsum of both hands. The remainder of the examination shows no abnormalities. Laboratory studies show:
Hemoglobin 12 g/dL
Leukocyte count 8,300/mm3
Platelet count 250,000/mm3
Serum
Glucose 170 mg/dL
Albumin 3.0 g/dL
Total bilirubin 2.2 mg/dL
Alkaline phosphatase 80 U/L
AST 92 U/L
ALT 76 U/L
Hepatitis B surface antigen negative
Hepatitis B surface antibody positive
Hepatitis B core antibody positive
Hepatitis C antibody positive
Which of the following is the most appropriate next step in diagnosis?
Q62
A 50-year-old woman comes to the physician for the evaluation of fatigue over the past 6 months. During this period, the patient has also had a 5 kg (11-lb) weight loss. She has a history of Hashimoto thyroiditis. She is sexually active with her husband only. She does not smoke. She drinks one glass of wine per day. She does not use illicit drugs. Her only medication is levothyroxine. Temperature is 37°C (98.6°F), pulse is 70/min, and blood pressure is 110/70 mm Hg. Abdominal examination shows tenderness in the right upper quadrant with no rebound or guarding. Laboratory studies show a serum alanine aminotransferase level of 190 U/L, serum aspartate aminotransferase level of 250 U/L, and serum total bilirubin level of 0.6 mg/dL. Liver biopsy shows plasma cell infiltration and areas of periportal piecemeal necrosis. Further evaluation of this patient is most likely to show which of the following findings?
Q63
A 52-year-old man comes to the physician because of a 1-month history of fatigue and blurry vision. Pulse oximetry on room air shows an oxygen saturation of 99%. Laboratory studies show a hemoglobin concentration of 17.5 g/dL, mean corpuscular volume of 88 μm3, red cell volume of 51.6 mL/kg, and plasma volume of 38 mL/kg. Erythropoietin concentration is elevated. Which of the following is the most likely explanation for these findings?
Q64
A 45-year-old woman presents to the office because of shortness of breath and chest tightness on exertion which she noticed for the past 2 months. She was diagnosed with asthma 1 month ago but says that the asthma medication has not improved her breathing. She does not smoke and works as a hotel manager. Examination shows mildly jaundiced conjunctivae, several spider nevi on her upper torso, and a barrel-chested appearance. Which of the following is the most likely diagnosis?
Q65
A 52-year-old man presents to his physician after his routine screening revealed that he has elevated liver enzymes. He complains of occasional headaches during the past year, but otherwise feels well. The patient reports that he was involved in a serious car accident in the 1980s. He does not smoke or drink alcohol. He has no history of illicit intravenous drug use. He does not currently take any medications and has no known allergies. His father had a history of alcoholism and died of liver cancer. The patient appears thin. His temperature is 37.8°C (100°F), pulse is 100/min, and blood pressure is 110/70 mm Hg. The physical examination reveals no abnormalities. The laboratory test results show the following:
Complete blood count
Hemoglobin 14 g/dL
Leukocyte count 10,000/mm3
Platelet count 146,000/mm3
Comprehensive metabolic profile
Glucose 150 mg/dL
Albumin 3.2 g/dL
Total bilirubin 1.5 mg/dL
Alkaline phosphatase 75 IU/L
AST 95 IU/L
ALT 73 IU/L
Other lab tests
HIV negative
Hepatitis B surface antigen negative
Hepatitis C antibody positive
HCV RNA positive
HCV genotype 1
A liver biopsy is performed and shows mononuclear infiltrates localized to portal tracts that reveal periportal hepatocyte necrosis. Which of the following is the most appropriate next step in management?
Q66
A 58-year-old man comes to the emergency department with complaints of abdominal pain, swelling, and fever for the last few days. Pain is situated in the right upper quadrant (RUQ) and is dull and aching. He scores it as 6/10 with no exacerbating or relieving factors. He also complains of anorexia for the same duration. The patient experiences a little discomfort while lying flat and has been sleeping in a recliner for the past 2 days. There has been no chest pain, nausea, vomiting, or change in bowel or bladder habit. He does not use tobacco, alcohol, or any recreational drug. He is suffering from polycythemia vera and undergoes therapeutic phlebotomy every 2 weeks, but he has missed several appointments. The patient’s mother died of a heart attack, and his father died from a stroke. Temperature is 38.2°C (100.8°F), blood pressure is 142/88 mm Hg, pulse is 106/min, respirations are 16/min, and BMI is 20 kg/m2. On physical examination, his heart and lungs appear normal. Abdominal exam reveals tenderness to palpation in the RUQ and shifting dullness.
Laboratory test
Hemoglobin 20.5 g/dL
Hematocrit 62%
WBC 16,000/mm3
Platelets 250,000/mm3
Albumin 3.8 g/dL
Diagnostic paracentesis
Albumin 2.2 g/dL
WBC 300/µL (reference range: < 500 leukocytes/µL)
What is the best next step in management of the patient?
Q67
A 40-year-old woman presents with abdominal pain and yellow discoloration of the skin for the past 4 days. She says that her symptoms onset gradually and progressively worsened. Past medical history is unremarkable. She has been taking oral contraceptive pills for 4 years. Her vitals include: pulse 102/min, respiratory rate 15/min, temperature 37.5°C (99.5°F), and blood pressure 116/76 mm Hg. Physical examination reveals abdominal pain on palpation, hepatomegaly 4 cm below the right costal margin, and shifting abdominal dullness with a positive fluid wave. Hepatitis viral panel is ordered which shows:
Anti-HAV IgM Negative
HBsAg Negative
Anti-HBs Negative
IgM anti-HBc Negative
Anti-HCV Negative
Anti-HDV Negative
Anti-HEV Negative
An abdominal ultrasound reveals evidence of hepatic vein thrombosis. A liver biopsy is performed which shows congestion and necrosis in the central zones. Which of the following is the most likely diagnosis in this patient?
Q68
A 22-year-old man comes to the physician because of yellow eyes and malaise for the past several hours. His symptoms began after he had cried at his father’s funeral this morning. He says that his father’s death was unexpected. He had a similar episode a year ago when he returned from a 2-day hiking trip. He has no history of any serious illness and takes no medications. His vital signs are within normal limits. His sclera are icteric. The remainder of the physical examination shows no abnormalities. Laboratory studies show:
Hemoglobin 15 g/dL
Mean corpuscular volume 95 μm3
Leukocyte count 6000/mm3 with a normal differential
Serum bilirubin, total 3.8 mg/dL
Direct bilirubin 0.5 mg/dL
Lactate dehydrogenase 320 U/L
Alkaline phosphatase 70 U/L
Aspartate aminotransferase (AST, GOT) 22 U/L
Alanine aminotransferase (ALT, GPT) 19 U/L
γ-Glutamyltransferase (GGT) 43 U/L (N=5-50 U/L)
Which of the following is the most appropriate next step in management?
Q69
A 49-year-old woman with a history of hepatitis C cirrhosis complicated by esophageal varices, ascites, and hepatic encephalopathy presents with 1 week of increasing abdominal discomfort. Currently, she takes lactulose, rifaximin, furosemide, and spironolactone. On physical examination, she has mild asterixis, generalized jaundice, and a distended abdomen with positive fluid wave. Diagnostic paracentesis yields a WBC count of 1196/uL with 85% neutrophils. Which of the following is the most appropriate treatment?
Q70
A 64-year-old man comes to the emergency department complaining of fatigue and abdominal distension. He has a remote history of intravenous drug use. Vital signs include a normal temperature, blood pressure of 120/80 mm Hg, and a pulse of 75/min. Physical examination reveals jaundice and a firm liver. Abdominal ultrasonography shows liver surface nodularity, moderate splenomegaly, and increased diameter of the portal vein. Complete blood count of the patient is shown:
Hemoglobin 14 g/dL
Mean corpuscular volume 90/μm3
Mean corpuscular hemoglobin 30 pg/cell
Mean corpuscular hemoglobin concentration 34%
Leukocyte count 7,000/mm3
Platelet count 50,000/mm3
Which of the following best represents the mechanism of low platelet count in this patient?
Liver disease US Medical PG Practice Questions and MCQs
Question 61: A 32-year-old woman comes to the physician because of a 3-month history of fatigue and myalgia. Over the past month, she has had intermittent episodes of nausea. She has a history of intravenous drug use, but she has not used illicit drugs for the past five years. She has smoked one pack of cigarettes daily for 14 years and drinks one alcoholic beverage daily. She takes no medications. Her last visit to a physician was 4 years ago. Her temperature is 37°C (98.6°F), pulse is 90/min, respirations are 20/min, and blood pressure is 110/70 mm Hg. Physical examination shows jaundice and hepatosplenomegaly. There are also blisters and erosions on the dorsum of both hands. The remainder of the examination shows no abnormalities. Laboratory studies show:
Hemoglobin 12 g/dL
Leukocyte count 8,300/mm3
Platelet count 250,000/mm3
Serum
Glucose 170 mg/dL
Albumin 3.0 g/dL
Total bilirubin 2.2 mg/dL
Alkaline phosphatase 80 U/L
AST 92 U/L
ALT 76 U/L
Hepatitis B surface antigen negative
Hepatitis B surface antibody positive
Hepatitis B core antibody positive
Hepatitis C antibody positive
Which of the following is the most appropriate next step in diagnosis?
A. PCR for viral DNA
B. Western blot for HIV
C. Serology for anti-HAV IgM
D. PCR for viral RNA (Correct Answer)
E. Liver biopsy
Explanation: ***Correct: PCR for viral RNA***
- The patient has high suspicion for **chronic hepatitis C infection** due to a history of intravenous drug use, the presence of **fatigue**, **myalgia**, **jaundice**, hepatosplenomegaly, and **elevated liver enzymes (AST and ALT)**
- The **blisters and erosions on the dorsum of both hands** are highly suggestive of **porphyria cutanea tarda (PCT)**, a well-established complication of chronic hepatitis C caused by hepatic uroporphyrinogen decarboxylase deficiency
- The positive **Hepatitis C antibody** indicates exposure to HCV, but does not distinguish between acute, chronic, or resolved infection
- **PCR for viral RNA (HCV RNA)** is required to confirm **active viral replication** and diagnose current hepatitis C infection, which is crucial for treatment decisions
- The elevated glucose (170 mg/dL) may also represent hepatogenous diabetes related to chronic liver disease
*Incorrect: PCR for viral DNA*
- This test is primarily used for diagnosing active infections caused by **DNA viruses**, such as **hepatitis B** (HBV DNA) or cytomegalovirus
- The patient's hepatitis B serology indicates **past infection with immunity** (HBsAg negative, HBsAb positive, HBcAb positive), so HBV DNA testing is not indicated
- The clinical picture points toward HCV (an RNA virus), not a DNA virus
*Incorrect: Western blot for HIV*
- While the patient has a history of intravenous drug use (a risk factor for HIV), initial HIV screening is done with a **fourth-generation antigen/antibody combination assay**, not Western blot
- **Western blot** is a confirmatory test used only when initial HIV screening tests are reactive
- HIV testing may be appropriate given her risk factors, but it does not address the most pressing concern of active hepatitis C infection with complications (PCT)
*Incorrect: Serology for anti-HAV IgM*
- **Anti-HAV IgM** indicates **acute hepatitis A infection**, typically transmitted via the fecal-oral route
- The patient's symptoms, risk factors (IV drug use), positive HCV antibody, and characteristic skin findings (PCT) are not consistent with hepatitis A as the primary diagnosis
- Hepatitis A would not explain the chronic nature of symptoms or the skin manifestations
*Incorrect: Liver biopsy*
- **Liver biopsy** is an invasive procedure used to assess the **extent of liver damage**, inflammation, and fibrosis/cirrhosis after diagnosis of liver disease has been established
- It is not the most appropriate initial step to confirm **active viral replication**; PCR for HCV RNA should be performed first to establish that there is ongoing infection
- Once active HCV is confirmed, non-invasive methods (e.g., FibroScan, serum markers) are often preferred over biopsy for staging liver fibrosis
Question 62: A 50-year-old woman comes to the physician for the evaluation of fatigue over the past 6 months. During this period, the patient has also had a 5 kg (11-lb) weight loss. She has a history of Hashimoto thyroiditis. She is sexually active with her husband only. She does not smoke. She drinks one glass of wine per day. She does not use illicit drugs. Her only medication is levothyroxine. Temperature is 37°C (98.6°F), pulse is 70/min, and blood pressure is 110/70 mm Hg. Abdominal examination shows tenderness in the right upper quadrant with no rebound or guarding. Laboratory studies show a serum alanine aminotransferase level of 190 U/L, serum aspartate aminotransferase level of 250 U/L, and serum total bilirubin level of 0.6 mg/dL. Liver biopsy shows plasma cell infiltration and areas of periportal piecemeal necrosis. Further evaluation of this patient is most likely to show which of the following findings?
A. Positive anti-smooth muscle antibodies (Correct Answer)
B. Elevated serum transferrin saturation
C. Positive anti-HCV antibodies
D. Positive anti-mitochondrial antibodies
E. Positive HBV surface antigen
Explanation: ***Positive anti-smooth muscle antibodies***
- The patient's history of **Hashimoto thyroiditis**, fatigue, weight loss, elevated transaminases, and liver biopsy showing **plasma cell infiltration** and **periportal piecemeal necrosis** are classic features of **autoimmune hepatitis**.
- **Type 1 autoimmune hepatitis**, accounting for about 80% of cases, is strongly associated with the presence of **anti-smooth muscle antibodies (ASMA)** and **antinuclear antibodies (ANA)**.
*Elevated serum transferrin saturation*
- **Elevated transferrin saturation** is a hallmark of **hemochromatosis**, a disorder of iron overload.
- While hemochromatosis can cause liver damage, the biopsy findings of plasma cell infiltration and periportal piecemeal necrosis are not consistent with iron deposition.
*Positive anti-HCV antibodies*
- **Positive anti-HCV antibodies** indicate exposure to the **hepatitis C virus**, which can cause chronic hepatitis and cirrhosis.
- However, the biopsy findings, particularly the **plasma cell infiltration**, are more characteristic of autoimmune hepatitis than viral hepatitis.
*Positive anti-mitochondrial antibodies*
- **Anti-mitochondrial antibodies (AMAs)** are the serological hallmark of **primary biliary cholangitis (PBC)**.
- PBC primarily affects the small bile ducts, leading to cholestasis, and typically presents with signs like **pruritus** and elevated **alkaline phosphatase**, which are not reported here.
*Positive HBV surface antigen*
- **Positive hepatitis B virus (HBV) surface antigen** indicates either acute or chronic **hepatitis B infection**.
- While HBV can cause chronic liver inflammation, the biopsy findings of **plasma cell infiltration** are not typical for viral hepatitis, making autoimmune hepatitis a more likely diagnosis given the clinical context.
Question 63: A 52-year-old man comes to the physician because of a 1-month history of fatigue and blurry vision. Pulse oximetry on room air shows an oxygen saturation of 99%. Laboratory studies show a hemoglobin concentration of 17.5 g/dL, mean corpuscular volume of 88 μm3, red cell volume of 51.6 mL/kg, and plasma volume of 38 mL/kg. Erythropoietin concentration is elevated. Which of the following is the most likely explanation for these findings?
A. Hepatocellular carcinoma (Correct Answer)
B. Chronic myelogenous leukemia
C. Polycythemia vera
D. Excessive diuretic use
E. Chronic obstructive pulmonary disease
Explanation: ***Hepatocellular carcinoma***
- The combination of **elevated hemoglobin**, **elevated erythropoietin** (EPO), and high red cell volume indicates **secondary polycythemia**. **Paraneoplastic syndromes**, such as ectopic EPO production by **hepatocellular carcinoma**, are a cause of secondary polycythemia.
- The patient's age and gender are consistent with the demographics for hepatocellular carcinoma, which is associated with **chronic liver diseases**.
*Chronic myelogenous leukemia*
- CML is a **myeloproliferative neoplasm** characterized by the **Philadelphia chromosome (BCR-ABL1 fusion gene)**, leading to increased production of mature and immature granulocytes.
- While CML can cause leukocytosis, it does not typically present with **elevated EPO** or significant polycythemia, but rather with low to normal EPO levels.
*Polycythemia vera*
- **Polycythemia vera** is a **myeloproliferative disorder** characterized by autonomous erythroid production, typically linked to a **JAK2 V617F mutation**.
- This condition presents with **low or undetectable EPO levels** due to negative feedback from high red cell mass, which contradicts the elevated EPO in this patient.
*Excessive diuretic use*
- Excessive diuretic use can lead to **dehydration** and **hemoconcentration**, resulting in a falsely elevated hemoglobin.
- However, it would not cause increased red cell volume or an **elevated erythropoietin level**, as the total red cell mass remains normal.
*Chronic obstructive pulmonary disease*
- COPD can cause **secondary polycythemia** due to chronic hypoxemia, which stimulates EPO production.
- However, the patient's **oxygen saturation of 99%** on room air rules out hypoxemia as the cause of elevated EPO.
Question 64: A 45-year-old woman presents to the office because of shortness of breath and chest tightness on exertion which she noticed for the past 2 months. She was diagnosed with asthma 1 month ago but says that the asthma medication has not improved her breathing. She does not smoke and works as a hotel manager. Examination shows mildly jaundiced conjunctivae, several spider nevi on her upper torso, and a barrel-chested appearance. Which of the following is the most likely diagnosis?
A. Pneumomediastinum
B. Kartagener syndrome
C. Alpha 1-antitrypsin deficiency (Correct Answer)
D. Pulmonary hypertension
E. Bilateral pneumothorax
Explanation: ***Alpha 1-antitrypsin deficiency***
- The patient's symptoms of **shortness of breath** and **chest tightness** refractory to asthma medication, coupled with a **barrel-chested appearance**, suggest **emphysema**. The **jaundiced conjunctivae** and **spider nevi** indicate liver involvement, which is characteristic of alpha 1-antitrypsin deficiency.
- This genetic disorder primarily affects the lungs, leading to **early-onset emphysema**, and can also cause **liver disease** due to the accumulation of misfolded alpha 1-antitrypsin protein.
*Pneumomediastinum*
- This condition involves air in the mediastinum, typically presenting with **acute chest pain**, **dyspnea**, and sometimes **subcutaneous emphysema**.
- It does not explain the chronic symptoms, liver signs, or barrel-chested appearance seen in this patient.
*Kartagener syndrome*
- This is a subgroup of **primary ciliary dyskinesia** characterized by the triad of **bronchiectasis**, **sinusitis**, and **situs inversus**.
- While it can cause chronic respiratory issues, it does not typically present with liver abnormalities or a barrel-chested appearance.
*Pulmonary hypertension*
- Patients with pulmonary hypertension experience progressive **dyspnea**, chest pain, and **fatigue**, often with signs of **right heart failure**.
- It does not account for the barrel chest, jaundice, or spider nevi, which point to a primary lung and liver disorder.
*Bilateral pneumothorax*
- A bilateral pneumothorax would present as an **acute, life-threatening emergency** with sudden onset of **severe dyspnea** and chest pain.
- This condition is unlikely given the 2-month history of worsening symptoms and the other physical exam findings.
Question 65: A 52-year-old man presents to his physician after his routine screening revealed that he has elevated liver enzymes. He complains of occasional headaches during the past year, but otherwise feels well. The patient reports that he was involved in a serious car accident in the 1980s. He does not smoke or drink alcohol. He has no history of illicit intravenous drug use. He does not currently take any medications and has no known allergies. His father had a history of alcoholism and died of liver cancer. The patient appears thin. His temperature is 37.8°C (100°F), pulse is 100/min, and blood pressure is 110/70 mm Hg. The physical examination reveals no abnormalities. The laboratory test results show the following:
Complete blood count
Hemoglobin 14 g/dL
Leukocyte count 10,000/mm3
Platelet count 146,000/mm3
Comprehensive metabolic profile
Glucose 150 mg/dL
Albumin 3.2 g/dL
Total bilirubin 1.5 mg/dL
Alkaline phosphatase 75 IU/L
AST 95 IU/L
ALT 73 IU/L
Other lab tests
HIV negative
Hepatitis B surface antigen negative
Hepatitis C antibody positive
HCV RNA positive
HCV genotype 1
A liver biopsy is performed and shows mononuclear infiltrates localized to portal tracts that reveal periportal hepatocyte necrosis. Which of the following is the most appropriate next step in management?
A. Peginterferon alpha therapy
B. Interferon and ribavirin therapy
C. Sofosbuvir and ledipasvir therapy (Correct Answer)
D. Tenofovir and entecavir therapy
E. Tenofovir and velpatasvir therapy
Explanation: ***Sofosbuvir and ledipasvir therapy***
- This patient has chronic **Hepatitis C (HCV) infection** (HCV antibody positive, HCV RNA positive). **Sofosbuvir/ledipasvir** is an effective **direct-acting antiviral (DAA)** regimen for **genotype 1 HCV**, which is indicated for treatment-naïve patients without cirrhosis.
- The liver biopsy findings of **mononuclear infiltrates** and **periportal necrosis** confirm active hepatitis and the need for antiviral treatment to prevent progression to cirrhosis.
*Peginterferon alpha therapy*
- **Peginterferon alpha** was historically used for HCV, but its use has largely been replaced by **DAAs** due to significant side effects and lower efficacy.
- This therapy is associated with numerous adverse effects, including **flu-like symptoms**, **depression**, and **bone marrow suppression**.
*Interferon and ribavirin therapy*
- This combination was a standard treatment for HCV before the advent of DAAs, but it is associated with a high burden of **side effects** like **hemolytic anemia** (from ribavirin) and **flu-like symptoms** (from interferon).
- Given the availability of highly effective and well-tolerated DAAs, this regimen is no longer considered first-line for chronic HCV.
*Tenofovir and entecavir therapy*
- **Tenofovir** and **entecavir** are antiviral medications primarily used for the treatment of **chronic Hepatitis B (HBV) infection**.
- This patient's **Hepatitis B surface antigen is negative**, ruling out chronic HBV infection as the primary issue requiring these specific drugs.
*Tenofovir and velpatasvir therapy*
- While **velpatasvir** is a DAA used for HCV, its combination with **tenofovir** is not a standard HCV treatment for genotype 1.
- **Tenofovir** is primarily an anti-HBV drug; for HCV, velpatasvir is typically combined with **sofosbuvir** (as in Epclusa) for pan-genotypic coverage.
Question 66: A 58-year-old man comes to the emergency department with complaints of abdominal pain, swelling, and fever for the last few days. Pain is situated in the right upper quadrant (RUQ) and is dull and aching. He scores it as 6/10 with no exacerbating or relieving factors. He also complains of anorexia for the same duration. The patient experiences a little discomfort while lying flat and has been sleeping in a recliner for the past 2 days. There has been no chest pain, nausea, vomiting, or change in bowel or bladder habit. He does not use tobacco, alcohol, or any recreational drug. He is suffering from polycythemia vera and undergoes therapeutic phlebotomy every 2 weeks, but he has missed several appointments. The patient’s mother died of a heart attack, and his father died from a stroke. Temperature is 38.2°C (100.8°F), blood pressure is 142/88 mm Hg, pulse is 106/min, respirations are 16/min, and BMI is 20 kg/m2. On physical examination, his heart and lungs appear normal. Abdominal exam reveals tenderness to palpation in the RUQ and shifting dullness.
Laboratory test
Hemoglobin 20.5 g/dL
Hematocrit 62%
WBC 16,000/mm3
Platelets 250,000/mm3
Albumin 3.8 g/dL
Diagnostic paracentesis
Albumin 2.2 g/dL
WBC 300/µL (reference range: < 500 leukocytes/µL)
What is the best next step in management of the patient?
A. Venography
B. MRI
C. Ultrasound (Correct Answer)
D. Liver biopsy
E. Echocardiography
Explanation: ***Ultrasound***
- The patient presents with **fever**, **RUQ pain**, and **ascites**, along with a history of **polycythemia vera** which increases the risk of **thrombosis**. These symptoms strongly suggest **Budd-Chiari syndrome**, a condition where there is **hepatic vein obstruction**.
- **Doppler ultrasound** is the **initial diagnostic test of choice** for suspected Budd-Chiari syndrome, as it is non-invasive and can visualize hepatic vein flow, identify clots, and detect ascites.
*Venography*
- **Hepatic venography** is considered the **gold standard** for diagnosing Budd-Chiari syndrome but is **invasive** and typically performed only if Doppler ultrasound is inconclusive or if interventional procedures are planned.
- It would not be the best **next step** given the availability of less invasive imaging options for initial assessment.
*MRI*
- **MRI** with MR venography can provide detailed visualization of hepatic veins and parenchyma, and is useful if ultrasound is inconclusive.
- However, similar to venography, it is **not typically the first-line imaging modality** due to its higher cost and longer acquisition time compared to ultrasound.
*Liver biopsy*
- A **liver biopsy** can confirm liver damage and identify the cause of liver disease, but it is **invasive** and associated with risks like bleeding.
- It is usually reserved for cases where other diagnostic methods have not provided a clear diagnosis, and it would not be the initial diagnostic step for suspected vascular obstruction.
*Echocardiography*
- **Echocardiography** evaluates the heart's structure and function. While important for assessing cardiac causes of abdominal symptoms (e.g., right-sided heart failure causing liver congestion), it would not directly diagnose hepatic vein obstruction.
- The patient's symptoms are localized to the abdomen with **RUQ pain** and signs of **ascites**, making a primary cardiac issue less likely as the initial diagnostic focus.
Question 67: A 40-year-old woman presents with abdominal pain and yellow discoloration of the skin for the past 4 days. She says that her symptoms onset gradually and progressively worsened. Past medical history is unremarkable. She has been taking oral contraceptive pills for 4 years. Her vitals include: pulse 102/min, respiratory rate 15/min, temperature 37.5°C (99.5°F), and blood pressure 116/76 mm Hg. Physical examination reveals abdominal pain on palpation, hepatomegaly 4 cm below the right costal margin, and shifting abdominal dullness with a positive fluid wave. Hepatitis viral panel is ordered which shows:
Anti-HAV IgM Negative
HBsAg Negative
Anti-HBs Negative
IgM anti-HBc Negative
Anti-HCV Negative
Anti-HDV Negative
Anti-HEV Negative
An abdominal ultrasound reveals evidence of hepatic vein thrombosis. A liver biopsy is performed which shows congestion and necrosis in the central zones. Which of the following is the most likely diagnosis in this patient?
A. C: Viral hepatitis
B. E: Drug-induced hepatitis
C. A: Budd-Chiari syndrome (Correct Answer)
D. B: Hemochromatosis
E. D: Nonalcoholic fatty liver disease
Explanation: ***Budd-Chiari syndrome***
- This diagnosis is strongly supported by the presence of **abdominal pain**, **jaundice**, **hepatomegaly**, and **ascites** (indicated by shifting abdominal dullness and a positive fluid wave), along with **hepatic vein thrombosis** on ultrasound.
- The patient's history of **oral contraceptive pill** use is a significant risk factor for thrombosis, further pointing to Budd-Chiari syndrome, and the liver biopsy findings of **central zone congestion and necrosis** are characteristic.
*Viral hepatitis*
- This is unlikely as the **hepatitis viral panel** shows **negative results** for all tested hepatitis viruses (HAV, HBV, HCV, HDV, HEV).
- Viral hepatitis typically presents with elevated liver enzymes and may progress to liver failure but does not inherently cause hepatic vein thrombosis.
*Drug-induced hepatitis*
- While oral contraceptive pills can cause liver abnormalities, severe acute drug-induced hepatitis leading to **hepatic vein thrombosis** as the primary pathology is less common than in Budd-Chiari syndrome.
- The clinical presentation and imaging findings are more specific to a vascular obstruction.
*Hemochromatosis*
- This is a genetic disorder of **iron overload** that typically presents with symptoms like **fatigue**, **joint pain**, **diabetes**, and **skin pigmentation**, often years later in life.
- It does not primarily cause acute hepatic vein thrombosis or the rapid onset of symptoms described.
*Nonalcoholic fatty liver disease*
- This is typically associated with **metabolic syndrome**, **obesity**, and **insulin resistance**, and usually has a more chronic and indolent course.
- It does not present with **acute hepatic vein thrombosis** or the rapid development of jaundice and ascites seen in this patient.
Question 68: A 22-year-old man comes to the physician because of yellow eyes and malaise for the past several hours. His symptoms began after he had cried at his father’s funeral this morning. He says that his father’s death was unexpected. He had a similar episode a year ago when he returned from a 2-day hiking trip. He has no history of any serious illness and takes no medications. His vital signs are within normal limits. His sclera are icteric. The remainder of the physical examination shows no abnormalities. Laboratory studies show:
Hemoglobin 15 g/dL
Mean corpuscular volume 95 μm3
Leukocyte count 6000/mm3 with a normal differential
Serum bilirubin, total 3.8 mg/dL
Direct bilirubin 0.5 mg/dL
Lactate dehydrogenase 320 U/L
Alkaline phosphatase 70 U/L
Aspartate aminotransferase (AST, GOT) 22 U/L
Alanine aminotransferase (ALT, GPT) 19 U/L
γ-Glutamyltransferase (GGT) 43 U/L (N=5-50 U/L)
Which of the following is the most appropriate next step in management?
A. Phenobarbital
B. Reassurance (Correct Answer)
C. Refer for liver transplantation
D. Packed cell transfusion
E. Prednisone
Explanation: ***Reassurance***
- The patient's presentation with **recurrent, stress-induced jaundice** (after crying and a hiking trip) and **unconjugated hyperbilirubinemia** with otherwise normal liver enzymes and CBC strongly suggests **Gilbert's syndrome**.
- Gilbert's syndrome is a **benign, inherited condition** characterized by decreased bilirubin conjugation, which often becomes noticeable during periods of stress, fasting, or illness, and requires no specific treatment beyond reassurance.
*Phenobarbital*
- While phenobarbital can induce **CYP450 enzymes** and accelerate bilirubin conjugation, it is typically used in more severe unconjugated hyperbilirubinemia conditions like Crigler-Najjar syndrome, not the benign Gilbert's syndrome.
- Gilbert's syndrome does not require medication as it is a harmless condition and treatment with phenobarbital would be unnecessary and potentially harmful due to its side effects.
*Refer for liver transplantation*
- Liver transplantation is a treatment for **severe, end-stage liver failure** or certain genetic disorders causing profound liver dysfunction.
- The patient's normal liver enzymes (AST, ALT, ALP, GGT), normal hemoglobin, and mild, intermittent hyperbilirubinemia indicate **no significant liver damage** or failure.
*Packed cell transfusion*
- Packed cell transfusions are indicated for **anemia** or significant blood loss.
- The patient's hemoglobin level of 15 g/dL is within the normal range, indicating that he is **not anemic**.
*Prednisone*
- Prednisone is a **corticosteroid** used to suppress inflammation or the immune system, typically in autoimmune conditions or severe inflammatory diseases.
- There is **no indication of an inflammatory or autoimmune process** affecting the liver or red blood cells in this patient.
Question 69: A 49-year-old woman with a history of hepatitis C cirrhosis complicated by esophageal varices, ascites, and hepatic encephalopathy presents with 1 week of increasing abdominal discomfort. Currently, she takes lactulose, rifaximin, furosemide, and spironolactone. On physical examination, she has mild asterixis, generalized jaundice, and a distended abdomen with positive fluid wave. Diagnostic paracentesis yields a WBC count of 1196/uL with 85% neutrophils. Which of the following is the most appropriate treatment?
A. Cefotaxime (Correct Answer)
B. Transjugular intrahepatic portosystemic shunt placement
C. Large volume paracentesis with albumin
D. Increased furosemide and spironolactone
E. Metronidazole
Explanation: ***Cefotaxime***
- The patient presents with classic signs of **spontaneous bacterial peritonitis (SBP)**: increasing abdominal discomfort in a cirrhotic patient with ascites, and a diagnostic paracentesis showing **ascitic fluid neutrophil count >250 cells/mm³** (1196 × 0.85 = 1016 neutrophils/μL).
- **Third-generation cephalosporins** like cefotaxime or ceftriaxone are the **first-line treatment** for SBP due to their broad-spectrum coverage against common enteric gram-negative bacteria (especially E. coli and Klebsiella).
- Treatment should be initiated promptly once SBP is diagnosed to reduce mortality.
*Transjugular intrahepatic portosystemic shunt placement*
- TIPS is primarily used for **refractory ascites** or **recurrent variceal bleeding** that is not responsive to medical management.
- It is **not indicated** for the acute treatment of SBP and would be inappropriate in the setting of active infection.
*Large volume paracentesis with albumin*
- Large volume paracentesis is used to relieve symptoms of **tense ascites** causing respiratory compromise or severe discomfort, not as a primary treatment for SBP.
- While albumin is often given with large volume paracentesis (>5L removed) to prevent post-paracentesis circulatory dysfunction, it does not treat the underlying bacterial infection.
*Increased furosemide and spironolactone*
- Diuretics like furosemide and spironolactone are used to manage **chronic ascites** by promoting fluid excretion.
- Increasing their dose will not address the active bacterial infection causing SBP and may worsen renal function in an acutely ill patient.
*Metronidazole*
- Metronidazole is primarily effective against **anaerobic bacteria** and some protozoa.
- While it might be considered in specific polymicrobial intra-abdominal infections, it is **not sufficient as monotherapy** for SBP, which commonly involves gram-negative aerobic bacteria like E. coli and Klebsiella species.
Question 70: A 64-year-old man comes to the emergency department complaining of fatigue and abdominal distension. He has a remote history of intravenous drug use. Vital signs include a normal temperature, blood pressure of 120/80 mm Hg, and a pulse of 75/min. Physical examination reveals jaundice and a firm liver. Abdominal ultrasonography shows liver surface nodularity, moderate splenomegaly, and increased diameter of the portal vein. Complete blood count of the patient is shown:
Hemoglobin 14 g/dL
Mean corpuscular volume 90/μm3
Mean corpuscular hemoglobin 30 pg/cell
Mean corpuscular hemoglobin concentration 34%
Leukocyte count 7,000/mm3
Platelet count 50,000/mm3
Which of the following best represents the mechanism of low platelet count in this patient?
A. Platelet sequestration (Correct Answer)
B. Dilutional effect
C. Bone marrow-based disorder
D. Increased platelet clearance
E. Genetic disorder
Explanation: ***Platelet sequestration***
- The patient's history of IV drug use, jaundice, abdominal distension, firm liver, splenomegaly, and increased portal vein diameter are highly suggestive of **portal hypertension** due to **cirrhosis**, which often leads to **splenomegaly**.
- An enlarged spleen (splenomegaly) sequesters a disproportionately high percentage of the body's platelets, leading to **thrombocytopenia**, even if total platelet production is normal.
- **Splenic sequestration** is the **primary mechanism** of thrombocytopenia in cirrhosis with portal hypertension; up to **90% of platelets** can be sequestered in an enlarged spleen.
- Additionally, the diseased liver produces less **thrombopoietin (TPO)**, which contributes to reduced platelet production, but sequestration remains the dominant mechanism.
*Dilutional effect*
- A dilutional effect on platelet count typically occurs with **massive transfusions** of packed red blood cells and crystalloids, which is not indicated in this patient's presentation.
- While fluid overload can dilute blood components, the patient's symptoms point specifically to a **liver pathology** and related complications, not simply volume expansion.
*Bone marrow-based disorder*
- A primary bone marrow disorder would likely affect other cell lines as well, but the patient's hemoglobin and leukocyte counts are within normal limits, making a general **bone marrow suppression** less likely.
- Furthermore, the strong evidence of **cirrhosis and portal hypertension** provides a more direct and common explanation for isolated thrombocytopenia in this context.
*Increased platelet clearance*
- While increased platelet clearance can cause thrombocytopenia (e.g., in immune thrombocytopenia or thrombotic microangiopathies), there are no signs of increased destruction or consumption in this case.
- Conditions involving increased clearance usually present with other features like petechiae, purpura, or schistocytes, which are not mentioned.
- The clinical picture is most consistent with **sequestration** rather than **destruction**.
*Genetic disorder*
- Genetic disorders causing thrombocytopenia typically present much earlier in life or have a family history, which does not fit this patient's age and clinical presentation.
- The patient's history of **IV drug use** and the findings of advanced liver disease indicate an **acquired condition**, not a congenital one.
