Biliary atresia and Kasai procedure — MCQs

A 5-day-old male newborn is brought to the physician by his mother because of yellowish discoloration of the skin for 1 day. The discoloration first appeared on his face and then spread to his trunk. There have been no changes in his bowel habits or urination. He was born at 38 weeks' gestation via uncomplicated vaginal delivery. He is exclusively breastfed every 2–3 hours. Examination shows scleral icterus and jaundice of the face, chest, and abdomen. Laboratory studies show: Hemoglobin 17.6 g/dL Reticulocytes 0.3% Maternal blood group A, Rh-negative Fetal blood group 0, Rh-positive Serum Bilirubin, total 7 mg/dL Direct 0.6 mg/dL Free T4 12 μg/dL Which of the following is the most likely diagnosis?

A 3-week-old newborn male is brought to the physician because of increasing yellowing of his eyes and skin for 2 weeks. The mother has noticed that his stools have been paler than usual for the past week. He is exclusively formula fed, and feeds every 4 hours with a strong sucking reflex. The patient was delivered vaginally at 39 weeks' gestation to a healthy woman without any complications. Vital signs are within normal limits. He is at the 50th percentile for length and at the 65th percentile for weight. Examination shows scleral icterus and jaundice. Abdominal examination reveals a palpable liver 2 cm below the right costal margin without splenomegaly. Serum studies show: Bilirubin Total 17 mg/dL Direct 13.3 mg/dL Alkaline phosphatase 1700 U/L AST 53 U/L ALT 45 U/L γ-Glutamyl transferase 174 U/L Blood group B positive This patient is at increased risk of developing which of the following?

A 28-year-old woman comes to the emergency department for a 1-week history of jaundice and nausea. She recalls eating some seafood last weekend at a cookout. She lives at home with her 2-year-old son who attends a daycare center. The child's immunizations are up-to-date, and his last hepatitis A vaccine was administered 6 weeks ago. The woman's temperature is 37.5°C (99.5°F), pulse is 82/min, and blood pressure is 134/84 mm Hg. Examination shows scleral icterus. The liver is palpated 2-cm below the right costal margin and is tender. Her serum studies show: Total bilirubin 3.4 mg/dL Alkaline phosphatase 89 U/L AST 185 U/L ALT 723 U/L Hepatitis A IgM antibody positive Hepatitis B surface antibody positive Hepatitis B surface antigen negative Hepatitis B core IgM antibody negative Hepatitis C antibody negative Which of the following health maintenance recommendations is most appropriate for the child at this time?

A 4-day-old girl presents with jaundice for the last 2 days. Although the patient’s parents were initially told that it was neonatal jaundice and would resolve quickly, they think that the yellow color of the patient’s skin appears to be more obvious today. The patient’s mother reports that the girl eats well, has normal stool and urine color. It’s her first child from the first healthy pregnancy. The patient was born at term via a spontaneous transvaginal delivery without any complications. Family history is significant for a paternal aunt who had 2 babies who died as infants from unknown causes and for a maternal uncle who has unexplained jaundice. On physical examination, the patient is awake, calm, and appears healthy except for the yellow tone of the skin and scleral icterus. Laboratory findings are significant for an elevated level of unconjugated bilirubin. A complete blood count and other routine biochemical blood tests are within expected parameters. The patient is treated with phototherapy, but her hyperbilirubinemia becomes more severe. Which of the following is the most appropriate course of treatment in this patient?

A previously healthy 2-year-old girl is brought to the physician because of a 1-week history of yellow discoloration of her skin, loss of appetite, and 3 episodes of vomiting. Her parents also report darkening of her urine and light stools. During the last 2 days, the girl has been scratching her abdomen and arms and has been crying excessively. She was born at 38 weeks' gestation after an uncomplicated pregnancy and delivery. Her family emigrated from Japan 8 years ago. Immunizations are up-to-date. Her vital signs are within normal limits. Examination shows jaundice of her skin and sclerae. Abdominal examination shows a mass in the right upper abdomen. Serum studies show: Bilirubin (total) 5 mg/dL Direct 4.2 mg/dL Aspartate aminotransferase (AST) 20 U/L Alanine aminotransferase (ALT) 40 U/L γ-Glutamyltransferase (GGT) 110 U/L Abdominal ultrasonography shows dilation of the gall bladder and a fusiform dilation of the extrahepatic bile duct. Which of the following is the most likely diagnosis?

A 31-year-old man presents with jaundice, scleral icterus, dark urine, and pruritus. He also says that he has been experiencing abdominal pain shortly after eating. He says that symptoms started a week ago and have not improved. The patient denies any associated fever or recent weight-loss. He is afebrile and vital signs are within normal limits. On physical examination, the patient’s skin appears yellowish. Scleral icterus is present. Remainder of physical examination is unremarkable. Laboratory findings are significant for: Conjugated bilirubin 5.1 mg/dL Total bilirubin 6.0 mg/dL AST 24 U/L ALT 22 U/L Alkaline phosphatase 662 U/L A contrast CT of the abdomen is unremarkable. An ultrasound of the right upper quadrant reveals a normal gallbladder, but the common bile duct is not visible. Which of the following is the next best step in the management of this patient?

A 45-year-old woman comes to the emergency department complaining of abdominal pain for the past day. The pain is situated in the right upper quadrant, colicky, 8/10, and radiates to the tip of the right shoulder with no aggravating or relieving factors. The pain is associated with nausea but no vomiting. She tried to take over-the-counter antacids which relieved her pain to a certain extent, but not entirely. She does not smoke cigarettes or drink alcohol. She has no past medical illness. Her father died of pancreatic cancer at the age of 75, and her mother has diabetes controlled with medications. Temperature is 38°C (100.4°F), blood pressure is 125/89 mm Hg, pulse is 104/min, respiratory rate is 20/min, and BMI is 29 kg/m2. On abdominal examination, her abdomen is tender to shallow and deep palpation of the right upper quadrant. Laboratory test Complete blood count Hemoglobin 13 g/dL WBC 15,500/mm3 Platelets 145,000/mm3 Basic metabolic panel Serum Na+ 137 mEq/L Serum K+ 3.6 mEq/L Serum Cl- 95 mEq/L Serum HCO3- 25 mEq/L BUN 10 mg/dL Serum creatinine 0.8 mg/dL Liver function test Total bilirubin 1.3 mg/dL AST 52 U/L ALT 60 U/L Ultrasonography of the abdomen shows normal findings. What is the best next step in management of this patient?

A 66-year-old man comes to the physician because of yellowish discoloration of his eyes and skin, abdominal discomfort, and generalized fatigue for the past 2 weeks. He has had dark urine and pale stools during this period. He has had a 10-kg (22-lb) weight loss since his last visit 6 months ago. He has hypertension. He has smoked one pack of cigarettes daily for 34 years. He drinks three to four beers over the weekends. His only medication is amlodipine. His temperature is 37.3°C (99.1°F), pulse is 89/min, respirations are 14/min, and blood pressure is 114/74 mm Hg. Examination shows jaundice of the sclera and skin and excoriation marks on his trunk and extremities. The lungs are clear to auscultation. The abdomen is soft and nontender. The remainder of the examination shows no abnormalities. Laboratory studies show: Hemoglobin 12 g/dL Leukocyte count 5,000/mm3 Platelet count 400,000/mm3 Serum Urea nitrogen 28 mg/dL Creatinine 1.2 mg/dL Bilirubin Total 7.0 mg/dL Direct 5.5 mg/dL Alkaline phosphatase 615 U/L Aspartate aminotransferase (AST, GOT) 170 U/L Alanine aminotransferase (ALT, GPT) 310 U/L γ-Glutamyltransferase (GGT) 592 U/L (N = 5–50 U/L) An ultrasound shows extrahepatic biliary dilation. A CT scan of the abdomen shows a 2.5-cm (1-in) mass in the head of the pancreas with no abdominal lymphadenopathy. The patient undergoes biliary stenting. Which of the following is the most appropriate next step in the management of this patient?

A 62-year-old man presents to his primary care physician. He was brought in by his daughter as he has refused to see a physician for the past 10 years. The patient has been having worsening abdominal pain. He claims that it was mild initially but has gotten worse over the past week. The patient has been eating lots of vegetables recently to help with his pain. The patient has a past medical history of constipation and a 50 pack-year smoking history. He is not currently taking any medications. On review of systems, the patient endorses trouble defecating and blood that coats his stool. His temperature is 99.5°F (37.5°C), blood pressure is 197/128 mmHg, pulse is 100/min, respirations are 17/min, and oxygen saturation is 98% on room air. On abdominal exam, the patient complains of right upper quadrant tenderness and a palpable liver edge that extends 4 cm beneath the costal margin. Murphy's sign is positive. HEENT exam is notable for poor dentition, normal sclera, and normal extraocular movements. There are no palpable lymph nodes. Laboratory studies are ordered as seen below. Hemoglobin: 9 g/dL Hematocrit: 30% Leukocyte count: 7,500/mm^3 with normal differential Platelet count: 199,000/mm^3 Serum: Na+: 140 mEq/L Cl-: 101 mEq/L K+: 4.0 mEq/L HCO3-: 23 mEq/L BUN: 29 mg/dL Glucose: 197 mg/dL Creatinine: 1.4 mg/dL Ca2+: 10.2 mg/dL Total bilirubin: 1.1 mg/dL AST: 150 U/L ALT: 112 U/L Which of the following is the most likely diagnosis?

A 50-year-old man is brought to the emergency department because of a 3-day history of left flank pain. The patient has had two episodes of urolithiasis during the last year. He initially had pain with urination that improved with oxycodone. Over the past day, the pain has worsened and he has additionally developed fever and chills. He has hypertension and type 2 diabetes mellitus. He has smoked one pack of cigarettes daily for 20 years. He does not drink alcohol. His current medications include metformin and lisinopril. The patient appears ill and uncomfortable. His temperature is 39.1°C (102.3°F), pulse is 108/min, respirations are 22/min, and blood pressure is 90/62 mm Hg. The lungs are clear to auscultation. Cardiac examination shows no murmurs, rubs, or gallops. Examination of the back shows left costovertebral angle tenderness. Physical and neurologic examinations show no other abnormalities. Laboratory studies show: Hemoglobin 14.2 g/dL Leukocyte count 13,900/mm3 Hemoglobin A1c 8.2% Serum Na+ 138 mEq/L K+ 3.8 mEq/L Cl- 98 mEq/L Calcium 9.3 mg/dL Glucose 190 mg/dL Creatinine 2.1 mg/dL Urine pH 8.3 Urine microscopy Bacteria moderate RBC 6–10/hpf WBC 10–15/hpf WBC casts numerous Ultrasound shows enlargement of the left kidney with a dilated pelvis and echogenic debris. CT scan shows a 16-mm stone at the left ureteropelvic junction, dilation of the collecting system, thickening of the wall of the renal pelvis, and signs of perirenal inflammation. Intravenous fluid resuscitation and intravenous ampicillin, gentamicin, and morphine are begun. Which of the following is the most appropriate next step in the management of this patient?