Internal medicine - Liver disease (78) Flashcards

1
Q

INT - 7.1
Male patient with liver cirrhosis is admitted to the hospital with massive hematemesis, with the possibility of variceal rupture. The followings should be done, except:

A) ensuring venous access with cannulation of 2 peripheral vein

B) determining blood group, INR, blood count

C) administration of iv. terlipressin

D) oesophagogastroscopy and ligation or sclerotherapy of esophageal varices after hemodynamic stability is reached

E) blood transfusion to increase hemoglobin level above 100 g/l

A

ANSWER
E) blood transfusion to increase hemoglobin level above 100 g/l

EXPLANATION
One of the most severe complications of liver cirrhosis is bleeding caused by variceal rupture. In such cases, the first measures of treatment include the assurance of venous access including the canulation of two peripheral veins, blood group determination, complete blood count (CBC), INR determination, commencement of intravenous terlipressin, emergency endoscopy, or hemostasis, performed with sclerotherapy or endoscopic ligation, if required. Transfusion is required in the case of attaining a restrictive hemoglobin level < 75 g/L, however, a higher level leads to an increased risk of additional bleeding in variceal bleeders, therefore, a hemoglobin level above 100 g/l is not recommended.

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2
Q

INT - 7.2
The extrahepatic complication of chronic hepatitis B might be:
A) periarteritis nodosa, immuncomplex vasculitis

B) glomerulonephritis

C) cryoglobulinaemia

D) arthritis

E) all of the above

A

ANSWER
E) all of the above

EXPLANATION
Extrahepatic manifestations of chronic hepatitis B virus (HBV) infection may be subject to all of the following four diseases: immune complex vasculitis, nephritis, cryoglobulinaemia or arthritis.

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3
Q

INT - 7.3
Characteristics of drug-induced liver injury, except:

A) it is always dose-dependent

B) idiosyncratic reaction is also possible

C) it can manifest few days or several weeks after drug intake

D) it is forbidden to readminister the drug which caused liver injury

E) cholestasis can be present

A

ANSWER
A) it is always dose-dependent

EXPLANATION
Drug-induced liver injury may be dose-dependent or dose-independent, and sometimes referred to as an idiosyncratic reaction. It can manifest itself within several days or over a period of weeks following the administered and recommended medication. It is forbidden to re-administer the medication, which resulted in the original injury to the liver. It can manifest as GOT and GPT or in the form of cholestasis.

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4
Q

INT - 7.4
A 65-year-old male patient presented with jaundice started 3 weeks before. What is the first step?

A) abdominal ultrasound

B) computer tomography (CT)

C) endoscopic retrograde cholangiopancreatography (ERCP)

D) percutaneous transhepatic cholangiography (PTC)

E) MR cholangio-pancreatography (MRCP)

A

ANSWER
A) abdominal ultrasound

EXPLANATION
In the differential diagnosis of jaundice, the first non-invasive imaging is abdominal ultrasound. It can reveal the presence of gallstones, the dilation of the ductus choledochus (common bile duct), including the space-occupying processes in the pancreatic head or the liver. Further examinations are generally conducted, if deemed medically necessary.

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5
Q

INT - 7.5
The most frequent cause of liver cirrhosis nowadays, which was earlier labeled as “cryptogen” cirrhosis:

A) Wilson’s disease

B) Hepatitis E virus (HEV) infection

C) Non alcoholic steatohepatitis (NASH)

D) Hemochromatosis

E) Drugs and other toxic agents

A

ANSWER
C) Non alcoholic steatohepatitis (NASH)

EXPLANATION
Today, liver cirrhosis, formerly referred to as cryptogen cirrhosis, is most frequently (in 70 percent of the cases) aligned with nonalcoholic steatohepatitis (NASH), and is directly correlated with insulin resistance.

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6
Q

INT - 7.6
Select the tumor where serum alpha-fetoprotein (AFP) is mostly pathognomic.

A) prostate cancer

B) osteogenic carcinoma

C) gastric cancer

D) colon cancer

E) hepatocellular cancer (HCC)

A

ANSWER
E) hepatocellular cancer (HCC)

EXPLANATION
Serum-α-fetoprotein (AFP) is a tumor marker and an oncofoetal antigen, characteristic of hepatocellular carcinoma (HCC). This tumor is particularly typical of increased concentration in the serum (20 ng/ml level may elevate to several thousand ng/ml). Otherwise, a moderate AFP increase can be observed in disease processes related to hepatocyte regeneration, such as hepatitis and cirrhosis. A higher AFP level can also occur atypically in other tumors. AFP is not suitable for HCC surveillance, while normal AFP-levels do not rule out liver cancer.

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7
Q

INT - 7.7
Characteristics of alcoholic hepatitis, except:

A) excessive alcohol consumption recently

B) corticosteroid administration is always necessary

C) elevated bilirubin, high INR, leukocytosis can be present

D) high mortality in severe cases

E) alcohol abstinence is essential during treatment

A

ANSWER
B) corticosteroid administration is always necessary

EXPLANATION
Alcoholic hepatitis is typically preceded by massive alcohol consumption. During treatment, reaching abstinence is generally based on an elevated serum bilirubin level, high INR, and leukocytosis. In severe cases, it results in a high mortality rate. Corticosteroid administration should be considered only if there is no contraindication (e.g., SBP, other infection, peptic or duodenal ulcer) and in the most severe cases. Its administration does not have a long-term mortality-reducing effect, but can increase the risk of infectious complications (e.g., sepsis and pneumonia).

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8
Q

INT - 7.9
Characteristics of primary biliary cholangitis (PBC), except:

A) antimitochondrial antibody (AMA) is present

B) serum-IgM is frequently elevated

C) female dominance

D) corticosteroid is indicated for treatment

E) it might be associated with scleroderma

A

ANSWER
D) corticosteroid is indicated for treatment

EXPLANATION
Primary biliary cholangitis (PBC) is an idiopathic cholestatic liver disease, presumably autoimmune in nature. It is predominant in women, and may be associated with scleroderma, the antimitochondrial antibody (AMA), is a typical serological marker of the disease, and may result in elevated levels of serum-IgM. Its treatment is not completely developed, and corticosteroid is not indicated. In its early phase, ursodeoxycholic acid is the most useful medication.

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9
Q

INT - 7.10
Which of the following medication can dose-dependently cause liver failure?

A) halothane

B) paracetamol (acetaminophen)

C) chlorpromazine

D) methyldopa

E) erythromycin

A

ANSWER
B) paracetamol (acetaminophen)

EXPLANATION
Paracetamol (acetaminophen) may cause liver failure, dose-dependently. Alcoholics and malnutritioned, starving individuals suffering from low protein intake are particularly at risk in this respect, whose reduced hepatic glutathione reserve and antioxidant defense system is notably decreased. In such cases, the neutralization of the toxic metabolite of paracetamol fails, which results in hepatocyte necrosis. The same premise also applies to the healthy organism, if the excessive dose of paracetamol (e.g. 12–16 g/day) exceeds the capacity of the level of antioxidant defense. In the above-mentioned alcoholic and malnutritioned patients, 4–6 g can qualify a toxic dose.) In the case of paracetamol overdose, the administration of N-acetylcystein can result in the restoration of the endogenous glutathione reserve and recovery. Additional use of medications and drugs, including, halothane, chlorpromazine, methyldopa and erythromycin, may cause liver failure, dose-independently, through an immunoallergic idiosyncratic mechanism.

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10
Q

INT - 7.11
It can trigger hepatic encephalopathy in severe liver cirrhosis, except:

A) gastrointestinal bleeding

B) metabolic acidosis

C) aggressive diuretic therapy

D) enteral infection

E) high amount of oral protein intake

A

ANSWER
B) metabolic acidosis

EXPLANATION
In severe liver cirrhosis patients, hepatic encephalopathy may be caused by gastrointestinal bleeding, aggressive diuretic therapy, enteral infection, or a large amount of per os protein intake, but not by metabolic acidosis.

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11
Q

INT - 7.12
Jaundice appears on the 3rd postoperative day after aortic aneurysms surgery in a female patient, who is afebrile, otherwise asymptomatic. Lab results: SeBi: direct 220 μmol/l, indirect 80 μmol/l, ALP 500 IU, AST, ALT, LDH are normal. What is the most likely diagnosis?

A) biliary tract obstruction

B) halothane-induced hepatitis

C) portal vein thrombosis

D) haemolysis

E) benign postoperative cholestasis

A

ANSWER
E) benign postoperative cholestasis

EXPLANATION
Benign postoperative cholestasis syndrome occurring during the postoperative days following a protracted cardiac surgery is primarily due to hypoxia and hypothermia. Halothane-induced hepatitis occurs only within one or two weeks, especially in case of repeated halothane narcosis. The latter involves high temperatures and significant elevated levels of transaminase. Haemolysis can be ruled out in this case, based on normal LDH and direct hyperbilirubinaemia jaundice.

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12
Q

INT - 7.14
Predisposing factor(s) for gallstone formation:

A) obesity

B) chronic hemolysis

C) octreotide therapy

D) bowel resection

E) all of the above

A

ANSWER
E) all of the above

EXPLANATION
All of the four mentioned cases (obesity, chronic haemolysis, octreotide treatment and bowel resection) are predisposing factors for gallstone formation.

Octreotide, a nonspecific somatostatin analogue
decrease GH level in acromegaly
treat severe diarrhea and other symptoms that occur with certain intestinal tumors (eg, vasoactive intestinal peptide tumors or VIPomas) or metastatic carcinoid tumors

Chronic hemolysis leads to increased bilirubin excretion and pigment gallstones formation

bowel resection: alteration of the concentration of bile salts in the enterohepatic circulation leading to the possible formation of gallbladder stones.

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13
Q

INT - 7.16
67-year-old patient sees a doctor with dull right hypochondriac pain, fever, weight loss. Lab findings: GGT 600 E, ALP 740 E, LDH: 900 E. What additional lab tests would be helpful to confirm the diagnosis?

A) antinuclear antibody (ANA)

B) serum α-fetoprotein (AFP)

C) antimitochondrial antibody (AMA)

D) anti smooth muscle antibody (SMA)

E) prostate specific antigen (PSA)

A

NSWER
B) serum α-fetoprotein (AFP)

EXPLANATION
The described syndrome raises the suspicion of hepatic cancer based on cirrhosis, which can further be substantiated by an increased serum-α-foetoprotein (AFP) level. However, normal AFP does not rule out hepatic cancer!

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14
Q

INT - 7.17
True for esophageal variceal bleeding, except:

A) sclerotherapy is needed only when recurrent bleeding occurs after portocaval shunt operation

B) iv. terlipressin is important to stop bleeding

C) deep jaundice and ascites increase the risk of mortality

D) per os propranolol or carvediol are useful in prevention of bleeding

E) portocavalis shunt increases the risk of hepatic encephalopathy

A

NSWER
A) sclerotherapy is needed only when recurrent bleeding occurs after portocaval shunt operation

EXPLANATION
Among the listed statements, it is not true that sclerotherapy is needed only when recurrent variceal bleeding occurs following portocaval shunt operative procedures. It is true, in the case of variceal bleeding, i.v. terlipressin is important in controlling excessive bleeding. Deep jaundice and ascites increase the mortality risk. Per os propranolol or carvediol are useful in the prevention of bleeding. Portocaval shunt increases the risk of hepatic encephalopathy, therefore, TIPS is contraindicated in the case of hepatic encephalopathy.

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15
Q

INT - 7.18
Liver biopsy is indicated, except:

A) suspected liver adenoma

B) unexplained abnormal liver function tests

C) for diagnosis of NASH

D) for diagnosis of autoimmune hepatitis

E) suspected hemangioma

A

ANSWER
E) suspected hemangioma

EXPLANATION
In the case of suspected haemangioma, liver biopsy is contraindicated due to high risk of bleeding complications.

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16
Q

INT - 7.19
The risk of following disorders is increased in female patients who are taking oral contraceptive pills, except:

A) liver adenoma

B) peliosis hepatis

C) focal nodular hyperplasia

D) angiosarcoma

E) thromboembolism

A

ANSWER
D) angiosarcoma

EXPLANATION
In female patients who are taking oral contraceptives, the risk of hepatic adenoma, focal nodular hyperplasia, peliosis hepatis associated with sinusoidal dilatation, and complications of thromboembolism increases. This is not applicable to angiosarcoma.

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17
Q

INT - 7.20
The effect of acetaldehyde produced in the metabolism of alcohol:

A) induces immunoreaction through neoantigen formation

B) damage of microtubular functions in hepatocytes

C) decrease of the glutathione reserve of liver

D) increase of superoxide formation

E) all of the above

A

ANSWER
E) all of the above

EXPLANATION
Acetaldehyde produced in the metabolism of alcohol has all the afore mentioned effects.

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18
Q

INT - 7.21
Characteristic laboratory values in chronic heavy drinkers, except:

A) high MCV, usually above 100 fl

B) elevated GGT

C) elevated triglyceride

D) AST/ALT ratio > 1

E) AST/ALT ratio < 1

A

ANSWER
E) AST/ALT ratio < 1

EXPLANATION
Characteristic laboratory values in chronic heavy drinkers include high levels of MCV, usually above 100 fl, elevated GGT and triglyceride, including AST/ALT ratio >1.

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19
Q

INT - 7.22
Characteristics of HCV infection, except:

A) infection can cause cirrhosis for decades

B) only the IFN-based therapy can lead to total recovery

C) it was transmitted through blood transfusion before 1992

D) infection spreads among intravenous drug users nowadays

E) it increases the risk of hepatocellular carcinoma

A

ANSWER
B) only the IFN-based therapy can lead to total recovery

EXPLANATION
It is a characteristic of HCV infection, in which cirrhosis is induced over a period of decades. Today, the therapy based on IFN-free, direct-acting antiviral medicine leads to healing in 90 percent of the cases, and the administration of IFN is no longer needed. Prior to 1992, the virus was also transmitted via blood transfusion. Today, it is primarily transmitted by intravenous narcotic users. It may increase the risk of hepatocellular carcinoma (HCC).

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20
Q

INT - 7.23
True for paracetamol- (acetaminophen) toxicity:

A) toxicity is dose-dependent

B) it is based on immune-allergy

C) it never results in severe toxicity

D) antidote is not known

E) it can safely be administered to alcoholics

A

ANSWER
A) toxicity is dose-dependent

EXPLANATION
Paracetamol causes hepatotoxicity dose-dependently. Its overdose might lead to severe liver failure. Its “antidote” is N-acetylcystein. Alcoholics are especially at risk of paracetamol-toxicity

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21
Q

INT - 7.24
Septic complications mostly occur in obstructive jaundice caused by Klatskin tumor:

A) after percutaneous transhepatic cholangiography

B) after MRCP

C) after duodenoscopy

D) after ERCP

E) none of the above

A

ANSWER
D) after ERCP

EXPLANATION
Septic complications mostly occur following ERCP.

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22
Q

INT - 7.25
Characteristics of ursodeoxycholic acid, except:

A) it has hydrophilic property

B) it is used in treatment of primary biliary cholangitis

C) it increases the risk of colorectal cancer in patients with primary sclerosing cholangitis

D) it takes part in the enterohepatic cycle

E) it is non-toxic bile acid

A

ANSWER
C) it increases the risk of colorectal cancer in patients with primary sclerosing cholangitis

EXPLANATION
Ursodeoxcholic acid is characteristic for its hydrophilic property. It is a non-toxic bile acid which takes part in the enterohepatic cycle. It is used in the treatment of primary biliary cholangitis. It reduces the risk of colorectal cancer in patients with primary sclerosing cholangitis.

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23
Q

INT - 7.26
True for hepatocellular carcinoma (HCC), except:

A) metastasis always occurs in the early phase

B) it has bad prognosis

C) it often develops in cirrhotic liver

D) serum-α-fetoprotein (AFP) level increases in half of the cases

E) it develops more frequently in males than in females

A

ANSWER
A) metastasis always occurs in the early phase

EXPLANATION
Hepatocellular carcinoma is not characteristic of metastasis-formation occurring in the early phase.

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24
Q

INT - 7.27
True for the ascites in liver cirrhosis without further cirrhotic complications:

A) it is bloody

B) protein content is always above 30 g/l

C) malignant cells are found in the sediment

D) serum albumin - ascites albumin gradient >11 g/l

E) neutrophil granulocyte count is above 1000/mm3

A

ANSWER
D) serum albumin - ascites albumin gradient >11 g/l

EXPLANATION
In cirrhosis, in which there are no additional complications, ascites develops as the consequence of portal hypertension, and, in such cases, it is typically characteristic of serum albumin - ascites albumin gradient is more than 11 g/l.

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25
Q

INT - 7.28
Characteristics of cholestatic jaundice, except:

A) level of conjugated bilirubin is high in serum

B) it can be accompanied by pruritus

C) it is associated with elevated level of ALP

D) it is always accompanied by increased level of AST

E) it is associated with elevated GGT

A

ANSWER
D) it is always accompanied by increased level of AST

EXPLANATION
Cholestasis is not associated with an increased level of AST.

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26
Q

INT - 7.29
Characteristics of Wilson’s disease, except:

A) biliary secretion of copper is damaged

B) level of serum ceruloplasmin decreases

C) Kayser–Fleischer-ring is visible with slit lamp examination in half of the cases

D) fulminant hepatitis can occur as acute liver failure

E) it always leads to development of HCC

A

ANSWER
E) it always leads to development of HCC

EXPLANATION
Wilson’s disease does not always lead to hepatocellular carcinoma.

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27
Q

INT - 7.30
Duration of development of hepatocellular carcinoma (HCC) after infection with hepatitis B virus (HBV) or hepatitis C virus (HCV):

A) 1–2 years

B) 5–10 years

C) 10–15 years

D) 20–25 years

E) few months

A

ANSWER
D) 20–25 years

EXPLANATION
Hepatocellular carcinoma develops 20-25 years following the chronic hepatitis B or C virus.

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28
Q

INT - 7.31
The earliest sign of primary biliary cholangitis (PBC) can be:

A) spider nevi

B) dilated abdominal wall veins

C) skin hematomas

D) jaundice

E) pruritus

A

ANSWER
E) pruritus

EXPLANATION
Itchiness may be the primary, early symptom in primary biliary cirrhosis

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29
Q

INT - 7.32
45-year-old alcoholic male patient is admitted to the hospital with ascites, restlessness, bizarre behavior. In his sudden deterioration provoking factors might be, except:

A) asymptomatic duodenal bleeding

B) aggressive diuretic therapy

C) he discontinued lactulose, consumed large amount of protein

D) his protein intake was insufficient

E) spontaneous bacterial peritonitis developed

A

ANSWER
D) his protein intake was insufficient

EXPLANATION
Except in the event of low or diminished protein intake! This does not cause hepatic encephalopathy!

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30
Q

INT - 7.33
Hepatic encephalopathy can be provoked by:

A) after TIPS procedure

B) gastrointestinal bleeding

C) aggressive diuretic therapy

D) spontaneous bacterial peritonitis

E) all of the above

A

ANSWER
E) all of the above

EXPLANATION
Hepatic encephalopathy may be induced by all of the listed circumstances.

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31
Q

INT - 7.34
Characteristics of autoimmune hepatitis, except:

A) mostly younger females are affected

B) high IgG level

C) it does not require liver biopsy to make diagnosis

D) good response to corticosteroid therapy

E) it leads to liver cirrhosis at a young age without treatment

A

ANSWER
C) it does not require liver biopsy to make diagnosis

EXPLANATION
It is characteristic for autoimmune hepatitis that primarily younger females are affected, implies a high IgG level, responds well to corticosteroid therapy, and leads to liver cirrhosis in young age if no therapy is administered. Liver biopsy is required to establish the diagnosis.

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32
Q

INT - 7.35
Characteristics of hepatic encephalopathy, except:

A) confusion

B) signs of focal neurological lesions

C) increased blood ammonia level

D) foetor

E) asterixis

A

ANSWER
B) signs of focal neurological lesions

EXPLANATION
Hepatic encephalopathy is not characteristic in the development of signs of focal neurological lesions.

33
Q

INT - 7.37
Cause of fatty liver can be, except:

A) metabolic syndrome

B) coeliac disease

C) Wilson’s disease

D) autoimmune liver disease

E) drugs

A

ANSWER
D) autoimmune liver disease

EXPLANATION
Fatty liver may be caused by metabolic syndrome, coeliac disease, Wilson’s disease and drug-induced liver injury. Autoimmune liver diseases are not associated with the development of fatty liver.null

34
Q

INT - 7.38
Characteristics of hepatitis B virus infection, except:

A) it is prevented by vaccination

B) chronic hepatitis develops mostly when newborns are infected

C) HBV incorporates into the host’s genome

D) it increases the risk of HCC

E) diagnosis is based on detection of HBV RNA

A

ANSWER
E) diagnosis is based on detection of HBV RNA

EXPLANATION
Hepatitis B virus infection is typically preventable in the event of vaccination. Chronic hepatitis develops mostly if and when newborns are infected. HBV incorporates into the host’s genome, therefore it increases the risk of HCC. The diagnostic of chronic HBV infection is based on the detection of HBV DNA, instead of a.

35
Q

INT - 7.39
Which medication is advised in acetaminophen / paracetamol overdose induced fulminant liver failure?

A) methylene blue

B) desferoxamine

C) atropin

D) silimarin

E) N-acetilcystein

A

ANSWER
E) N-acetilcystein

EXPLANATION
In fulminant liver failure induced by acetaminophen overdose, the treatment ideally is premised on N-acetilcystein or liver transplantation in the most severe cases.null

36
Q

INT - 7.40
Characteristics of primary biliary cholangitis, except:

A) it remains asymptomatic for a long time

B) pruritus might be the first symptom

C) antimitochondrial antibody (AMA) is often positive

D) circulating immuncomplexes, increased IgM level

E) usually younger females are affected

A

ANSWER
E) usually younger females are affected

EXPLANATION
The primary biliary cholangitis is typically asymptomatic for a lengthy period of time, therefore, it is usually diagnosed in middle-aged women and not seen in younger women. Itchiness may arise as a primary symptom. The antimitochondrial antibody (AMA) is often positive and circulating immune complexes, and an increased IgM level may also be observed.null

37
Q

INT - 7.41
In haemochromatosis frequent complication can be, except:

A) diabetes mellitus

B) diabetes insipidus

C) impotence

D) hepatocellular carcinoma

E) pseudogout

A

ANSWER
B) diabetes insipidus

EXPLANATION
Diabetes insipidus is not a common complication of haemochromatosis, contrary to diabetes mellitus, liver cirrhosis, hepatocellular carcinoma, impotence, or pseudogout.

38
Q

INT - 7.42
Side effects of interferon therapy, except:

A) leukopenia

B) autoimmune thyreoiditis

C) fever

D) depression

E) excess of body hair

A

ANSWER
E) excess of body hair

EXPLANATION
Interferon therapy may have side effects including influenza-like fever syndrome, leukopenia, autoimmune thyroiditis and depression, however, not excessive body hair.

39
Q

INT - 7.43
Enzyme which is responsible for alcohol metabolism:

A) alcohol reductase

B) alcohol oxidase

C) alcohol dehydrogenase

D) alcohol synthetase

A

ANSWER
C) alcohol dehydrogenase

EXPLANATION
Among the listed factors, alcohol dehydrogenase is responsible for alcohol metabolism. As an effect, acetaldehyde is produced, which is further metabolized by aldehyde dehydrogenase.

40
Q

INT - 7.44
First investigation(s) when alkaline phosphatase (ALP) is increased:

A) abdominal ultrasound, GGT, serum bilirubin measurement

B) liver-CT

C) bone scintigraphy

D) liver biopsy

E) ERCP

A

ANSWER
A) abdominal ultrasound, GGT, serum bilirubin measurement

EXPLANATION
In the case of increased serum alkaline phosphatase (ALP), the first investigation is abdominal ultrasound and GGT determination may also be applied to rule out possible biliary obstruction. Additional examinations can be applied, only following that in terms of differential diagnosis.

41
Q

INT - 7.45
Protein electrophoresis shows increased polyclonal gammopathy in primary biliary cholangitis, which is mostly:

A) IgA

B) IgM

C) IgG

D) IgD

E) IgE

A

ANSWER
B) IgM

EXPLANATION
Primary biliary cirrhosis (PBC) is characteristic for the increased serum IgM immunoglobulins.

42
Q

INT - 7.46
It is important in the pathogenesis of non-alcoholic steatohepatitis (NASH):

A) inflammatory cytokines

B) altered gut microbiome, increased LPS level in the portal circulation

C) genetic factors

D) high level of free fatty acids

E) all of the above

A

ANSWER
E) all of the above

EXPLANATION
All of the listed factors are important in the pathogenesis of nonalcoholic steatohepatitis (NASH).

43
Q

INT - 7.47
The extrahepatic manifestation of chronic HCV might be, except:

A) cryoglobulinemia

B) chronic fatigue

C) immunthrombocytopenia

D) acute glomerulonephritis

E) atrial fibrillation

A

ANSWER
E) atrial fibrillation

EXPLANATION
Extrahepatic manifestations of chronic HCV hepatitis may include cryoglobulinemia, chronic fatigue, immune thrombocytopenia, and acute glomerulonephritis. Association with the atrial fibrillation is not typical of the disease.

44
Q

INT - 7.48
Characteristic(s) of haemochromatosis:

1) it is familial disorder

2) hepatocellular carcinoma can be frequent sequelae

3) it is based on inherited disorder of iron metabolism

4) it is more frequent in females

A) 1., 2. and 3. answers are correct

B) 1. and 3. answers are correct

C) 2. and 4. answers are correct

D) only 4. answer is correct

E) all of the answers are correct

A

ANSWER
A) 1., 2. and 3. answers are correct

EXPLANATION
Haemochromatosis is a familial disorder based on the inherited disorder of iron metabolism. Hepatocellular carcinoma may be one of its complications. It is equally dominant in women and in men.null

45
Q

INT - 7.49
Which parameters can indicate the development of hepatocellular cancer in a patient with long-standing cirrhosis?

1) right hypochondriac pain and cachexia

2) fever of unknown origin

3) high LDH in serum

4) increased AFP level

A) 1., 2. and 3. answers are correct

B) 1. and 3. answers are correct

C) 2. and 4. answers are correct

D) only 4. answer is correct

E) all 4 answers are correct

A

ANSWER
E) all 4 answers are correct

EXPLANATION
All of the four data may indicate development of hepatic cancer in cirrhotic patients.null

46
Q

INT - 7.50
It can cause chronic hepatitis in immunocompromised patients:

1) hepatitis B-virus

2) hepatitis E-virus

3) hepatitis C-virus

4) hepatitis A-virus

A) 1., 2. and 3. answers are correct

B) 1. and 3. answers are correct

C) 2. and 4. answers are correct

D) only 4. answer is correct

E) all of the answers are correct

A

ANSWER
A) 1., 2. and 3. answers are correct

EXPLANATION
In immunocompromised patients, chronic hepatitis may be caused by hepatitis B-, C-and E- virus, as well. Hepatitis A-virus does not lead to chronic hepatitis.

47
Q

INT - 7.51
Characteristics of primary biliary cholangitis:

1) it is asymptomatic, never causes pruritus

2) it might be associated with antineutrophil cytoplasmic antibody (ANCA) positivity

3) it significantly increases the risk of cholangiocellular carcinoma

4) middle-age females are mostly affected

A) 1., 2. and 3. answers are correct

B) 1. and 3. answers are correct

C) 2. and 4. answers are correct

D) only 4. answer is correct

E) all of the answers are correct

A

ANSWER
D) only 4. answer is correct

EXPLANATION
Primary biliary cholangitis typically involves itchiness, mostly affects middle-age females, and may be associated with antimitochondrial antibody (AMA) positivity (not ANCA). As opposed to PSC, it does not significantly increase the risk of cholangiocellular carcimona.null

48
Q

INT - 7.52
True for hepatocellular carcinoma:

1) it might be associated with HBV genome integration

2) HCV-infection also might be the etiology

3) it can be caused by aflatoxin

4) it characteristically develops after hepatitis A infection

A) 1., 2. and 3. answers are correct

B) 1. and 3. answers are correct

C) 2. and 4. answers are correct

D) only 4. answer is correct

E) all of the answers are correct

A

ANSWER
A) 1., 2. and 3. answers are correct

EXPLANATION
The first three statements are true in support of hepatocellular carcinoma (HCC), however, the hepatitis A-virus (HAV) infection does not cause chronic hepatitis and HCC.null

49
Q

INT - 7.53
Characteristic(s) of primary sclerosing cholangitis:

1) it is more frequent in males

2) it can be associated with ulcerative colitis

3) it can increase the risk of cholangiocellular carcinoma

4) it can be associated with antineutrophil cytoplasmatic antibody (ANCA) positivity

A) 1., 2. and 3. answers are correct

B) 1. and 3. answers are correct

C) 2. and 4. answers are correct

D) only 4. answer is correct

E) all of the answers are correct

A

ANSWER
E) all of the answers are correct

EXPLANATION
All of the four features are characteristic for the primary sclerosing cholangitis (PSC)

50
Q

INT - 7.54
It is useful in the therapy of primary sclerosing cholangitis:

1) ursodeoxycholic acid

2) ballondilatation of dominant biliary stricture

3) liver transplantation

4) cyclophosphamide

A) 1., 2. and 3. answers are correct

B) 1. and 3. answers are correct

C) 2. and 4. answers are correct

D) only 4. answer is correct

E) all of the answers are correct

A

ANSWER
A) 1., 2. and 3. answers are correct

EXPLANATION
Cyclophosphamide is typically not involved in the treatment of PSC, as opposed to the first three treatments.null

51
Q

INT - 7.55
Characteristic(s) of autoimmune hepatitis:

1) low level of serum IgG

2) antinuclear antibody (ANA) positivity

3) young males are affected

4) good response to corticosteroid therapy

A) 1., 2. and 3. answers are correct

B) 1. and 3. answers are correct

C) 2. and 4. answers are correct

D) only 4. answer is correct

E) all of the answers are correct

A

ANSWER
C) 2. and 4. answers are correct

EXPLANATION
Autoimmune hepatitis is characteristic for ANA positivity, increased levels of serum IgG and good response to corticosteroid therapy. The disease predominantly affects young women.

52
Q

INT - 7.56
It can be used for the treatment of chronic hepatitis B:

1) interferon

2) entecavir

3) tenofovir

4) azathioprin

A) 1., 2. and 3. answers are correct

B) 1. and 3. answers are correct

C) 2. and 4. answers are correct

D) only 4. answer is correct

E) all of the answers are correct

A

ANSWER
A) 1., 2. and 3. answers are correct

EXPLANATION
Among the listed statements, the treatment of chronic hepatitis B involves interferon, entecavir and tenofovir.

53
Q

INT - 7.57
Characteristic(s) of hepatitis E viral infection:

1) it can be transmitted with consumption of undercooked pork meet

2) it can become chronic infection in immunocompromised patients

3) it can cause central nervous system symptoms

4) it never causes cirrhosis

A) 1., 2. and 3. answers are correct

B) 1. and 3. answers are correct

C) 2. and 4. answers are correct

D) only 4. answer is correct

E) all of the answers are correct

A

ANSWER
A) 1., 2. and 3. answers are correct

EXPLANATION
Hepatitis E-virus infection is typically transmitted by the consumption of undercooked pork meat. The infection may become chronic in immunocompromised patients, and may also lead to cirrhosis. It can cause symptoms directly related to the central nervous system.

54
Q

INT - 7.58
It plays a role in the transmission of hepatitis C virus infection:

1) iv. narcotic users

2) tattoo

3) blood transfusion before 1992

4) prostitution, male homosexuality

A) 1., 2. and 3. answers are correct

B) 1. and 3. answers are correct

C) 2. and 4. answers are correct

D) only 4. answer is correct

E) all of the answers are correct

A

ANSWER
E) all of the answers are correct

EXPLANATION
Today, the transmission of hepatitis C virus infection is predominantly due to IV narcotic usage, the transmission associated with the application of a tattoo, and earlier, to blood transfusions, however, prostitution and male homosexuality need to be considered as risk factors in this respect.

55
Q

INT - 7.59
It can cause obstructive jaundice:

1) neoplasia of papilla of Vater

2) common bile duct stone

3) cancer of pancreatic head

4) cancer of pancreatic tail

A) 1., 2. and 3. answers are correct

B) 1. and 3. answers are correct

C) 2. and 4. answers are correct

D) only 4. answer is correct

E) all of the answers are correct

A

ANSWER
A) 1., 2. and 3. answers are correct

EXPLANATION
Obstructive jaundice is predominantly caused by the first three lesions, contrary to pancreatic tail cancer.null

56
Q

INT - 7.60
Antiviral therapy of chronic hepatitis C:

1) it is suggested only in cases of elevated ALT

2) it is suggested only under age of 60 years

3) it is suggested only if Fibroscan shows severe liver fibrosis

4) it can be considered in every HCV infected patients independently of ALT level and degree of fibrosis

A) 1., 2. and 3. answers are correct

B) 1. and 3. answers are correct

C) 2. and 4. answers are correct

D) only 4. answer is correct

E) all of the answers are correct

A

ANSWER
D) only 4. answer is correct

EXPLANATION
The direct-acting antiviral therapy of chronic hepatitis C can be considered in every HCV infected patient, independently of the ALT level and the degree of fibrosis. The main purpose of the therapy is to prevent and eliminate the worldwide transmission of the virus infection.

57
Q

INT - 7.61
Characteristics of Gilbert syndrome:

1) increased level of indirect bilirubin

2) increased reticulocyte count

3) normal LDH level

4) low serum haptoglobin level

A) 1., 2. and 3. answers are correct

B) 1. and 3. answers are correct

C) 2. and 4. answers are correct

D) only 4. answer is correct

E) all of the answers are correct

A

ANSWER
B) 1. and 3. answers are correct

EXPLANATION
Gilbert syndrome, a functional hyperbilirubinaemia, is characteristic of increased levels of serum indirect bilirubin. Haemolysis can be ruled out, far more easily, as Gilbert syndrome involves normal serum LDH levels, the serum haptoglobin level is not reduced, and the reticulocyte count is not increased.null

58
Q

INT - 7.62
Characteristics of alcoholic hepatitis:

1) granulocyte infiltration in liver tissue

2) leukocytosis, fever

3) increased level of GGT

4) increased level of LDH

A) 1., 2. and 3. answers are correct

B) 1. and 3. answers are correct

C) 2. and 4. answers are correct

D) only 4. answer is correct

E) all of the answers are correct

A

ANSWER
A) 1., 2. and 3. answers are correct

EXPLANATION
Alcoholic hepatitis is usually not characteristic for an increased level of LDH.

59
Q

INT - 7.63
It can be administered to prevent rebleeding of esophageal varicosity:

1) endoscopic variceal sclerotherapy or ligation

2) portocaval shunt insertion

3) propranolol

4) carvediol

A) 1., 2. and 3. answers are correct

B) 1. and 3. answers are correct

C) 2. and 4. answers are correct

D) only 4. answer is correct

E) all 4 answers are correct

A

NSWER
E) all 4 answers are correct

EXPLANATION
The most commonly applied therapies in the prevention of the rebleeding of esophageal varices include variceal sclerotherapy or ligation, TIPS implantation, and propranolol and carvediol treatment.

60
Q

INT - 7.64
Hepatitis B virus infection frequently occurs in:

1) West-Europe

2) the USA

3) Hungary

4) Far-East, Taiwan

A) 1., 2. and 3. answers are correct

B) 1. and 3. answers are correct

C) 2. and 4. answers are correct

D) only 4. answer is correct

E) all of the answers are correct

A

ANSWER
D) only 4. answer is correct

EXPLANATION
HBV infection occurs more frequently in the Far-East, including Taiwan, when compared with Europe and the USA.

61
Q

INT - 7.65
Biological effects of interferon therapy in chronic B hepatitis:

1) antiproliferative, antineoplastic

2) immunmodulatory

3) antiviral

4) antibacterial

A) 1., 2. and 3. answers are correct

B) 1. and 3. answers are correct

C) 2. and 4. answers are correct

D) only 4. answer is correct

E) all of the answers are correct

A

ANSWER
A) 1., 2. and 3. answers are correct

EXPLANATION
Interferons are antiproliferative, immunomodulatory and antiviral cytokines without antibacterial effects.

62
Q

INT - 7.66
It can be the side effects of interferon therapy:

1) flu-like symptoms

2) leukopenia

3) depression

4) relapse of autoimmune diseases

A) 1., 2. and 3. answers are correct

B) 1. and 3. answers are correct

C) 2. and 4. answers are correct

D) only 4. answer is correct

E) all of the answers are correct

A

ANSWER
E) all of the answers are correct

EXPLANATION
The side effects of interferon therapy may include flu-like symptoms, leukopenia, depression and a relapse of autoimmune diseases.null

63
Q

INT - 7.67
True for hepatitis C virus infection:

1) it can lead to cirrhosis for decades

2) acute hepatitis is usually asymptomatic

3) it increases the risk of HCC

4) liver transplantation is never recommended

A) 1., 2. and 3. answers are correct

B) 1. and 3. answers are correct

C) 2. and 4. answers are correct

D) only 4. answer is correct

E) all of the answers are correct

A

ANSWER
A) 1., 2. and 3. answers are correct

EXPLANATION
It is true in the case of hepatitis C virus infection, in which it often leads to cirrhosis, over a period of decades, and therefore, increases the risk of HCC. Acute hepatitis is usually symptom-free. If liver cirrhosis is induced by decompensated HCV, the expected survival is shorter than 1-2 years. In the event there is no surgical contraindication, liver transplantation in patients is recommended.null

64
Q

NT-7.68-7.72
The following symptoms indicate liver disease. Choose the most probable diagnosis for each case.

A) primary biliary cholangitis

B) viral hepatitis

C) acute cholecystitis

D) autoimmune hepatitis

E) hepatic encephalopathy

INT - 7.68 -
Pruritus, xanthomas, hepatosplenomegaly, high cholesterol level

INT - 7.69 -
Jaundice, anorexia, nausea, elevated ALT, normal ALP

INT - 7.70 -
Hepatosplenomegaly, hypergammaglobulinaemia, anti-smooth muscle antibody

INT - 7.71 -
Fever, right hypochondric pain, leukocytosis

INT - 7.72 -
Confusion, flapping tremor, jaundice, high plasma ammonia level

A

ANSWER
INT - 7.68 -
Pruritus, xanthomas, hepatosplenomegaly, high cholesterol level - A) PBC

INT - 7.69 -
Jaundice, anorexia, nausea, elevated ALT, normal ALP - B) Viral

INT - 7.70 -
Hepatosplenomegaly, hypergammaglobulinaemia, anti-smooth muscle antibody - D) Autoimmune

INT - 7.71 -
Fever, right hypochondric pain, leukocytosis - C) Acute cholecystitis

INT - 7.72 -
Confusion, flapping tremor, jaundice, high plasma ammonia level - E) Hepatic encephalopathy

65
Q

INT - 7.73
Chronic hepatitis C can be cured with new direct antiviral therapies in approximately 90% of the cases, because these medications can be given to patients with cirrhosis.

A) both parts are correct, causative relation exists

B) both parts are correct, causative relation does not exist

C) first part is correct, the second is incorrect

D) first part is incorrect, second part is correct

E) both parts are incorrect

A

ANSWER
B) both parts are correct, causative relation does not exist

EXPLANATION
In approximately 90% of the cases, chronic hepatitis C can be cured with the new direct-acting antiviral therapies inhibiting the replication of the virus. Furthermore, these new medications can be administered to cirrhotic patients who formerly could not benefit from IFN therapy. However, there is no cause-effect relation between the two statements.

66
Q

INT - 7.74
Gynocomasty is frequent abnormality in cirrhotic males, because the ratio of oestrogen/androgen shifts to the former.

A) both parts are correct, causative relation exists

B) both parts are correct, causative relation does not exist

C) first part is correct, the second is incorrect

D) first part is incorrect, second part is correct

E) both parts are incorrect

A

ANSWER
A) both parts are correct, causative relation exists

EXPLANATION
The gynecomasty in cirrhotic patients is related to increased oestrogen effect

67
Q

INT - 7.75
Gallstone can be impacted into the cystic duct, therefore biliary pancreatitis develops as a complication of gallstone disease.

A) both parts are correct, causative relation exists

B) both parts are correct, causative relation does not exist

C) first part is correct, the second is incorrect

D) first part is incorrect, second part is correct

E) both parts are incorrect

A

ANSWER
B) both parts are correct, causative relation does not exist

EXPLANATION
In the case of cholelithiasis, biliary pancreatitis can develop, however, it is not caused by gallstone impaction into the cystic duct.null

68
Q

INT - 7.76
Portal hypertension might develop as a consequence of liver cirrhosis; therefore liver cirrhosis can be accompanied by jaundice.

A) both parts are correct, causative relation exists

B) both parts are correct, causative relation does not exist

C) first part is correct, the second is incorrect

D) first part is incorrect, second part is correct

E) both parts are incorrect

A

ANSWER
B) both parts are correct, causative relation does not exist

EXPLANATION
Jaundice does not develop as a consequence of liver cirrhosis, due to portal hypertension. Jaundice is the sign of hepatic parenchymal decompensation.null

69
Q

INT - 7.77
Hepatitis B virus infection is acquired in newborns in the Far-East, therefore the hepatocellular carcinoma is more common there.

A) both parts are correct, causative relation exists

B) both parts are correct, causative relation does not exist

C) first part is correct, the second is incorrect

D) first part is incorrect, second part is correct

E) both parts are incorrect

A

ANSWER
A) both parts are correct, causative relation exists

EXPLANATION
It is true in which hepatitis B virus infection is acquired in newborns in the Far-East, therefore, hepatocellular cancer is far more prevalent.null

70
Q

INT - 7.78
Chronic hepatitis C is susceptible of spontaneous healing; therefore chronic HCV infection should be rarely treated.

A) both parts are correct, causative relation exists

B) both parts are correct, causative relation does not exist

C) first part is correct, the second is incorrect

D) first part is incorrect, second part is correct

E) both parts are incorrect

A

ANSWER
E) both parts are incorrect

EXPLANATION
Chronic hepatitis C is not susceptible of spontaneous healing, therefore, it requires frequent attentive treatment.null

71
Q

INT - 7.79
Autoimmune disorders might relapse as a side effect of interferon therapy; therefore interferon therapy is contraindicated in autoimmune hepatitis.

A) both parts are correct, causative relation exists

B) both parts are correct, causative relation does not exist

C) first part is correct, the second is incorrect

D) first part is incorrect, second part is correct

E) both parts are incorrect

A

ANSWER
A) both parts are correct, causative relation exists

EXPLANATION
Autoimmune disorders may relapse, as a side effect of interferon therapy, therefore, interferon therapy is contraindicated in autoimmune hepatitis.null

72
Q

INT - 7.80
In haemolyticus icterus unconjugated bilirubin is increased in blood; therefore the patient has direct hyperbilirubinaemia in hemolysis.

A) both parts are correct, causative relation exists

B) both parts are correct, causative relation does not exist

C) first part is correct, the second is incorrect

D) first part is incorrect, second part is correct

E) both parts are incorrect

A

ANSWER
C) first part is correct, the second is incorrect

EXPLANATION
In haemolytic jaundice, direct hyperbilirubinaemia is present, and increased levels of unconjugated bilirubin is apparent in the blood.null

73
Q

INT - 7.81
Postransfusion hepatitis was significantly decreased by the screening of blood donors for HBsAg and anti-HCV antibody, therefore post-transfusion hepatitis does not occur nowadays.

A) both parts are correct, causative relation exists

B) both parts are correct, causative relation does not exist

C) first part is correct, the second is incorrect

D) first part is incorrect, second part is correct

E) both parts are incorrect

A

NSWER
C) first part is correct, the second is incorrect

EXPLANATION
Despite the fact in which post-transfusion virus hepatitis was significantly decreased by the screening of blood donors for HBsAg and anti-HCV antibody, today, the syndrome rarely occurs.

74
Q

INT - 7.82
What is the diagnosis?

50-year-old alcoholic male patient visits his physician with following symptoms: fatigue for months, abdominal girth is increased, distended, swelling of the legs, jaundice appeared, lost some weight. He became febrile few days ago and felt abdominal pain. Physical examination reveals jaundice, ascites, enlarged liver with finely irregular surface, mild diffuse abdominal tenderness. Laboratory parameters: serum bilirubin 65 μmol/l, AST 60 E, GGT 560 E, albumin 26 g/l, INR: 1.7, leucocyte count 12 000 G/l, platelet count: 75 000 G/l.

A) alcoholic hepatitis

B) hepatocellular carcinoma

C) liver cirrhosis

D) right-sided cardiac failure

A

ANSWER
C) liver cirrhosis

EXPLANATION
The case indicates liver cirrhosis.

75
Q

INT - 7.83

What type of investigation would be the next step?
50-year-old alcoholic male patient visits his physician with following symptoms: fatigue for months, abdominal girth is increased, distended, swelling of the legs, jaundice appeared, lost some weight. He became febrile few days ago and felt abdominal pain. Physical examination reveals jaundice, ascites, enlarged liver with finely irregular surface, mild diffuse abdominal tenderness. Laboratory parameters: serum bilirubin 65 μmol/l, AST 60 E, GGT 560 E, albumin 26 g/l, INR: 1.7, leucocyte count 12 000 G/l, platelet count: 75 000 G/l.

A) diagnostic ascites tapping

B) oesophagogastroscopy

C) MR cholangiography

D) endoscopic retrograde cholangiography (ERCP)

E) none of the above

A

ANSWER
A) diagnostic ascites tapping

EXPLANATION
In order to justify the type of ascites and spontaneous bacterial peritonitis, early diagnostic abdominal puncture is deemed an important measure.

76
Q

INT - 7.84

What other investigations would be recommended?
50-year-old alcoholic male patient visits his physician with following symptoms: fatigue for months, abdominal girth is increased, distended, swelling of the legs, jaundice appeared, lost some weight. He became febrile few days ago and felt abdominal pain. Physical examination reveals jaundice, ascites, enlarged liver with finely irregular surface, mild diffuse abdominal tenderness. Laboratory parameters: serum bilirubin 65 μmol/l, AST 60 E, GGT 560 E, albumin 26 g/l, INR: 1.7, leucocyte count 12 000 G/l, platelet count: 75 000 G/l.

A) percutaneous liver biopsy

B) liver scintigraphy

C) abdominal ultrasound

D) echocardiography

E) none of the above

A

ANSWER
C) abdominal ultrasound

EXPLANATION
Abdominal ultrasound is recommended as a first investigation, and in the case of symptoms indicating cirrhosis, expressively sought for ruling-out hepatocellular carcinoma (HCC).

77
Q

INT - 7.85

What can be the complication of disease, based on the laboratory findings and symptomatology?
50-year-old alcoholic male patient visits his physician with following symptoms: fatigue for months, abdominal girth is increased, distended, swelling of the legs, jaundice appeared, lost some weight. He became febrile few days ago and felt abdominal pain. Physical examination reveals jaundice, ascites, enlarged liver with finely irregular surface, mild diffuse abdominal tenderness. Laboratory parameters: serum bilirubin 65 μmol/l, AST 60 E, GGT 560 E, albumin 26 g/l, INR: 1.7, leucocyte count 12 000 G/l, platelet count: 75 000 G/l.

A) acute cholecystitis

B) spontaneous bacterial peritonitis

C) acute pancreatitis

D) hepatic encephalopathy

E) duodenal erosion

A

ANSWER
B) spontaneous bacterial peritonitis

EXPLANATION
The symptomatology including ascites, fever and abdominal pain raises the suspicion of spontaneous bacterial peritonitis.

78
Q

INT - 7.86

What would be the recommended drug therapy for this complication?
50-year-old alcoholic male patient visits his physician with following symptoms: fatigue for months, abdominal girth is increased, distended, swelling of the legs, jaundice appeared, lost some weight. He became febrile few days ago and felt abdominal pain. Physical examination reveals jaundice, ascites, enlarged liver with finely irregular surface, mild diffuse abdominal tenderness. Laboratory parameters: serum bilirubin 65 μmol/l, AST 60 E, GGT 560 E, albumin 26 g/l, INR: 1.7, leucocyte count 12 000 G/l, platelet count: 75 000 G/l.

A) penicillin

B) rifaximin

C) lactulose

D) norfloxacin or ceftriaxon

E) all of the above

A

ANSWER
D) norfloxacin or ceftriaxon

EXPLANATION
Among the listed medications, norfloxacin or ceftriaxone, are the most recommended treatments for spontaneous bacterial peritonitis.