Internal_Liver Diseases

Question 1

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

Answer 1

E) all of the above

HE flips the brain after Bleeds, Bugs, TIPS, and Pee pills!

Question 2

Cause of fatty liver can be, except:
A) metabolic syndrome
B) coeliac disease
C) Wilson’s disease
D) autoimmune liver disease
E) drugs

Answer 2

D) autoimmune liver disease

Fatty liver skips autoimmunity—D is the odd one out!

Question 3

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)

Answer 3

E) hepatocellular cancer (HCC)

AFP = Always Find Primary in the Liver → Think HCC

Question 4

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

Answer 4

E) all of the above

NASH = Not just fat—cytokines, bugs, genes, fats all hit!

Question 5

Predisposing factor(s) for gallstone formation:
A) obesity
B) chronic hemolysis
C) octreotide therapy
D) bowel resection
E) all of the above

Answer 5

E) all of the above

Fat, Blood, Gut, Drugs — all make gallstones stuck

Question 6

In haemochromatosis frequent complication can be, except:
A) diabetes mellitus
B) diabetes insipidus
C) impotence
D) hepatocellular carcinoma
E) pseudogout

Answer 6

B) diabetes insipidus

Question 7

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

Answer 7

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

Cystic duct ≠ Pancreas: Different pipes, same stones

Question 8

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

Answer 8

C) liver cirrhosis

Cirrhosis = Chronic signs + Scarring + Synthetic failure

Question 9

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

Answer 9

E) it always leads to development of HCC

Wilson’s harms liver—but not always with cancer → E is false

Question 10

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

Answer 10

E) all of the answers are correct

1) iv. narcotic users
2) tattoo
3) blood transfusion before 1992
4) prostitution, male homosexuality

HCV rides on Needles, Ink, Old Blood, and Risky Sex.

Question 11

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

Answer 11

E) usually younger females are affected

PBC itches middle-aged women—not young → E is false

Question 12

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

Answer 12

E) suspected hemangioma

Don’t poke a hemangioma — image, don’t bleed!

Question 13

Which of the following medication can dose-dependently cause liver failure?
A) halothane
B) paracetamol (acetaminophen)
C) chlorpromazine
D) methyldopa
E) erythromycin

Answer 13

B) paracetamol (acetaminophen)

Too much para? Liver says bye
→ Only NSAID kills with higher doses.

Question 14

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

Answer 14

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

1) neoplasia of papilla of Vater
2) common bile duct stone
3) cancer of pancreatic head

Jaundice loves bile duct stones, tumors at the papilla and head!

Question 15

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

Answer 15

C) it does not require liver biopsy to make diagnosis

AIH needs a biopsy—don’t trust labs alone! That’s why C is false

Question 16

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

Answer 16

E) both parts are incorrect

Chronic HCV stays — Treat always, don’t wait

Question 17

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

Answer 17

D) only 4. answer is correct

4) middle-age females are mostly affected

Question 18

The following symptoms indicate liver disease.

Hepatosplenomegaly, hypergammaglobulinaemia, anti-smooth muscle antibody

Choose the most probable diagnosis for each case.
A) primary biliary cholangitis
B) viral hepatitis
C) acute cholecystitis
D) autoimmune hepatitis
E) hepatic encephalopathy

Answer 18

D) autoimmune hepatitis

Autoimmune = ASMA + Antibodies + Amplified IgG

Question 19

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

Answer 19

B) metabolic acidosis

→ GI bleed, infections, electrolytes, protein cause HE — not acidosis

Question 20

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

Answer 20

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

1) it can lead to cirrhosis for decades
2) acute hepatitis is usually asymptomatic
3) it increases the risk of HCC

HCV = Hidden, Chronic, Cancer, (not) Contra for transplant

Question 21

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 of the answers are correct

Answer 21

E) all of the answers are correct

1) endoscopic variceal sclerotherapy or ligation
2) portocaval shunt insertion
3) propranolol
4) carvediol

To stop variceal bleeds: Band it, Block it, or Bypass it!”

Question 22

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

Answer 22

A) both parts are correct, causative relation exists

Interferon fires up immunity — avoid in autoimmune

Question 23

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

Answer 23

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

DAAs Cure Most — Cirrhosis OK, but not the cause

Question 24

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

Answer 24

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

Varices? Stop, Scope, Squeeze, Save blood (Hb < 100!)

Question 25

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

Answer 25

E) all of the above | Acetaldehyde wrecks the liver: ROS, GSH, tubes, and immune

Question 26

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

Answer 26

A) 1., 2. and 3. answers are correct 1) it is familial disorder 2) hepatocellular carcinoma can be frequent sequelae 3) it is based on inherited disorder of iron metabolism | Hemochromatosis: Genes, Iron, Cancer—but not common in women!

Question 27

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)

Answer 27

B) serum α-fetoprotein (AFP) | AFP rises with liver mass — think cancer, not autoimmunity

Question 28

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

Answer 28

A) toxicity is dose-dependent | Dose harms; NAC rescues—no allergy, no safety with booze

Question 29

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

Answer 29

D) angiosarcoma | OCPs: Clots, benign liver, but not angiosarcoma

Question 30

Enzyme which is responsible for alcohol metabolism: A) alcohol reductase B) alcohol oxidase C) alcohol dehydrogenase D) alcohol synthetase

Answer 30

C) alcohol dehydrogenase | Drink it? Break it with dehydrogenase! ADH does the job.

Question 31

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

Answer 31

C) first part is correct, the second is incorrect | Hemolysis = High heme → Indirect bili rises

Question 32

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

Answer 32

A) 1., 2. and 3. answers are correct 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 | HEV hides in pork, hits the brain, and haunts the weak!

Question 33

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

Answer 33

B) corticosteroid administration is always necessary

Question 34

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

Answer 34

C) Non alcoholic steatohepatitis (NASH) | Cryptic Fat = Cryptogenic → NASH

Question 35

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

Answer 35

A) 1., 2. and 3. answers are correct 1) antiproliferative, antineoplastic 2) immunmodulatory 3) antiviral | Interferon = Immune, Infection (virus), Inhibits tumors

Question 36

The following symptoms indicate liver disease. Fever, right hypochondric pain, leukocytosis Choose the most probable diagnosis for each case. A) primary biliary cholangitis B) viral hepatitis C) acute cholecystitis D) autoimmune hepatitis E) hepatic encephalopathy

Answer 36

C) acute cholecystitis | Fever + RUQ pain = Cholecystitis Clue

Question 37

Side effects of interferon therapy, **except**: A) leukopenia B) autoimmune thyreoiditis C) fever D) depression E) excess of body hair

Answer 37

E) excess of body hair | IFN makes you sick, sad, and bald—not hairy!

Question 38

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

Answer 38

D) norfloxacin or ceftriaxon | SBP? Start Broad with Ceftriaxone

Question 39

Protein electrophoresis shows increased polyclonal gammopathy in primary biliary cholangitis, which is mostly: A) IgA B) IgM C) IgG D) IgD E) IgE

Answer 39

B) IgM | PBC = Pruritus, Bile, and Climbing IgM

Question 40

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

Answer 40

D) 20–25 years | Viral HCC = a long game—think 2 decades, not 2 years!

Question 41

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

Answer 41

A) 1., 2. and 3. answers are correct 1) ursodeoxycholic acid 2) ballondilatation of dominant biliary stricture 3) liver transplantation | PSC needs UDCA, balloons, and livers—not chemo drugs!

Question 42

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

Answer 42

E) all 4 answers are correct 1) right hypochondriac pain and cachexia 2) fever of unknown origin 3) high LDH in serum 4) increased AFP level | HCC flags: Pain, Fever, AFP, and LDH—all four are red alerts!

Question 43

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

Answer 43

D) his protein intake was insufficient | HE loves Bleeds, Bugs, Diuretics, and Beef—but not Low Protein!

Question 44

Characteristics of hepatic encephalopathy, **except**: A) confusion B) signs of focal neurological lesions C) increased blood ammonia level D) foetor E) asterixis

Answer 44

B) signs of focal neurological lesions | HE = diffuse brain damamge not focal

Question 45

Characteristics of drug-induced liver injury, **except**: A) it is always dose-dependent B) indiosyncratic 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

Answer 45

A) it is always dose-dependent | DILI = Dose or Not – but Never redose

Question 46

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

Answer 46

A) abdominal ultrasound, GGT, serum bilirubin measurement | High ALP? Start with scan, GGT, and bili—it’s A all the way

Question 47

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

Answer 47

C) first part is correct, the second is incorrect | Screening slashed it — but zero risk’s a myth

Question 48

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

Answer 48

B) only the IFN-based therapy can lead to total recovery | DAAs cure HCV; ‘only IFN works’ is bogus—choose B

Question 49

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

Answer 49

**E) all of the above** A) periarteritis nodosa, immuncomplex vasculitis B) glomerulonephritis C) cryoglobulinaemia D) arthritis | HBV = PAN, GN, Cryo, and painful joints – all immune stuff!

Question 50

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

Answer 50

E) it is associated with elevated GGT | Cholestasis: ↑ALP, GGT, conj. bili—not always ↑AST → D is false

Question 51

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

Answer 51

A) both parts are correct, causative relation exists | Cirrhosis converts men: More estrogen, more chest

Question 52

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

Answer 52

D) only 4. answer is correct 4) it can be considered in every HCV infected patients independently of ALT level and degree of fibrosis | HCV? Treat everyone—no need to wait for ALT or age!

Question 53

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

Answer 53

A) 1., 2. and 3. answers are correct 1) hepatitis B-virus 2) hepatitis E-virus 3) hepatitis C-virus | Be Careful, Even the A = Ain’t chronic — never causes chronic hepatitis

Question 54

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

Answer 54

C) abdominal ultrasound | Cirrhotic belly? Scan with ultrasound first

Question 55

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

Answer 55

B) spontaneous bacterial peritonitis | Fever + fluid in cirrhosis? Think SBP first

Question 56

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

Answer 56

B) 1. and 3. answers are correct 1) increased level of indirect bilirubin 3) normal LDH level | Gilbert’s = G for Gradual bilirubin rise, but no signs of hemolysis

Question 57

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

Answer 57

E) pruritus | PBC = itchy palms before yellow eyes—pruritus comes first!

Question 58

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

Answer 58

D) corticosteroid is indicated for treatment Female, IgM, Mitochondria, Autoimmune | F-I-M-A Sclerosis, No Steroids

Question 59

Which medication is advised in acetaminophen / paracetamol overdose induced fulminant liver failure? A) methylene blue B) desferoxamine C) atropin D) silimarin E) N-acetilcystein

Answer 59

E) N-acetilcystein | Paracetamol poisons → NAC saves the liver—go with E

Question 60

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

Answer 60

A) diagnostic ascites tapping | Fever + ascites = Tap before it’s too late

Question 61

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

Answer 61

A) sclerotherapy is needed only when recurrent bleeding occurs after portocaval shunt operation | Band or bleed first — shunt is last, not sclerotherapy's start

Question 62

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

Answer 62

D) after ERCP | Klatskin + ERCP = cholangitis risk

Question 63

The following symptoms indicate liver disease. Confusion, flapping tremor, jaundice, high plasma ammonia level Choose the most probable diagnosis for each case. A) primary biliary cholangitis B) viral hepatitis C) acute cholecystitis D) autoimmune hepatitis E) hepatic encephalopathy

Answer 63

E) hepatic encephalopathy | High ammonia = Head fog = Hepatic encephalopathy

Question 64

The following symptoms indicate liver disease. Jaundice, anorexia, nausea, elevated ALT, normal ALP Choose the most probable diagnosis for each case. A) primary biliary cholangitis B) viral hepatitis C) acute cholecystitis D) autoimmune hepatitis E) hepatic encephalopathy

Answer 64

B) viral hepatitis | Viral = Vomiting + high ALT, but ALP stays Low

Question 65

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

Answer 65

A) metastasis always occurs in the early phase | HCC often, not always, spreads early—so A is false

Question 66

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

Answer 66

C) 2. and 4. answers are correct 2) antinuclear antibody (ANA) positivity 4) good response to corticosteroid therapy | AIH = ANA+, IgG high, hits women—steroids save the day!

Question 67

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

Answer 67

A) 1., 2. and 3. answers are correct 1) it might be associated with HBV genome integration 2) HCV-infection also might be the etiology 3) it can be caused by aflatoxin | HCC: Blame B, C, and Bad Beans—not Hep A

Question 68

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

Answer 68

E) diagnosis is based on detection of HBV RNA | HBV = DNA virus—so RNA test? Nah, E is false!

Question 69

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

Answer 69

A) 1., 2. and 3. answers are correct 1) granulocyte infiltration in liver tissue 2) leukocytosis, fever 3) increased level of GGT | Alcoholic hep = Fever, Neutrophils, GGT ↑ — but not LDH!

Question 70

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

Answer 70

E) AST/ALT ratio < 1 | Alcohol ups MCV, GGT, TG, AST→ALT—so AST < ALT must be wrong

Question 71

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

Answer 71

E) benign postoperative cholestasis | BPC = Bilirubin Post-surgery, Cholestasis, no Pain

Question 72

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

Answer 72

E) all of the answers are correct 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 | PSC: P for P-ANCA, S for SIBD, C for Cancer risk in men.

Question 73

The extrahepatic manifestation of chronic HCV might be, **except**: A) cryoglobulinemia B) chronic fatigue C) immunthrombocytopenia D) acute glomerulonephritis E) atrial fibrillation

Answer 73

E) atrial fibrillation | HCV hits blood, kidneys, energy—but not your heartbeat!

Question 74

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

Answer 74

B) both parts are correct, causative relation does not exist | Cirrhosis: One cause, many paths — not all connected

Question 75

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

Answer 75

A) both parts are correct, causative relation exists | Born with HBV → Burden of HCC in East Asia

Question 76

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

Answer 76

E) all of the answers are correct 1) flu-like symptoms 2) leukopenia 3) depression 4) relapse of autoimmune diseases | Flu, Low WBC, Low mood, Lupus: Interferon fallout

Question 77

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)

Answer 77

A) abdominal ultrasound | Old man + yellow = Start with scan that's simple and mellow → U/S

Question 78

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

Answer 78

D) serum albumin - ascites albumin gradient >11 g/l | Cirrhotic ascites = high SAAG, low protein, no blood or bugs.

Question 79

The following symptoms indicate liver disease. Pruritus, xanthomas, hepatosplenomegaly, high cholesterol level Choose the most probable diagnosis for each case. A) primary biliary cholangitis B) viral hepatitis C) acute cholecystitis D) autoimmune hepatitis E) hepatic encephalopathy

Answer 79

A) primary biliary cholangitis | PBC: Pruritus, Bile backup, Cholesterol

Question 80

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

Answer 80

A) 1., 2. and 3. answers are correct 1) interferon 2) entecavir 3) tenofovir | HBV = INF + Entecavir + Tenofovir — but never Azathioprin

Question 81

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

Answer 81

C) it increases the risk of colorectal cancer in patients with primary sclerosing cholangitis | UDCA helps PBC, not harms PSC—so C is false

Question 82

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

Answer 82

D) only 4. answer is correct 4) Far-East, Taiwan | Hep B’s home base? Head East—Taiwan leads the pack!