Liver disease — MCQs

A 58-year-old woman presents to her primary care provider complaining fatigue and a vague muscle pain in her limbs. She always seems tired and has difficulty getting through her workday and doing chores around the house. This has been going on for several months and her symptoms seem to be getting worse. She also admits to long bouts of constipation. Past medical history is significant for cirrhosis and kidney stones. She was taking acetaminophen for the pain, but that no longer provides relief, and polyethylene glycol to treat her constipation. Today, her temperature is 37.0°C (98.6°F), blood pressure is 110/80 mm Hg, heart rate is 85/min, and oxygen saturation is 99% on room air. On physical exam, she has a regular rhythm, and her lungs are clear to auscultation bilaterally. Her laboratory results are as follows: Alanine aminotransferase (ALT) 62 U/L Aspartate aminotransferase (AST) 50 U/L Total bilirubin 1.10 mg/dL Serum albumin 2.0 g/dL Calcium 10.6 mg/dL What is the cause of this patient's symptoms?

A 48-year-old man comes to the physician because of increasing generalized fatigue for 1 month. He has been unable to do normal household duties or go for his evening walks during this period. He has hypertension, hyperlipidemia, and type 2 diabetes mellitus. His father died of liver cancer at the age of 60 years. He does not smoke. He drinks one alcoholic beverage daily. Current medications include atorvastatin, enalapril, metformin, and insulin glargine. He is 170 cm (5 ft 7 in) tall and weighs 100 kg (220 lb); BMI is 34.6 kg/m2. His temperature is 36.6°C (97.9°F), pulse is 116/min, and blood pressure is 140/90 mm Hg. Examination shows hyperpigmented skin over the nape of the neck and extremities. The liver is palpated 4 cm below the right costal margin. Laboratory studies show: Hemoglobin 10.6 g/dL Mean corpuscular volume 87 μm3 Leukocyte count 9,700/mm3 Platelet count 182,000/mm3 Serum Glucose 213 mg/dL Creatinine 1.4 mg/dL Albumin 4.1 g/dL Total bilirubin 1.1 mg/dL Alkaline phosphatase 66 U/L AST 100 U/L ALT 69 U/L γ-glutamyl transferase 28 U/L (N=5–50) Hepatitis B surface antigen negative Hepatitis C antibody negative Iron studies Iron 261 μg/dL Ferritin 558 ng/dL Transferrin saturation 83% Anti-nuclear antibody negative Which of the following is the most appropriate next step to confirm the diagnosis?

A 56-year-old woman is brought to the emergency department by her family with altered mental status. Her husband says that she complained of fever, vomiting, and abdominal pain 2 days ago. She has a history of long-standing alcoholism and previous episodes of hepatic encephalopathy. Current vital signs include a temperature of 38.3°C (101°F), blood pressure of 85/60 mm Hg, pulse of 95/min, and a respiratory rate 30/min. On physical examination, the patient appears ill and obtunded. She is noted to have jaundice, a palpable firm liver, and massive abdominal distension with shifting dullness. Which of the following is the best initial step in management of this patient's condition?

A 42-year-old woman presents with pruritus and progressive weakness for the past 3 months. She says she feels excessively tired during the daytime and is losing interest in activities that used to be fun. The patient reports a history of heavy alcohol use and drinks around 20 ounces per week. Laboratory studies show: Proteins 6.5 g/dL Albumin 4.5 g/dL Globulin 1.9 g/dL Bilirubin 5.8 mg/dL Serum alanine aminotransferase (ALT) 86 U/L Serum aspartate transaminase (AST) 84 U/L Serum alkaline phosphatase (ALP) 224 U/L Antinuclear antibody (ANA) positive Antimitochondrial antibody (AMA) positive anti-HBs positive anti-HBc negative Which is the most likely diagnosis in this patient?

A 48-year-old man is brought to the emergency department by his wife because of a 3-day history of increasing confusion and lethargy. He complains of decreased urine output and abdominal pain for the past month. Two months ago, he was hospitalized for pyelonephritis and treated with ceftriaxone. He has a history of chronic hepatitis C. He does not take any medications. He appears pale and irritable. His temperature is 37°C (98.6°F), pulse is 90/min, and blood pressure is 98/60 mm Hg. On mental status examination, he is oriented to person but not to time or place. Physical examination shows scleral icterus and jaundice. There is 2+ pitting edema of the lower extremities. The abdomen is distended with a positive fluid wave. Laboratory studies show: Hemoglobin 10.1 g/dL Leukocyte count 4300/mm3 Platelet count 89,000/mm3 Prothrombin time 19 sec Serum Urea nitrogen 71 mg/dL Glucose 99 mg/dL Creatinine 3.5 mg/dL ALT 137 mg/dL AST 154 mg/dL Urinalysis shows no abnormalities. The FeNa is < 1%. Ultrasound of the kidneys is unremarkable. Intravenous fluids are administered for 36 hours but do not improve urine output. Which of the following is the most likely cause of the kidney dysfunction in this patient?

A 24-year-old woman arrives to an urgent care clinic for "eye discoloration." She states that for the past 3 days she has had the “stomach flu” and has not been eating much. Today, she reports she is feeling better, but when she woke up "the whites of [her] eyes were yellow." She denies fever, headache, palpitations, abdominal pain, nausea, vomiting, and diarrhea. She was recently diagnosed with polycystic ovary syndrome during a gynecology appointment 2 weeks ago for irregular menses. Since then, she has been taking a daily combined oral contraceptive. She takes no other medications. Her temperature is 98.6°F (37°C), blood pressure is 120/80 mmHg, and pulse is 76/min. Body mass index is 32 kg/m^2. On physical examination, there is scleral icterus and mild jaundice. Liver function tests are drawn, as shown below: Alanine aminotransferase (ALT): 19 U/L Aspartate aminotransferase (AST): 15 U/L Alkaline phosphatase: 85 U/L Albumin: 4.0 g/dL Total bilirubin: 12 mg/dL Direct bilirubin: 10 mg/dL Prothrombin time: 13 seconds If a liver biopsy were to be performed and it showed a normal pathology, which of the following would be the most likely diagnosis?

A 45-year-old man is brought to the emergency department because of a 1-day history of malaise and abdominal pain. Six weeks ago, he had vomiting and watery diarrhea for 2 days that resolved without treatment. Twelve weeks ago, he underwent orthotopic liver transplantation for alcoholic cirrhosis. At the time of discharge, his total serum bilirubin concentration was 1.0 mg/dL. He stopped drinking alcohol one year ago. His current medications include daily tacrolimus, prednisone, valganciclovir, and trimethoprim-sulfamethoxazole. His temperature is 37.7°C (99.9°F), pulse is 95/min, and blood pressure is 150/80 mm Hg. He appears uncomfortable and has mild jaundice. Examination shows scleral icterus. The abdomen is soft and tender to deep palpation over the right upper quadrant, where there is a well-healed surgical scar. His leukocyte count is 2500/mm3, serum bilirubin concentration is 2.6 mg/dL, and serum tacrolimus concentration is within therapeutic range. Which of the following is the next appropriate step in diagnosis?

A 69-year-old man with aggressive metastatic cholangiocarcinoma presents after the second round of chemotherapy. He has suffered a great deal of pain from the metastasis to his spine, and he is experiencing side effects from the cytotoxic chemotherapy drugs. Imaging shows no change in the tumor mass and reveals the presence of several new metastatic lesions. The patient is not willing to undergo any more chemotherapy unless he gets something for pain that will “knock him out”. High-dose opioids would be effective, in his case, but carry a risk of bradypnea and sudden respiratory failure. Which of the following is the most appropriate next step in management?

A 30-year-old man presents to clinic. He was born in southeast Asia and immigrated to the US three years ago. He has a history of chronic hepatitis C which he contracted from intravenous drug use. He reports that he has been receiving treatment for his hepatitis C, but unfortunately has started using heroin again. The patient was seen in the clinic last week and had blood work done. His results are as follows: HBsAg - negative; HBsAb - negative; HBcAb - negative. In addition to encouraging the patient to seek treatment for his heroin addiction, what else should be done at this health visit for general health maintenance?

A 53-year-old man comes to the physician because of a 3-month history of a nonpruritic rash. He has been feeling more tired than usual and occasionally experiences pain in his wrists and ankles. He does not smoke or drink alcohol. His temperature is 37.6°C (99.7°F), pulse is 98/min, respirations are 18/min, and blood pressure is 130/75 mm Hg. Physical examination shows multiple, erythematous, purpuric papules on his trunk and extremities that do not blanch when pressed. The remainder of the examination shows no abnormalities. The patient's hemoglobin is 14 g/dL, leukocyte count is 9,500/mm3, and platelet count is 228,000/mm3. Urinalysis and liver function tests are within normal limits. The test for rheumatoid factor is positive. Serum ANA is negative. Serum complement levels are decreased. Serum protein electrophoresis and immunofixation shows increased gammaglobulins with pronounced polyclonal IgM and IgG bands. Testing for cryoglobulins shows no precipitate after 24 hours. Chest x-ray and ECG show no abnormalities. Which of the following is the most appropriate next step in management?