Hepatology Board Review
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Hepatology Board Review

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Hepatology Board Review Hepatology Board Review Presentation Transcript

  • Hepatology ABIM Review
  • A 74-year-old man is hospitalized after a 90-minute episode of lightheadedness and severe nausea that occurred earlier today but that has now almost completely resolved. The patient had a myocardial infarction 8 years ago. He has had no chest pain since then and is quite active. Current medications are atenolol, simvastatin, and aspirin, 81 mg. On physical examination, he appears well. Temperature is 36.7 °C (98.0 °F), pulse rate is 84/min and regular, respiration rate is 14/min, and blood pressure is 130/80 mm Hg. The remainder of the examination is normal. Laboratory Studies Hemoglobin 15.2 g/dL Leukocyte count 8700/ μ L Serum creatine kinase 48 U/L Serum troponin I 0.2 mg/mL (normal: <0.5 mg/mL) Blood urea nitrogen 19 mg/dL Serum creatinine 1.1 mg/dL INR 1.2 Serum aspartate aminotransferase 1800 U/L Serum alanine aminotransferase 2400 U/L Serum alkaline phosphatase 145 U/L Serum total bilirubin 1.6 mg/dL Serum amylase 90 U/L
  • An electrocardiogram shows sinus rhythm at a rate of 70/min with an occasional ventricular premature contraction, an old inferior wall myocardial infarction, and no acute ST- or T-wave changes. Ultrasonography of the right upper abdominal quadrant shows gallstones; the common bile duct and pancreas are normal. Simvastatin is stopped; aspirin and atenolol are continued. On hospital days 1 and 2, he has three episodes of nonsustained ventricular tachycardia. On hospital day 3, results of all laboratory studies are normal. Which of the following is the most likely explanation for this patient's serum aminotransferase elevations on admission? ( A ) Passage of a common bile duct stone ( B ) Shock liver (ischemic hepatitis) ( C ) Simvastatin-induced liver injury ( D ) Viral hepatitis
  • A 63-year-old woman is evaluated because of epigastric pain and chronic diarrhea. She is otherwise well and works full time as a teacher's aide. She does not smoke cigarettes, drink alcoholic beverages, or take analgesics except for occasional acetaminophen. The patient is adopted. Physical examination is normal except for obesity. Laboratory Studies Plasma glucose (fasting) 80 mg/dL Serum creatinine 0.9 mg/dL Serum calcium 11.0 mg/dL Serum phosphorus 2.1 mg/dL Serum parathyroid hormone Upper limit of normal Serum gastrin (fasting) 35 pg/mL (normal: <100 pg/mL) Serum alkaline phosphatase 250 U/L Serum γ- glutamyltransferase 250 U/L Other liver chemistry studies Normal
  • Upper endoscopy shows a 2-cm submucosal mass in the lateral portion of the second duodenum, and biopsy specimens show normal overlying duodenal mucosa. Which of the following is the most likely diagnosis? ( A ) Duodenal adenoma ( B ) Duodenal adenocarcinoma ( C ) Pancreatic carcinoma invading the duodenum ( D ) Neuroendocrine tumor of the duodenum
  • A 48-year-old morbidly obese woman undergoes abdominal ultrasonography to screen for gallstones prior to elective gastric bypass surgery. The gallbladder is normal, but a 2-cm round, hyperechoic lesion is seen in the inferior aspect of the right hepatic lobe. MRI confirms the presence of the lesion, which is consistent with a hemangioma. Which of the following is most appropriate for managing this patient at this time? ( A ) Triphasic CT scan of the liver ( B ) Positron emission tomography ( C ) Laparoscopic resection of the lesion prior to gastric bypass surgery ( D ) Resection of the lesion at the time of gastric bypass surgery ( E ) No further diagnostic studies or treatment at this time
  • A 48-year-old woman with Sjögren's (sicca) syndrome develops pruritus that she attributes to dry skin. Physical examination reveals numerous excoriations, xerostomia, and multiple dental fillings. The liver is slightly enlarged. The spleen is not palpable, and there is no ascites. Rectal examination discloses brown stool. Neurologic examination is normal. Laboratory Studies Hemoglobin 11.9 g/dL Leukocyte count 6800/µL Platelet count 150,000/µL INR 1.1 Serum creatinine 0.8 mg/dL Serum aspartate aminotransferase 45 U/L Serum alanine aminotransferase 58 U/L Serum alkaline phosphatase 648 U/L Serum γ- glutamyltransferase 400 U/L Serum total bilirubin 0.9 mg/dL Serum total protein 7.2 g/dL Serum albumin 3.8 g/dL
  • Which of the following diagnostic studies is most appropriate at this time? ( A ) Magnetic resonance cholangiopancreatography ( B ) Endoscopic retrograde cholangiopancreatography ( C ) CT scan of the abdomen ( D ) Serum antimitochondrial antibody titer ( E ) Serum antiendomysial antibody titer
  • A 45-year-old Hispanic male migrant worker has a 2-month history of increasing abdominal girth, intermittent fever, and weakness. Medical history is unremarkable. The patient does not believe that he has ever had hepatitis. He drinks one or two glasses of wine weekly, takes no medications, and denies use of illicit drugs. His weight has increased by about 7 kg (15 lb) over the past 2 months. On physical examination, he appears chronically ill. Temperature is 38.5 °C (101.3 °F), pulse rate is 104/min, respiration rate is 26/min, and blood pressure is 110/65 mm Hg. There are no stigmata of chronic liver disease. Abdominal examination reveals distention and shifting dullness without organomegaly.
  • Laboratory Studies Hematocrit 38% Leukocyte count 12,400/µL (with 46% lymphocytes, 16% monocytes, and 35% neutrophils) Platelet count 225,000/µL INR 1.0 Activated partial thromboplastin time Normal Blood urea nitrogen 26 mg/dL Serum creatinine 1.5 mg/dL Serum electrolytes Normal Serum aspartate aminotransferase 35 U/L Serum alanine aminotransferase 37 U/L Serum total protein 6.5 g/dL Serum albumin 3.6 g/dL
  • Paracentesis reveals clear fluid that contains 350 cells/µL (90% mononuclear cells), total protein of 3.2 g/dL, and albumin of 2.8 g/dL. Cultures of ascitic fluid are negative at 48 hours. Which of the following is the most appropriate management at this time? ( A ) Administration of furosemide and spironolactone ( B ) Administration of metronidazole ( C ) Skin tests for tuberculosis and fungal diseases ( D ) Diagnostic laparoscopy with biopsy and culture of peritoneal tissue ( E ) Liver biopsy for tissue culture and histologic studies
  • A 28-year-old man has a 1-week history of itching and jaundice. He has had ulcerative colitis for 9 years that is well controlled with sulfasalazine, 1 g twice daily, which he has taken since the disease was diagnosed. Which of the following is the most likely diagnosis? ( A ) Autoimmune hepatitis ( B ) Sulfasalazine-induced hepatitis ( C ) Pancreatic cancer ( D ) Primary biliary cirrhosis ( E ) Primary sclerosing cholangitis Laboratory Studies Serum alanine aminotransferase 87 U/L Serum alkaline phosphatase 450 U/L Serum total bilirubin 3.7 mg/dL Serum albumin 4.1 g/dL
  • A 63-year-old woman comes to the emergency department because of nausea, vomiting, shaking chills, fever, and upper abdominal pain of 4 hours' duration. Physical examination discloses a temperature of 39.2 °C (102.5 °F), scleral icterus, and epigastric tenderness. Abdominal ultrasonography shows gallstones and a dilated common bile duct. Laboratory Studies Hematocrit 35% Leukocyte count 18,000/µL (with 80% polymorphonuclear leukocytes and 4% band forms) Serum creatinine 1.8 mg/dL Serum alanine aminotransferase 250 U/L Serum alkaline phosphatase 350 U/L Serum total bilirubin 4.5 mg/dL Serum amylase 1280 U/L Serum lipase 920 U/L
  • In addition to beginning intravenous antibiotics, which of the following is most appropriate at this time? ( A ) Observation; elective surgery at a later date ( B ) Emergent endoscopic retrograde cholangiography and papillotomy ( C ) Emergent laparotomy with cholecystectomy, common duct exploration, and T-tube drainage of the common duct ( D ) Emergent laparoscopic cholecystectomy ( E ) Hepato-iminodiacetic acid (HIDA) scan
  • A 26-year-old white woman who is in the 34th week of her fourth pregnancy has a 4-day history of malaise and right upper quadrant abdominal pain and a 2-day history of nausea and vomiting. Her pregnancy had been uneventful until this time, and her three previous pregnancies were normal. On physical examination, blood pressure is 140/90 mm Hg. Other vital signs are normal. Abdominal examination is consistent with a 34-week gestation; no abnormal masses are palpated. Murphy's sign is negative. There is 3+ pitting edema of both lower extremities.
  • A peripheral blood smear shows helmet cells and erythrocyte fragments. Which of the following is the most likely diagnosis? ( A ) HELLP syndrome (hemolysis, elevated liver enzymes, low platelets) ( B ) Acute fatty liver of pregnancy ( C ) Cholestasis of pregnancy ( D ) Hemolytic-uremic syndrome ( E ) Immune thrombocytopenic purpura Laboratory Studies Hemoglobin 8.0 g/dL (was 12.0 g/dL 1 month ago) Leukocyte count 12,000/µL (with 80% segmented neutrophils and 5% band forms) Platelet count 80,000/µL INR 1.1 Serum aspartate aminotransferase 300 U/L Serum alanine aminotransferase 300 U/L Serum lactate dehydrogenase 1000 U/L Serum creatinine 0.8 mg/dL Serum uric acid 6.0 mg/dL Serum total bilirubin 5.0 mg/dL Serum direct bilirubin 0.4 mg/dL Urinalysis Increased urobilinogen
  • A 30-year-old woman, who is in the 36th week of her first pregnancy, is hospitalized because of jaundice, confusion, nausea, vomiting, and right upper quadrant abdominal pain. Her pregnancy had been uneventful until now, and medical history is unremarkable. She returned from a 2-week trip to Mexico 2 months ago. On physical examination, she is jaundiced and confused, and asterixis is present. Blood pressure is 110/70 mm Hg; other vital signs are also normal. There is mild right upper quadrant abdominal tenderness. The uterus is of normal size for a 36-week gestation. No other organs are enlarged.
  • A peripheral blood smear shows helmet cells and nucleated erythrocytes. Which of the following is the most likely diagnosis? ( A ) Acute fatty liver of pregnancy ( B ) Thrombotic thrombocytopenic purpura ( C ) HELLP syndrome (hemolysis, elevated liver enzymes, low platelets) ( D ) Hepatitis E Laboratory Studies Hemoglobin 10.0 g/dL Leukocyte count 15,000/µL (80% segmented neutrophils, 5% band forms, 15% lymphocytes) Platelet count 36,000/µL INR 1.5 Activated partial thromboplastin time 40 s Plasma fibrinogen 91 mg/dL D-Dimer Elevated Plasma glucose 45 mg/dL Blood urea nitrogen 20 mg/dL Serum creatinine 1.7 mg/dL Serum uric acid 10.5 mg/dL Serum aspartate aminotransferase 300 U/L Serum alanine aminotransferase 400 U/L Serum alkaline phosphatase 600 U/L Serum total bilirubin 5.0 mg/dL Serum direct bilirubin 2.5 mg/dL Urinalysis Normal
  • A 58-year-old woman has a 1-week history of diffuse abdominal discomfort, fever, and night sweats. The patient has cirrhosis and has had poorly controlled ascites for the past 6 months despite diuretic therapy. Medications are furosemide, 80 mg daily, and spironolactone, 200 mg daily. She denies alcohol consumption. On physical examination, temperature is 37.5 °C (99.5 °F), pulse rate is 90/min and regular, and blood pressure is 110/80 mm Hg. There is no jaundice, but mild asterixis is present. Cardiopulmonary examination is normal. The abdomen is soft with tenderness to palpation in all quadrants but no rebound tenderness or guarding. Ascites is present. The liver edge cannot be palpated. The spleen tip is palpated just below the left costal margin. Bowel sounds are decreased.
  • A peripheral blood smear shows target cells. Diagnostic paracentesis yields ascitic fluid with a neutrophil count of 750/µL, albumin of 1.0 g/dL, and negative Gram stain for bacteria. Results of ascitic fluid cultures are pending. Which of the following is the most appropriate next step in this patient's management? ( A ) Observation until culture results are available ( B ) Abdominal ultrasonography ( C ) Increase in the diuretic dose ( D ) Administration of lactulose ( E ) Administration of cefotaxime Laboratory Studies Hemoglobin 11.5 g/dL Leukocyte count 8500/µL Platelet count 95,000/µL INR 1.2 Serum aspartate aminotransferase 70 U/L Serum alanine aminotransferase 65 U/L Serum alkaline phosphatase 140 U/L Serum total bilirubin 1.5 mg/dL Serum albumin 2.6 g/dL
  • A 38-year-old homeless woman is evaluated because of severe odynophagia and mild dysphagia of 7 days' duration. She cannot eat solid foods and can only drink cold ginger ale and ice water. The patient has a history of injection drug use and chronic hepatitis C, but she is not certain whether she was ever tested for HIV. Physical examination is unremarkable except for mild dehydration. There are no oral or cutaneous lesions. Complete blood count shows normocytic anemia and mild leukopenia with lymphopenia. In addition to requesting a serologic study for HIV infection, which of the following is most appropriate at this time? ( A ) Administration of valacyclovir ( B ) Administration of fluconazole ( C ) Barium swallow study ( D ) Upper endoscopy
  • A 43-year-old man is evaluated because of generalized arthralgias and a rash involving his lower extremities that have both worsened over the last 6 weeks. The patient is a former injection drug user and has chronic hepatitis C virus (HCV) infection. He reports no other medical problems. A recent course of pegylated interferon was ineffective, and he continues to have circulating HCV RNA levels. He takes milk thistle for his hepatitis, which he obtains from a nutritional supplement store. He does not drink alcoholic beverages. On physical examination, temperature is 36.8 °C (98.2 °F), pulse rate is 80/min, and blood pressure is 120/78 mm Hg. There is no scleral icterus. Several small spider telangiectasias are seen on his upper back, and multiple small, purplish, nonblanching maculopapular lesions are present on his shins. Abdominal examination reveals mild tenderness to percussion in the right upper quadrant and a liver span of 10 cm. There is no ascites or peripheral edema. Which of the following diagnostic studies should be done next? ( A ) Antinuclear antibody assay ( B ) Measurement of serum creatine kinase ( C ) Measurement of urine porphyrins ( D ) Measurement of serum cryoglobulins ( E ) Repeat measurement of quantitative HCV RNA
  • A 54-year-old white man is evaluated because of hematemesis. Medical history is significant for cardiomyopathy, hypothyroidism, and type 2 diabetes mellitus. Medications are enalapril, metformin, and aspirin. He also takes acetaminophen, up to 3 g daily, for pain in the hands that is most severe at the end of the day. He has never consumed alcoholic beverages, never required a blood transfusion, and has no history of liver disease. On physical examination, pulse rate is 76/min, and blood pressure is 122/74 mm Hg. The skin, heart, and lungs are normal. The abdomen is obese, but examination is otherwise unremarkable. There is tenderness to palpation over the second and third metacarpophalangeal joints bilaterally. Upper endoscopy shows bleeding esophageal varices.
  • Which of the following studies should be done next? ( A ) Antimitochondrial antibody titer ( B ) HBV DNA assay ( C ) Evaluation for the C282Y gene mutation ( D ) Urine porphyrin measurement ( E ) Serum iron, total iron-binding capacity, and ferritin Laboratory Studies Hemoglobin 10.0 g/dL Leukocyte count 11,000/µL Platelet count 184,000/µL Mean corpuscular volume 92 fL INR 1.5 Serum aspartate aminotransferase 98 U/L Serum alanine aminotransferase 110 U/L Serum alkaline phosphatase 110 U/L Serum total bilirubin 1.8 mg/dL Hepatitis B surface antigen (HBsAg) Negative Antibodies to hepatitis B surface antigen (anti-HBs) Positive Antibodies to hepatitis B core antigen (anti-HBc) Negative Antibodies to hepatitis C virus (anti-HCV) Negative Rheumatoid factor Negative
  • A 22-year-old woman has a 1-week history of jaundice and an 8-month history of progressive fatigue. She takes no medications, does not use alcohol or illicit drugs, and has never required a blood transfusion. Physical examination findings include scleral icterus, multiple spider telangiectasias over the chest and back, a liver edge palpable 4 cm below the right costal margin, and an enlarged spleen palpable 6 cm below the left costal margin. Laboratory Studies Complete blood count Normal INR 1.3 Blood urea nitrogen Normal Serum creatinine Normal Serum electrolytes Normal Serum aspartate aminotransferase 680 U/L Serum alanine aminotransferase 780 U/L Serum alkaline phosphatase 145 U/L Serum total bilirubin 10.2 mg/dL Serum total protein 11.5 g/dL Serum albumin 3.2 g/dL Serologic tests for hepatitis A, B, and C Negative
  • Which of the following is the most likely diagnosis? ( A ) Primary biliary cirrhosis ( B ) Cholecystitis ( C ) Autoimmune hepatitis ( D ) Budd-Chiari syndrome
  • A 24-year-old male college student is brought to the emergency department because of a 1-week history of nausea, fatigue, and progressive jaundice. He takes no medications and does not drink alcoholic beverages to excess. On physical examination, temperature is normal, pulse rate is 96/min, and blood pressure is 102/64 mm Hg. His skin is icteric, but there is no evidence of stigmata of chronic liver disease. He is oriented but lethargic and is unable to recite his telephone number in reverse order. No asterixis or focal neurologic deficits are noted. The remainder of the examination is normal. Laboratory Studies Complete blood count Normal INR 2.3 Plasma glucose 76 mg/dL Serum aspartate aminotransferase 940 U/L Serum total bilirubin 12.6 mg/dL Serum ammonia 136 µg/dL Hepatitis B surface antigen (HBsAg) Positive IgM antibodies to hepatitis B core antigen (IgM anti-HBc) Positive Serum toxicology screen Negative
  • In addition to hospitalization, which of the following is the most appropriate treatment at this time? ( A ) Administration of 50% glucose (dextrose) intravenously ( B ) Administration of β-blockers ( C ) Administration of lamivudine and interferon ( D ) Transfer to an intensive care unit at a liver transplantation center
  • A 39-year-old woman is brought to the emergency department by her sister following an intentional drug overdose. Approximately 18 hours ago, the patient consumed an unknown quantity of lorazepam and &quot;other pills&quot; in a suicide attempt. She has been under treatment for depression. On physical examination, temperature is 35.8 °C (96.4 °F), pulse rate is 106/min, respiration rate is 14/min, and blood pressure is 100/60 mm Hg. Cardiopulmonary and abdominal examinations are normal. The patient is somnolent but arousable to painful stimuli. She does not answer questions appropriately. Neurologic examination is otherwise unremarkable. Gastric aspiration and lavage are done; there is no evidence of pill fragments. A serum toxicology screen is positive for benzodiazepines, acetaminophen, aspirin, delta-9-tetrahydrocannabinol (marijuana), and amitriptyline. An electrocardiogram shows sinus tachycardia. Laboratory Studies Leukocyte count 14,200/µL INR 1.8 Serum aspartate aminotransferase 98 U/L Serum alanine aminotransferase 106 U/L Serum alkaline phosphatase 145 U/L Serum total bilirubin 1.2 mg/dL
  • Ingestion of which of the following most likely explains this patient's liver chemistry abnormalities? ( A ) Lorazepam ( B ) Acetaminophen ( C ) Aspirin ( D ) Marijuana ( E ) Amitriptyline
  • A 52-year-old man has malaise and weight loss of 1 year's duration. He was in good health until approximately 2 years ago, when he developed intermittent arthralgias involving multiple joints. Over the past year, he has lost 13.6 kg (30 lb) and has had progressive weakness, occasional fever, mild cough, three to four loose stools daily, and abdominal swelling. Physical examination reveals cachexia, generalized lymphadenopathy, and hyperpigmentation of the skin. There are no stigmata of chronic liver disease. Examination of the abdomen discloses shifting dullness and a tender, ill-defined mass to the right of the umbilicus. Neurologic examination is normal. Laboratory Studies Hemoglobin 8.2 g/dL Leukocyte count 5000/µL INR 1.3 Blood urea nitrogen 15 mg/dL Serum creatinine 0.8 mg/dL Serum aspartate aminotransferase 24 U/L Serum alanine aminotransferase 20 U/L Serum alkaline phosphatase 135 U/L Serum albumin 2.2 g/dL Serologic test for HIV Negative Urinalysis Normal
  • A CT scan of the abdomen shows ascites and enteric lymphadenopathy. Upper endoscopy is normal; an endoscopic biopsy specimen from the duodenum is shown. Which of the following is the most likely diagnosis? ( A ) Small bowel lymphoma ( B ) Celiac sprue ( C ) Mycobacterium avium complex infection ( D ) Whipple's disease ( E ) Small bowel bacterial overgrowth
  • A 22-year-old man has a 5-day history of jaundice and a 2-week history of fatigue. He also notes difficulty concentrating. The patient returned from a vacation in Mexico 3 months ago. He takes no medications (including vitamins and dietary supplements), does not use alcohol or illicit drugs, and is unaware of exposure to persons with hepatitis or to occupational or environmental toxins. He has never required a blood transfusion. A brother died 1 year ago at the age of 31 years of &quot;liver disease.&quot; Physical examination is normal except for the presence of jaundice.
  • Laboratory Studies Hemoglobin 10.0 g/dL Leukocyte count 11,000/µL Platelet count 162,000/µL INR 1.7 Serum ferritin 315 ng/mL Blood urea nitrogen 16 mg/dL Serum creatinine 1.1 mg/dL Serum aspartate aminotransferase 500 U/L Serum alanine aminotransferase 450 U/L Serum alkaline phosphatase 88 U/L Serum total bilirubin 5.0 mg/dL Serum direct bilirubin 2.0 mg/dL Serum total protein 5.8 g/dL Serum albumin 2.5 g/dL Antinuclear antibodies Negative Serologic studies for hepatitis A, B, and C Negative
  • Pending confirmation of the suspected diagnosis, which of the following is most likely to benefit this patient at this time? ( A ) Penicillamine ( B ) Therapeutic phlebotomy ( C ) Deferoxamine ( D ) Interferon ( E ) Prednisone
  • A 46-year-old man is hospitalized because of progressive ascites and a 36-hour history of fever and malaise. He had been well until 1 year ago, when hepatitis C (genotype 1) was diagnosed after he developed bleeding esophageal varices. Liver biopsy at that time showed bridging necrosis, regenerative nodules, and mild inflammation. Currently, his only medication is nadolol. The patient does not drink alcoholic beverages or use illicit drugs. On physical examination, he appears very ill. Temperature is 38.0 °C (100.4 °F), pulse rate is 62/min, and blood pressure is 96/74 mm Hg. Scleral icterus, spider angiomata, and wasting of the muscles of the shoulder girdle are noted. Abdominal examination discloses bulging flanks, prominent periumbilical veins, and a ballotable spleen. There is no abdominal tenderness, and the liver is not palpable. Results of abdominal paracentesis are consistent with spontaneous bacterial peritonitis, and intravenous cefotaxime and fluids are begun. The patient responds well to therapy. He has been afebrile since admission, and on hospital day 4 he is able to maintain adequate oral intake on a salt-restricted diet.
  • Which of the following is the most appropriate management at this time? ( A ) Ribavirin and pegylated interferon ( B ) Transjugular intrahepatic portosystemic shunt ( C ) Hepatic angiography ( D ) Evaluation for liver transplantation ( E ) Antibiotic prophylaxis with metronidazole
  • A 52-year-old man comes to the emergency department because of abdominal swelling. He admits to heavy alcohol use for the past 15 years, but has no other risk factors for or a history of liver disease. On physical examination, vital signs are normal. The patient is not jaundiced and has no cutaneous stigmata of chronic liver disease. Abdominal examination discloses increased girth and shifting dullness. Serum aspartate aminotransferase is 124 U/L, serum alanine aminotransferase is 87 U/L, and serum albumin is 3.4 g/dL. Other routine laboratory studies are normal. Diagnostic paracentesis is performed. The ascitic fluid is clear yellow with a leukocyte count of 300/µL (40% polymorphonuclear cells), an absolute neutrophil count of 140/µL, total protein of 3.1 g/dL, and albumin of 2.7 g/dL. Which of the following is the most likely diagnosis? ( A ) Peritoneal carcinomatosis ( B ) Alcoholic hepatitis ( C ) Constrictive pericarditis ( D ) Cirrhosis ( E ) Spontaneous bacterial peritonitis
  • A 62-year-old Asian man with cirrhosis secondary to chronic hepatitis B comes for a routine follow-up visit. Hepatitis B was diagnosed 20 years ago, and liver biopsy 4 years ago showed fibrosis. The patient has no history of ascites, hepatic encephalopathy, or variceal bleeding. Screening colonoscopy 6 years ago showed a diminutive 4-mm hyperplastic polyp in the sigmoid colon; the polyp was removed. Physical examination is normal except for the presence of palmar erythema. Laboratory Studies INR 1.5 Serum aspartate aminotransferase 42 U/L Serum alanine aminotransferase 36 U/L Serum alkaline phosphatase 121 U/L Serum total bilirubin 2.2 mg/dL Serum albumin 3.1 g/dL Hepatitis B surface antigen (HBsAg) Positive Hepatitis B e antigen (HBeAg) Negative IgG antibodies to hepatitis A virus (IgG anti-HAV) Positive Antibodies to hepatitis C virus (anti-HCV) Negative Serum α- fetoprotein 10 ng/mL
  • Ultrasound examination of the abdomen shows a small liver with nodularity consistent with cirrhosis. Which of the following is the most appropriate management at this time? ( A ) Surveillance colonoscopy ( B ) Upper endoscopy ( C ) CT scan of the abdomen ( D ) Administration of lamivudine ( E ) Administration of lansoprazole
  • A 45-year-old man has a 2-month history of vague right upper quadrant abdominal discomfort. Medical history is noncontributory. He takes no medications, does not smoke or drink alcoholic beverages, and has never required surgery. On physical examination, vital signs are normal and BMI is 29. There are no stigmata of chronic liver disease. Examination of the abdomen discloses mild right upper quadrant tenderness. The liver span is 11 cm, and the liver is palpated 3 cm below the right costal margin. Laboratory Studies INR 1.0 Serum aspartate aminotransferase 124 U/L Serum alanine aminotransferase 141 U/L Serum alkaline phosphatase 145 U/L Serum total bilirubin 0.9 mg/dL Serum ferritin 220 ng/mL Serum ceruloplasmin 38 mg/dL Hepatitis B surface antigen (HBsAg) Negative Antibodies to hepatitis B core antigen (anti-HBc) Negative Antibodies to hepatitis B surface antigen (anti-HBs) Positive Antibodies to hepatitis C virus (anti-HCV) Negative Serum protein electrophoresis Normal
  • Abdominal ultrasonography discloses a diffusely echogenic liver. This patient's liver disease is most frequently associated with which of the following findings? ( A ) Increased insulin resistance ( B ) Inflammatory bowel disease ( C ) Paroxysmal nocturnal hemoglobinuria ( D ) Post-viral inflammation
  • A 76-year-old man is hospitalized because of fever, chills, and mental status changes of 2 days' duration. He has a history of chronic renal failure attributed to longstanding hypertension but his health has recently been stable. On physical examination on admission, temperature is 39.8 °C (103.6 °F), pulse rate is 120/min, respiration rate is 35/min, and systolic blood pressure is 70 mm Hg. Cardiopulmonary and abdominal examinations are normal. Rectal examination discloses an enlarged prostate. The leukocyte count is 17,000/µL with a marked left shift. Urinalysis shows numerous leukocytes and leukocyte casts/hpf and gram-negative rods. A chest radiograph is normal. Intravenous ceftazidime and fluids are begun, after which his temperature normalizes and his mental status improves. On hospital day 3, his temperature rises to 38.8 °C (101.8 °F). Physical examination is normal. A CT scan of the abdomen and pelvis shows aortic calcifications, marked thickening of the gallbladder wall, and pericholecystic fluid. Ultrasound examination of the right upper abdominal quadrant confirms these findings and is negative for gallstones, ductal dilatation, and abnormal hepatic parenchyma. The following laboratory studies are obtained on hospital day 3:
  • Which of the following is the most likely diagnosis? ( A ) Acute calculous cholecystitis ( B ) Acute acalculous cholecystitis ( C ) Gallstone pancreatitis ( D ) Mirizzi's syndrome ( E ) Ascending cholangitis Laboratory Studies Leukocyte count 20,500/µL Blood urea nitrogen 52 mg/dL Serum creatinine 3.1 mg/dL Serum aspartate aminotransferase 43 U/L Serum alanine aminotransferase 48 U/L Serum alkaline phosphatase 200 U/L Serum total bilirubin 2.0 mg/dL Serum amylase 270 U/L Urinalysis 2–3 leukocytes/hpf; otherwise normal