Добавил:

Sekretar kiopkiopkiop18@yandex.ru t.me/Prokururor I Вовсе не секретарь, но почту проверяю Опубликованный материал нарушает ваши авторские права? Сообщите нам.

Вуз:

Ростовский Государственный Медицинский Университет

Предмет:

Медицина общая

Файл:

Книга_40_библиотеки_им_акад_М_И_Перельмана

.pdf

Скачиваний:

Добавлен:

15.09.2026

Размер:

13 Мб

Скачать

☆

<<< < Предыдущая 13 14 15 16 17 18 19 20 21 22 23 2425 / 4125 26 27 28 29 30 31 32 33 34 35 36 37 > Следующая >>>

208

https://t.me/medicina_free

CHAPTER 7 | INFLAMMATORY BOWEL DISEASE AND COLONICDISORDERS

Rome IV diagnostic criteria forIBS

• Recurrent abdominal pain on average at least one day/ week in the past three months, associated with two or more of the following:

• related to defecation and/ or

• associated with a change in frequency of stool and/ or

• associated with a change in form (appearance) of stool

• In IBS- C, more than one- fourth (25%) of bowel movements with Bristol Stool Scale Types 1- 2

Secondary causes ofconstipation

• Colonic pathology (e.g. stricture, cancer, anal ssure, proctitis, rectocoele)

• Metabolic pathology (e.g. hypercalcaemia, hypothyroidism, diabetes mellitus)

• Neurological disorders (e.g. parkinsonism, spinal cord lesions)

• Psychiatric disorders

• Drugs (e.g. opioids)

• Diet and behavioural lifestyle

Drossman D.Functional gastrointestinal disorders:history, pathophysiology, clinical features, and Rome IV. Gastroenterology. 206 Feb;9. pii:S006- 5085(6)00223- 7. Doi:0.053/ j.gastro.206.02.032.

https://t.me/medicina_free

chapter

LIVERDISORDERS

1. A 65- year- old man with known Child- Pugh Aalcohol- related cirrhosis was

QUESTIONS

admitted with abdominal pain.

Investigations:

CT triple phase liver 5 × 5cm mass in right liver lobe enhancing vividly during

late arterial phase and becoming hypoattenuating in the portal venous phase.

After multidisciplinary team discussion, the man was referred for transarterial chemoembolization (TACE), which required access to the hepatic arterial blood supply.

From which artery does the common hepatic artery (HA) directly arise?

A. Aorta

B. Coeliac axis

C. Left gastric artery

D. Right gastric artery

E. Superior mesenteric artery

2. The conuence of which structures lead to the formation of the structure marked in the image (Fig. 8.1)?

A. Inferior mesenteric vein and splenic vein

B. Left and right hepatic duct

C. Left and right hepatic duct and cystic duct

D. Superior mesenteric artery and splenic artery

E. Superior mesenteric vein and splenic vein

Best of Five MCQs for the European Specialty Examination in Gastroenterology and Hepatology. Thomas Marjot, Colleen G C McGregor, Tim Ambrose, Aminda N De Silva, Jeremy Cobbold, and Simon Travis, Oxford University Press (2021). © Oxford University Press. DOI: 10.1093/oso/9780198834373.003.0008

210

https://t.me/medicina_free

CHAPTER 8 | LIVERDISORDERS

Fig.8.1 CT abdomen

Courtesy of Dr Shahana Shahid, OUH NHS Foundation Trust

3. A 43- year- old woman was admitted with new onset jaundice and abdominal distension. She went on to have a transjugular liver biopsy with measurement of portal pressures.

What hepatic venous pressure gradient would be compatible with clinically signicant portal hypertension?

A. 5mmHg

B. 6mmHg

C. 8mmHg

D. 9mmHg

E. 10mmHg

CHAPTER 8 | QUESTIONS

https://t.me/medicina_free

211

4. A 52- year- old man with type 2 diabetes was recently diagnosed with non- alcoholic steatohepatitis (NASH) with cirrhosis. He currently has no clinical features of decompensation. His screening gastroscopy demonstrated two columns of oesophageal varices that attened completely upon insuation of air. There was mild portal hypertensive gastropathy, but no gastric varices.

Which is the most appropriate regarding further surveillance and treatment?

A. Prescribe non- selective beta blocker (e.g. Propranolol) and no further varices surveillance

required

B. Repeat gastroscopy in one year, without current primary prophylaxis for varices

C. Repeat gastroscopy in 2– 3years, without current primary prophylaxis for varices

D. Repeat gastroscopy only in the event of hepatic decompensation, without current primary

prophylaxis for varices

E. Repeat gastroscopy with endoscopic variceal ligation (EVL) in 4– 6 weeks.

5. A 58- year- old woman came to clinic to discuss the results of a recent liver biopsy that conrmed cirrhosis due to autoimmune hepatitis (AIH). She had not previously had a gastroscopy.

Investigations:

Serum alanine aminotransferase (ALT) 32 U/ L Serum aspartate transaminase (AST) 38 U/ L Serum bilirubin 21 μmol/ L Serum albumin 34 g/ L International normalized ratio (INR) 1.1 Platelet count 178 × 109/ L

Which additional investigation result would be best used to avoid screening gastroscopy for varices for one year?

A. Absence of ascites on transabdominal ultrasound

B. Enhanced liver brosis (ELF) score of 10.6

C. Hepatic venous pressure gradient (HVPG) measurement of 11mmHg

D. Liver stiness reading of 18.4 kPa

E. Spleen diameter of 12.5cm on transabdominal ultrasound

6. A 46- year- old man with cirrhosis had his rst screening gastroscopy, which showed small gastro- oesophageal varices.

Which of the following is the strongest predictor for the progression from small to large varices?

A. Alcohol aetiology of cirrhosis

B. Female sex

C. HVPG 10mmHg

D. NASH aetiology of cirrhosis

E. Spider naevi

212

https://t.me/medicina_free

CHAPTER 8 | LIVERDISORDERS

7. A 40- year- old man with cirrhosis and known oesophageal varices presented to hospital with haematemesis.

Which of the following statements regarding the resuscitation of patients with cirrhosis and VH is most accurate?

A. Hyponatraemia is a recognized side eect of terlipressin

B. Optimal timing for diagnostic endoscopy is at 12– 24 hours after presentation

C. Packed red blood cells should be transfused when haemoglobin falls below 9 g/ dL

D. Platelet transfusion in severe thrombocytopaenia (platelet count <50 × 109/ L) helps

prevent re- bleeding

E. Severe coagulopathy (INR >4) should be corrected with recombinant factor VII or fresh

frozen plasma

8. A 44- year- old woman from Pakistan presented to the emergency department with new ascites.

Investigations:

Haemoglobin 120 g/ L White cell count 9.6 × 109/ L Platelet count 150 × 109/ L Serum bilirubin 30 µmol/ L Serum ALP 120 U/ L Serum ALT 25 U/ L Serum creatinine 75 µmol/ L Serum albumin 30 g/ L Serum Ca 125 200 U/ mL Ascitic uid white cell count 100 cells/ mm3 (75% neutrophils) Ascitic uid albumin 15 g/ L Ascitic uid protein 20 g/ L Ascitic uid Gram stain No organisms

What is the most likely diagnosis?

A. Cirrhosis

B. Gynaecological malignancy

C. Heart failure

D. Nephrotic syndrome

E. Tuberculosis

CHAPTER 8 | QUESTIONS

https://t.me/medicina_free

213

9. A 59- year- old man with NASH cirrhosis and diuretic- intolerant ascites presented to the emergency department with abdominal pain. On examination, he had tense ascites and diuse abdominal tenderness. He had a temperature of 38°C, heart rate 105 beats per minute and blood pressure 90/ 59mm/ Hg. He was treated empirically with intravenous ceftriaxone and a diagnostic paracentesis was performed.

Investigations:

Ascitic uid cell count 1,555 cells/ mm3 (90% neutrophils) Ascitic uid culture at 24 hours Clostridium perfringens

Bacteroides vulgatus Enterococcus faecalis

What is the next best approach to management?

A. Continue ceftriaxone and add metronidazole

B. Continue ceftriaxone and repeat diagnostic paracentesis in 48 hours

C. Give 1.5 g/ kg human albumin solution

D. Perform large volume paracentesis

E. Request computed tomography (CT) abdomen and pelvis

10. A 53- year- old woman with alcohol- related cirrhosis was admitted with hepatic encephalopathy (HE). Her medications were lactulose 20 ml three times a day and carvedilol 3.75 mg once a day.

Investigations:

Serum sodium 130mmol/ L Serum potassium 4.7mmol/ L Serum urea 1.6mmol/ L Serum creatinine 90 µmol/ L Serum creatinine ve days

40 µmol/ L

previously Serum bilirubin 50 µmol/ L Serum ALT 30 U/ L Serum ALP 150 U/ L Serum albumin 20 g/ L INR 1.4 Haemoglobin 13 g/ L Liver ultrasound Irregular liver edge, moderate ascites, normal portal vein

ow, spleen 15cm Renal ultrasound Normal Full septic screen Negative

What is the most appropriate next management step for the patient’s renal dysfunction?

A. Infusion of crystalloid 1L over eight hours

B. Large volume paracentesis with human albumin replacement.

C. Monitor renal function

D. Terlipressin (1 mg four times a day)

E. Twenty per cent human albumin solution (1 g/ kg) for two consecutive days

214

https://t.me/medicina_free

CHAPTER 8 | LIVERDISORDERS

11. A 54- year- old man with alcohol- related cirrhosis was admitted with acute kidney injury (AKI). Forty- eight hours into his admission, he was diagnosed with hepatorenal syndrome– acute kidney injury (HRS- AKI) and started on terlipressin 1 mg every six hours and 40 g of human albumin daily.

Investigations:

Baseline serum creatinine Peak serum creatinine before terlipressin 102 µmol/ L Serum creatinine after 48 hours of terlipressin 94 µmol/ L

What would be the next most appropriate management step?

A. Continue current doses of terlipressin and human albumin

B. Continue terlipressin 1 mg every 6 hours and increase human albumin to 80 g daily

C. Increase terlipressin to 2 mg every six hours and continue 40 g human albumin daily

D. Noradrenaline infusion

E. Renal replacement therapy

40 µmol/ L

12. Which of the following is the earliest feature in the pathogenesis of HRS- AKI?

A. Activation of the renin– angiotensin– aldosterone system (RAAS)

B. Reduced cardiac output

C. Renal vasoconstriction

D. Splanchnic arterial vasodilation

E. Systemic inammatory response syndrome

13. Which of the following investigations would most favour a diagnosis of acute tubular necrosis (ATN) over hepatorenal syndrome (HRS)?

A. Low fractional excretion of sodium (<1%)

B. Low fractional excretion of urea (<35%)

C. Normal renal ultrasound scan

D. Urinary muddy brown casts

E. Urinary protein >500 mg in 24 hours

14. Which of the following statements is correct regarding ammonia in HE?

A. An elevated blood ammonia has no prognostic signicance in patients with acute liver

failure (ALF)

B. An elevated blood ammonia has no prognostic signicance in patients with cirrhosis

C. An elevated blood ammonia >150 g/dL is diagnostic for HE in patients with cirrhosis

D. Delay in laboratory measurement of ammonia in a venous sample leads to high false-

negative rates

E. Rifaximin has no impact on circulating ammonia levels

CHAPTER 8 | QUESTIONS

https://t.me/medicina_free

215

15. Which of the following is correct regarding the natural history of hepatocellular carcinoma (HCC)?

A. Ahigh serum Hepatitis B virus (HBV) DNA level is not a risk factor for HCC

B. Approximately half the cases of NASH- related HCC arise in non- cirrhotic patients

C. HCC surveillance can be stopped in patients with hepatitis C virus (HCV) cirrhosis who

achieve sustained virologic response (SVR)

D. Ten per cent of patients with cirrhosis will develop HCC during their lifetime

E. There is a low rate of HCC recurrence post- treatment with curative intent in patients with

HCV cirrhosis who achieve SVR with direct- acting antivirals (DAAs)

16. A 62- year- old man with compensated cirrhosis due to HCV was diagnosed with HCC. He was asymptomatic and had unlimited exercise tolerance. Sustained viralogical response was achieved three years previously.

Investigations:

Magnetic resonance imaging (MRI) liver

Gastroscopy Grade 1 oesophageal varices Serum alpha fetoprotein 54 ng/ ml MELD 8.5

What would be the preferred management approach for this patient?

A. Liver transplantation (LT)

B. Palliative chemotherapy (e.g. oral Sorafenib)

C. Radiofrequency ablation

D. Surgical resection

E. Transarterial embolization

28mm HCC lesion in segment 5 and 18mm HCC lesion in segment 7; no macroscopic vascular invasion or extrahepatic spread; portosystemic collaterals; no ascites

216

https://t.me/medicina_free

CHAPTER 8 | LIVERDISORDERS

17. A 38- year- old woman was referred to clinic after a 6cm liver mass was identied incidentally on a CT kidneys, ureters, and bladder. She had a body mass index (BMI) of 32kg/ m2, no other co- morbidities and was taking the oral contraceptive pill (OCP).

Investigations:

CT liver triple phase Well- demarcated mass with early enhancement in the

arterial phase before iso- attenuation in the portal venous phase

MRI liver Hyperintense lesion on T1 and T2 weighted imaging, with

early enhancement with gadolinium.

Following discussion at the multi- disciplinary meeting, what would be the most appropriate recommendation?

A. Discharge, no follow- up needed

B. Lifestyle changes and repeat MRI in six months

C. Referral for LT

D. Surgical resection

E. Transarterial embolization

18. A 36- year- old man with alcohol- related cirrhosis presented to the emergency department with haematemesis. On examination, he had moderate ascites and Grade 2 encephalopathy. Agastroscopy showed three columns of Grade 3 varices, which were banded. His oral intake remained inadequate on the ward for 48 hours after the procedure.

Investigations:

Haemoglobin 97 g/ L White cell count 11.5 × 109/ L Platelet count 89 × 109/ L Serum bilirubin 163 µmol/ L Serum ALP 213 U/ L Serum ALT 79 U/ L Prothrombin time 29 seconds

What is the most appropriate nutritional management?

A. Nasogastric feeding

B. Nasojejunal feeding

C. Oral nutritional supplements

D. Parenteral nutrition

E. Trial of low protein oral nutrition for further 24 hours

CHAPTER 8 | QUESTIONS

https://t.me/medicina_free

217

19. A 24- year- old woman had blood tests after her mother tested positive for HBV. She had no symptoms or signs of chronic liver disease.

Investigations:

Serum bilirubin Serum ALT 86 U/ L Serum creatinine 65 µmol/ L Haemoglobin 120 g/ L Platelet count 214 × 109/ L HBsAg Positive HBeAb Positive HBeAg Negative HBV DNA 21,000 IU/ ml HCV antibody Negative Hepatitis D (HDV) antibody Negative HIV antibody Negative Ultrasound abdomen Normal

What is the best next step in her management?

A. Liver biopsy and start treatment with tenofovir if evidence of cirrhosis

B. Start treatment with tenofovir

C. Transient elastography (TE) and no treatment if liver stiness measurement (LSM) <6 kPa

with follow- up in one year with repeat ALT, HBV DNA, and TE

D. TE and start treatment with pegIFNα if LSM >9 kPa.

E. TE and start treatment with tenofovir if LSM >12 kPa.

15 µmol/ L

20. A 35- year- old Vietnamese man was referred to clinic after his primary care doctor investigated abnormal LFTs and subsequently found him to be positive for HBsAg.

Investigations:

HBsAg Positive HBeAg Positive HBV DNA 230,000 IU/ mL Serum ALT 99 U/ L Liver stiness 8.2 kPa

What should be the main goal of antiviral treatment?

A. Loss of HBeAg

B. Loss of HBsAg

C. Normalization of ALT

D. Reduction in liver stiness <7 kPa

E. Suppression of HBV DNA

<<< < Предыдущая 13 14 15 16 17 18 19 20 21 22 23 2425 / 4125 26 27 28 29 30 31 32 33 34 35 36 37 > Следующая >>>

Соседние файлы в папке Библиотека им академика М.И. Перельмана

#
10.10.20267 Мб0Книга_3932_Библиотеки_им_академика_М_И_Перельмана.pdf
#
10.10.20267 Мб0Книга_3934_Библиотеки_им_академика_М_И_Перельмана.pdf
#
10.10.20267 Мб0Книга_3936_Библиотеки_им_академика_М_И_Перельмана.pdf
#
10.10.20267 Мб0Книга_3937_Библиотеки_им_академика_М_И_Перельмана.pdf
#
10.10.20267 Мб0Книга_3938_Библиотеки_им_академика_М_И_Перельмана.pdf
#
15.09.202613 Мб0Книга_40_библиотеки_им_акад_М_И_Перельмана.pdf
#
15.09.202612 Мб0Книга_41_библиотеки_им_акад_М_И_Перельмана.pdf
#
29.08.2026101 Мб0Книга_4366_Библиотеки_им_академика_М_И_Перельмана.pdf
#
29.08.202698 Мб0Книга_4368_Библиотеки_им_академика_М_И_Перельмана.pdf
#
29.08.202694 Мб0Книга_4372_Библиотеки_им_академика_М_И_Перельмана.pdf
#
29.08.202693 Мб0Книга_4373_Библиотеки_им_академика_М_И_Перельмана.epub