Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_40_библиотеки_им_акад_М_И_Перельмана
.pdf
218
https://t.me/medicina_free
CHAPTER 8 | LIVERDISORDERS
21. A 76- year- old woman was recently diagnosed with diuse large B- cell
Lymphoma. She was about to be started on R- CHOP chemotherapy and
has some pre- treatment blood tests.
Investigations:
Serum ALT 34 U/ L
Serum bilirubin 4 umol/ L
HBsAg Positive
HBeAg Negative
HBeAb Positive
HBV DNA 310 copies/ ml
Liver stiness 3.4 kPa
What is the next most appropriate approach to her management?
A. Advise haematologist to avoid Rituximab
B. Pre- emptive approach with monthly blood tests and to start treatment if HBV DNA
>2,000 copies/ ml or ALT >upper limit of normal (ULN)
C. Prophylaxis with entecavir throughout R- CHOP treatment and for 6months after its
discontinuation
D. Prophylaxis with entecavir throughout R- CHOP treatment and for 12months after its
discontinuation
E. Prophylaxis with entecavir throughout R- CHOP treatment and for 18months after its
discontinuation
22. Which of the following combinations is a pangenotypic treatment
regimen for HCV?
A. Grazoprevir, elbasvir
B. Sofosbuvir, ledipasvir
C. Sofosbuvir, ledipasvir, ribavirin
D. Sofosbuvir, velpatasvir
E. Velpatasvir, ledipasvir, ribavirin
23. A 61- year- old man with HCV cirrhosis developed progressive jaundice,
ascites, and encephalopathy, and was listed for LT.
What is the best approach to treating his HCV infection with DAAs?
A. Treat with DAAs post- LT if MELD ≥18– 20 and time to transplantation likely to be
<6months
B. Treat with DAAs post- LT if MELD <18- 20 irrespective of likely time until transplantation
C. Treat with DAAs post- LT irrespective of MELD and waiting time
D. Treat with DAAs pre- LT if MELD ≥18– 20 and time to transplantation likely to be
<6months
E. Treat with DAAs pre- LT irrespective of MELD and waiting time
CHAPTER 8 | QUESTIONS
https://t.me/medicina_free
219
24. A 50- year- old man with known untreated chronic HBV infection (CHB)
was referred to hepatology clinic with worsening LFTs and malaise. He
recently returned to the UK from a four- week trip to Thailand where
he reported having unprotected sex with a sex- worker. His examination
was unremarkable.
Investigations:
Haemoglobin 145 g/ L
White cell count 5 × 109/ L
Platelet count 190 × 109/ L
Serum ALT 600 U/ L
Serum bilirubin 25 μmol/ L
Serum creatinine 84 μmol/ L
HBsAg Positive
HBeAg Negative
HBeAb Positive
HDV RNA Detectable
HBV DNA 1,900 U/ L
HCV Ab Negative
HIV antibody Negative
Liver ultrasound Normal
Liver stiness 8.7 kPa
What is the most appropriate approach to his management?
A. No change to management
B. Referral for LT assessment
C. Treatment with combination of nucleoside reverse transcriptase inhibitors (NRTIs) and
non- nucleoside reverse transcriptase inhibitors (NNRTIs) for 48 weeks
D. Treatment with Peg- IFNα for 48 weeks
E. Treatment with tenofovir for 48 weeks
25. A 66- year- old woman had a liver biopsy performed as part of her workup for abnormal LFTs.
Investigations:
Liver biopsy A dense inltrate of immune cells in the lobules and within the portal
How would you treat this patient?
A. Azathioprine 100 mg daily
B. Budesonide 9 mg daily and azathioprine 50 mg daily
C. Observe with repeat liver biochemistry in three months’ time.
D. Prednisolone 40 mg daily
E. Ursodeoxycholic acid (UDCA) 500 mg twice a day
tracts with prominent interface hepatitis. There is a predominance
of plasma cells, as well as some lymphocytes, and the presence of
hepatic rosette formation and emperipolesis. There is some steatosis
(40%), bridging brosis with nodule formation, and Ishak brosis
score 6/ 6.
220
https://t.me/medicina_free
CHAPTER 8 | LIVERDISORDERS
26. A 31- year- old man presented with three weeks of lethargy and
arthralgia.
Investigations:
Serum ALT 710 U/ L
Serum ALP 210 U/ L
Serum bilirubin 50 µmol/ L
Platelet count 233 × 109/ L
Antinuclear antibody (ANA) Positive 1:40
Liver kidney microsomal antibody Positive 1:40
IgG 28 g/ L
HCV Ab Negative
HBsAg Negative
Hepatitis E IgM Negative
Hepatitis AIgM Negative
Liver biopsy histology Interface hepatitis with lymphoplasmocytic-
rich inltrate in portal tracts extending into
the lobule.
Which of the following carries the lowest weighting in the simplied
diagnostic criteria of the International Autoimmune Hepatitis Group?
A. Absence of viral hepatitis
B. ANA or SMA ≥1:40
C. IgG >1.1 × ULN
D. Liver histology typical of AIH
E. LKM ≥1:40
27. A 40- year- old woman with AIH, previously treated with prednisolone
and azathioprine for three years, and who has been in complete
biochemical remission for one year on azathioprine monotherapy, asks
whether her treatment can be stopped.
Which of the following is true?
A. Biochemical remission for over one year is associated with a better outcome in those who
discontinue treatment
B. Immunosuppressive treatment should be continued for at least ve years
C. Relapse commonly occurs within the rst year of treatment withdrawal
D. The majority of patients will stay in remission without maintenance therapy
E. There is no role for repeat liver biopsy prior to withdrawal of treatment
CHAPTER 8 | QUESTIONS
https://t.me/medicina_free
221
28. A 38- year- old woman complained of one year of lethargy. She had
a history of Raynaud’s phenomenon and gastro- oesophageal reux.
Her medications were omeprazole 40 mg and the OCP. She recently
had a course of trimethoprim for a urinary tract infection. Clinical
examination was unremarkable.
Investigations:
Serum bilirubin
Serum ALP 211 U/ L
Serum ALT 55 U/ L
Serum albumin 39 g/ L
Full blood count Normal
INR 0.9
ANA Negative
Antinuclear cytosplasmic antibody Negative
Anti- mitochondrial antibody Positive
Anti- smooth muscle antibody Negative
IgA 0.9 g/ L
IgG 10.1 g/ L
IgM 3.5 g/ L
HBV/ HCV Negative
Liver ultrasound Normal
What is the most likely diagnosis?
A. Cholelithiasis
B. Drug- induced liver injury (DILI)
C. Non- alcoholic fatty liver disease (NAFLD)
D. Primary biliary cholangitis (PBC)
E. Primary sclerosing cholangitis
13 µmol/ L
222
https://t.me/medicina_free
CHAPTER 8 | LIVERDISORDERS
29. A 53- year- old woman presented with fatigue and pruritis. She had a
history of hypothyroidism and ‘minor liver function test elevations’ one
year previously. She drank no alcohol and was a non- smoker. On clinical
examination, she had xanthelasma, borderline hepatomegaly, and
excoriation marks over her limbs.
Investigations:
Serum bilirubin
Serum ALP 256 U/ L
Serum ALT 67 U/ L
Serum albumin 35 g/ L
Full blood count Normal
INR 1.0
ANA Positive, 1:320, nuclear dot pattern
Anti- mitochondrial antibody Negative
Anti- smooth muscle antibody Negative
Anti- sp100 Positive
Anti- gp210 Negative
IgA 1.5 g/ L
IgG 12 g/ L
IgM 4.1 g/ L
HBsAg Negative
HCV antibody Negative
Ultrasound upper abdomen Normal
What would be the next best step?
A. Liver biopsy
B. MRCP
C. Serum autotaxin levels
D. Start UDCA 13– 15 mg/ kg/ day
E. Start UDCA 15– 20 mg/ kg/ day
17 µmol/ L
30. A 31- year- old man with PBC presented one year after starting UDCA
500 mg twice a day. His baseline alkaline phosphatase (ALP) prior to
starting UDCA was 401 U/ L. He was asymptomatic, had normal clinical
examination, and was taking no other medications. His weight was 70kg.
Investigations:
Serum bilirubin
Serum ALP 321 U/ L
Serum ALT 80 U/ L
Serum albumin 37 g/ L
Liver ultrasound Normal
How would you manage this patient?
A. Consider second- line therapy with obeticholic acid (OCA)
B. Continue current management
C. Increase UDCA to 750 mg twice a day
D. Refer for early consideration of LT
E. Stop UDCA
21 µmol/ L
CHAPTER 8 | QUESTIONS
https://t.me/medicina_free
223
31. A 35- year- old woman with PBC attended clinic. Her medications were
UDCA 1,000 mg once a day and OCA 10 mg once a day. She had been
on OCA for one year and her ALP prior to OCA was 423 U/ L. She was
asymptomatic with normal clinical examination and weighed 70kg.
Investigations:
Serum ALT 75 U/ L
Serum ALP 338 U/ L
Serum bilirubin 35 µmol/ L
Serum albumin 37 g/ L
How would you counsel her regarding her prognosis?
A. Good prognostic group because her ALP has reduced by >15% from baseline on OCA
B. Good prognostic group because she is asymptomatic, female, and less than 45years old
C. Poor prognostic group because her ALP is above 2 × ULN and her bilirubin is above
the ULN.
D. Poor prognostic group because she is female and her albumin is <40 g/ L.
E. Referral for LT is required
32. A 31- year- old man with ulcerative pancolitis attended clinic to discuss
his up- to- date investigations after nding abnormal liver function tests
six months previously.
Investigations:
Serum bilirubin
Serum ALP 432 IU/ L
Serum ALT 85 IU/ L
Haemoglobin 134 g/ L
White cell count 8 × 109/ L
Platelet count 210 × 109/ L
ANA Positive 1:160
Antineutrophilic cytoplasmic antibody Positive (p- ANCA)
Anti- mitochondrial antibody Negative
Anti- smooth muscle antibody Negative
Anti- sp100 Negative
Anti- gp210 Negative
IgA 1.45 g/ L
IgG 16.7 g/ L
IgM 1.59 g/ L
Liver ultrasound Normal liver, biliary tree and gallbladder; no
What would be the best next step?
A. ERCP
B. Liver biopsy
C. MRCP
D. Repeat liver biochemistry in six months’ time
E. Serum copper and caeruloplasmin
18 µmol/ L
cholelithiasis
224
https://t.me/medicina_free
CHAPTER 8 | LIVERDISORDERS
33. A 40- year- old man presented with abnormal liver biochemistry. He was
asymptomatic.
Investigations:
Serum ALT 78 IU/ L
Serum ALP 327 IU/ L
Serum bilirubin 17 µmol/ L
Serum albumin 39 g/ L
Liver ultrasound Normal liver echotexture, normal biliary tree,
and gallbladder
MRCP Normal
Liver biopsy histology (See Fig. 8.2)
Fig.8.2 Liver biopsy histology specimen. See also Plate 17
Image courtesy of Dr Eve Fryer, OUH NHS Foundation Trust, Oxford
What is the diagnosis?
A. AIH
B. Classical primary sclerosing cholangitis
C. PBC
D. Primary sclerosing cholangitis (PSC)/ AIH overlap
E. Small- duct PSC
34. A 56- year- old man with PSC was followed up in clinic. He complained
of increasing pruritus aecting his hands, feet, and back, uctuating
during the day and typically worse after a hot bath. Blood tests revealed
cholestatic liver biochemistry with preserved synthetic function.
Which of the following options is true regarding pruritus in this case?
A. Pruritus is not an indication for LT
B. Pruritus usually gets worse as liver disease progresses and end- stage liver disease ensues
C. Rifampicin causes drug- induced hepatitis and signicant liver dysfunction in 5% of patients
D. There is an extensive evidence base for use of cholestyramine as rst- line treatment for
cholestatic itch
E. UDCA can cause paradoxical worsening of pruritus in cholestatic liver disease
CHAPTER 8 | QUESTIONS
https://t.me/medicina_free
225
35. Which one of the following blood results usually remains unchanged
throughout pregnancy?
A. Alkaline phosphatase
B. α- fetoprotein
C. Bilirubin
D. Immunoglobulin G
E. Platelet count
36. A 28- year- old woman who was 32 weeks’ pregnant presented with
worsening pruritis. Initially, this was conned to her palms and soles
but progressed to aect her entire body. Her husband commented that
she had become yellow over the last week. On examination, she was
jaundiced with widespread excoriations.
Investigations:
Haemoglobin 108 g/ L
White cell count 10.4 × 109/ L
Platelet count 160 × 109/ L
Bilirubin 74 µmol/ L
ALP 306 IU/ L
ALT 106 IU/ L
Prothrombin time 14.5 seconds
Serum bile acids 70 µmol/ L
What is the most appropriate rst- line treatment for this patient?
A. Chlorphenamine
B. Cholestyramine
C. Prednisolone
D. Rifampicin
E. UDCA
226
https://t.me/medicina_free
CHAPTER 8 | LIVERDISORDERS
37. A41- year- old primigravida women who was 33 weeks’ pregnant
presented with right upper quadrant pain, headache, and vomiting. Her
antenatal care to date had been unremarkable. On examination, she
was tender over the right upper quadrant and there was mild peripheral
oedema. She was afebrile with a heart rate was 105 bpm and blood
pressure of 152/ 92mmHg.
Investigations:
Haemoglobin 88 g/ L
White cell count 13.4 × 109/ L
Platelet count 76 × 109/ L
Blood lm Spherocytosis with schistocytes present; no platelet
clumps
Serum bilirubin 40 µmol/ L
Serum ALT 381 IU/ L
Serum ALP 204 IU/ L
Prothrombin time 15 seconds
Serum LDH 805mmol/ L
Urine dipstick protein 3+
Liver ultrasound Hepatomegaly, no biliary dilatation; non- obstructing
Which is the most likely diagnosis?
A. Acute fatty liver of pregnancy (AFLP)
B. Gallstones
C. Haemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome
D. Hyperemesis gravidarum
E. Pre- eclampsia
gallstones
38. What is the estimated global population prevalence of NAFLD?
A. 5%
B. 10%
C. 25%
D. 40%
E. 50%
CHAPTER 8 | QUESTIONS
https://t.me/medicina_free
227
39. A 49- year- old woman was referred to clinic for evaluation of abnormal
liver enzymes and moderate steatosis on liver ultrasound. She did not
drink alcohol, had a BMI of 32.6kg/ m2 and a past medical history of type
2 diabetes. She was subsequently diagnosed with NAFLD.
Which test result would be most predictive of advanced (bridging)
brosis on liver biopsy?
A. APRI score 0.404
B. AST:ALT 0.63
C. ELF score 10.76
D. FIB4 score 1.18
E. NAFLD brosis score - 0.058
40. A 37- year- old man presented to the emergency department with a
paracetamol overdose. What is the toxic metabolite most responsible
for liver injury?
A. Acetaminophen
B. Glutathione
C. Glycoaldehyde
D. N- acetyl- p- benzoquinoneimine (NAPQI)
E. Sulphydyl
Соседние файлы в папке Библиотека им академика М.И. Перельмана