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13 Cards in this Set

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MG01 [1986] [1987] [1988] [Mar90] [Sep90]

An alcoholic man has pale stools, dark urine, RUQ pain, AST 2000,
ALP 100, Bilirubin 50, vomiting and diarrhoea. The most likely diagnosis is:

A. Drug-induced hepatitis

B. Viral hepatitis

C. Obstructive jaundice

D. Chronic active hepatitis

E. Alcoholic cirrhosis
ANSWER B

Viral hepatitis on the background of alcoholism

* Mildly elevated ALT level (less than 1.5 times normal)
o ALT value could be normal for gender, ethnicity or body mass index.
o Consider muscle injury or myopathy.

* Alcoholic hepatitis
o Laboratory values can appear cholestatic, and symptoms can mimic cholecystitis.
o Minimal elevations of AST and ALT often occur.

* AST level greater than 500 U per L
o The AST elevation is unlikely to result from alcohol intake alone.
o In a heavy drinker, consider acetaminophen toxicity.

* Isolated rise in AST
o consider extrahepatic source such as cardiac muscle

* Common bile duct stone
o Condition can simulate acute hepatitis.
o AST and ALT become elevated immediately, but elevation of AP and GGT is delayed.

* Isolated elevation of GGT level
o This situation may be induced by alcohol and aromatic medications, usually with no actual liver disease.

* Isolated elevation of AP level (asymptomatic patient with normal GGT level)
o Consider bone growth or injury, or primary biliary cirrhosis.
o AP level rises in late pregnancy.

* Isolated elevation of unconjugated bilirubin level
o Consider Gilbert syndrome or hemolysis.

* Low albumin level
o Low albumin is most often caused by acute or chronic inflammation, urinary loss, severe malnutrition or liver disease
o It is sometimes caused by gastrointestinal loss (e.g., colitis or some uncommon small bowel disease).
o Normal values are lower in pregnancy.

* Blood ammonia level
o Blood ammonia values are not necessarily elevated in patients with hepatic encephalopathy.
o Determination of blood ammonia levels is most useful in patients with altered mental status of new onset or unknown origin.


ALT=alanine aminotransferase; AST=aspartate aminotransferase; AP=alkaline phosphatase; GGT=gamma-glutamyltransferase.
MG01b [1986] [1987] [1988] [Mar90] [Sep90] [Mar95] [Jul98] [Apr99] [2005-Apr] Q87, [Apr07]

A known alcoholic with anorexia and nausea has become jaundiced. His urine is dark and his faeces pale. He has discomfort in the right hypochondrium. The AST (SGOT) is 2000 IU.l-l, the alkaline phosphatase 100 IU.l-I and the serum bilirubin is 75 micromol.1-l. The best treatment would be

A. withdrawal of alcohol

B. expectant

C. operation to remove obstruction (gallstones tumour)

D. urgent liver biopsy

E. endoscopy
ANSWER A
MG02

Jaundice without bilirubin in the urine is seen in:

A. Carcinomatosis

B. Acquired haemolytic anaemia

C. Obstruction of common bile duct

D. Infective hepatitis

E. Chlorpromazine hepatitis
ANSWER B

* This is also known as acholuric jaundice
* The other causes are due to obstruction or failure of excretion of conjugated bilirubin (ie. intra and extra hepatic obstruction)
o Prehepatic jaundice

In prehepatic jaundice, excess unconjugated bilirubin is produced faster than the liver is able to conjugate it for excretion. The liver can excrete six times the normal daily load before bilirubin concentrations in the plasma rise. Unconjugated bilirubin is insoluble and is not excreted in the urine. It is most commonly due to increased haemolysis--for example, in spherocytosis, homozygous sickle cell disease, or thalassaemia major--and patients are often anaemic with splenomegaly. The cause can usually be determined by further haematological tests (red cell film for reticulocytes and abnormal red cell shapes, haemoglobin electrophoresis, red cell antibodies, and osmotic fragility).
MG04 [1988]

Hepatocellular damage indicated by raised:

A. AST

B. Alkaline phosphatase

C. Alanine transaminase

D. CK
ANSWER A and C
MG05 ANZCA version [2003-Aug] Q4, [2004-Aug] Q79, [2005-Apr] Q47, [Mar06] Q53, [Jul06] Q31, [Jul07], [Mar10]

All of the following may be associated with ulcerative colitis EXCEPT

A. cirrhosis

B. iritis

C. psoriasis

D. arthritis

E. sclerosing cholangitis
ANSWER A

Extraintestinal complications — Ulcerative colitis may be associated with a number of extraintestinal complications. These include:

** Eye involvement with uveitis and episcleritis (picture 7A-B) (see "Skin and eye manifestations of inflammatory bowel disease")
** Skin disorders such as erythema nodosum and pyoderma gangrenosum (picture 8A-C)
** A peripheral arthritis, which primarily involves large joints (with no synovial destruction), and ankylosing spondylitis; furthermore, an undifferentiated spondyloarthropathy or ankylosing spondylitis may be the presenting manifestation of ulcerative colitis (see "Arthritis associated with gastrointestinal disease")
** Sclerosing cholangitis which typically presents with an elevation in the serum alkaline phosphatase concentration
** Lung disease, ranging in severity from asymptomatic decreases in diffusing capacity to disabling bronchiectasis (see "Pulmonary complications of inflammatory bowel disease")
** Venous and arterial thromboembolism [24-28] (table 2)
** Autoimmune hemolytic anemia
MG07 [Mar91] [Mar92]

Campylobacter jejuni:

A. Associated with meningitis

B. May be treated with numerous single antibiotics

C. Commonest cause of chronic gastritis

D. Commonest colonizing organism after aspiration

E. Causes diarrhoea in third world countries
ANSWER E

Campylobacter jejuni
-curved, helical shaped, non spore forming
-Gram negative
-microaerophillic bacteria

Found in animal faeces
-most common cause of human gastroenteritis
-severely debilitating
-rarely life-threatening
-subsequent development in Guillian Barre Syndrome (2-3 weeks after)

No antibiotics are usually given as the disease is self-limiting, however, severe or prolonged cases may require ciprofloxacin, erythromycin or norfloxacin.

Rare cause of bacteremia (especially in immune compromised), meningitis and endocarditis.
MG12 ANZCA Version [Jul06] Q141, [Apr07]

The most important aspect of the peri-operative management of a patient with Gilbert's syndrome is

A. avoidance of fasting

B. avoidance of stress

C. pre-operative transfusion of fresh frozen plasma (FFP)

D. prophylaxis against hepato-renal syndrome

E. recognition of aetiology of the laboratory abnormality
ANSWER E

Gilbert syndrome is a metabolic disorder of little consequence.

common hereditary cause of increased bilirubin and is found in up to 5% of the population

It has no anaesthetic implications or clinical manifestations.

This syndrome is considered harmless.
AC139 ANZCA version [2005-Apr] Q107, [2005-Sep] Q55, [Mar06] Q20

The risk of transmission of Hepatitis C to a health care worker from an infected patient
after a needle stick injury is approximately

A. 0.5%

B. 2-8%

C. 8-15%

D. 15-20%

E. 20-30%
ANSWER B

B. 2-8% - true:

* "The average incidence of seroconversion to HCV after unintentional needle sticks or sharps exposures from an HCV-positive source is 1.8 percent (range, 0-7 percent) [40]. A study from Japan reported an incidence of HCV infection of 10 percent based upon detection of HCV RNA by reverse transcriptase polymerase chain reaction (RT-PCR) [41]. No incidence studies have documented transmission after exposure of nonintact skin. Transmission of HCV from blood splashes to the conjunctiva has been described. Hepatitis C virus has been demonstrated to survive on environmental surfaces for at least 16 hours but not four or seven days" (Uptodate, Management of healthcare workers exposed to hepatitis B virus or hepatitis C virus)
MZ73 ANZCA Version [Mar06] Q143

The double stranded hepatitis B virus can survive outside the body for

A. less than 4 hours

B. six to twelve hours

C. one to two days

D. two to seven days

E. more than seven days
ANSWER E
MZ74 ANZCA version [2005-Sep] Q116, [Mar06] Q52

Immunological evidence of immunity to hepatitis B is the presence of

A. hepatitis B core antibodies

B. hepatitis B core antigen

C. hepatitis B surface antibodies

D. hepatitis B surface antigen

E. any of the above
ANSWER C

Vaccine : + for HBV surface antibody

Infected : + HBV surface antigen and Core Antigen

Chronic : HBV antigen but no core

Acute : Core Antigen
SZ19 ANZCA version [2004-Aug] Q122, [2005-Apr] Q68, [Mar06] Q29, [Jul06] Q3

The most correct statement regarding the Child-Pugh score for liver disease is that

A. a high-risk score is not possible with normal aminotransferase levels

B. a high-risk score is possible without encephalopathy

C. a prothrombin time greater than 10 seconds above normal confers extra points to the raw score

D. it has not been validated for non-shunt and non-transplant laparotomies

E. it was originally developed for patients undergoing hepatic transplantation
ANSWER B

* A False - AST/ALT not part of classification

* B True - could score 13/15 without encephalopathy (>9 is Class C)

* C False - more than 6 secs scores a 3 (see below)

* D False - it was initially used in the context of non-shunt & non-transplant laparotomies

* E False
IC84 ANZCA Version [Jul06] Q145, [Jul07]

A 32-year-old patient is admitted with early acute liver failure (unrelated to paracetamol
ingestion). Management should include:

A. avoidance of intubation to monitor encephalopathic progress

B. consideration for liver transplant if the INR (international normalised ratio) is over 3

C. limited use of sodium containing fluids during acute resuscitation

D. N-acetyl-cysteine as a generall hepatoprotective agent

E. prophylactic antibiotics
ANSWER E

* A. avoidance of intubation to monitor encephalopathic progress - partly true, partly false: If they need intubation, intubate them. You do however want to monitor the patient's encephalopathy, which is a bit harder when intubated and sedated.

* B. consideration for liver transplant if the INR (international normalised ratio) is over 3 - false

* C. limited use of sodium containing fluids during acute resuscitation - can be bad: "Patients with ALF often require aggressive fluid resuscitation at presentation to correct commonly associated hypovolaemia. There is a tendency to avoid excessive sodium in patients with chronic liver disease, and this is often translated into the care of patients with ALF. The overzealous use of 5% dextrose in the early stages of resuscitation results in severe hyponatraemia."

* D. N-acetyl-cysteine as a generall hepatoprotective agent - false

* E. prophylactic antibiotics - true: "Prophylactic antimicrobials with broad-spectrum coverage of gram-positive and gram-negative activity including an anti-fungal (e.g. piperacillin with tazobactam and fluconazole) should be administered on admission, as this halves the incidence of infective episodes when compared with commencement at the time of suspected infection. However, this benefit must be balanced against the risk of developing multi-resistant pathogens." (Continuing Education in Anaesthesia, Critical Care & Pain | Volume 4 Number 2 2004, p40f)
Black Bank March 2010

90.Timing of worst coagulopathy after liver transplant

a. 1-2 days

b. 3-4 days

c. 5-6 days

etc
ANSWER A