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6 Cards in this Set

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A 53-year-old woman presents complaining of fatigue over the past 6 months. During this time, she has also developed pruritus and lost 4 pounds. She is not sexually active, and her past medical history is significant only for Sjögren syndrome. On physical examination, she is afebrile and has mildly icteric sclera. There are excoriations noted on all four extremities and trunk and back. The liver edge is smooth and non-tender and measures 9 cm at the midclavicular line. There is no ascites, splenomegaly, or peripheral edema. Laboratory results reveal a normal complete blood count, normal electrolytes, and liver function tests with an alkaline phosphatase of 260 U/L (normal, <110 U/L), total bilirubin of 3.1 mg/dL, and normal transaminase levels. Which of the following is the most likely diagnosis?

A. Acute cholecystitis
B. Acute hepatitis A infection
C. Bacterial cholangitis
D. Primary biliary cirrhosis
E. Primary sclerosing cholangitis
The correct answer is D. This woman has a classic presentation of primary biliary cirrhosis. It typically affects middle-aged women and will progress gradually to the point of end-stage liver disease over a number of years. The disease is due to an autoimmune destruction of intrahepatic bile ductules, and the diagnosis is made by liver biopsy. The serology that should be checked is the antimitochondrial antibody. Primary biliary cirrhosis is often seen in individuals with other autoimmune diseases, such as Sjögren syndrome, pernicious anemia, and Hashimoto thyroiditis.

Acute cholecystitis (choice A) presents acutely with right upper quadrant pain and fever and not with chronic fatigue and pruritus.

Acute hepatitis A (choice B) may cause jaundice and fatigue, but it is a self-limiting infection and does not last 6 months.

Cholangitis (choice C) is due to acute obstruction of the common bile duct and presents urgently with fever, right upper quadrant pain, and jaundice (Charcot's triad).

Primary sclerosing cholangitis (choice E) is a sclerosing process of the extra- and intrahepatic ducts, which usually presents in young males with underlying inflammatory bowel disease.
A 54-year-old, malnourished man is admitted for evaluation of jaundice, ascites, and tenderness in the right upper abdomen. His temperature is 38 C (100.4 F). Physical examination reveals mild hepatomegaly and splenomegaly, as well as generalized muscle wasting. Ultrasound examination confirms the presence of an enlarged liver and a small amount of ascitic fluid. Laboratory studies show:

Serum albumin...........................2.5 g/dL

Globulin.....................................3.8 g/dL

Bilirubin:

Total........................................3.5 mg/dL

Direct......................................1.7 mg/dL

AST.........................................300 U/L

ALT.........................................120 U/L

Amylase...................................100 U/L

Alkaline phosphatase................100 U/L

Hematologic hemoglobin...........10 g/dL

Mean corpuscular volume.........100 µm

Leukocyte count.......................4000/mm3

Segmented neutrophils..............66%

Bands......................................7%

Prothrombin time......................18 sec

Which of the following is the most likely diagnosis?

A. Acute pancreatitis
B. Alcoholic hepatitis
C. Cholecystitis
D. Duodenal peptic ulcer
E. Viral hepatitis
The correct answer is B. This patient's symptomatology is consistent with acute hepatitis. Although alcoholic hepatitis may be indistinguishable from other forms of acute hepatitis, an alcoholic etiology is favored by prevalent elevation of AST (more than two times) compared with ALT. All the remaining laboratory findings, e.g., neutropenia with relative granulocytosis, hypoalbuminemia with hypergammaglobulinemia, and prolonged PT, may be present in many other forms of acute hepatitis, including viral hepatitis (choice E). Evidence of malnourishment is also consistent with alcoholism. Macrocytic anemia is a frequent coexisting finding due to vitamin B12 and folic acid deficiency. In short, only the presence of AST elevation greater than 2 times that of ALT is highly suggestive of alcoholic hepatitis. None of the remaining symptoms or laboratory changes is pathognomonic of this condition. Alcoholic injury is, however, the most likely etiology in consideration of the whole clinical picture.

Acute pancreatitis (choice A) most frequently develops in patients with a history of alcoholism or cholelithiasis. It presents with a dramatic picture of extremely severe, deep abdominal pain often radiating to the back. The patient is restless and diaphoretic. Serum levels of amylase and lipase are usually markedly elevated. Mild elevations of the latter enzymes are often seen in alcoholic hepatitis.

Cholecystitis (choice C) is usually secondary to a stone impacted in the cystic duct, resulting in distention of the gallbladder and colicky pain. Fever and mild jaundice may be present, but usually AST and ALT are normal or slightly elevated.

Duodenal peptic ulcer (choice D) is accompanied by epigastric pain or discomfort. If perforation occurs, the pain begins suddenly and is associated with abdominal guarding. Jaundice, laboratory evidence of liver damage, and ascites are absent.
A 29-year-old man presents to the local health clinic after complaining of severe fatigue and low-grade fevers over the past 3 weeks. In addition, he has noted "yellow eyeballs" over the past several days and has become increasingly nauseated. He admits to occasionally injecting IV cocaine. He is a sexually active heterosexual who usually, but not always, uses barrier contraceptive devices. On physical examination, his temperature is 38.4 C (101.1 F), and he has mildly icteric sclera. The liver edge is smooth and mildly tender and measures 13 cm in the midclavicular line. The spleen tip is not palpable, and there is no shifting dullness. Which of the following would most likely be found on serologic testing to explain his current symptoms?

A. Hepatitis A IgG antibodies
B. Hepatitis B surface antibodies
C. Hepatitis B surface antigen
D. Hepatitis C antibodies
E. Hepatitis D antibodies
The correct answer is C. This man has multiple risk factors for hepatitis B infection, i.e., IV drug use and occasional "unsafe" sex. The symptoms are consistent with a mild to moderate case of hepatitis B infection. This is confirmed by serologic evidence of hepatitis B surface antigen positivity.

Hepatitis A IgG (choice A) is found in patients who have had a prior hepatitis A infection and have developed immunity.

Hepatitis B surface antibody (choice B) is found in patients who have had a prior hepatitis B infection or who have received the hepatitis B vaccine.

Hepatitis C antibodies (choice D) are found in patients who have been exposed to hepatitis C. This patient is at risk for hepatitis C, given his use of IV drugs and the associated possibility of delivering the blood-borne hepatitis C. However, hepatitis C rarely presents with an acute viral hepatitis syndrome and instead will generally present as an indolent chronic hepatitis.

Hepatitis D (choice E) is found as a co-existing infection to hepatitis B and is usually found in patients with a very severe course of hepatitis B, which is not described in this patient.
A patient with acute hepatitis B presents to your office complaining of severe fatigue, low-grade fevers and weight loss. He was diagnosed 2 weeks earlier, and hepatitis B surface antigen was positive. A physical examination reveals jaundice with diffuse skin excoriations. His liver and spleen are both markedly enlarged and tender. Peripheral edema is present. Which of the following would be the worst prognostic sign?

A. Albumin of 3.1 g/dL
B. Bilirubin of 9.4 mg/dL
C. Prothrombin time of 19 seconds with an INR of 2.1
D. SGOT (AST) of 2 U/L
E. SGOT (AST) of 1200 U/L
The correct answer is C. Many liver function test abnormalities can be seen in a patient with acute hepatitis B, but the signs of hepatic failure, including coagulopathy or encephalopathy, are the worst prognostic signs. These patients may require emergent liver transplantation, as more conservative measures may not be lifesaving.

A minimally reduced albumin of 3.1 (choice A) is not an important prognostic factor, although it may indicate longstanding hepatic synthetic dysfunction if no other etiology of hypoalbuminemia is present.

An elevated bilirubin (choice B) is not a poor prognostic sign. In fact, patients with hepatitis B may become very deeply jaundiced, with bilirubin elevation as high as 30, and still return to normal.

A low SGOT (choice D) has no prognostic importance.

An elevated SGOT (choice E) may be seen in these patients but is not a specific prognostic sign.
A 31-year-old professional bodybuilder presents complaining of 3 weeks of worsening fatigue, low-grade fevers, and myalgias, as well as the gradual onset of jaundice over the past week. He admits to unprotected anal sex 3 months earlier after a championship bodybuilding event. He denies any other homosexual activities. He has no other medical problems and is on no medications. On physical examination, he appears acutely ill, with a temperature of 39.3 C (102.7 F), a blood pressure of 116/60 mm Hg, and a pulse of 114/min. He is deeply icteric and has multiple excoriations over his entire body. His liver edge is smooth and very tender and measures 14 cm in the midclavicular line. There is no shifting dullness, and a spleen tip is palpable 4 cm below the left costal margin. Stool is brown and guaiac negative, and there is no peripheral edema. Which of the following laboratory findings would most likely indicate the worst prognosis?

A. Prothrombin time of 19.6 seconds
B. Aspartate aminotransferase (AST) of 983 U/L
C. Alanine aminotransferase (ALT) of 13,420 U/L
D. Total bilirubin of 27.4 mg/dL
E. White blood cell count of 18,400/mm3
The correct answer is A. This patient has probable acute hepatitis. Features specifically suggesting acute hepatitis include his jaundice, itchiness leading to multiple excoriations, tender enlarge liver, and palpable spleen tip. He reports no risk factors for hepatitis A infection, such as drinking water in a foreign country with periodic epidemics of hepatitis A. He does have a risk factor for hepatitis B, which can be transmitted through blood products (now rare because of blood screening), contaminated syringes among drug users, and sexual contact (particularly when involving the rectum). The findings of a coagulopathy or of an encephalopathy confer the worst prognosis in patients with an acute viral hepatitis. Most patients with hepatitis B, even with severe laboratory abnormalities, may be followed conservatively so long as they do not develop a coagulopathy or exhibit signs of encephalopathy. These findings, in fact, suggest the possibility of fulminant hepatic failure.

Although the transaminases may rise to very high levels (choices B and C), they are not of prognostic value in viral hepatitis.

Similarly, severe jaundice (choice D) is of limited prognostic value, as is leukocytosis (choice E).
Ten days after undergoing liver transplantation, a patient's levels of gamma-glutamyl transferase (GGT), alkaline phosphatase, and bilirubin begin to rise. Which of the following is the most appropriate next step in diagnosis?

A. Measurement of preformed antibody levels
B. Ultrasound of biliary tract and Doppler studies of the anastomosed vessels
C. Liver biopsy and determination of portal pressures
D. Liver biopsy and more detailed liver function tests
E. Liver biopsy and trial of steroid boluses
The correct answer is B. In all other solid organ transplants, deterioration of function 10 days out would suggest an acute rejection episode, and appropriate biopsies would be done to confirm the diagnosis. In the case of the liver, however, antigenic reactions are less common, whereas technical problems with the biliary and vascular anastomosis are the most common cause of early functional deterioration. They are, therefore, the first anomalies to be sought.

Preformed antibodies (choice A) are responsible for hyperacute rejection, which would be evident within minutes of establishing blood flow to the graft.

Choices C, D, and E are centered on liver biopsy, which would be done only after technical problems have been ruled out.