Internal Medicine Chronic Liver Disease Complications Questions and Answers — Questions and Answers
Question 1: A 64-year-old man with cirrhosis due to non-alcoholic steatohepatitis presents with increasing confusion, lethargy, and asterixis. His family notes he has been more forgetful over the past week. He has no fever or abdominal pain. What is the most appropriate initial pharmacologic therapy for this patient's condition?
- Rifaximin
- Lactulose (Correct answer)
- Intravenous albumin
- Propranolol
Correct answer: Lactulose
The patient is presenting with signs of overt hepatic encephalopathy (HE). According to guidelines from the American Association for the Study of Liver Diseases (AASLD) and the European Association for the Study of the Liver (EASL), lactulose is the first-line treatment for an episode of overt HE. It works by decreasing the intestinal production and absorption of ammonia. Rifaximin is an effective add-on therapy, particularly for preventing recurrence, but is not the initial monotherapy of choice. Intravenous albumin is used in specific complications like hepatorenal syndrome or SBP, and propranolol is used for portal hypertension and variceal prophylaxis.
Question 2: A 59-year-old female with decompensated alcoholic cirrhosis and ascites is admitted with fever and diffuse abdominal tenderness. A diagnostic paracentesis is performed. Which of the following ascitic fluid findings is the most critical for diagnosing spontaneous bacterial peritonitis (SBP)?
- Serum-ascites albumin gradient (SAAG) > 1.1 g/dL
- Total protein < 1.0 g/dL
- Positive bacterial culture
- Polymorphonuclear (PMN) leukocyte count ≥ 250 cells/mm³ (Correct answer)
Correct answer: Polymorphonuclear (PMN) leukocyte count ≥ 250 cells/mm³
The diagnosis of spontaneous bacterial peritonitis (SBP) is established by an ascitic fluid polymorphonuclear (PMN) leukocyte count of 250 cells/mm³ or greater, with or without a positive culture. Treatment should be initiated empirically based on this cell count without waiting for culture results, which may be negative in many cases (culture-negative neutrocytic ascites). A SAAG > 1.1 g/dL indicates portal hypertension but not infection, and a low ascitic protein is a risk factor for SBP, not a diagnostic criterion.
Question 3: A 62-year-old male with cirrhosis, portal hypertension, and medium-sized esophageal varices noted on a screening endoscopy has no history of gastrointestinal bleeding. He is hemodynamically stable. Which of the following medications is the most appropriate choice for primary prophylaxis against variceal hemorrhage?
- Octreotide
- Nadolol (Correct answer)
- Furosemide
- Omeprazole
Correct answer: Nadolol
Non-selective beta-blockers (NSBBs), such as nadolol or propranolol, are the first-line pharmacologic therapy for the primary prevention of bleeding from medium to large esophageal varices. They work by reducing portal pressure through both a decrease in cardiac output (β1 blockade) and splanchnic vasoconstriction (β2 blockade). Octreotide is used for treating active variceal bleeding, not for primary prophylaxis. Furosemide is a diuretic for ascites management, and omeprazole is a proton-pump inhibitor with no role in preventing variceal bleeding.
Question 4: According to the American Association for the Study of Liver Diseases (AASLD) guidelines, which of the following is the recommended surveillance strategy for hepatocellular carcinoma (HCC) in an adult patient with compensated cirrhosis?
- Annual contrast-enhanced abdominal MRI
- Serum alpha-fetoprotein (AFP) level every 3 months
- Abdominal ultrasound with or without AFP every 6 months (Correct answer)
- Flexible sigmoidoscopy every 5 years
Correct answer: Abdominal ultrasound with or without AFP every 6 months
Major society guidelines, including the AASLD, recommend surveillance for hepatocellular carcinoma (HCC) in patients with cirrhosis using an abdominal ultrasound every 6 months. The addition of serum alpha-fetoprotein (AFP) testing to ultrasound is also recommended as it may increase sensitivity. More frequent AFP testing alone or annual advanced imaging like MRI or CT are not the standard of care for routine surveillance. Flexible sigmoidoscopy is for colorectal cancer screening.
Question 5: A 60-year-old male with alcoholic cirrhosis and ascites is admitted with a serum creatinine of 2.8 mg/dL, which has risen from a baseline of 1.0 mg/dL over three days. He is hypotensive with a urine sodium of 5 mEq/L. A renal ultrasound is unremarkable. After withholding diuretics and administering a 2-day trial of intravenous albumin (1 g/kg/day), his creatinine fails to improve. Which of the following is the most likely diagnosis?
- Acute tubular necrosis (ATN)
- Pre-renal azotemia due to dehydration
- Hepatorenal syndrome-acute kidney injury (HRS-AKI) (Correct answer)
- Post-renal obstruction
Correct answer: Hepatorenal syndrome-acute kidney injury (HRS-AKI)
The patient meets the diagnostic criteria for hepatorenal syndrome-acute kidney injury (HRS-AKI). This is a diagnosis of exclusion in a patient with cirrhosis and ascites who develops AKI. Key features include the absence of shock, no recent use of nephrotoxic drugs, no signs of structural kidney disease, and a lack of improvement in renal function after at least two days of diuretic withdrawal and volume expansion with albumin. His failure to respond to albumin makes simple pre-renal azotemia less likely. ATN typically presents with higher urine sodium and granular casts. The normal ultrasound rules out post-renal obstruction.
Question 6: A patient with advanced cirrhosis has a prolonged INR of 2.5. Despite this, he develops a spontaneous portal vein thrombosis. Which of the following pathophysiologic changes best explains this prothrombotic tendency?
- A severe deficiency of anticoagulant proteins C and S
- Markedly elevated levels of Factor VIII and von Willebrand factor (Correct answer)
- Thrombocytopenia secondary to splenomegaly
- Decreased clearance of activated clotting factors
Correct answer: Markedly elevated levels of Factor VIII and von Willebrand factor
While patients with cirrhosis are deficient in many liver-synthesized pro-coagulant and anti-coagulant factors, they have markedly elevated levels of Factor VIII and von Willebrand factor, which are produced by endothelial cells. This increase in pro-thrombotic factors can disrupt the 'rebalanced hemostasis' and tip the patient into a hypercoagulable state, leading to thrombotic events like portal vein thrombosis despite a prolonged INR. While deficiency of proteins C and S and decreased factor clearance contribute to the complex picture, the significant elevation of FVIII/vWF is a key driver of this paradoxical thrombosis. Thrombocytopenia would favor bleeding, not clotting.
Internal Medicine Chronic Liver Disease Complications Questions and Answers
A 64-year-old man with cirrhosis due to non-alcoholic steatohepatitis presents with increasing confusion, lethargy, and asterixis.
His family notes he has been more forgetful over the past week.
He has no fever or abdominal pain.
What is the most appropriate initial pharmacologic therapy for this patient's condition?