Internal Medicine Exam Chronic Liver Disease Complications 3 — Questions and Answers
Question 1: A patient with alcoholic cirrhosis presents with acute upper GI bleeding. Endoscopy shows actively bleeding esophageal varices treated with band ligation. Which medication should be started immediately upon admission?
- Pantoprazole IV infusion
- Octreotide IV infusion (Correct answer)
- Propranolol orally
- Furosemide IV
Correct answer: Octreotide IV infusion
Octreotide (or terlipressin) reduces splanchnic blood flow and portal pressure; it should be started at admission and continued for 3–5 days during acute variceal hemorrhage.
Question 2: Which of the following is the strongest independent risk factor for spontaneous bacterial peritonitis (SBP) in cirrhotic patients with ascites?
- Serum albumin <2.5 g/dL
- Ascitic fluid protein <1.5 g/dL (Correct answer)
- Platelet count <100,000/μL
- Child-Pugh class B
Correct answer: Ascitic fluid protein <1.5 g/dL
Low ascitic fluid protein (<1.5 g/dL) reflects reduced opsonic activity and is the strongest independent risk factor for SBP in cirrhotic ascites.
Question 3: A cirrhotic patient with known varices has not bled. What is the recommended primary prophylaxis approach for large varices?
- Sclerotherapy alone
- Non-selective beta-blockers or endoscopic band ligation (Correct answer)
- TIPS procedure
- Shunt surgery
Correct answer: Non-selective beta-blockers or endoscopic band ligation
Non-selective beta-blockers (propranolol, nadolol, carvedilol) or endoscopic band ligation are equally effective first-line primary prophylaxis for large esophageal varices.
Question 4: A patient with cirrhosis and hepatic encephalopathy is found to have hyponatremia (Na 121 mEq/L). Which treatment is most appropriate?
- Rapid sodium correction with 3% saline
- Fluid restriction and consideration of vaptans (Correct answer)
- Isotonic saline infusion
- Increased diuretic doses
Correct answer: Fluid restriction and consideration of vaptans
Dilutional hyponatremia in cirrhosis is managed with fluid restriction; vasopressin receptor antagonists (vaptans) may be used in resistant cases.
Question 5: Which complication of cirrhosis is characterized by intrapulmonary vascular dilatations leading to hypoxemia that improves with 100% oxygen administration?
- Portopulmonary hypertension
- Hepatopulmonary syndrome (Correct answer)
- Hepatic hydrothorax
- Transfusion-related acute lung injury
Correct answer: Hepatopulmonary syndrome
Hepatopulmonary syndrome results from intrapulmonary vasodilation causing V/Q mismatch and right-to-left shunting, with PaO2 improving on 100% O2.
Question 6: A cirrhotic patient with tense ascites undergoes large-volume paracentesis (5 liters removed) without albumin infusion. What complication is most likely to occur within 6 hours?
- Refeeding syndrome
- Paracentesis-induced circulatory dysfunction (Correct answer)
- Spontaneous bacterial peritonitis
- Hepatic encephalopathy
Correct answer: Paracentesis-induced circulatory dysfunction
Paracentesis-induced circulatory dysfunction (PICD) occurs when >5L is removed without albumin replacement, causing plasma renin activation and renal/circulatory compromise.
Question 7: Which finding on ascitic fluid analysis most reliably distinguishes SBP from secondary bacterial peritonitis?
- Ascitic fluid glucose <50 mg/dL
- PMN count >250 cells/mm³ with single organism on culture
- Lactate dehydrogenase elevated in ascitic fluid
- Ascitic fluid protein >1 g/dL with multiple organisms (Correct answer)
Correct answer: Ascitic fluid protein >1 g/dL with multiple organisms
Secondary peritonitis typically shows multiple organisms on culture, high protein, high LDH, and low glucose in ascitic fluid, distinguishing it from SBP.
Internal Medicine Exam Chronic Liver Disease Complications 3
A patient with alcoholic cirrhosis presents with acute upper GI bleeding.
Endoscopy shows actively bleeding esophageal varices treated with band ligation.
Which medication should be started immediately upon admission?