Internal Medicine Exam Chronic Liver Disease Complications 4 — Questions and Answers
Question 1: A cirrhotic patient develops sudden onset of right-sided pleural effusion. Thoracentesis reveals transudative fluid with SAAG >1.1. No pulmonary pathology is identified. What is the diagnosis?
- Chylothorax
- Hepatic hydrothorax (Correct answer)
- Parapneumonic effusion
- Malignant pleural effusion
Correct answer: Hepatic hydrothorax
Hepatic hydrothorax is a transudative pleural effusion (usually right-sided) caused by passage of ascitic fluid through diaphragmatic defects in cirrhotic patients.
Question 2: Which of the following best explains thrombocytopenia in patients with cirrhosis and portal hypertension?
- Autoimmune platelet destruction
- Splenic sequestration due to splenomegaly (Correct answer)
- Disseminated intravascular coagulation
- Vitamin K deficiency
Correct answer: Splenic sequestration due to splenomegaly
Splenomegaly from portal hypertension causes splenic sequestration of platelets, and reduced thrombopoietin synthesis by the liver also contributes.
Question 3: A patient with cirrhosis develops rapidly progressive renal failure. Terlipressin plus albumin is started. What is the proposed mechanism of terlipressin in hepatorenal syndrome?
- Increases glomerular filtration via tubular dilation
- Causes splanchnic vasoconstriction, reducing portal pressure and improving renal perfusion (Correct answer)
- Directly increases renal blood flow via vasodilation
- Blocks aldosterone receptors in the distal tubule
Correct answer: Causes splanchnic vasoconstriction, reducing portal pressure and improving renal perfusion
Terlipressin is a vasopressin analogue that constricts splanchnic vasculature, reduces portal hypertension-driven vasodilation, and improves systemic and renal perfusion.
Question 4: Which screening test is recommended every 6 months for hepatocellular carcinoma surveillance in patients with cirrhosis?
- CT scan of abdomen with contrast
- Liver ultrasound with or without AFP (Correct answer)
- MRI of abdomen with gadolinium
- Serum AFP alone
Correct answer: Liver ultrasound with or without AFP
AASLD guidelines recommend abdominal ultrasound every 6 months, with optional AFP, for HCC surveillance in cirrhotic patients.
Question 5: A cirrhotic patient develops bilateral lower extremity edema and tense ascites. Serum albumin is 1.9 g/dL. Which mechanism primarily drives ascite formation in this scenario?
- Increased hepatic lymph production alone
- Sinusoidal hypertension and splanchnic vasodilation with sodium and water retention (Correct answer)
- Reduced oncotic pressure from hypoalbuminemia alone
- Right heart failure-induced venous congestion
Correct answer: Sinusoidal hypertension and splanchnic vasodilation with sodium and water retention
The "peripheral vasodilation hypothesis" holds that portal hypertension-driven splanchnic vasodilation leads to RAAS and SNS activation, causing renal sodium and water retention and ascites formation.
Question 6: A 58-year-old with hepatitis C cirrhosis is prescribed rifaximin for secondary prophylaxis of hepatic encephalopathy. What is rifaximin's primary mechanism of action?
- Acidifies colonic pH to trap ammonia as ammonium
- Non-absorbable antibiotic that reduces ammonia-producing gut bacteria (Correct answer)
- Inhibits glutaminase enzyme in the gut
- Enhances branched-chain amino acid absorption
Correct answer: Non-absorbable antibiotic that reduces ammonia-producing gut bacteria
Rifaximin is a non-absorbable antibiotic that reduces the ammonia-producing gut bacteria, lowering portal ammonia load and decreasing recurrent encephalopathy episodes.
Question 7: Which of the following best describes the 'washout' appearance of hepatocellular carcinoma on contrast-enhanced MRI?
- Low signal on T2-weighted imaging with peripheral enhancement
- Arterial phase hyperenhancement followed by portal/delayed phase hypoenhancement (Correct answer)
- Rim enhancement in all phases with central necrosis
- Homogeneous enhancement persisting in all phases
Correct answer: Arterial phase hyperenhancement followed by portal/delayed phase hypoenhancement
The LI-RADS criteria define HCC's hallmark as arterial hyperenhancement (APHE) followed by washout (hypoenhancement) in portal venous or delayed phases.
Internal Medicine Exam Chronic Liver Disease Complications 4
A cirrhotic patient develops sudden onset of right-sided pleural effusion.
Thoracentesis reveals transudative fluid with SAAG >1.1.
No pulmonary pathology is identified.
What is the diagnosis?