ITE Gastroenterology and Hepatology 4 — Questions and Answers
Question 1: A 65-year-old man with cirrhosis and ascites develops acute kidney injury. Creatinine rises from 1.0 to 2.6 mg/dL over 48 hours despite albumin infusion and diuretic discontinuation. Urine sodium is <10 mEq/L. What is the most likely diagnosis?
- Acute tubular necrosis
- Prerenal azotemia
- Hepatorenal syndrome (Correct answer)
- Contrast nephropathy
Correct answer: Hepatorenal syndrome
Hepatorenal syndrome (HRS) is characterized by functional renal failure in cirrhotic patients with very low urine sodium (<10), absence of improvement with volume expansion, and no intrinsic renal disease.
Question 2: A 25-year-old woman has elevated transaminases, Kayser-Fleischer rings, and neuropsychiatric symptoms. Serum ceruloplasmin is low. Which test best confirms the diagnosis of Wilson's disease?
- Liver biopsy with quantitative copper (Correct answer)
- 24-hour urine copper
- Genetic testing for ATP7B mutation
- Serum copper level
Correct answer: Liver biopsy with quantitative copper
Liver biopsy with quantitative hepatic copper content >250 mcg/g dry weight is the gold standard for confirming Wilson's disease when clinical criteria are equivocal.
Question 3: A 52-year-old man with hepatitis C-related cirrhosis has a 2.5 cm liver lesion showing arterial enhancement and washout on multiphasic MRI. What is the most appropriate next step?
- Liver biopsy
- Repeat MRI in 3 months
- Alpha-fetoprotein measurement only
- Proceed with treatment per LI-RADS 5 criteria (Correct answer)
Correct answer: Proceed with treatment per LI-RADS 5 criteria
A LI-RADS 5 lesion (arterial hyperenhancement with washout and capsule in a cirrhotic patient) is diagnostic for hepatocellular carcinoma; biopsy is not required before treatment planning.
Question 4: A 48-year-old woman with ulcerative colitis develops worsening right upper quadrant pain, jaundice, and pruritus. MRCP shows multifocal strictures and dilations of intrahepatic and extrahepatic bile ducts. What is the most likely diagnosis?
- Primary biliary cholangitis
- Primary sclerosing cholangitis (Correct answer)
- Choledocholithiasis
- IgG4-related cholangiopathy
Correct answer: Primary sclerosing cholangitis
Primary sclerosing cholangitis (PSC) is strongly associated with ulcerative colitis and presents with the characteristic 'beaded' appearance of multifocal biliary strictures on MRCP.
Question 5: Which scoring system is used to prioritize liver transplant allocation in the United States?
- Child-Pugh score
- MELD score (Correct answer)
- APACHE II
- King's College Criteria
Correct answer: MELD score
The MELD (Model for End-stage Liver Disease) score, based on bilirubin, INR, and creatinine, is used by UNOS to prioritize patients for liver transplant allocation.
Question 6: A 30-year-old presents with crampy abdominal pain, bloody diarrhea, and fever after eating at a barbecue. Stool culture grows Shiga toxin-producing E. coli O157:H7. Which treatment should be avoided?
- Fluid replacement
- Electrolyte monitoring
- Antibiotics (Correct answer)
- Rest
Correct answer: Antibiotics
Antibiotics are contraindicated in STEC O157:H7 infection because they may increase Shiga toxin release, raising the risk of hemolytic uremic syndrome (HUS).
Question 7: A 44-year-old woman presents with episodic epigastric pain, diarrhea, and multiple duodenal ulcers despite PPI therapy. Fasting gastrin level is 1200 pg/mL (normal <100). What is the most appropriate next diagnostic step?
- H. pylori testing
- Secretin stimulation test (Correct answer)
- CT scan of the abdomen
- Repeat endoscopy
Correct answer: Secretin stimulation test
The secretin stimulation test is the gold standard for diagnosing Zollinger-Ellison syndrome; paradoxical rise in gastrin >200 pg/mL after secretin injection confirms gastrinoma.
ITE Gastroenterology and Hepatology 4
A 65-year-old man with cirrhosis and ascites develops acute kidney injury.
Creatinine rises from 1.0 to 2.6 mg/dL over 48 hours despite albumin infusion and diuretic discontinuation.
Urine sodium is <10 mEq/L.
What is the most likely diagnosis?