Internal Medicine Exam Chronic Liver Disease Complications 2 — Questions and Answers
Question 1: A cirrhotic patient develops confusion and asterixis after a high-protein meal. Serum ammonia is elevated. Which neurotransmitter system is most implicated in hepatic encephalopathy?
- Dopaminergic system
- GABAergic system (Correct answer)
- Cholinergic system
- Serotonergic system
Correct answer: GABAergic system
Elevated ammonia enhances GABAergic neurotransmission, promoting inhibitory tone and causing hepatic encephalopathy.
Question 2: A patient with cirrhosis has ascites refractory to diuretics. Diagnostic paracentesis shows SAAG of 1.8 g/dL. What is the most appropriate next management step?
- Large-volume paracentesis with albumin infusion (Correct answer)
- Increase spironolactone dose
- TIPS procedure
- Liver biopsy
Correct answer: Large-volume paracentesis with albumin infusion
Refractory ascites is managed with large-volume paracentesis (LVP) plus IV albumin (6–8 g per liter removed) to prevent paracentesis-induced circulatory dysfunction.
Question 3: Which Child-Pugh score component best correlates with the severity of synthetic liver dysfunction?
- Bilirubin level
- Prothrombin time/INR (Correct answer)
- Presence of ascites
- Degree of encephalopathy
Correct answer: Prothrombin time/INR
Prothrombin time/INR reflects hepatic synthesis of clotting factors and is the most direct measure of synthetic dysfunction in the Child-Pugh score.
Question 4: A cirrhotic patient with esophageal varices is started on non-selective beta-blocker therapy. Which parameter best confirms adequate pharmacologic response?
- Heart rate reduced to <55 bpm
- Hepatic venous pressure gradient (HVPG) <12 mmHg or ≥20% reduction (Correct answer)
- Reduction of spleen size on ultrasound
- Normalization of platelet count
Correct answer: Hepatic venous pressure gradient (HVPG) <12 mmHg or ≥20% reduction
Adequate beta-blocker response is confirmed by HVPG reduction to <12 mmHg or ≥20% from baseline, which significantly reduces variceal bleeding risk.
Question 5: A patient with decompensated cirrhosis develops oliguria, rising creatinine, and a FENa <0.01% despite adequate volume status. Urine microscopy is bland. What is the most likely diagnosis?
- Acute tubular necrosis
- Hepatorenal syndrome type 1 (Correct answer)
- Pre-renal azotemia
- Contrast nephropathy
Correct answer: Hepatorenal syndrome type 1
HRS type 1 presents with rapidly progressive renal failure, FENa <0.01%, bland urine sediment, and normal renal parenchyma in a cirrhotic patient without alternative cause.
Question 6: Which scoring system is currently used to prioritize liver transplant candidates in the United States?
- Child-Pugh score
- MELD-Na score (Correct answer)
- King's College Criteria
- APACHE II score
Correct answer: MELD-Na score
The MELD-Na score (incorporating sodium, bilirubin, INR, and creatinine) is used by UNOS to prioritize liver transplant allocation in the US.
Question 7: A cirrhotic patient on lactulose for hepatic encephalopathy develops diarrhea and worsening confusion. Serum sodium is 128 mEq/L. What is the most appropriate adjustment?
- Increase lactulose dose to achieve 4 bowel movements/day
- Reduce lactulose dose and add rifaximin (Correct answer)
- Add neomycin to enhance ammonia clearance
- Start zinc supplementation immediately
Correct answer: Reduce lactulose dose and add rifaximin
Diarrhea from lactulose can cause dehydration and electrolyte disturbances that worsen encephalopathy; reducing the dose and adding rifaximin is the preferred adjustment.
Internal Medicine Exam Chronic Liver Disease Complications 2
A cirrhotic patient develops confusion and asterixis after a high-protein meal.
Serum ammonia is elevated.
Which neurotransmitter system is most implicated in hepatic encephalopathy?