Internal Medicine Exam Chronic Liver Disease Complications 5 — Questions and Answers
Question 1: A patient with cirrhosis and grade 2 hepatic encephalopathy is precipitated by a GI bleed. After controlling the bleed, which intervention specifically targets ammonia reduction to treat the encephalopathy?
- IV thiamine supplementation
- Lactulose titrated to 2–3 soft stools per day (Correct answer)
- Branched-chain amino acid infusion
- Low-protein enteral nutrition
Correct answer: Lactulose titrated to 2–3 soft stools per day
Lactulose is the first-line treatment for hepatic encephalopathy; it acidifies the colon, traps ammonia as ammonium, and accelerates its fecal excretion.
Question 2: Portal vein thrombosis (PVT) is found incidentally in a patient with cirrhosis. It is non-occlusive and asymptomatic. What is the most appropriate management?
- Emergent TIPS placement
- Anticoagulation with low-molecular-weight heparin or direct oral anticoagulants (Correct answer)
- Observation only without anticoagulation
- Surgical thrombectomy
Correct answer: Anticoagulation with low-molecular-weight heparin or direct oral anticoagulants
Anticoagulation is recommended for non-occlusive PVT in cirrhosis to prevent extension and promote recanalization, as the bleeding risk is generally outweighed by thrombosis risk.
Question 3: Which antibiotic regimen is recommended for SBP prophylaxis in a cirrhotic patient with a prior episode of SBP?
- Metronidazole 500 mg twice daily
- Norfloxacin 400 mg daily (or trimethoprim-sulfamethoxazole) (Correct answer)
- Ceftriaxone 1 g IV weekly
- Amoxicillin-clavulanate 875 mg daily
Correct answer: Norfloxacin 400 mg daily (or trimethoprim-sulfamethoxazole)
Indefinite secondary prophylaxis with norfloxacin 400 mg/day or TMP-SMX is recommended after a first episode of SBP to prevent recurrence.
Question 4: A cirrhotic patient develops portopulmonary hypertension (PoPH). Which finding on echocardiography is most consistent with this diagnosis?
- Reduced left ventricular ejection fraction <40%
- Elevated right ventricular systolic pressure >50 mmHg with right heart strain (Correct answer)
- Pericardial effusion with tamponade physiology
- Severe mitral regurgitation
Correct answer: Elevated right ventricular systolic pressure >50 mmHg with right heart strain
PoPH is characterized by pulmonary arterial hypertension in the setting of portal hypertension; echo shows elevated RVSP and right heart dilation/strain.
Question 5: A patient with alcoholic cirrhosis has a prolonged INR of 2.4 but no active bleeding. Surgery is required for cholecystitis. Which intervention is most appropriate to assess true bleeding risk?
- Administer fresh frozen plasma to correct INR to <1.5
- Measure thromboelastography (TEG) or rotational thromboelastometry (ROTEM) (Correct answer)
- Transfuse platelets to >100,000/μL
- Vitamin K infusion for 3 days
Correct answer: Measure thromboelastography (TEG) or rotational thromboelastometry (ROTEM)
INR in cirrhosis overestimates bleeding risk because it does not reflect the balanced reduction in both pro- and anticoagulant factors; viscoelastic testing (TEG/ROTEM) provides a more accurate assessment.
Question 6: Zinc deficiency is common in cirrhosis. What is the most clinically relevant consequence of zinc deficiency in this population?
- Increased risk of hepatocellular carcinoma
- Impaired urea cycle function contributing to hyperammonemia (Correct answer)
- Worsening portal hypertension
- Reduced bile acid synthesis
Correct answer: Impaired urea cycle function contributing to hyperammonemia
Zinc is an essential cofactor for urea cycle enzymes; deficiency impairs ammonia detoxification and can worsen hepatic encephalopathy.
Question 7: A cirrhotic patient with refractory ascites is being evaluated for TIPS. Which condition is an absolute contraindication to TIPS placement?
- Platelet count <50,000/μL
- Severe hepatic encephalopathy (grade 3–4) or severe hepatic dysfunction (Correct answer)
- Moderate ascites on diuretics
- History of one prior variceal bleed
Correct answer: Severe hepatic encephalopathy (grade 3–4) or severe hepatic dysfunction
Severe or refractory hepatic encephalopathy and advanced hepatic failure (Child-Pugh C >13 or MELD >18) are absolute contraindications to TIPS due to the risk of worsening encephalopathy and liver failure.
Internal Medicine Exam Chronic Liver Disease Complications 5
A patient with cirrhosis and grade 2 hepatic encephalopathy is precipitated by a GI bleed.
After controlling the bleed, which intervention specifically targets ammonia reduction to treat the encephalopathy?