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1. A 35 year old white male is being evaluated for a one week episode of jaundice he had two months prior to this visit. There were no symptoms and he had not taken any medications (including over the counter drugs) at the time. He occasionally eats raw shellfish and is sexually active. He denies intravenous drug abuse or excessive alcohol intake (confirmed on further questioning). He has had no other symptoms and has been well his whole life. He does not recall having any hepatitis vaccine and has he has not travelled outside of the USA in the past 7 years. Physical examination reveals normal vital signs and no significant findings. Serum electrolytes are normal, BUN 15mg/dL, Creatinine 1.1mg/dL, Total Bilirubin 1.4mg/dL, Direct Bilirubin 0.8mg/dL, AST (SGOT) 15 U/mL, ALT 10 U/mL, Alkaline Phosphatase 78 U/mL, Hepatitis A IgM negative, Hepatitis A IgG negative, Hepatitis B surface antigen (HBsAg) negative, HBsAb positive, HBcAb positive, HBeAb positive, HBeAg negative, Hepatitis C Ab (ELISA) positive, Hepatitis C Ab (RIBA) negative. The most likely explanation for the episode of jaundice is [1]:

   A. Acute Hepatitis A Viral Infection
   B. Hepatitis B Viral Infection with Carrier State
   C. Hepatitis B Virus Vaccination
   D. Hepatitis B Viral Infection, cleared
   E. Hepatitis C Viral Infection (chronic)

2. The patient in Question 1 does well for several years but returns with a recurrent episode of jaundice and right sided abdominal pain. He has gained thirty pounds over the past 2 years and is not very active and had been eating raw oysters two nights before. He had a fever the prior night with some mild chills but feels well except for nausea after taking two extra strength Tylenol® (acetaminophen). He did not take his temperature. On exam he is an obese male with a pulse of 105bpm, blood pressure 145/90 mmHg, respiratory rate 16/minute, temperature 99.2° po. Other than slight scleral and sublingular icterus and mild right sided guarding without rebound tenderness. Bowel sounds are light but present in all four quadrants and rectal is normal (negative guaiac). A complete blood count reveals a leukocytosis (16K/µl, differential pending), hematocrit 37%, platelet count 390/µl (normal 150-350/µl). Serum electrolytes are notable for a sodium of 133mM (normal 135-145mM), potassium 3.4mM (normal 3.5-5.2mM), chloride 98mM (normal), bicarbonate 22mM (normal 24-30mM). The BUN is 25mg/dL, creatinine 1.2mg/dL, and the glucose is 70mg/dL. Total bilirubin is 3.8mg/dL with a Direct Bilirubin 2.8mg/dL, AST 500 U/mL, ALT 650 U/mL, Alkaline Phosphatase 800 U/mL (normal <110 U/mL). Amylase is 75 U/mL (normal). The most likely diagnosis is [2]:

   A. Acute Cholecystitis
   B. Acute Hepatitis A Virus Infection
   C. Sclerosing Cholangitis
   D. Gallstone Pancreatitis
   E. Ascending Cholangitis (due to Gallstone)

3. A 38 year old woman presents with six months of increasing difficulty swallowing food. She also complains of vomiting up her food and being hungry all of the time. On questioning, she noted that solids were regurgitated slightly more frequently than liquids, but that both would come up at times. She has lost 10 pounds over the past six months and has a constant feeling of chest fullness. She does not really feel pain. She denies other symptoms including fevers, night sweats, change in bowel or urinary habits, sour taste in her mouth, rashes, shortness of breath, or palpitations. She has had no major medical problems. The most likely diagnosis is [3]:

   A. Achalasia
   B. Diffuse Esophageal Spasm
   C. Scleroderma
   D. Anxiety with Panic Attacks
   E. Stricture

4. Which of the following is NOT true about gallstones (cholelithiasis) [4] ?

   A. Abdominal radiographs detect 10-20% of gallstones
   B. Ultrasonography is more sensitive than CT scanning for detection of gall bladder stones
   C. Failure to visualize the gall bladder on HIDA nuclear scanning indicates cholecystitis
   D. Stones in the common bile duct are the most common cause of ascending cholangitis
   E. Pigmented gallstones are usually found in patients with erythrocyte disorders

5. A 70 year woman presents to your clinic for evaluation of increasing fatigue. Her past medical history is notable for a partial gastrectomy 8 years earlier for a benign leiomyoma of the stomach. There is dyspnea on exertion and "funny feelings" in her legs. She denies other symptoms of cardiac disease and has noted no changes in her bowel or bladder habbits. On exam, palor is noted and she is tachycardic at 104 bpm; other vital signs are within normal limits. Physical examination is otherwise unremarkable including a negative stool guaiac (blood) test. Laboratory exam is notable for a hematocrit of 26% with a mean corpuscular volume (MCV) of 105fL. Which of the following is most likely to be true on further evaluation [5] ?

   A. A xylose absorption test will show reduced urinary xylose excretion
   B. A Schilling's Test Part 1 will be abnormal with a normal Part 2
   C. A Schilling's Test Part 1 will be normal with an abnormal Part 2
   D. An echocardiogram will show a patent ventricular septal defect
   E. A bentiromide test will confirm the diagnosis

6. Which of the following is NOT true about Peptic Ulcer Disease [6] ?

   A. Posterior perforation is more common than anterior and causes more complications
   B. Over 80% of peptic ulcers are caused by, or associated with, Helicobacter pylori infection
   C. In patients at risk for non-steroidal anti-inflammatory drug (NSAID) induced ulcers, misoprostal provides protection from ulceration and serious bleeding
   D. Up to 10% of gastric ulcers are associated with gastric adenocarcinoma
   E. Positive anti-Helicobacter pylori serology is frequently found in persons without ulcers

7. A 45 year man with a 25 year drinking history presents to your office with increasing weight gain, lower extremity edema, and increasing abdominal girth. He has had increasing fatigue and decreased appetite, with a sense of early satiety. He has noticed increasing bruising and some funny red rashes on his stomach. He denies headaches, fever, chest pain, confusion, forgetfullness, trouble walking, or tremors. His past medical history includes hypertension, diagnosed at age 40, for which he takes enalapril (Vasotec®). General physical and screening blood tests 1 year ago were normal. Aside from alcohol, he smokes 1/2 pack of cigarettes per day (for 20 years) and has never used recreational drugs. On examination he appears fatigued. He is thin boned with a moderately protruberant abdomen. His vital signs are normal. There is very mild scleral icterus; otherwise his head and neck exam is normal. His chest is clear and cardiac exam is normal. The abdomen is protruberant with a fluid wave, no rebound or point tenderness. The liver and spleen are not appreciated. There are several spider angiomata on the abdomen near the umbilicus. Rectal exam is normal except for a prominant external hemorrhoid (occult blood negative). Mild (1+) bilateral pitting edema to the ankles is present. Asterixis is not present. Neurological exam is grossly normal. Mental status is grossly intact.

• The serum albumin is 3.2gm/dL, Total Bilirubin 3.1mg/dL, Direct Bilirubin 2.2mg/dL,

• Which of the following is NOT likely to be effective in treating the ascites [9]:

  A. Discontinuing the Enalapril
  B. Large Volume Paracentesis with Albumin Infusions
  C. Addition of Furosemide (Lasix®) to the medical regimen
  D. Albumin Infusions alone
  E. Transjugular Intrahepatic Portosystemic Shunt (TIPSS)

• All of the following additional tests should be performed EXCEPT [10]:

  A. Serum alphafetoprotein (AFP) Level
  B. Hepatic Ultrasound
  C. Hepatitis Virus Serologies
  D. Serum Iron, Ferritin, and Transferrin Saturation
  E. Liver Biopsy

Answers

1. D
2. E (elevated transaminases and alkaline phosphatase with evidence of infection)
3. A (absence of pain, regurgitation of solids and liquids)
4. C
5. B
6. A
7. C
8. B (ACE inhibitors are contraindicated in patients with cirrhotic ascites.)
9. D (Abumin alone is not effective in reducing ascites, even with low serum albumin.)
10. E (No indication at this point for liver biopsy)
11. TOPIC CARD REFERENCES
12. See Card "Viral Hepatitis"
13. See Card "Bacterial Cholangitis" ; See Card "Gallstones"
14. See Card "Esophageal Dysmotility"
15. See Card "Gallstones"
16. See Card "Malabsorption"
17. See Card "Peptic Ulcer"
18. See Card "Cirrhosis" ; See Card "Alcoholic Hepatitis"
19. 8-See Card "Ascites"