Liver Disease (Cirrhosis, Hepatitis, Autoimmune, Wilson's, Hemochromatosis) MCQs

Medicine · 155 free questions with answers & explanations.

  1. A 38-year-old man presents with tremor, dysarthria, personality changes, and elevated liver enzymes. Kayser-Fleischer rings are present on slit-lamp examination. Serum ceruloplasmin is 8 mg/dL (normal 20–35 mg/dL). 24-hour urine copper is 280 μg/day (normal < 100 μg/day). What is the most appropriate initial pharmacological treatment?
  2. A 55-year-old woman with known chronic hepatitis C cirrhosis (Child-Pugh B) presents with confusion, asterixis, and inability to perform serial subtractions. She recently had an episode of GI bleeding. Serum ammonia is 112 μmol/L. Which of the following mechanisms best explains the pathogenesis of hepatic encephalopathy?
  3. A 45-year-old man with cirrhosis due to NASH develops new-onset ascites. Diagnostic paracentesis shows: serum-ascites albumin gradient (SAAG) = 1.5 g/dL, ascitic fluid protein 1.8 g/dL, glucose 90 mg/dL, LDH 80 U/L. What does the SAAG value indicate?
  4. A 28-year-old woman presents with jaundice, fatigue, arthralgias, and amenorrhea. Serum ALT is 380 U/L, AST 320 U/L, total bilirubin 4.2 mg/dL, ANA 1:320 positive, anti-smooth muscle antibody (ASMA) positive 1:640, serum IgG 28 g/L. Liver biopsy shows interface hepatitis with plasma cell infiltration. What is the diagnosis and cornerstone of treatment?
  5. A 45-year-old man with alcoholic cirrhosis presents with tense ascites and is not responding to spironolactone 400 mg and furosemide 160 mg. Serum creatinine is 0.9 mg/dL, sodium 128 mEq/L. He undergoes large-volume paracentesis (LVP) of 7 liters. Which agent should be given post-LVP to prevent circulatory dysfunction?
  6. A 22-year-old woman presents with jaundice, behavioral changes, and kayser-Fleischer rings on slit-lamp examination. Serum ceruloplasmin is 8 mg/dL (low). 24-hour urine copper is 280 μg/day. LFTs show AST 320, ALT 290, bilirubin 9.2 mg/dL. She is diagnosed with Wilson's disease and started on D-penicillamine. Which critical monitoring is required early in treatment?
  7. A 52-year-old man with hereditary hemochromatosis (HFE C282Y homozygous) is managed with weekly phlebotomy until ferritin <50 ng/mL. His ferritin has normalized at 38 ng/mL after 18 months. He develops symptomatic aching in the second and third metacarpophalangeal joints bilaterally with chondrocalcinosis on X-ray. What is the mechanism of arthropathy in hemochromatosis?
  8. A 38-year-old woman with autoimmune hepatitis on prednisolone and azathioprine has been in biochemical remission for 2 years (ALT 18 IU/L, normal IgG). A liver biopsy is performed before considering drug withdrawal. It shows minimal lobular activity (HAI score 3/18) with complete fibrosis regression (Metavir F1). What does current guidance recommend regarding immunosuppression withdrawal?
  9. A 45-year-old woman with autoimmune hepatitis on azathioprine and prednisolone achieves remission (ALT normal, liver biopsy shows no interface hepatitis). After 2 years of sustained remission, she requests to discontinue therapy. What is the recurrence rate after stopping immunosuppression, and what factor predicts a higher risk of relapse?
  10. A 32-year-old man presents with haemolytic anaemia, elevated liver enzymes, behavioural changes, and a Kayser-Fleischer ring on slit-lamp examination. Serum ceruloplasmin is <10 mg/dL. 24-hour urinary copper is 200 μg/day. A liver biopsy shows cirrhosis with hepatic copper >250 μg/g dry weight. Which treatment is the definitive therapy for Wilson's disease?
  11. A 55-year-old man with compensated cirrhosis (Child-Pugh A) and hepatocellular carcinoma is found to have two nodules: a 3.5 cm nodule with arterial enhancement and portal venous washout, and a 2.0 cm nodule with similar characteristics. By Barcelona Clinic Liver Cancer (BCLC) staging, this represents which stage, and what is the preferred treatment?
  12. In non-cirrhotic portal hypertension due to non-alcoholic steatohepatitis (NASH), which recent clinical trial (NASH-focused) demonstrated significant regression of hepatic fibrosis by at least one stage with an investigational agent?
  13. The Model for End-stage Liver Disease (MELD-Na) score includes serum sodium as it independently predicts mortality. A patient with MELD score 20 (by original MELD) and serum Na 125 mEq/L would have MELD-Na of approximately 30. This is because hyponatraemia in cirrhosis reflects:
  14. In Wilson's disease, the Kayser-Fleischer ring results from copper deposition in Descemet's membrane. However, K-F rings can be absent in patients presenting with Wilson's liver disease alone. Which diagnostic test has highest sensitivity when K-F rings are absent?
  15. Hepatitis D virus (HDV) requires which essential co-factor from the host hepatocyte for entry, making it unable to infect cells without prior or simultaneous HBV infection?
  16. In hereditary haemochromatosis (HFE-related), homozygous C282Y mutation disrupts the interaction of HFE protein with TfR1/TfR2, leading to decreased hepcidin synthesis. The resulting low hepcidin causes iron overload by which mechanism?
  17. A 50-year-old man with Child-Pugh C cirrhosis (alcoholic) presents with sudden large-volume haematemesis. Endoscopy confirms oesophageal variceal bleeding which is controlled with band ligation. The MOST appropriate pharmacological agent to add alongside endoscopic therapy to reduce early re-bleeding and portal pressure is:
  18. A 25-year-old woman presents with acute liver failure, haemolytic anaemia, and psychiatric symptoms. Kayser-Fleischer rings are absent on slit-lamp examination. Serum ceruloplasmin is 8 mg/dL (normal 20–60). The MOST appropriate first-line treatment for this presentation is:
  19. A 58-year-old man with hereditary haemochromatosis (HFE gene C282Y homozygous) has serum ferritin 2800 ng/mL and transferrin saturation 82%. Liver biopsy shows hepatic iron index of 2.1 (normal <1.9), with fibrosis stage F2. The FIRST-LINE treatment is:
  20. Which autoantibody pattern is MOST characteristic of type 1 autoimmune hepatitis (AIH-1) and correlates with disease activity and relapse?
  21. A 52-year-old man with Child-Pugh B cirrhosis from NASH develops spontaneous bacterial peritonitis (SBP, SAAG 1.3 g/dL, ascitic PMN >250/µL). After starting IV cefotaxime, which adjunctive therapy has been shown in the SORT trial (Sort et al., 1999, NEJM) to significantly reduce the risk of hepatorenal syndrome and improve survival?
  22. A 28-year-old woman presents with hemolytic anemia, acute liver failure, Kayser-Fleischer rings on slit-lamp examination, and serum ceruloplasmin of 8 mg/dL (normal 20–60). Urine copper is 450 µg/24h. She is in acute hepatic failure with encephalopathy. The treatment approach for this acute severe Wilson's disease presentation is:
  23. A 48-year-old man presents with fatigue, arthralgia (MCP joints bilaterally), elevated liver enzymes (AST 85, ALT 92), serum ferritin 1850 µg/L, transferrin saturation 78%. Liver biopsy shows grade 3 hepatic iron deposition with periportal fibrosis. HFE gene testing reveals C282Y homozygosity. Regarding treatment with phlebotomy, what is the therapeutic target?
  24. A 42-year-old woman with autoimmune hepatitis (AIH) achieves complete biochemical remission (normal ALT, normal IgG) on azathioprine 100 mg/day after 3 years of treatment. She wishes to stop medication. According to EASL guidelines for AIH, the minimum recommended duration of treatment before considering withdrawal is:
  25. A 55-year-old man with decompensated alcoholic cirrhosis (Child-Pugh C) develops spontaneous bacterial peritonitis (SBP). Paracentesis shows PMN count of 380/mm³. He is started on cefotaxime. Which additional intervention reduces 3-month mortality in this setting?
  26. A 30-year-old man presents with acute liver failure, hemolytic anemia (Coombs-negative), and Kayser-Fleischer rings. Serum ceruloplasmin is 6 mg/dL (normal 20–35). Urine copper is 1800 μg/24h. He deteriorates rapidly. What is the definitive treatment?
  27. A 45-year-old man with chronic hepatitis C (genotype 1b) is treated with sofosbuvir/ledipasvir for 12 weeks. His cirrhosis status is Child-Pugh A. He achieves SVR12. Three years later, his AFP rises to 65 ng/mL and a 3 cm hepatic nodule is detected showing arterial enhancement and portal venous washout on MRI. LI-RADS category is 5. What is the recommended first-line treatment?
  28. In primary biliary cholangitis (PBC), the first-line therapy is ursodeoxycholic acid (UDCA). Which biochemical response criterion at 12 months is used to define inadequate UDCA response (Paris-II criteria), indicating need for add-on therapy?
  29. A 38-year-old man with cirrhosis develops acute ascites decompensation. Diagnostic paracentesis shows SAAG 1.8 g/dL, total protein 1.5 g/dL, cell count 380 cells/µL with 75% neutrophils. Serum creatinine rises from 0.9 to 2.6 mg/dL over 48 hours. Which management is proven to prevent HRS and reduce mortality in this context?
  30. A 52-year-old man with chronic hepatitis B (HBeAg negative, HBV DNA 32,000 IU/mL, ALT 3× ULN, METAVIR F3) is assessed for therapy. Which first-line antiviral is preferred per EASL 2017 and APASL 2023 guidelines?
  31. A 25-year-old woman presents with acute liver failure, Kayser-Fleischer rings, serum ceruloplasmin 8 mg/dL, 24-hour urine copper 680 µg/day, and haemolytic anaemia. The AASLD revised diagnostic score is calculated. Which combination of findings gives the highest diagnostic certainty for Wilson's disease?
  32. A 50-year-old man with alcoholic cirrhosis is hospitalized with acute decompensation (ascites, encephalopathy). Diagnostic paracentesis: SAAG 1.5 g/dL, PMN count 380 cells/μL. He has no fever or abdominal pain. The appropriate treatment is:
  33. A 28-year-old woman presents with progressive jaundice, hepatosplenomegaly, and low serum ceruloplasmin (8 mg/dL, normal 20–40). Kayser-Fleischer rings are present on slit-lamp examination. Liver biopsy shows copper content 420 μg/g dry weight (normal <50). She has neuropsychiatric symptoms including dysarthria and dysphagia. The most appropriate long-term treatment that is ALSO recommended for neurologically symptomatic Wilson's disease as first-line is:
  34. A 58-year-old man with non-alcoholic steatohepatitis (NASH)-related cirrhosis (Child-Pugh B, MELD 14) has hepatocellular carcinoma detected: single lesion 3 cm, AFP 450 ng/mL, portal vein patent. ECOG performance status 0. According to Barcelona Clinic Liver Cancer (BCLC) staging and treatment algorithm, the appropriate management is:
  35. A 45-year-old man with compensated cirrhosis from chronic HCV infection is started on sofosbuvir/velpatasvir (pangenotypic DAA) for 12 weeks. Four weeks into treatment he remains undetectable on HCV RNA PCR. Which monitoring parameter is MOST critical during DAA treatment in a cirrhotic patient?
  36. A 45-year-old woman with autoimmune hepatitis on azathioprine and prednisolone develops decompensation (ascites, jaundice). Liver biopsy shows bridging fibrosis and interface hepatitis with plasma cell infiltrate. ALT is 280 U/L. The best therapeutic decision is:
  37. A 32-year-old man with cirrhosis presents with confusion, asterixis, and jaundice. Serum ceruloplasmin is 9 mg/dL (normal 20–40). Kayser-Fleischer rings are present. 24-hour urine copper is 680 µg/day (normal <100). The treatment of choice for this acute presentation of Wilson disease with neurological involvement is:
  38. A 58-year-old man with hepatitis C cirrhosis (Child-Pugh B, MELD 16) undergoes surveillance ultrasound showing a 2.8 cm arterially enhancing hepatic nodule with portal venous washout on dynamic CT. AFP is 520 ng/mL. According to BCLC staging, this is:
  39. A 50-year-old man with hereditary hemochromatosis (HFE C282Y homozygous) has serum ferritin 1850 ng/mL and transferrin saturation 72%. He is now being treated with regular phlebotomy. What is the therapeutic target for serum ferritin?
  40. A 52-year-old man with hepatitis C cirrhosis and Child-Pugh B (score 8) develops new onset ascites. Paracentesis shows SAAG 1.4 g/dL, total protein 1.8 g/dL, WBC 400/µL (82% neutrophils). He has no fever. What is the diagnosis and first-line treatment?
  41. A 28-year-old woman presents with acute liver failure, haemolytic anaemia (Coombs negative), and Kayser-Fleischer rings. Serum caeruloplasmin is 8 mg/dL (low). Which combination of findings on liver copper studies is most characteristic of Wilson's disease presenting as acute liver failure?
  42. A 44-year-old man with MASLD (metabolic dysfunction-associated steatotic liver disease), T2DM, and obesity (BMI 34) is found to have liver biopsy-confirmed MASH (metabolic-associated steatohepatitis) with fibrosis stage F2. He asks about pharmacotherapy for liver disease per 2023–2024 FDA approvals. Which agent is the first FDA-approved drug specifically for MASH with fibrosis?
  43. A 58-year-old man with hereditary haemochromatosis (HFE C282Y homozygous) presents with serum ferritin 1850 ng/mL and transferrin saturation 82%. He has no cirrhosis on biopsy. He is initiated on phlebotomy. What is the target ferritin for maintenance phlebotomy after depletion therapy?
  44. The PRECIOSA trial and PREDESCI trial both studied non-selective beta-blockers (NSBB) in cirrhosis. The current recommendation regarding NSBBs in cirrhotic patients with refractory ascites is:
  45. A 24-year-old woman has elevated serum copper (225 μg/dL), low caeruloplasmin (8 mg/dL), 24-hour urine copper 280 μg/day, Kayser-Fleischer rings, and elevated liver enzymes. Liver biopsy shows copper deposition > 250 μg/g dry weight. The diagnosis is Wilson's disease. Which statement about its treatment is MOST accurate?
  46. The HFE gene mutation most strongly associated with hereditary haemochromatosis in Northern European populations, the resulting biochemical defect, and the approximate threshold for phlebotomy initiation are:
  47. A 50-year-old woman has autoimmune hepatitis (AIH) with interface hepatitis on biopsy, IgG 3200 mg/dL, ANA 1:640, anti-smooth muscle antibody positive. She is started on prednisolone. At 3 months, her ALT has normalised but prednisolone dose is being tapered. Which maintenance strategy reduces steroid toxicity while maintaining remission?
  48. A 45-year-old man with alcoholic cirrhosis (Child-Pugh C) presents with fever, abdominal pain, and ascites. Diagnostic paracentesis reveals PMN count 350 cells/mm³, ascitic fluid protein 1.8 g/dL, serum albumin 2.1 g/dL (SAAG 1.3 g/dL). What is the diagnosis and immediate empirical treatment?
  49. Wilson's disease presents with hepatic, neuropsychiatric, and ophthalmologic features. Which investigation is most sensitive for confirming the diagnosis in a patient with equivocal ceruloplasmin and KF rings?
  50. A 52-year-old man with compensated cirrhosis secondary to HCV infection (Child-Pugh A5) achieved sustained virological response (SVR) 2 years ago with sofosbuvir/velpatasvir. He undergoes routine hepatocellular carcinoma surveillance. HCC screening with US and AFP is recommended at which interval?
  51. Hepatic encephalopathy (HE) pathogenesis is primarily attributed to which metabolite acting on astrocytes and neurons?
  52. A 52-year-old man with alcohol-related liver cirrhosis (Child-Pugh C) develops increasing abdominal girth. Ascitic fluid analysis: protein 12 g/L, SAAG 1.5 g/dL, WBC 80 cells/mm³ with 30% neutrophils. No spontaneous bacterial peritonitis. The FIRST-LINE treatment for ascites management is:
  53. A 38-year-old woman is found to have elevated ALT/AST (5× ULN), total bilirubin 4 mg/dL, and gamma-globulin 4.8 g/dL. ANA titer is 1:640, anti-smooth muscle antibody (ASMA) positive, and IgG 3.2× ULN. Liver biopsy shows interface hepatitis with plasma cell infiltrate. The simplified AIH score (Hennes criteria) gives a score of 7. What does this indicate?
  54. A 22-year-old woman presents with jaundice, hemolytic anemia (Coombs negative), and behavioral changes. Slit-lamp examination reveals golden-brown rings at the corneal periphery. Serum ceruloplasmin is 6 mg/dL (normal 20–40). The FIRST-LINE treatment for symptomatic Wilson's disease is:
  55. A 58-year-old man with HCV genotype 1 cirrhosis (Child-Pugh A) is started on sofosbuvir/velpatasvir for 12 weeks. His treatment response is assessed by HCV RNA at 12 weeks post-treatment completion. A sustained virological response (SVR12) defined as undetectable HCV RNA at 12 weeks after treatment end achieves cure in what approximate percentage of patients with pan-genotypic direct-acting antivirals?
  56. A 45-year-old man with haemochromatosis (C282Y homozygous) is confirmed on liver biopsy. Serum ferritin is 1800 μg/L and liver iron concentration is markedly elevated. The GOLD STANDARD treatment to reduce iron overload is:
  57. A 48-year-old woman with decompensated cirrhosis (Child-Pugh C, MELD 22) is admitted with fever, abdominal pain, and confusion. Paracentesis shows ascitic fluid WBC 650 cells/µL with 80% PMN. Ascitic fluid culture grows Escherichia coli. Which statement about management is CORRECT?
  58. A 25-year-old man presents with acute hepatitis, Coombs-negative hemolytic anemia, and neuropsychiatric symptoms (personality change, dysarthria). Serum ceruloplasmin is 8 mg/dL (normal 20–40). Slit-lamp examination shows Kayser-Fleischer rings. What is the pathophysiology of hemolysis in this condition?
  59. A 50-year-old man of Northern European descent is found to have transferrin saturation of 68%, serum ferritin 1400 ng/mL, and elevated LFTs. Liver biopsy shows iron deposition predominantly in periportal hepatocytes. Genetic testing reveals C282Y homozygosity. What is the most important initial treatment?
  60. A 40-year-old woman presents with jaundice, pruritus, and fatigue. ANA 1:640, smooth muscle antibody (SMA) positive. Serum IgG 3200 mg/dL. Liver biopsy shows interface hepatitis with rosette formation and plasma cell infiltration. Which treatment is MOST appropriate?
  61. A 55-year-old man with alcoholic cirrhosis (Child-Pugh C, MELD-Na 22) presents with his second episode of spontaneous bacterial peritonitis. Ascitic fluid shows PMN count 320 cells/µL. He is started on cefotaxime. Which additional intervention has been shown in a randomised trial to reduce mortality in SBP?
  62. A 28-year-old woman presents with jaundice, Coombs-negative haemolytic anaemia, elevated transaminases (AST 480 U/L), and neuropsychiatric symptoms including dysarthria and tremor. Slit-lamp examination reveals golden-brown rings at the corneal periphery. Serum ceruloplasmin is 8 mg/dL (normal 20–35). The diagnosis is Wilson's disease. Which scoring system helps quantify organ involvement and guide treatment decisions?
  63. A 48-year-old man is found to have transferrin saturation 62% and serum ferritin 1840 ng/mL. He has mild hepatomegaly and elevated ALT 78 U/L. Genetic testing confirms homozygous C282Y mutation in HFE gene. Liver biopsy shows grade 3 hepatic iron deposition with early fibrosis. Which is the first-line treatment?
  64. A 45-year-old woman with no alcohol history, BMI 34, type 2 diabetes and hypertension has elevated transaminases. Liver biopsy shows hepatocyte ballooning, lobular inflammation, pericellular fibrosis and Mallory-Denk bodies. FIB-4 score is 3.2. The diagnosis is NASH with advanced fibrosis. Which recently FDA-approved (2024) agent directly targets hepatic steatosis and fibrosis in NASH/MAFLD?
  65. A 55-year-old man with Child-Pugh B cirrhosis develops massive hematemesis. He is resuscitated and upper GI endoscopy reveals large esophageal varices with active spurting. After endoscopic band ligation and vasoactive therapy, which agent is recommended to prevent bacterial infections in this setting as it reduces mortality?
  66. A 30-year-old man presents with acute hepatitis, hemolytic anemia (Coombs negative), neuropsychiatric symptoms, and a low serum ceruloplasmin (<10 mg/dL). Slit-lamp examination reveals Kayser-Fleischer rings. What is the mechanism of hemolysis in Wilson disease?
  67. A 48-year-old man with known cirrhosis and previous SBP is on norfloxacin prophylaxis. He presents with fever, abdominal pain, and ascites with neutrophil count of 320 cells/mm³ in diagnostic paracentesis. Blood cultures are negative. Ascitic fluid protein is >1 g/dL. What is the appropriate treatment?
  68. A 50-year-old man with hemochromatosis (HFE gene: C282Y homozygous) has serum ferritin 2400 ng/mL and transferrin saturation 78%. Liver biopsy shows grade 3 hepatic iron deposition with early bridging fibrosis but no cirrhosis. What is the treatment of choice and the goal of therapy?
  69. A 45-year-old woman presents with jaundice, pruritus, and fatigue for 6 months. ALP is 5× upper limit of normal with proportionally less elevated ALT/AST. Anti-mitochondrial antibody (AMA) is positive at 1:640 titre. Liver biopsy shows granulomatous destruction of medium-sized bile ducts with lymphocytic infiltrate. What is the first-line treatment?
  70. A 52-year-old man with alcoholic cirrhosis (Child-Pugh C, MELD 22) presents with fever, abdominal pain, and confusion. Paracentesis shows 350 PMN/µL in ascitic fluid. Blood cultures are pending. The most appropriate immediate management is:
  71. A 28-year-old woman presents with chronic hepatitis, haemolytic anaemia (Coombs-negative), psychiatric symptoms (personality change), and Kayser-Fleischer rings on slit-lamp examination. Serum ceruloplasmin is 8 mg/dL (normal 20–60). The initial treatment of choice for this condition is:
  72. A 45-year-old man with chronic hepatitis C genotype 1b is started on direct-acting antiviral therapy with sofosbuvir-ledipasvir for 12 weeks. The primary efficacy endpoint at 12 weeks post-treatment completion is:
  73. A 50-year-old man presents with diabetes, bronze skin discolouration, hepatomegaly, and arthropathy of the metacarpophalangeal joints. Serum ferritin is 2800 ng/mL and transferrin saturation is 72%. HFE gene analysis shows C282Y homozygosity. The most effective long-term treatment to prevent progression to cirrhosis is:
  74. A 48-year-old man with alcoholic cirrhosis (Child-Pugh B) is admitted with large volume ascites. Abdominal paracentesis drains 5.5 litres. Serum albumin is 2.8 g/dL. Which intervention prevents post-paracentesis circulatory dysfunction (PPCD) most effectively?
  75. A 19-year-old woman is investigated for a combination of psychiatric symptoms (lability, psychosis), liver disease (ALT 320 U/L), haemolytic anaemia (Coombs-negative), and a golden-brown ring at the corneal periphery on slit-lamp examination. Serum ceruloplasmin is 8 mg/dL. What is the MOST specific biochemical test to confirm the diagnosis?
  76. A 55-year-old man with compensated cirrhosis from HCV infection is being monitored for hepatocellular carcinoma (HCC). Ultrasound shows a new 2.2 cm arterially enhancing lesion with washout appearance on contrast-enhanced CT (LI-RADS 5). AFP is 68 ng/mL. He has no extrahepatic disease and his liver function is Child-Pugh A. What is the preferred curative treatment?
  77. A 62-year-old man with hereditary haemochromatosis (HFE C282Y homozygous) has been on regular phlebotomy therapy. His target ferritin has now been reached (<50 μg/L). He asks about alcohol use. He drinks 3 units/day. Apart from continued monitoring, which complication is he MOST at risk for in the long term if he drinks alcohol?
  78. A 52-year-old man with hepatitis C cirrhosis (Child-Pugh B) is started on sofosbuvir/ledipasvir. He achieves SVR12. His MELD score was 14 at baseline. Which statement correctly describes the expected outcome post-SVR in cirrhotic patients?
  79. A 32-year-old woman presents with acute liver failure, haemolytic anaemia with Coombs-negative haemolysis, and low serum caeruloplasmin. AST/ALT ratio is >4, alkaline phosphatase is very low. Slit-lamp examination shows Kayser-Fleischer rings. What is the most appropriate management?
  80. A 48-year-old man with hereditary haemochromatosis (HFE C282Y homozygous) has serum ferritin 1840 ng/mL and transferrin saturation 72%. He has no symptoms and liver biopsy shows grade 2 fibrosis (hepatic iron index 4.8). What is the cornerstone of treatment and frequency of monitoring phlebotomy?
  81. A cirrhotic patient with MELD score 18 develops ascites refractory to maximally tolerated diuretics. He is not a transplant candidate currently. What procedure is indicated and what is the key complication to prevent pharmacologically?
  82. A 52-year-old man with Child-Pugh B cirrhosis (score 8) secondary to alcohol presents with large volume ascites. Paracentesis of 6 litres is performed. Albumin infusion of 8 g per litre of ascites removed should be administered post-procedure. Total albumin required for this procedure is:
  83. A 32-year-old woman presents with haemolytic anaemia, elevated serum ferritin, low ceruloplasmin, and elevated 24-hour urine copper (480 µg/day). Slit-lamp examination reveals Kayser-Fleischer rings. She has a serum copper of 28 µg/dL (reference >70 µg/dL) and elevated free copper. Liver biopsy shows copper >250 µg/g dry weight. She is asymptomatic neurologically. First-line treatment is:
  84. A 44-year-old man with compensated cirrhosis from chronic hepatitis C (genotype 1b) is treated with glecaprevir/pibrentasvir (8-week regimen). At end of treatment and 12 weeks post-treatment, HCV RNA is undetectable. This is defined as:
  85. A 58-year-old man with alcoholic cirrhosis develops spontaneous bacterial peritonitis (SBP). Ascitic fluid PMN count is 280 cells/µL. Blood cultures are negative. The preferred antibiotic and the key adjunctive therapy to prevent hepatorenal syndrome in this patient are:
  86. A 48-year-old woman with autoimmune hepatitis on azathioprine 100 mg/day and prednisolone 5 mg/day has been in histological remission for 3 years. She requests withdrawal of therapy. What is the major risk on drug withdrawal and how should it be managed?
  87. A 32-year-old man presents with acute liver failure, haemolytic anaemia, neuropsychiatric symptoms, and Kayser-Fleischer rings. Serum ceruloplasmin is 10 mg/dL (reference: 20–60). Which treatment is the definitive long-term option for Wilson's disease?
  88. A 55-year-old man with haemochromatosis (HFE C282Y homozygous, ferritin 2400 ng/mL, transferrin saturation 78%) has been treated with weekly phlebotomy for 18 months. Which ferritin target indicates adequate iron depletion therapy?
  89. In a patient with decompensated cirrhosis and ascites, which investigation is mandatory before starting empirical antibiotic treatment for suspected spontaneous bacterial peritonitis (SBP)?
  90. A 55-year-old man with hepatitis C cirrhosis (Child-Pugh A) achieves sustained virological response (SVR12) after DAA therapy. Three years later, surveillance ultrasound reveals a 2.2 cm arterially enhancing nodule with washout on portal venous phase. AFP is 45 ng/mL. LI-RADS category is LR-5. What is the appropriate management?
  91. A 45-year-old man with autoimmune hepatitis (AIH) achieves biochemical remission on azathioprine 100 mg/day + prednisolone 5 mg/day. After 3 years of remission, a liver biopsy shows histological remission (minimal inflammatory activity, no fibrosis). He asks about stopping therapy. What is the correct counselling?
  92. A 30-year-old woman presents with hemolytic anemia, liver cirrhosis, psychiatric symptoms, and Kayser-Fleischer rings on slit-lamp examination. Serum ceruloplasmin is 8 mg/dL (low). Which investigation confirms the diagnosis of Wilson's disease in the setting of this clinical suspicion?
  93. A 55-year-old man with decompensated cirrhosis (Child-Pugh C) develops acute kidney injury with creatinine rising from 0.9 to 3.2 mg/dL over 5 days. Urine sodium is 8 mEq/L, urine osmolality higher than plasma. No response to albumin challenge for 48 hours. Ultrasound shows no obstruction. Urinalysis is bland. What is the diagnosis and first-line treatment?
  94. A 28-year-old woman presents with acute hepatitis, Coombs-negative haemolytic anaemia, neuropsychiatric symptoms, and Kayser-Fleischer rings. Serum ceruloplasmin is 8 mg/dL (low). Which of the following features on liver histology is most characteristic of Wilson's disease?
  95. A 60-year-old man with hereditary haemochromatosis (C282Y homozygous) and cirrhosis has AFP rising from 12 to 340 ng/mL over 3 months. Triphasic CT shows a 3.2 cm arterially enhancing liver lesion with washout. What is the most appropriate next step?
  96. A patient with autoimmune hepatitis (AIH) achieves remission on prednisolone and azathioprine. After 3 years, liver biopsy is repeated showing no inflammatory activity and normal liver enzymes for 2 years. What is the recommended next step regarding immunosuppression?
  97. A 48-year-old man with alcohol-related cirrhosis presents with sudden-onset fever, abdominal pain, and altered mental status. Paracentesis shows ascitic fluid PMN count 320/mm³, ascitic fluid culture negative. Serum-ascites albumin gradient (SAAG) is 1.8 g/dL. What is the diagnosis and treatment?
  98. A 38-year-old man presents with acute liver failure (encephalopathy, INR 3.2) 10 days after starting isoniazid for LTBI. What is the MOST important immediate management step?
  99. A 44-year-old woman with autoimmune hepatitis is in remission on azathioprine 1.5 mg/kg/day. She wishes to conceive. What is the safest approach?
  100. A 52-year-old man with HCV genotype 1b infection and compensated cirrhosis (Child-Pugh A) is being evaluated for direct-acting antiviral (DAA) therapy. Which DAA regimen is appropriate and what is the expected sustained virological response (SVR) rate?
  101. A 48-year-old man with alcohol-related cirrhosis and Child-Pugh B presents with his second episode of spontaneous bacterial peritonitis (SBP). He survives with norfloxacin prophylaxis started. Creatinine is 1.1 mg/dL. What additional agent should be started given the high 1-year mortality risk?
  102. A 30-year-old woman presents with abnormal liver enzymes (AST 280, ALT 340 U/L), serum immunoglobulin G 28 g/L, positive anti-smooth muscle antibody titre 1:160, and no history of hepatotoxin exposure. Liver biopsy shows interface hepatitis with plasma cell infiltration. What is the first-line treatment?
  103. A 22-year-old man presents with tremor, dysarthria, psychiatric symptoms, and elevated serum copper. Slit-lamp examination reveals Kayser-Fleischer rings. Serum ceruloplasmin is 8 mg/dL. He is diagnosed with Wilson's disease. Which initial treatment is preferred for symptomatic Wilson's disease with neurological involvement?
  104. A 52-year-old man with hereditary haemochromatosis (C282Y homozygous) presents with bronzed skin, diabetes, and cirrhosis. Serum ferritin is 4200 µg/L. He has no cardiac involvement. What is the treatment of choice?
  105. A 40-year-old woman has autoimmune hepatitis (AIH) and cirrhosis. She is on azathioprine 75 mg/day and prednisolone 5 mg/day. Her TPMT enzyme activity is low (detected retrospectively). She develops pancytopenia. What is the mechanism of azathioprine toxicity in this context?
  106. A 25-year-old man has progressive neurological symptoms (dysarthria, tremor, psychiatric changes), hepatic dysfunction, and Kayser-Fleischer rings on slit-lamp. Serum ceruloplasmin is 8 mg/dL (low) and 24-hour urine copper is 280 µg/day (elevated). Which finding in Wilson's disease is most sensitive for the diagnosis when ceruloplasmin is normal?
  107. A cirrhotic patient (Child-Pugh B) develops ascites. He is treated with spironolactone and furosemide. After 8 weeks, ascites persists despite doses of spironolactone 400 mg/day and furosemide 160 mg/day. Serum creatinine is rising. What is the next best step?
  108. A 55-year-old man with HCV cirrhosis develops hepatorenal syndrome type 1 (HRS-AKI) — serum creatinine rises from 0.9 to 2.8 mg/dL in 48 hours without response to 2 days of albumin. Urine sodium is 8 mEq/L. Which vasopressor therapy combined with albumin is the standard medical bridge therapy in HRS-AKI?
  109. A 38-year-old man with Child-Pugh B cirrhosis develops large-volume ascites. He is started on spironolactone 100 mg and furosemide 40 mg with restricted sodium intake. After 4 weeks, serum sodium is 128 mEq/L, potassium 3.2 mEq/L, and ascites persist. Which adjustment is MOST appropriate?
  110. A 29-year-old woman presents with acute liver failure, Coombs-negative haemolytic anaemia, neuropsychiatric symptoms, and serum ceruloplasmin 12 mg/dL. Slit-lamp examination shows Kayser-Fleischer rings. The MOST appropriate immediate pharmacological treatment is:
  111. A 55-year-old man has chronic hepatitis C (genotype 1b), cirrhosis (Child-Pugh A), and an AFP 320 ng/mL. Ultrasound shows a 3.2 cm single hepatic lesion with arterial enhancement and portal venous washout on dynamic CT. No vascular invasion or extra-hepatic spread. BCLC staging and PREFERRED treatment are:
  112. Hereditary haemochromatosis most commonly results from which mutation, and which HFE genotype accounts for the majority of cases in Northern European populations?
  113. A 48-year-old woman with autoimmune hepatitis (anti-smooth muscle antibody positive, IgG 2800 mg/dL) achieves biochemical remission on azathioprine and prednisolone. Her liver biopsy at 2 years shows no histological activity. Prednisolone is tapered off. What is the standard recommendation regarding azathioprine?
  114. A 52-year-old man with Child-Pugh B cirrhosis (alcohol) develops increasing ascites. Diagnostic paracentesis shows: serum-ascites albumin gradient (SAAG) 1.4 g/dL, protein 15 g/dL, WBC 350 cells/mm³ with 320 PMN/mm³. Temperature is 38.4°C. Cultures pending. MOST appropriate management is:
  115. A 30-year-old man has decompensated liver disease with Kayser-Fleischer rings and serum ceruloplasmin 8 mg/dL (normal 20-60). He has haemolytic anaemia and psychiatric symptoms. He is diagnosed with Wilson's disease. MELD score is 28. Which statement about treatment is MOST accurate?
  116. In the staging of hepatic fibrosis, a FibroScan (transient elastography) value of 18 kPa in a patient with chronic hepatitis C correlates with which Metavir stage?
  117. A 48-year-old woman with autoimmune hepatitis (AIH) type 1 (ANA+, anti-SMA+) is on azathioprine 1.5 mg/kg/day and prednisolone 5 mg/day with normal ALT in remission. She now needs long-term management. Which parameter is MOST important to check before dose adjustment of azathioprine?
  118. A 50-year-old man with hepatitis C-related cirrhosis (Child-Pugh B) develops fever, abdominal pain, and confusion. Ascitic fluid shows 480 PMN/µL. He is started on cefotaxime. What must be co-administered to prevent hepatorenal syndrome?
  119. A 30-year-old woman presents with acute liver failure, hemolytic anemia (Coombs-negative), neuropsychiatric symptoms, and a Kayser-Fleischer ring visible on slit-lamp. Serum ceruloplasmin is 8 mg/dL (low). Urinary copper is 1800 µg/24h. She is deeply jaundiced with INR 4.8. What is the definitive treatment?
  120. A 40-year-old man with hereditary hemochromatosis (HFE C282Y homozygous) undergoes liver biopsy due to elevated ferritin (2800 ng/mL). Biopsy shows hepatic iron concentration (HIC) 380 µmol/g dry weight and hepatic iron index (HII) 6.1, with mild fibrosis (F2). What is the target of phlebotomy therapy?
  121. A 55-year-old woman with autoimmune hepatitis (AIH) on prednisolone 5 mg + azathioprine 100 mg achieves biochemical remission (normal ALT, IgG). She has been in remission for 3 years. Liver biopsy is performed and shows minimal interface hepatitis (HAI 3/18). What is the next appropriate management step?
  122. A 45-year-old man with alcohol-related cirrhosis presents with worsening ascites. Diagnostic paracentesis shows ascitic fluid: total protein 2.8 g/dL, SAAG 1.3 g/dL. Two weeks ago he had a SAAG of 1.2 g/dL. He is now febrile with abdominal pain. Diagnostic criteria for spontaneous bacterial peritonitis (SBP) include:
  123. A 35-year-old woman presents with elevated transaminases, elevated serum IgG (2800 mg/dL), positive ANA (1:320) and anti-smooth muscle antibody (ASMA), and liver biopsy showing interface hepatitis with plasma cell infiltration and rosette formation. She is diagnosed with autoimmune hepatitis (AIH). Her simplified AIH score (Hennes criteria) is 8, indicating definite AIH. First-line treatment includes:
  124. A 24-year-old man presents with tremor, dysarthria, psychiatric symptoms, and Kayser-Fleischer rings. Serum ceruloplasmin is 8 mg/dL (low). 24-hour urinary copper is 180 μg/day (elevated). He is diagnosed with Wilson's disease. The PREFERRED treatment for the neurological presentation is:
  125. A 50-year-old man with hereditary haemochromatosis (HFE gene C282Y homozygous) has ferritin 2400 ng/mL, transferrin saturation 78%, and serum ALT 68 IU/L. Liver MRI shows T2* signal loss consistent with hepatic iron overload. He is asymptomatic. The BEST initial treatment is:
  126. In spontaneous bacterial peritonitis (SBP), which diagnostic ascitic fluid finding confirms the diagnosis and mandates empirical antibiotic therapy even without a positive culture?
  127. In Wilson's disease, the Kayser-Fleischer ring is absent in which major hepatic presentation, making ophthalmic slit-lamp examination unreliable as a sole diagnostic test?
  128. A 45-year-old man with hereditary hemochromatosis (HFE C282Y homozygous) has serum ferritin 1800 µg/L and transferrin saturation 72%. He is asymptomatic with normal LFTs. What is the recommended treatment?
  129. The Model for End-Stage Liver Disease (MELD) score is now the standard for liver transplant prioritisation. The MELD-Na score adds serum sodium because hyponatraemia independently predicts which adverse outcome?
  130. A 48-year-old man with decompensated cirrhosis (Child-Pugh C) develops spontaneous bacterial peritonitis (SBP). Ascitic fluid PMN count is 310 cells/mm³. Serum creatinine is 1.3 mg/dL. Which additional treatment alongside antibiotics has been shown to reduce mortality and prevent hepatorenal syndrome?
  131. In Wilson's disease, which mutation type is most commonly found in European patients and in which gene?
  132. A 35-year-old woman is diagnosed with autoimmune hepatitis (AIH). Liver biopsy shows interface hepatitis with plasma cell infiltration. ALT is 620 U/L and IgG is 28 g/L. She is started on prednisolone. After 4 weeks her ALT remains at 310 U/L. What is the standard add-on immunosuppressive therapy at this stage?
  133. A 48-year-old cirrhotic patient (Child-Pugh B, ascites controlled on spironolactone 200 mg, MELD score 14) develops confusion, asterixis, and day-night reversal. Serum ammonia is 148 µg/dL. He experienced a GI bleed 3 days ago. Which precipitant and primary treatment principle applies here?
  134. A 36-year-old woman is diagnosed with autoimmune hepatitis (AIH) type 1 (ANA positive, ASMA positive, IgG 2.6 × ULN, interface hepatitis on biopsy). She achieves biochemical remission on azathioprine 100 mg/day and prednisone 5 mg/day after 2 years. How long should maintenance therapy continue and when is treatment withdrawal considered?
  135. A 22-year-old student presents with acute hepatitis (bilirubin 12 mg/dL, ALT 980 U/L), haemolytic anaemia (Hb 7.8 g/dL, negative Coombs test), kayser-Fleischer rings on slit lamp, serum caeruloplasmin 8 mg/dL, and 24-hour urinary copper 980 µg/day. Liver biopsy shows massive hepatic copper accumulation. The MOST dangerous pharmacological interaction to avoid in the acute management of Wilson's disease is:
  136. A 52-year-old man with known hepatitis B (HBsAg positive, HBeAg negative, HBV DNA 38,000 IU/mL, ALT 84 U/L, liver biopsy Metavir F2-F3) requires antiviral therapy. His wife is pregnant and will deliver in 8 weeks. Considering both indications, the preferred antiviral is:
  137. A 48-year-old woman with primary biliary cholangitis (PBC) and pruritus fails to respond to ursodeoxycholic acid (UDCA) after 1 year (inadequate biochemical response by Paris criteria). What is the MOST appropriate add-on therapy per current guidelines?
  138. In acute hepatic decompensation of Wilson's disease presenting with Coombs-negative hemolytic anemia, liver failure, and low ceruloplasmin, which parameter from the Wilson's Index (Nazer score) indicates need for urgent liver transplantation?
  139. A 55-year-old man with HCV cirrhosis (Child-Pugh B) develops hepatorenal syndrome type 1 (HRS-1). Creatinine rises from 0.8 to 2.4 mg/dL over 48 hours. What is the MOST appropriate pharmacological treatment?
  140. Hereditary hemochromatosis is most commonly caused by a C282Y mutation in the HFE gene. A homozygous C282Y patient with ferritin 850 ng/mL and transferrin saturation 72% is asymptomatic. What is the target ferritin level during phlebotomy therapy?
  141. A 45-year-old woman with autoimmune hepatitis on azathioprine 100 mg/day and prednisolone 5 mg/day has sustained remission (normal transaminases, normal IgG) for 3 years. She asks about withdrawing therapy. Liver biopsy shows minimal interface hepatitis. What is the relapse rate after azathioprine withdrawal in autoimmune hepatitis achieving biochemical and histological remission?
  142. A 38-year-old man is referred for persistently elevated serum ferritin of 2,400 ng/mL and transferrin saturation of 72% over 6 months. He has no alcohol history. HFE gene testing shows he is homozygous for C282Y mutation. Liver biopsy shows hepatic iron concentration (HIC) of 220 µmol/g dry weight (normal < 36). The hepatic iron index (HII = HIC/age in years) is calculated. What HII value confirms hereditary haemochromatosis (HH)?
  143. A 52-year-old man with decompensated cirrhosis (Child-Pugh C, MELD-Na 22) develops spontaneous bacterial peritonitis (SBP). Ascitic fluid PMN count is 380/µL. He is started on IV cefotaxime 2g every 8 hours. Which intervention significantly reduces the risk of hepatorenal syndrome (HRS) in this setting?
  144. A 19-year-old woman presents with acute hepatitis (AST 1200 U/L, ALT 980 U/L, ALP 45 U/L — disproportionately low), Coombs-negative haemolytic anaemia, and neuropsychiatric symptoms. Serum ceruloplasmin is 8 mg/dL (low). Kayser-Fleischer rings are absent on slit-lamp examination. Which SINGLE investigation would MOST definitively confirm Wilson's disease in this presentation?
  145. A 45-year-old man with alcoholic cirrhosis develops acute kidney injury (creatinine rise from 0.9 to 2.8 mg/dL over 48 hours). Urine sodium is <10 mEq/L, urinary sediment is bland. Urine output is reduced. Volume challenge with albumin 1 g/kg (max 100 g) over 48 hours does not improve renal function. The MOST likely diagnosis is:
  146. Kayser-Fleischer rings in Wilson's disease are best detected by:
  147. A 50-year-old man presents with elevated liver enzymes, bronze skin pigmentation, joint pain in MCPs, and reduced libido. Serum transferrin saturation is 72%, ferritin 2800 µg/L. HFE gene testing confirms C282Y homozygosity. Which complication is the leading cause of death in treated hereditary haemochromatosis?
  148. A 32-year-old woman is diagnosed with autoimmune hepatitis type 1 (ANA+, anti-SMA+, elevated IgG, interface hepatitis on biopsy). She is started on prednisolone and azathioprine. Her ALT normalises at 6 months. What defines COMPLETE remission in autoimmune hepatitis?
  149. A 45-year-old man with Child-Pugh C cirrhosis develops acute-on-chronic liver failure (ACLF) precipitated by bacterial infection. Which scoring system is MOST validated for short-term mortality prediction in ACLF?
  150. A 30-year-old woman presents with acute hepatitis, neuropsychiatric symptoms, and a golden-brown ring around the corneal limbus on slit-lamp examination. Serum caeruloplasmin is 6 mg/dL (normal 20-40). What is the MOST appropriate long-term treatment?
  151. A 55-year-old man with alcoholic cirrhosis presents with acute tense ascites. He is treated with large-volume paracentesis (5 litres). Which intervention MUST accompany this procedure to prevent post-paracentesis circulatory dysfunction?
  152. A 48-year-old man with hereditary haemochromatosis (HFE C282Y homozygous) has serum ferritin 2,400 ng/mL, transferrin saturation 82%, and liver biopsy showing hepatic iron index of 2.1 with bridging fibrosis. What is the FIRST-LINE treatment?
  153. A patient with hepatitis C virus (HCV) genotype 1 infection and compensated cirrhosis is started on sofosbuvir/ledipasvir for 12 weeks. Which baseline factor most significantly increases the risk of treatment failure with this regimen?
  154. A 52-year-old man with Child-Pugh B cirrhosis from alcohol (abstinent 8 months) develops worsening ascites and peripheral edema. Paracentesis shows SAAG 1.8 g/dL. He is started on spironolactone 100 mg and furosemide 40 mg daily. After 5 days, he is not losing weight and ascites persists. Serum creatinine is stable at 1.0 mg/dL, and serum potassium is 4.2 mEq/L. The next step is:
  155. A 30-year-old asymptomatic man is found to have serum bilirubin of 3.2 mg/dL (indirect 2.8, direct 0.4) on a routine preoperative check. All other LFTs including ALT, AST, and ALP are normal. CBC, reticulocyte count, and peripheral smear are normal. The bilirubin rises significantly with fasting and returns to normal with caloric intake. The diagnosis is:
Sponsored

Practise this topic as a timed set and track your accuracy.

Create a free account →