HEPATOBILIARY EXAM

1. The following parameters are components of the Child Pugh score, except:
A. Serum bilirubin
B. Serum albumin
C. Serum creatinine
D. Prothrombin time

2. The stigmata of liver cirrhosis include all of the following except:

A. Testicular atrophy
B. Spider angiomata
C. Gynecomastia
D. Esophageal varices

3. Which of the following hepatitis virus causes the most cases of chronic liver
disease in humans?
A. hepatitis A
B. hepatitis B
C. hepatitis C
D. hepatitis D

4. A middle-aged man presents with tiredness, itchiness, weakness, loss of

appetite, and weight loss. Physical examination reveals the presence of spider
telangiectasias, palmar erythema, Dupuytren's contractures, gynecomastia, and
testicular atrophy. Laboratory results are AST 100 U/L and ALT 150 U/L. Levels
of which of the following is likely to be decreased?
A. Ammonia
B. Iron
C. Bilirubin
D. Albumin

5. A 56-year-old male patient presented with symptoms of intermittent episodes of

constant, sharp, right upper quadrant (RUQ) abdominal pain associated with
nausea and vomiting, normal physical examination findings, and normal laboratory
test results. Which of the following is pertinent to the underlying
pathophysiological?
A. Disproportionately higher branched amino-acid intake
B. Microangiopathy in the common bile duct microvasculature
C. Hyperuricemia
D. Cholesterol supersaturation mechanism
6. Which of the following would present with an elevated AFP?
A. prostate cancer
B. cirrhosis
C. ovarian germ cell tumor
D both B and C

7. A 28-year-old pregnant woman at 16 weeks gestation comes to the office due to

fatigue, intermittent joint pains, and loss of appetite for several months. Her past
medical history is unremarkable. She does not use tobacco, alcohol, or any other
illicit drugs. She has multiple sexual partners and does not use condoms regularly.
Her laboratory values show elevated serum aspartate aminotransferase and alanine
aminotransferase. Her serologic markers are positive for hepatitis B infection.
Which of the following markers has the strongest associated with viral replication
and increased infectivity in this patient?
A. HBcAg
B. Anti-HBsAg
C. HBeAg
D. HBcAg

8. A 54-year-old woman with a history of hepatitis C presents to the clinic for a

rash that developed over the past two weeks. Physical examination reveals
purplish, intensely itchy lesions on her forearm and ankles. Which of the following
best describes the most likely prognosis of these lesions
A. Resolution with the treatment of the infection
B. Gradual worsening over time
C. Malignant transformation
D. Ulceration

9. A 30-year-old woman tests positive for hepatitis C when she undergoes

screening for blood-borne infection at a blood donation camp. She presents to her
primary care provider with the results, asking about the natural course of the
disease. What is the most common presentation of the patients infected with
hepatitis C?
A. Jaundice
B. Without symptoms
C. Liver failure
D. Erythema nodosum
10. A patient presents with the following serologic pattern: HBsAG reactive, Anti-
HAV IgM reactive, anti-HBC IgG positive. The patient is most likely suffering
from?
A. Acute hepatits A and B
B. Acute hepatitis B
C. Acute Hepatitis A
D. Acute hepatitis A superimposed on Chronic Hepatitis B

11. Which of the following is a poor prognostic indicator for alcoholic hepatitis?
A. Discriminant function of 28
B. Prolonged PT
C. Total bilirubin of 18mg/dl
D. AST > 400U/L

12. A 53-year-old man presents with a three-month history of fatigue, weakness,

generalized itching, anorexia, and weight loss. He has no significant past medical
history, takes no medication, and does not smoke or drink alcohol. Physical
examination shows spider telangiectasias, palmar erythema, Dupuytren
contractures, and testicular atrophy. Laboratory testing reveals an aspartate
aminotransferase (AST) level of 135 U/L and an alanine aminotransferase (ALT)
level of 160 U/L. The upper limit of normal for both aminotransferases for this lab
is 45 U/L. Serum bilirubin is 2.4 mg/dL, and platelet count is 120000/mm3.
Hepatitis C antibodies are positive. Hepatitis B and HIV antibodies are negative.
What is the aspartate aminotransferase (AST) to platelet ratio index (APRI) score
for this patient?
A. 0.125
B. 1.125
C. 2.5
D. 3.9

13. A patient with complete biliary obstruction developed bleeding tendencies.

Which of the following parameters may be prolonged?
A. Partial thromboplastin time
B. Prothrombin time
C. Bleeding time
D. A and B

14. Which of the following is best for monitoring therapeutic response in liver
cancer?
A. AFP
B. CEA
C. CA 19-9
D. CA 125

15. What is the standard immunization schedule for primary Hepatitis B

vaccination among adults? A. 0, 1 and 6 months from initial vaccination
B. 0, 1 and 2 months (4 weeks interval)
C. 0, 6 and 12 months (6 months interval)
D. 0, 1 and 2 months plus a booster dose after 1 year of the last dose

16. A 35-year-old man presents to the clinic with complaints of anorexia, mild
fatigue, intermittent nausea and vomiting, and low-grade fever. He just recently
traveled 2 weeks before to the United States from Nigeria to attend a wedding in
the family. Workup is done, and labs return unremarkable. Hepatitis panel is
checked and comes back positive for IgM antibodies to the hepatitis A virus. What
is the best initial step in the management of this patient?
A. Reassurance
B. Immediate hospitalization
C. Serum IgG titer for hepatitis A
D. Tenofovir

17. 30 year old male patient developed bipedal edema and hypertension. Work-up
revealed hypoalbuminemia, proteinuria, hematuria and hypercholesterolemia.
Liver enzymes are normal. Renal biopsy revealed uniform thickening of the
basement membrane along the peripheral capillary loops seen by light microscopy.
Subepithelial deposits are seen in electron microscopy. This condition is associated
with which of the following?
A. Schistosomiasis
B. Gastric cancer
C. Hepatitis B
D. All of the above

18. If a virus invaded a liver cell, that liver cell would

A. Display fragments of viral proteins on its MHC I protein
B. Display fragments of viral proteins on its MHC II protein
C. Begin making viral proteins and nucleic acids (e.g., DNA, RNA).
D. Both A and C

19. In a patient suspected of hepatitis B, what laboratory parameter is the earliest

indicator?
A. HBsAg
B. Anti-HBc IgM
C. Anti-HBeAg
D. ALT and AST

20. A 65-year-old female with a past medical history of hypertension, type 2

diabetes mellitus, and hyperlipidemia presents to her clinician for a regular follow-
up. The patient has an established diagnosis of non-alcoholic steatohepatitis
(NASH)-related cirrhosis. What is the most common cause of mortality in NASH-
related cirrhosis?
A. Hepatocellular carcinoma
B. End-stage liver disease
C. Cardiovascular disease
D. End-stage renal disease

21. A person who has been vaccinated against Hepatitis B will have a reactive
serologic test to
A. HBsAg
B. Anti-HBs
C. HBeAg
D. Anti-HBe

22. What are the boundaries of the triangle of Calot?

A. Cystic duct, common hepatic duct, inferior border of the liver
B. Cystic duct, common hepatic duct, common bile duct
C. Common bile duct, common hepatic duct, inferior margin of the liver
D. Cystic duct, common bile duct, inferior border of the liver

23. What is the single most common risk factor for hepatitis C?
A. Injection drug use
B. hemodialysis
C. Promiscuous activity
D. Maternal-fetal transmission
E. Unprotected sex

24. A 32 year-old man was found to have chronic fatigue and AST elevations 4x
the upper limit. He had a series of blood transfusions 4 years ago in a secondary
hospital in a remote island due to vehicular trauma. Vascular biopsy was done and
showed polyarteritis. Which of the following is the most likely cause of his
condition?
A. Hepatitis A
B. Hepatitis B
C. Hepatitis C
D. Hepatitis D

25. Which of the following is a posthepatic etiology for portal hypertension?

A. Congenital hepatic fibrosis
B. Alcoholic liver cirrhosis
C. Schistosomiasis
D. Budd-Chiari syndrome

26. Which of the following are absolute contraindications of liver transplantation

except?
A. untreated sepsis
B. alcohol abuse
C. 72 years old
D. congestive heart failure

27. A 40-year-old obese female presents for a routine follow up to her primary care
provider. She reported increasing fatigue for the last year. On physical examination
the patient was afebrile, heart rate was 71 bpm, blood pressure was 120/76 mm Hg
and RR of 10/min. The patient is currently not taking any medications. The patient
denied smoking, alcohol or any other illicit drug use. Labs showed hemoglobin -11
g/dl, WBC- 6000/microL, platelet- 320,000, microL, AST -160 u/L, ALT -100 u/L,
ALP -70 u/L, total bilirubin -0.8 mg/dL, hepatitis panel -negative, and iron panel -
normal. A liver biopsy was done. What is the finding on the biopsy?
A. Bridging necrosis and interface hepatitis
B. Periportal iron accumulation
C. Macrovesicular steatosis
D. Periductal concentric fibrosis

28. A patient came in to your clinic for the interpretation of his hepatitis profile
you noted that Anti-Hbc IgM is positive, what does it mean?
A. The patient is actively replicating Hepa B virus
B. The patient is at the window preiod following 6 months of acute infection
C. The patient has recovered from Hepa B
D. The patient was immunized before E. It is insignificant

29. A 57 year old alcoholic with chronic liver disease presents with dyspnea that
worsens on moving from supine to upright position. This was supported by the
finding of decreased O2 saturation on pulse oximetry when moving from supine to
upright position. What is treatment of choice for this condition?
A. Liver transplantation
B. Continuous O2 support
C. Long acting Beta 2 agonist
D. Tiotropium

30. Given the following clicical picture: (+) HbsAg, (- )anti-Hbs, (+) anti-Hbc IgG,
(-) HbeAg, (+) anti-Hbe, (+) anti-HbA IgG, (+) anti-HbC, what is the diagnosis?
A. Past Hepatitis A infection, Chronic Hepatitis B carrier, Hepatitis C infection
B. Acute Hepatitis A infection, Chronic Hepatitis B carrier, Hepatitis C infection
C. Past Hepatitis A infection, Chronic Active Hepatitis B, Hepatitis C infection
D. Acute Hepatitis A infection, Chronic Hepatitis B carrier, Resolved Hepatitis C
infection

31. A liver function panel shows: NORMAL AST, ALT, and LDH; LOW total
protein and albumin; HIGH bilirubin and ammonia. The most likely hepatic
condition based on these lab results pattern is:
A. Hepatitis
B. Biliary obstruction
C. Passive hepatic congestion
D. Cirrhosis

32. This is the single BEST acute measure of hepatic synthetic function and helpful
in both the diagnosis and assessing prognosis of acute parenchymal liver disease
A. Total albumin
B. Coagulation factors
C. AST
D. ALT

33. A 56-year-old patient with advanced alcoholic cirrhosis and known ascites is
found to have abdominal pain, fever to 102 F, and a peripheral white blood cell
count of 17,000 with a shift to the left. Which of the following statements
regarding the primary diagnosis is correct?
A. It is more likely when ascitic fluid total protein exceeds 1 mg/dL.
B. It develops in the setting of preexisting ascites.
C. The ascitic polymorphonuclear count is less than 100 cells/mm3.
D. It is often associated with aspergillosis.

34. Transfusion-associated Viral Hepatitis is due to:

A. Hepatitis A
B. Hepatitis B
C. Hepatitis C
D. Hepatitis D

35. The liver enzyme test of a 41 year old female patient with jaundice revealed the
following results: AST= 40 IU/L, ALT= 55 IU/L, alkaline phosphatase and
gamma-glutamyl transpeptidase are elevated. What should you request next?
A. serum albumin
B. ultrasound
C. liver biopsy
D. prothrombin time

36. A nurse working in the hospital is accidentally stuck by a needle while drawing
blood from a patient. In which scenario is this nurse at the most significant risk of
an acute infection?
A. The nurse is hepatitis B surface antibody positive.
B. The patient is hepatitis B core antibody positive.
C. The nurse is hepatitis B surface antibody negative.
D. The patient is hepatitis B surface antigen negative.

37. In a patient suspected of hepatitis B, what laboratory parameter is the earliest

indicator?
A. HBsAg
B. Anti-HBc IgM
C. Anti-HBeAg
D. ALT and AST

38. A 28-year-old pregnant woman at 16 weeks gestation comes to the office due
to fatigue, intermittent joint pains, and loss of appetite for several months. Her past
medical history is unremarkable. She does not use tobacco, alcohol, or any other
illicit drugs. She has multiple sexual partners and does not use condoms regularly.
Her laboratory values show elevated serum aspartate aminotransferase and alanine
aminotransferase. Her serologic markers are positive for hepatitis B infection.
Which of the following markers has the strongest associated with viral replication
and increased infectivity in this patient?
A. HBcAg
B. Anti-HBsAg
C. HBeAg
D. HBcAg
39 Patients with liver cirrhosis develop edema and ascites due to
A. Decreased plasma oncotic pressure
B. Increased capillary hydrostatic pressure
C. Increased interstitial oncotic pressure
D. Decreased interstitial hydrostatic pressure

40. The liver has several functions including the storage of vitamin A and other fat
soluble vitamins. This is specifically a function of the Ito Cells which are found in
the:
A. Sinusoids
B. Bile canaliculi
C. Principal parenchyma cell
D. Space of disse

Answer Keys:
1. C
2. D
3. C
4. D
5. D
6. D
7. C
8. A
9. B
10.C
11.B
12.C
13.D
14.A
15.A
16.A
17.D
18.D
19.A
20.C
21.B
22.A
23.A
24.B
25.D
26.C
27.C
28.B
29.A
30.A
31.D
32.B
33.B
34.C
35.B
36.D
37.A
38.C
39.A
40.D