1. Liver Disease tutoring Part 2
By Alaina Darby

2. JR is 44 yo wm with a history of alcohol abuse and cirrhosis
JR is 44 yo wm with a history of alcohol abuse and cirrhosis. Which of the following is the most likely lethal complication in this patient?
Encephalopathy
Coagulopathy
Variceal bleeding
Ascites c

3. JR is 44 yo wm with a history of alcohol abuse and cirrhosis
JR is 44 yo wm with a history of alcohol abuse and cirrhosis. His hr is 94 and bp is 120/80 and HVPG is 13. What should be done now?
Give fluids
EGD
Give nadolol
Give propranolol b

4. JR is 44 yo wm with a history of alcohol abuse and cirrhosis
JR is 44 yo wm with a history of alcohol abuse and cirrhosis. His hr is 94 and bp is 120/80 and HVPG is 13. His EGD shows varices. What should be done now?
Give propranolol PO to target HR <100
Give propranolol PO to target HPVG <12
Give propranolol IV to target HR <100
Give propranolol IV to target HPVG <12
b… primary prophylaxis!!

5. JR is 44 yo wm with a history of alcohol abuse and cirrhosis
JR is 44 yo wm with a history of alcohol abuse and cirrhosis. He has developed bloody emesis. Now His hr is 122 and bp is 100/62 and HVPG is 13. What should you do first?
Give antibiotics
Give vasopressin
EGD
Give fluids d

6. JR is 44 yo wm with a history of alcohol abuse and cirrhosis
JR is 44 yo wm with a history of alcohol abuse and cirrhosis. He has developed bloody emesis Now His hr is 122 and bp is 100/62 and HVPG is 13. his bp corrects to 128/89 with fluid administration. What should you use as pharmacological management?
Give antibiotics + octreotide + nitroglycerin
Give antibiotics + vasopressin + nitroglycerin
Give octreotide + nitroglycerin
Give octreotide + vasopressin b

7. JR is 44 yo wm with a history of alcohol abuse and cirrhosis
JR is 44 yo wm with a history of alcohol abuse and cirrhosis. He has developed bloody emesis Now His hr is 122 and bp is 100/62 and HVPG is 13. his bp corrects to 128/89 with fluid administration. Which of the following antibiotics would you consider?
Cetriaxone 1g IV Q day
Norfloxacin 400mg IV Q12
Ciprofloxacin 400mg PO BID
Levofloxacin 500mg PO BID a

8. JR is 44 yo wm with a history of alcohol abuse and cirrhosis
JR is 44 yo wm with a history of alcohol abuse and cirrhosis. He has developed bloody emesis Now His hr is 122 and bp is 100/62 and HVPG is 13. his bp corrects to 128/89 with fluid administration. How long should he receive antibiotics?
3 days
7 days
10 days
28 days b

9. JR is 44 yo wm with a history of alcohol abuse and cirrhosis
JR is 44 yo wm with a history of alcohol abuse and cirrhosis. He has developed bloody emesis Now His hr is 122 and bp is 100/62 and HVPG is 13. his bp corrects to 128/89 with fluid administration. Which of the following would be preferred if he has a history of hypertension?
Octreotide x 24 hours
Vasopressin x 24 hours
Octreotide x 72 hours
Vasopressin x 72 hours c

10. JR is 44 yo wm with a history of alcohol abuse and cirrhosis
JR is 44 yo wm with a history of alcohol abuse and cirrhosis. He has developed bloody emesis Now His hr is 122 and bp is 100/62 and HVPG is 13. his bp corrects to 128/89 with fluid administration. Which of the following would be preferred if he has a history of diabetes?
Octreotide x 24 hours
Vasopressin x 24 hours
Octreotide x 72 hours
Vasopressin x 72 hours b

11. JR is 44 yo wm with a history of alcohol abuse and cirrhosis
JR is 44 yo wm with a history of alcohol abuse and cirrhosis. He has developed bloody emesis Now His hr is 122 and bp is 100/62 and HVPG is 13. his bp corrects to 128/89 with fluid administration. Which of the following might be preferred if his hr dips to 54 and he has a history of hypertension?
Octreotide x 24 hours
Vasopressin + NTG x 24 hours
Octreotide x 72 hours
Vasopressin + NTG x 72 hours b

12. JR is 44 yo wm with a history of alcohol abuse and encephalopathy due to cirrhosis. He has developed bloody emesis Now His hr is 122 and bp is 100/62 and HVPG is 13. his bp corrects to 128/89 with fluid administration. Which of the following would be least preferred method of treatment?
Pharmacological
EVL
TIPS
Sclerotherapy c

13. JR is 44 yo wm with a history of alcohol abuse and encephalopathy due to cirrhosis. After his variceal hemorrhage is treated with propranolol and shunt, what should he receive for prophylaxis?
TIPS procedure
EVL
Nadolol
Prophylaxis not indicated c

14. Which of the following is true?
SAAG of 2.1 indicates another cause of ascites
SAAG of 1.5 indicates another cause of ascites
SAAG of 1.5 indicates portal HTN-induced ascites
SAAG of 0.9 indicates portal HTN-induced ascites c

15. Which of the following is true?
SAAG of 1.5 indicates increased serum and/or increased ascetic albumin
SAAG of 1.5 indicates decreased serum and/or increased ascetic albumin
SAAG of 1.5 indicates increased serum and/or decreased ascetic albumin
SAAG of 1.5 indicates decreased serum and/or decreased ascetic albumin c

16. RO has ascites and liver failure. SAAG is 1. 0 and Na+ 118
RO has ascites and liver failure. SAAG is 1.0 and Na How should this patient be managed initially?
Na+ restriction
Fluid restriction
Paracentesis
Liver transplant b

17. RO has ascites and liver failure. SAAG is 1. 0 and Na+ 118
RO has ascites and liver failure. SAAG is 1.0 and Na How should this patient be managed if fluid restriction is not effective for relieving ascites?
Evaluate kidney function
Evaluate cardiac function
Paracentesis
Liver transplant
a & b

18. jr has ascites and liver failure. SAAG is 2. 0 and Na+ is 140
jr has ascites and liver failure. SAAG is 2.0 and Na+ is 140. How shouldn’t this patient be managed?
Alcohol abstinence
Fluid restriction
Sodium restriction
Diuretic therapy a

19. jr has ascites and liver failure. SAAG is 2. 0 and Na+ is 140
jr has ascites and liver failure. SAAG is 2.0 and Na+ is 140. What is the preferred diuretic(s)?
Furosemide
HCTZ
HCTZ + spironolactone
Furosemide + spironolactone d

20. jr has ascites and liver failure. SAAG is 2. 0 and Na+ is 140
jr has ascites and liver failure. SAAG is 2.0 and Na+ is 140. you start her on Furosemide and Spironolactone. When would you discontinue it?
SCr 1.8
Ammonia increases
Na+ 118
Ascites resolves a

21. jr has ascites and liver failure. SAAG is 2. 0 and Na+ is 140
jr has ascites and liver failure. SAAG is 2.0 and Na+ is 140. you start her on Furosemide and Spironolactone. The medication is not working and you decide that paracentesis is warranted. How much albumin should you administer if you remove 3l of fluid?
none 8g
24g
64g a

22. jr has ascites and liver failure. SAAG is 2. 0 and Na+ is 140
jr has ascites and liver failure. SAAG is 2.0 and Na+ is 140. you start her on Furosemide and Spironolactone. The medication is not working and you decide that paracentesis is warranted. How much albumin should you administer if you remove 8l of fluid?
none 8g
24g
64g c

23. jr has ascites and liver failure. SAAG is 2. 0 and Na+ is 140
jr has ascites and liver failure. SAAG is 2.0 and Na+ is 140. you start her on Furosemide and Spironolactone. The medication is not working and fluid quickly accumulates after paracentesis. What should you do immediately?
TIPS
Peritoneovenous shunt
Add midodrine
Liver transplant c

24. jr has ascites and liver failure. SAAG is 2. 0 and Na+ is 140
jr has ascites and liver failure. SAAG is 2.0 and Na+ is 140. you start her on Furosemide and Spironolactone. The medication is not working and fluid quickly accumulates after paracentesis. Now she has an infection in her ascetic fluid. Which of the following types of microbes is it most likely?
Aerobic gram negative
Aerobic gram positive
Anaerobic gram negative
Anaerobic gram positive a

25. jr has ascites and liver failure. SAAG is 2. 0 and Na+ is 140
jr has ascites and liver failure. SAAG is 2.0 and Na+ is 140. you start her on Furosemide and Spironolactone. The medication is not working and fluid quickly accumulates after paracentesis. Now she has an infection in her ascetic fluid. Which of the following types of microbes is it most likely?
Aerobic gram negative
Aerobic gram positive
Anaerobic gram negative
Anaerobic gram positive a

26. jr has ascites and liver failure. SAAG is 2. 0 and Na+ is 140
jr has ascites and liver failure. SAAG is 2.0 and Na+ is 140. you start her on Furosemide and Spironolactone. The medication is not working and fluid quickly accumulates after paracentesis. Now she has an infection in her ascetic fluid. How should it be treated?
Ceftriaxone 2g IV Q24
Ceftriaxone 2g IV Q12
Ceftriaxone 1g IV Q24
Ceftriaxone 1g IV Q12 d

27. jr has ascites and liver failure. SAAG is 2. 0 and Na+ is 140
jr has ascites and liver failure. SAAG is 2.0 and Na+ is 140. you start her on Furosemide and Spironolactone. The medication is not working and fluid quickly accumulates after paracentesis. Now she has an infection in her ascetic fluid. When should you stop treatment?
5 days
10 days
PMNs >250
PMNs <250
a… don’t usually repeat paracentesis

28. jr has ascites and liver failure. SAAG is 2. 0 and Na+ is 140
jr has ascites and liver failure. SAAG is 2.0 and Na+ is 140. you start her on Furosemide and Spironolactone. The medication is not working and fluid quickly accumulates after paracentesis. Now she has an infection in her ascetic fluid. Would this patient be indicated for prophylaxis?
Yes, ceftriaxone 1g Q day
Yes, norfloxacin 400mg Q day
Yes, Bactrim DS Q day No b

29. AH is a 73 yo wf who was previously diagnosed with liver failure comes in to pick up her prescriptions. She is currently taking docusate, Xanax, and aspirin. She also drinks a significant amount of ensure. You notice that she seems a little more confused than normal. Which of the following would be least important to evaluate?
Protein intake
Bowel movements
Ammonia level
GI integrity c

30. AH is a 73 yo wf who was previously diagnosed with liver failure comes in to pick up her prescriptions. She is currently taking docusate, Xanax, and aspirin. She also drinks a significant amount of ensure. You notice that she seems a little more confused than normal. Which of the following might complicate a diagnosis of hepatic encephalopathy?
Xanax use
Development of asterixis
Increased protein intake
High ammonia levels a

31. AH is a 73 yo wf who was previously diagnosed with liver failure comes in to pick up her prescriptions. She is currently taking docusate, Xanax, and aspirin. She also drinks a significant amount of ensure. You notice that she seems a little more confused than normal. Which of the following would you not want to recommend to correct underlying issues?
Discontinue/reduce Xanax dosage
Discontinue/reduce ASA dosage
Discontinue/reduce Ensure
Discontinue/reduce docusate dosage d

32. Ammonia… Increased Availability Decreased Clearance
Other (not ammonia)
Dietary protein (production)
Renal (excretion)
Psych meds (altered baseline)
GI hemorrhage (release)
Constipation (excretion)
Infection (production)
Liver function (metabolism)

33. AH is a 73 yo wf who was previously diagnosed with liver failure comes in to pick up her prescriptions. She is currently taking docusate, Xanax, and aspirin. She also drinks a significant amount of ensure. You notice that she seems a little more confused than normal. What he category would she fall into at this time?
Grade I
Grade II
Grade III
Grade IV a

34. AH is a 73 yo wf who was previously diagnosed with liver failure comes in to pick up her prescriptions. She is currently taking docusate, Xanax, and aspirin. She also drinks a significant amount of ensure. You notice that she seems a little more confused than normal. Which of the following pharmacological therapies would you most likely consider?
Lactulose
Neomycin
Rifaximin
Metronidazole a

35. AH is a 73 yo wf who was previously diagnosed with liver failure comes in to pick up her prescriptions. She is currently taking docusate, Xanax, and aspirin. She also drinks a significant amount of ensure. You notice that she seems a little more confused than normal. Which of the following might you be able to discontinue with lactulose therapy?
ASA
Xanax
Ensure
Docusate d

36. AH is a 73 yo wf who was previously diagnosed with liver failure comes in to pick up her prescriptions. She is currently taking docusate, Xanax, and aspirin. She also drinks a significant amount of ensure. You notice that she seems a little more confused than normal. Why might you use rifamixin in addition to lactulose?
Decrease dizziness
Decrease drug interaction
Decrease abdominal cramping
Decrease peripheral edema c

37. AH is a 73 yo wf who was previously diagnosed with liver failure comes in to pick up her prescriptions. She is currently taking docusate, Xanax, and aspirin. She also drinks a significant amount of ensure. You notice that she seems a little more confused than normal. When her symptoms resolve, should she receive prophylaxis? If so, what? No
Yes, lactulose
Yes, rifamixin
Yes, neomycin c

38. Which of the following would be indicative of increased bleed risk in liver failure?
Low levels of factor II
Vitamin K deficiency
Low level of protein C
Increased NO production
Elevated INR
2 of the above
3 of the above
4 of the above
All of the above
g… a, b, and d

39. Which of the following would be least likely to trigger hepatorenal syndrome?
Variceal bleed
Paracentesis
Infection
Rapid diuresis d

40. Which of the following patients would you treat with albumin + norepinephrine?
SCr 2.4 (baseline 1.2), BP 98/65
SCr 2.4 (baseline 1.2), BP 128/95
SCr 2.8 (baseline 1.2), BP 98/65
SCr 2.8 (baseline 1.2), BP 128/95 c

41. Which of the following would you give to both type 1 and type 2 HRS patients?
Terlipressin
Midodrine
Albumin
Octreotide c

42. Which of the following is the best first-line option for HPS management?
Liver transplant
Lung transplant
Albuterol
Albumin a