Answers to Multiple Choice Questions

Hepatobiliary Quiz Answers – 18 (2016)

Answers: A, C and E

Ectopic varices are dilated portosystemic collateral veins located at sites other than the gastroesophageal region. These constitute upto 5% of variceal bleeds in patients with intrahepatic portal hypertension, and 20% to 30% of those with extrahepatic portal hypertension.1, 2, 3 Of all patients with ectopic varices, the frequency according to site are as follows- duodenal varices(32.9%), jejunum(4%), ileum(1.2%), colon(3.5%), rectal (44.5%) and peristomal (5.8%)⁴. Another study shows the

Answers: B, C and D

Hepatotoxicity due to antitubercular therapy (ATT) is seen in 5%–28% of people treated with these drugs, leading to discontinuation of drug in 11% of patients. The liver injury is idiosyncratic in nature. ATT hepatitis is usually due to metabolic idiosyncrasy due to the drug metabolites, not hypersensitive idiosyncracy. Hypersensitive idiosyncrasy is associated with skin rashes, fever, eosinophilia and/or lymphadenopathy, which is usually seen with antiepileptics and sulfonomides.6, 7

Answers: B, C and D

Gram-negative bacilli (GNB) are the major cause of SBP, with E. coli being the commonest organism. Gram-positive cocci (GPC) are responsible for less than a quarter of cases. However, among patients on norfloxacin prophylaxis, GPCs were found in 57% of patients with SBP, of which Methillin Resistant Staphylococcus aureus constituted 77%.¹³

Risk factors for recurrence of SBP include ascitic fluid protein <1 gm/dl, bilirubin >4 mg/dl and Prothrombin index ≤45%.¹⁴ Proton Pump Inhibitor (PPI) therapy

Answers: B and C

Cirrhosis is marked by a state of hyperdynamic circulation and decreased systemic vascular resistance, effectively leading to circulatory hypovolemia and splanchnic vasoconstriction. Thus, blood flow to the liver is reduced, especially in the presence of portal hypertension. Hemodynamic alterations during surgery are thus poorly tolerated by these patients, who are highly susceptible to fluid shifts due to volume loss and vasoactive drugs. This results in hypoxemic injury to the liver, and may

Answers: A and D

Women constitute 27% of adults with cirrhosis. This lower prevalence in women seems to be related to the lower prevalence of viral hepatitis and alcohol abuse, as well as iron overload.²⁵

The natural history of HCV too differs between women and men. Spontaneous clearance of the virus occurs more frequently among women (37% vs 21%).²⁶ Female sex is also protective against progression of liver fibrosis, especially in premenopausal age group. Even among post menopausal patients, fibrosis was less

Answer: D

Premenopausal women with cirrhosis frequently have irregular menstruation and ovulation, secondary to hypothalamic-pituitary dysfunction and altered sex hormone metabolism. Almost 27% women have irregular menstruation, and 20% have amenorrhea. However, over half of the women (53%) had regular menstrual cycles.31, 32, 33

Though there have been concerns regarding a potential association between oral contraceptive use and risk of Hepatocellular Carcinoma (HCC), a meta-analysis of existing evidence

Answers: D and E

Primary Biliary Cirrhosis (PBC) is a liver-specific autoimmune disease which predominantly affects women in their 5th and 6th decade. Over 90% of the cases are females, and first degree relatives are 10 times more likely to be affected than the general population.⁴¹

The exact pathophysiology is unknown, however, both genetic and environmental factors seem to be involved. Pathogenesis may include a combination of sex hormone abnormalities and X chromosome instabilities and defects.⁴²

Diagnosis is

Answers: A, C, D and E

Prophylactic antibiotics in cirrhotic patients with high risk of infections has led to a decreased incidence of bacterial infections. However, this is at the cost of altering microbial flora and promoting development of resistant organisms. Thus, judicious use of antibiotic prophylaxis is warranted.⁴⁸

Long-term prophylaxis with norfloxacin is indicated in patients who have had one episode of SBP. These patients have a 3 fold higher chance of recurrence of SBP if not on antibiotic prophylaxis as

Answers: B, C and E

Cholangiocarcinoma (CCA) is the second most common type of primary liver cancer, and forms ∼3% of all gastrointestinal neoplasias. It is much more commonly seen in certain countries and regions, including Chile, Bolivia, South Korea and North Thailand. Based on location, CCAs can be classified into intrahepatic (iCCA), perihilar (pCCA) and distal CCA (dCCA). There has been a plateau in the incidence of iCCA incidence worldwide over the last decade. Conversely, the incidences of both pCCA and

Answers: A, B and C

Cirrhotic patients who are malnourished are more likely to have portal hypertension, portosystemic collaterals, and varices. They also have more severe portal hypertension and higher risk of variceal bleeding.⁶⁰

Most of our body proteins are located in the skeletal muscle, thus, adult protein malnutrition is primarily defined as skeletal muscle loss. Sarcopenia in cirrhosis worsens with advancing Child Pugh score and the development of portosystemic shunting.⁶¹

Bioelectrical Impedance analysis

Conflict of Interest

The authors have none to declare.