Liver disease: hepatitis, cirrhosis and complications

28 NEET-PG practice questions on Liver disease: hepatitis, cirrhosis and complications, part of General Medicine. The first 25 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

1. Question 1 · Medium

   A 48-year-old man with alcohol-related cirrhosis and ascites is admitted with fever, diffuse abdominal tenderness and mild confusion. Diagnostic paracentesis: neutrophils 420/µL, total protein 0.8 g/dL, glucose 110 mg/dL, Gram stain shows no organisms. Serum creatinine 1.4 mg/dL. What is the next best step?

   1. AIV cefotaxime with IV albumin
   2. BCT abdomen and surgical review for perforation
   3. CAwait ascitic culture before antibiotics
   4. DLarge-volume paracentesis with albumin

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   Answer: A · IV cefotaxime with IV albumin

   An ascitic neutrophil count of 250/µL or more in cirrhosis is spontaneous bacterial peritonitis, and empirical treatment starts at once with a third-generation cephalosporin such as cefotaxime. IV albumin on day 1 and day 3 is added when creatinine, urea or bilirubin is raised, because it lowers the risk of hepatorenal syndrome and death. After recovery, long-term antibiotic prophylaxis is given to prevent recurrence. His confusion is hepatic encephalopathy triggered by the infection.

   • B: Low protein, normal glucose and no organisms on Gram stain argue against secondary peritonitis.
   • C: The neutrophil count alone justifies treatment; delay worsens survival.
   • D: Large-volume paracentesis during SBP risks renal failure and is not the treatment.

2. Question 2 · Medium

   A 61-year-old man with cirrhosis and ascites, stable on furosemide and spironolactone, is brought by his son because he has become sleepy and confused over 2 days. He has asterixis. He has had no fever, bleeding or constipation, and takes no sedatives. Na 132 mmol/L, K 2.8 mmol/L, HCO3 34 mmol/L, creatinine 1.0 mg/dL. Which factor most likely precipitated his encephalopathy?

   1. AHypokalaemic metabolic alkalosis
   2. BSpironolactone-induced hyperkalaemia
   3. CRising serum creatinine
   4. DHyponatraemia

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   Answer: A · Hypokalaemic metabolic alkalosis

   Hypokalaemia increases renal ammonia production, and alkalosis converts ammonium to ammonia (NH3), which crosses into the brain more easily. Both are common after diuretics and are classic triggers of hepatic encephalopathy. Correcting potassium, adjusting diuretics and giving lactulose usually reverse the episode; GI bleeding, infection and constipation should also be checked.

   • B: Potassium is low, not high.
   • C: His creatinine is normal.
   • D: Mild hyponatraemia of this degree rarely causes confusion on its own.

3. Question 3 · Hard

   A 54-year-old man with cirrhosis and ascites develops severe abdominal pain and fever. Ascitic fluid: neutrophils 6,800/µL, total protein 2.3 g/dL, glucose 22 mg/dL, LDH 640 U/L (serum upper limit 250). Gram stain shows gram-negative bacilli, gram-positive cocci and anaerobic-looking bacilli. What is the next best step?

   1. ARepeat paracentesis after 48 hours of antibiotics
   2. BIV cefotaxime and IV albumin as for SBP
   3. CUrgent CT abdomen to look for a perforation
   4. DLarge-volume paracentesis with albumin

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   Answer: C · Urgent CT abdomen to look for a perforation

   Spontaneous bacterial peritonitis is almost always monomicrobial with low protein and normal glucose. Here two of Runyon's criteria for secondary peritonitis are met (protein above 1 g/dL, glucose below 50 mg/dL, LDH above the serum upper limit; all three in fact), and the Gram stain is polymicrobial. This suggests a perforated viscus or abscess, so urgent CT and surgical review are needed, along with broad-spectrum antibiotics covering anaerobes. Treating it as SBP would miss a surgical cause and carries very high mortality.

   • A: Waiting 48 hours delays surgery for a likely perforation.
   • B: Cefotaxime alone does not cover anaerobes or a surgical source.
   • D: Removing fluid does not treat the infection or its source.

4. Question 4 · Medium

   A 35-year-old woman is HBsAg positive on antenatal screening in her first pregnancy, which ended in a healthy delivery 2 years ago. Repeated tests since then: HBeAg negative, anti-HBe positive, HBV DNA 600 IU/mL, ALT 24-30 U/L (upper limit 40), and FibroScan shows no fibrosis. What should she be advised?

   1. ALiver biopsy to stage the disease
   2. BMonitor ALT and HBV DNA every 6-12 months
   3. CStart tenofovir for life
   4. DStart entecavir for one year

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   Answer: B · Monitor ALT and HBV DNA every 6-12 months

   HBeAg-negative infection with HBV DNA below 2,000 IU/mL, normal ALT and no fibrosis is the inactive carrier state (HBeAg-negative chronic infection). The risk of progression is low, so antivirals are not given, but she is followed with ALT and HBV DNA because reactivation can occur. Her household contacts should be screened and vaccinated, and she should be told the virus can still be transmitted.

   • A: Non-invasive tests already show no fibrosis; biopsy adds nothing.
   • C: Lifelong antivirals are not indicated in the inactive phase.
   • D: A fixed one-year course has no benefit here.

5. Question 5 · Easy

   A 22-year-old medical student is screened before her clinical postings. Results: HBsAg negative, anti-HBc (total) negative, anti-HBs 150 mIU/mL. What does this profile show?

   1. AImmunity from hepatitis B vaccination
   2. BOccult hepatitis B infection
   3. CWindow period of acute hepatitis B
   4. DImmunity after natural hepatitis B infection

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   Answer: A · Immunity from hepatitis B vaccination

   The vaccine contains only HBsAg, so a vaccinated person makes anti-HBs but no anti-HBc. Anti-HBs of 10 mIU/mL or more is protective. Natural infection, by contrast, always leaves anti-HBc, with or without anti-HBs.

   • B: Occult infection has HBV DNA, usually with anti-HBc, despite a negative HBsAg.
   • C: The window period has IgM anti-HBc without HBsAg or anti-HBs.
   • D: Natural infection leaves anti-HBc, which is negative here.

6. Question 6 · Hard

   A 62-year-old man has had progressive abdominal distension and leg swelling for 3 months. He has breathlessness on lying flat, a raised JVP and hepatomegaly; he does not drink alcohol. Results: serum albumin 3.4 g/dL; ascitic fluid albumin 2.0 g/dL, total protein 3.1 g/dL, neutrophils 90/µL, no malignant cells. What is the most likely cause of the ascites?

   1. APeritoneal tuberculosis
   2. BPeritoneal carcinomatosis
   3. CCongestive cardiac failure
   4. DCirrhosis of the liver

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7. Question 7 · Easy

   A 58-year-old man with cirrhosis is started on lactulose for hepatic encephalopathy. How does lactulose lower blood ammonia?

   1. AIt acidifies the colon, trapping ammonia as ammonium
   2. BIt binds ammonia in the gut for excretion
   3. CIt inhibits glutaminase in the small intestine
   4. DIt increases urea synthesis in hepatocytes

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8. Question 8 · Medium

   A primigravida who is HBsAg positive delivers a healthy 3.1 kg baby at a district hospital. What should the baby receive?

   1. AHepatitis B vaccine at 6 weeks with the pentavalent
   2. BHepatitis B vaccine and HBIG within 12 hours
   3. CHBIG alone, with vaccine after 6 months
   4. DOral tenofovir for 4 weeks

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9. Question 9 · Medium

   A 30-year-old man has had jaundice for 3 weeks after a week of malaise. ALT is 410 U/L, falling from a peak of 2,200 U/L. Serology: HBsAg negative, anti-HBs negative, IgM anti-HBc positive, anti-HCV negative, IgM anti-HAV negative, IgM anti-HEV negative. What is the most likely interpretation?

   1. AIsolated anti-HBc from remote infection
   2. BFalse-positive anti-HBc; hepatitis excluded
   3. CChronic hepatitis B with HBsAg mutant
   4. DAcute hepatitis B in the window period

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10. Question 10 · Easy

    A 49-year-old man with compensated alcohol-related cirrhosis has screening endoscopy, which shows large oesophageal varices without red signs; he has never bled. BP is 128/80 mmHg, pulse 84/min, and he has no asthma. Which drug is preferred to prevent a first variceal bleed?

    1. AAmlodipine
    2. BCarvedilol
    3. CIsosorbide mononitrate
    4. DSpironolactone

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11. Question 11 · Easy

    A 66-year-old retired schoolteacher in Thrissur is tapped in the ward for new-onset ascites. On the same morning, serum albumin is 2.9 g/dL and ascitic fluid albumin is 0.8 g/dL. Which cause of ascites does this serum-ascites albumin gradient (SAAG) point to?

    1. AAscites due to nephrotic syndrome
    2. BAscites due to tuberculous peritonitis
    3. CAscites due to peritoneal carcinomatosis
    4. DAscites due to portal hypertension

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12. Question 12 · Medium

    A 60-year-old man with cirrhosis has had two episodes of hepatic encephalopathy. Consider these statements about his long-term care: 1. Lactulose is adjusted to give 2-3 soft stools a day. 2. Daily dietary protein should be cut below 0.5 g/kg. 3. Benzodiazepines should be avoided. 4. Constipation and infections should be looked for at every episode. Which statements are correct?

    1. A1, 3 and 4 only
    2. B1, 2, 3 and 4
    3. C1, 2 and 3 only
    4. D2 and 4 only

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13. Question 13 · Medium

    A 50-year-old man with compensated hepatitis C cirrhosis has large oesophageal varices on screening endoscopy. He has severe asthma, needing repeated hospital admissions. He has never bled. What is the best way to prevent a first bleed?

    1. APropranolol in a low dose
    2. BEndoscopic variceal ligation
    3. CEndoscopic sclerotherapy
    4. DTIPS placement

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14. Question 14 · Medium

    A 38-year-old man who received multiple blood transfusions for a road accident 15 years ago is found to be anti-HCV positive on screening before donating blood. He is well, and ALT is 58 U/L. What is the next step?

    1. AStart sofosbuvir and velpatasvir at once
    2. BLiver biopsy to confirm hepatitis C
    3. CHCV RNA test to confirm active infection
    4. DRepeat anti-HCV after 6 months

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15. Question 15 · Medium

    A 55-year-old woman with cirrhosis due to non-alcoholic fatty liver disease has had a second episode of overt hepatic encephalopathy in 4 months despite taking lactulose regularly with 2-3 soft stools a day. No other precipitant is found. What should be added to prevent further episodes?

    1. ANeomycin for long-term use
    2. BMetronidazole for long-term use
    3. CStrict protein restriction
    4. DRifaximin

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16. Question 16 · Medium

    A transplant coordinator calculates the MELD score for a 46-year-old man with decompensated cirrhosis being listed for liver transplant. Which set of results is used in the original MELD score?

    1. AINR, platelet count and creatinine
    2. BBilirubin, INR and creatinine
    3. CAlbumin, ascites and encephalopathy
    4. DBilirubin, albumin and INR

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17. Question 17 · Easy

    A 44-year-old man is anti-HCV positive with HCV RNA 3.2 million IU/mL; he has no cirrhosis and has never been treated. The genotype is not known. Which treatment is recommended?

    1. APegylated interferon with ribavirin for 48 weeks
    2. BTenofovir for an indefinite period
    3. CRibavirin alone for 24 weeks
    4. DSofosbuvir with velpatasvir for 12 weeks

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18. Question 18 · Easy

    A 26-year-old man has had jaundice, anorexia and dark urine for 10 days. ALT is 1,850 U/L. Hepatitis serology: HBsAg positive, IgM anti-HBc positive, HBeAg positive, anti-HBs negative. What is the most likely diagnosis?

    1. AImmunity from hepatitis B vaccination
    2. BAcute hepatitis B
    3. CChronic hepatitis B, HBeAg-positive phase
    4. DResolved past hepatitis B

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19. Question 19 · Hard

    A 63-year-old man with diffuse large B-cell lymphoma is to start R-CHOP chemotherapy. Screening shows HBsAg negative, total anti-HBc positive, anti-HBs negative, HBV DNA undetectable, ALT normal. What should be done regarding hepatitis B?

    1. AMonitor ALT only after chemotherapy ends
    2. BNo action, as HBsAg is negative
    3. CStart entecavir or tenofovir prophylaxis before chemotherapy
    4. DGive hepatitis B vaccine before chemotherapy

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20. Question 20 · Hard

    A 57-year-old man with cirrhosis vomits blood. After resuscitation, terlipressin and ceftriaxone, endoscopy shows small oesophageal varices without stigmata and a large, actively bleeding varix in the gastric fundus with no oesophageal varix leading to it (isolated gastric varix, IGV1). What is the most appropriate endoscopic treatment?

    1. ASclerotherapy with ethanolamine
    2. BAdrenaline injection with clips
    3. CBand ligation of the fundal varix
    4. DInjection of cyanoacrylate glue

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21. Question 21 · Hard

    A 43-year-old man with HIV and chronic hepatitis B has been well on TLD for 2 years, with an undetectable HIV viral load and undetectable HBV DNA. At a private clinic his regimen was changed to zidovudine, lamivudine and dolutegravir because of mild bone loss. Four months later he has jaundice; ALT is 980 U/L and HBV DNA is 5,40,000 IU/mL. HIV viral load remains undetectable. What is the most likely cause?

    1. AHepatitis B flare after tenofovir was withdrawn
    2. BDolutegravir-induced hepatotoxicity
    3. CImmune reconstitution against hepatitis B
    4. DZidovudine-induced lactic acidosis

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22. Question 22 · Medium

    A 47-year-old man with alcohol-related cirrhosis vomits about 500 mL of fresh blood. Pulse 118/min, BP 96/64 mmHg, Hb 7.6 g/dL. Consider these statements about his care before endoscopy: 1. Start terlipressin or octreotide at once. 2. Give a prophylactic antibiotic such as ceftriaxone. 3. Transfuse to keep Hb near 10-12 g/dL. 4. Arrange endoscopy within 12 hours. Which statements are correct?

    1. A1, 3 and 4 only
    2. B1, 2, 3 and 4
    3. C1, 2 and 4 only
    4. D1 and 2 only

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23. Question 23 · Medium

    A 64-year-old man with chronic hepatitis C and atrial fibrillation, controlled on amiodarone, is started on sofosbuvir and daclatasvir. Five days later he is brought to casualty after a fainting spell. Pulse is 34/min and the ECG shows junctional bradycardia. What is the most likely cause?

    1. ADaclatasvir-induced QT prolongation
    2. BHepatic decompensation from viral clearance
    3. CHypokalaemia from direct-acting antivirals
    4. DInteraction of sofosbuvir with amiodarone

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24. Question 24 · Medium

    A 41-year-old man is found to be HBsAg positive during screening before a hernia repair. Tests over 6 months: HBeAg negative, anti-HBe positive, HBV DNA 80,000 IU/mL, ALT 96 and 104 U/L (upper limit 40). Ultrasound shows a coarse liver without cirrhosis, and other causes of liver disease are excluded. What is the next best step?

    1. AGive hepatitis B vaccine and immunoglobulin
    2. BStart pegylated interferon with ribavirin
    3. CStart tenofovir or entecavir
    4. DMonitor ALT and HBV DNA every 6 months

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25. Question 25 · Medium

    A 56-year-old man with alcohol-related cirrhosis, who has stopped drinking, has moderate ascites. Serum Na 134 mmol/L, K 4.2 mmol/L, creatinine 0.9 mg/dL. He has never had diuretics. Besides a 2 g/day salt diet, what is the best initial treatment?

    1. ASpironolactone 100 mg with furosemide 40 mg daily
    2. BLarge-volume paracentesis every 2 weeks
    3. CFurosemide 80 mg daily alone
    4. DHydrochlorothiazide 25 mg daily

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