Three weeks after a meal at a fast food cafe, a 21-year-old man develops malaise, fatigue, and loss of appetite. He notes passing dark urine. On examination, he has scleral icterus and right upper quadrant tenderness. Lab studies show serum AST of 62 U/L and ALT of 58 U/L. The total bilirubin concentration is 3.9 mg/dL, and the direct bilirubin concentration is 2.8 mg/dL. His symptoms abate over the next 3 weeks. On returning, he finds that it has been closed by the city's health department. Which of the following serologic test results is most likely to be positive in this patient?

A Anti-HBs

B IgM anti-HDV

C Anti-HCV

D IgM anti-HAV

E Anti-HBc

A 41-year-old woman who works as a tattoo artist, has had increasing malaise and nausea for 2 weeks. On physical examination, she has icterus and mild right upper quadrant tenderness. Laboratory studies show serum AST of79 U/L, ALT of 85 U/L, total bilirubin of 3.3 mg/dL, and direct bilirubin of 2.5 mg/dL. She continues to have malaise for the next year. A liver biopsy is undertaken, and the biopsy specimen shows minimal hepatocyte necrosis, mild steatosis, and minimal portal bridging fibrosis. An infection with which of the following viruses is most likely to produce these findings?

A HAV

B HBV

C HCV

D HEV

E Coinfection with HBV and HDV

A 40-year-old woman wishes to donate blood to help alleviate the chronic shortage of blood. She is found to be positive for HBsAg and is excluded as a blood donor. She feels fine. There are no significant physical examination findings. Lab findings for total serum bilirubin, AST, ALT, alkaline phosphatase, and albumin are normal. Further serologictest results are negative for IgM anti-HAV, anti-HBc, and anti-HCV. Repeat testing 6 months later yields the same results. Which of the following is the most appropriate statement the physician can make to this patient?

A You must have been vaccinated in the past for HBV

B You will develop clinically overt, infectious hepatitis within 1 year

C You probably have a chronic carrier state from vertical transmission

D These test results are probably erroneous and need to be repeated

E You have recently contracted acute hepatitis B

Seven years ago, a 30-year-old man saw his GP with malaise, fever, and jaundice. On examination, there were needle tracks in the left antecubital fossa & mitral regurgitation. Serologic test results were positive for HBsAg, HBV DNA, and IgG anti-HBc. He did not return for follow-up. Two years later, he was seen in A&E with hematemesis and ascites. Serologic test results were similar to those reported earlier. Sclerotherapy to treat esophageal varices was performed, and he was discharged. He again failed to return for follow-up. Five years after this episode, he now sees a physician because of a 5-kg weight loss, worsening abdominal pain, and rapid enlargement of the abdomen over the past month. Physical examination shows an increased liver span. Which of the following lab tests is most likely to be diagnostic of this last phase of his disease?

A Prolonged prothrombin time

B Elevated serum α-fetoprotein level

C Elevated serum ALT level

D Elevated serum alkaline phosphatase level

E Elevated serum ferritin level

F Increased blood ammonia level

A 44-year-old woman has noticed increasingly severe generalized pruritus for the past 8 months. Serum levels of alkaline phosphatase and cholesterol are elevated; antimitochondrial antibody titer is elevated, but ANAs are not present. The serum total bilirubin concentration increases. A liver biopsy is done, and the biopsy specimen shows nonsuppurative, granulomatous destruction of medium-sized bile ducts. Which of the following conditions is most likely to be present?

A α1-Antitrypsin deficiency

B Autoimmune hepatitis

C Primary biliary cirrhosis

D Primary sclerosing cholangitis

E Wilson's disease

A 41-year-old man has experienced progressive fatigue, pruritus, and icterus for several months. On physical examination, he now has generalized jaundice. The abdomen is not distended; on palpation, there is no abdominal pain and no masses. Laboratory studies show a serum alkaline phosphatase level of 285 U/L, with normal transaminases. He is positive ANCA, but other autoantibodies normal. What is the most appropriate initial investigation?

A MRCP

B Liver biopsy

C Viral hepatitis screen

D Abdo USS

E Serum CEA and CA19-9 levels

A 31-year-old woman has experienced increasing malaise for the past 4 months. She has raised AST and ALT (AST > ALT), with mildly raised ALP. Results of serological testing for HAV, HBV, and HCV are negative. Test results for ANA and anti–smooth muscle (ASM) antibody are positive. What investigation would be diagnostic in this setting?

A Liver biopsy

B MRCP

C Liver USS

D Copper and caeruloplasmin levels

E Blood alcohol level

A 54-year-old male presents in A&E with profound haematemesis and a blood pressure of 90/60 mmHg which does not respond to fluid resuscitation. On examination, you notice dilated veins around his umbilicus and suspect a variceal haemorrhage, secondary to cirrhosis. Which of the following drugs should be administered immediately to control the bleeding?

a. Vasopressin

b. Terlipressin

c. Octreotide

d. Propanolol

e. Bisoprolol

A 63-year-old lady with a BMI of 28 presents to the GP with persistent fatigue and mild right upper quadrant abdominal pain. The GP performs a set of routine blood tests which are within normal range apart from her ALT which is mildly raised. What would be the next step in the management of this patient?

a. Offer lifestyle modification advice on weight loss and diet

b. Refer for a liver biopsy

c. Perform additional blood tests such as auto-antibodies (AMA, cANCA, etc)

d. Refer to a hepatologist for further management

e. Start her on statins