15% of the liver is composed of cells other than hepatocytes
clearance of bacteria, viruses and erythrocytes is done by Kupffer cells
Ito cells have a role in the uptake and storage of vitamin A
Vitamin K and folic acids are stored in a huge amount
hapatic synthesis of urea, endogenous proteins and amino acid release by the liver all are suppressed during fasting
The following statements are true except
low blood urea is seen in many acute and chronic liver diseases
high blood urea in the context of severe liver damage may indicates gastrointestinal hemorrhage or hepatorenal syndrome
hyponatremia is very common in severe liver disease and usually multifactorial
raised gamma GT enzyme level may occur during treatment with carbamazepin
large increase in serum aminotrnsferases activity with a small rise in alkaline phsophatase activity is in favor of biliary obstruction
Drugs that induce hepatic microsomal enzymes, all are true except
chronic ethanol ingestion
glucocorticoids
Grisofulvin
carbamazepin
Cimetidin
Imaging in liver diseases, all are true except:
ultrasound of the liver is a rapid, cheap and easy method and usually the first imaging to be done, yet its main limitation is that small focal lesions less than 2 cm will be missed
color Doppler studies are very useful and used to investigate hepatic veins, portal vein and hepatic artery diseases
MRI is usually used for pancreaticobiliary diseases rather than parenchymal liver diseases
outlining the biliary tree can be done by injecting a contrast medium into the biliary tree through the skin or by an endoscopic approach
plain abdominal radiographs are very helpful in liver diseases
Regarding liver biopsy, all are true except
the patient should be cooperative
the PT prolongation if present, should be less than 4 seconds above the upper normal control value
severe COPD is a contraindication
marked ascites will make the procedure easier
local skin infection should not be present
Regarding the metabolism of bilirubins , all are true except
every day, about 300 mg of indirect bilirubin is produced
jaundice will be seen clinically if the total bilirubin exceeds 50 micromole / L
about 100-200 mg of stercobilinogen is lost in stool
about 40 mg of urobilinogen is passed outside in urine
the indirect bilirubin will be conjugated in the endoplasmic reticulum of hepatocytes to be water soluble
Causes of indirect hyperbilirubinemia ,all are true except
B12 deficiency
Wilson's disease
Gilbert's syndrome
Rotor syndrome
major ABO incompatibility reaction
When examining a patient with a direct bilirubin of 30 micromole / L, all are useful signs in guessing the diagnosis, except
a palpable gall bladder
an upper abdominal paramedian scar
irregular hard liver
upper midline abdominal mass
scratcing marks
Local measure to stop a variceal upper GIT bleeding, all are true except
banding
sclerotherapy
esophageal transection
ballon tamponade
terlipressin infusion
Measures to prevent variceal recurrent upper GIT bleeding, all are true except
oral propranolol
sclerotherapy / banding
transjugular intra hepatic portosystemic shunt ( TIPSS
esophageal transection
selective or non selective portosystemic shunt surgery
A patient with chronic liver disease presents with upper GIT bleeding , all are true except
upper GIT endoscope should be done in all cases as 20% of cases the bleeding is non variceal
despite all advances in the management, the mortality rate is still high
portosystemic shunt surgery in this patient may have a mortality of 50%
vasopressin is contraindicated in ischemic heart disease
esophageal transection is commonly used as a first line treatment
TIPSS ( transjugular intrahepatic Porto-systemic shunt ) , all are true except
it is done by placing a stent between the hepatic vein and the portal vein in the liver under radiological control.
the objective is to produce a Porto systemic shunt to reduce the portal pressure and hence the variceal bleeding
prior patency of the portal vein should checked before hand by angiography
may precipitate or worsen hepatic encephalopathy
when rebleeding occurs, the shunt should be removed
Spontaneous bacterial peritonitis in the context of cirrhosis, all are true except
unfortunaterly, up to one third of cases the abdominal signs are mild or absent
almost always a mono-microbial infection state
recurrence is common but unfortunately there is no way to prevent it
The commonest organisms are enteric gram negatives, but no source of infection is usually present
the ascitic fluid is cloudy with more than 250 neutrophils / mm3
Precipitating factors for hepatic encephalopathy in a patient with cirrhosis, all are true except
occult infection
aggressive diuresis
diarrhea or constipation
treamtent with oral neomycin
excesss dietary proteins
Differential diagnosis of hepatic encephalopathy, all are true except:
primary psychiatric disease
hypoglycemia
Wernick's encephalopathy
subdural hematoma
treamtent by enemas
Acute fulminant hepatic failure, all are true except
the commonest causes are viral hepatitis and medications-induced
the hallmark is the presence of acute hepatic encephalopathy
the absence of jaundice is against the diagnosis
there are long listed complications and these usually complicates the picture further
the patient should be managed in an intensive care unit or a high dependency unit once the PT is prolonged
Hepatorenal failure, all are true except
carries a very bad prognosis unless hepatic transplantation is carried out
one of the causes of fractional Na excretion of more than 1 .
characterictically presents as rapidly evolving uremia with bland urinary sediment
seen in advanced cirrhosis and ascites is almost always present
Renal dose dopamine has a role in the management, yet the improvement in renal function depends entirely on improvement of the liver function
Causes of micro-vesicular steatosis, all are true except
fatty liver of pregnancy
Rye's syndrome
treatment with didanosine
Wolman's disease and Alpers syndrome
treatment with amiodarone
Causes of acute hepatitis, all are true except
Halothane
Wilson's disease
autoimmune hepatitis
CMV
hemochromatosis
Causes of chronic liver disease and cirrhosis, all are true except
alpha 1 anti-trypsin deficiency
Hepatitis C
hemochromatosis
autoimmune hepatitis
EBV
Liver cirrhosis, all are true except
hyperpigmentation is seen in hemochromatosis and prolonged biliary obstruction
spider telangiectasias are seen early in the course of cirrhosis but 2 % in normal healthy population
parotid gland enlargement goes with liver etiology
ascites is seen early
finger clubbing is a non specific sign
The hepatitis viruses, all are true except
hepatitis A is an RNA enterovirus which does not lead to a carrier state
hepatitis B is a DNA virus that 42 nm in diameter and leads to chronic infection up to 10% of adults versus 90% of neonatal hepatitis B infection
hepatitis C is an RNA flavivirus that is the commonest cause of chronic liver disease in USA and of those infected ,up to 20 % of them will develop cirrhosis after 20 years
hepatitis D is a defective RNA virus that can be prevented by preventing hepatitis B infection in high risk groups by using hepatitis B vaccine and immunoglobulin
hepatitis E is a RNA calicivirus that carries a mortality of 2% if the infection occurs in pregnancy
The followings predict poor response to INF alpha treatment in chronic hepatitis B viral infection, except
being a male
pre-core mutant strains
being an Asian
very high pretreatment serum hepatitis B viral DNA level by PCR
absence of cirrhosis
Autoimmnue hepatitis, all are true except
type I is ANA and antismooth muscle antibodies positive, while type II is anti LKM antibodies positive
amenorrhea is the rule and cushingoid faces may be seen
25% of cases present as a hepatitis like picture
corticosterois are effective in the treatment of acute attacks and at prevention of future attacks but do not prevent the progression to frank cirrhosis
hepatocelluar carcinoma as a complication is common
Histological changes in alcoholic liver disease, all are true except
mitochonsrial swelling
siderosis
lipogranulomas
autoimmune (interface) hepatitis
few endoplasmic reticula
Primary biliary cirrhosis, all are true except
anti mitochondrial antibodies are seen up to 96% of cases
early, there is proliferation of small bile ductules
hypercholesteremia is common and greatly increases the risk of coronary artery disease
polished nails with clubbing is a good clue in an appropriate clinical setting
ursodeyoxycholic acid has been shown to improve the liver function tests.
Primary sclerosing cholangitis , all are true except
80% of cases are seen in the context of ulcerative colitis
spontaneuos ascending cholangitis is uncommon but usually occur after biliary instrumentation like post ERCP
Is risk factor for cholangiocarcinoma
there is an association with HIV infection and retroperitoneal fibrosis
corticosterois and immune-suppressants are useful in the treatment
Hepatocelluar carcinoma (HCC ), all are true except
occurs in the background of cirrhosis in up to 80% of cases
chronic hepatitis B infection is the commonest cause world-wide
may be treated by liver transplantation
any patient with cirrhosis should be screened for the development of HCC by serial serum alpha fetoprotein and liver ultrasound
the fibrolammellar variant has a very poor prognosis
Criteria for giving ursodeoxycholic acid as a medical treatment for gall stones solubilization , all are true except
the stone should be radiolucent
the stone size is up 15 mm
functioning gall bladder
moderate obesity
prominent symptoms ascribed to the stone
Risk factors for pigment gall stones, all are true except
