CME Hepatology SAQs (95275): Self-assessment questionnaire

SAQs and answers are ONLINE for RCP fellows and collegiate members

The SAQs printed in the CME section can only be answered online to achieve external CPD credits. Any comments should be sent in via email only: clinicalmedicine@rcplondon.ac.uk

Format

Candidates are asked to choose the best answer from the five possible answers. This best of five format is used in many medical examinations, however the questions are not intended to be representative of those used in the MRCP(UK) Part 1 or Part 2 Written Examinations.

The answering process

1. Go to www.rcplondon.ac.uk/SAQ

2. Log on using your usual RCP username and password

3. Select the relevant CME question paper

4. Answer all 10 questions by selecting the best answer from the options provided

5. Once you have answered all the questions, click on Submit

Registering your external CPD credits

Carrying out this activity allows you to claim two external CPD credits. These will be automatically transferred to your CPD diary, where you can review the activity and claim your points.

1. A 45-year-old man was referred by his GP with abnormal liver function tests showing an ALT 113 U/l (5–35), GGT 99 U/l (males: <50), bilirubin 10 μmol/l (1–22), albumin 40 g/l (37–49) and ALP 90 U/l (45–105). His BMI was 39 kg/m² (18–25). Ultrasound scan showed an echo-bright liver with moderate fatty infiltration and no biliary dilatation. He had a history of dyslipidaemia and type 2 diabetes that was diagnosed 8 years previously. He was currently on metformin 1g bd, and had suboptimal control of diabetes with a recent HbA1c of 65.

   Which investigation would you consider next?

   (a) liver biopsy

   (b) non-invasive assessment of liver fibrosis

   (c) reassure and discharge the patient with lifestyle advice

   (d) repeat LFTs

   (e) request a liver CT/MRI

2. A 45-year-old man was referred by his GP with abnormal liver function tests showing an ALT 113 U/l (5–35), GGT 99 U/l (males: <50), bilirubin 10 μmol/l (1–22), albumin 40 g/l (37–49) and ALP 90 U/l (45–105). His BMI was 39 kg/m² (18–25). Ultrasound scan showed an echo-bright liver with moderate fatty infiltration and no biliary dilatation. He had a history of dyslipidaemia and type 2 diabetes that was diagnosed 8 years previously. He was currently on metformin 1g BD, and had suboptimal control of diabetes with a recent HbA1c of 65. Liver biopsy shows significant non-alcoholic steatohepatitis (NASH). Lifestyle advice is given to the patient.

   Which of the following treatments have not been shown to have efficacy in patients with NASH?

   (a) bariatric surgery

   (b) gliclazide

   (c) liraglutide

   (d) pioglitazone

   (e) vitamin E

3. From April 2015, which of the following factors would make patients with G1 HCV eligible for all oral therapy?

   (a) age >50 years

   (b) a history of intolerance to interferon

   (c) a history of previous severe depression

   (d) decompensated cirrhosis of the liver

   (e) high HCV viral load

4. Which of the following statement is true of the Abbvie combination regimen for HCV infection?

   (a) a weekly injectable treatment

   (b) has no significant drug–drug interactions

   (c) offers cure rates >90% in all genotypes of HCV

   (d) regimen contains agents targeting specific viral proteins involved in replication

   (e) unlikely to be cost effective

5. A 56-year-old man was diagnosed with hepatitis B-related cirrhosis. He was established on antiviral therapy with undetectable HBV DNA.

   In terms of ongoing monitoring to exclude the development of hepatocellular carcinoma, which of the following should the patient undergo?

   (a) annual MRI liver

   (b) annual triple-phase CT liver

   (c) six-monthly ultrasound scan

   (d) three-monthly HBV DNA

   (e) three-monthly serum AFP

6. A 22-year-old Chinese student was diagnosed with chronic hepatitis B (CHB). She was reported in China to have immune-tolerant CHB. As part of her disease assessment in the UK, the above clinical profile is being questioned.

   Which of the following parameters is at odds with a diagnosis of immune-tolerant CHB?

   (a) ALT 20 U/l

   (b) HBsAg >102,000 IU/ml

   (c) HBeAg positive

   (d) HBV DNA >8.5 log IU/ml

   (e) Ishak fibrosis stage 4/6

7. A 76-year-old woman with cirrhosis due to non-alcohol-related fatty liver had moderate volume ascites, which did not respond to a low sodium diet. Her liver synthetic function was relatively preserved with bilirubin 22 μmol/l (1–22), albumin 34 g/l (37–49) and INR 1.2, and she had never had encephalopathy. Serum sodium was 139 mmol/l (137–144) and eGFR was 68 ml/min/1.73m² (>60).

   Which of the following should be instituted as the next treatment strategy?

   (a) large volume paracentesis (LVP) every 4 weeks with - co-administration of intravenous human albumin

   (b) spironolactone at 100 mg once per day

   (c) spironolactone at 100 mg once per day and increase dose in increments of 100 mg every week until ascites is controlled or the maximum dose of 400 mg per day is reached

   (d) spironolactone at 100 mg twice per day

   (e) transjugular intrahepatic portosystemic shunt (TIPS)

8. A 59-year-old man with cirrhosis due to alcohol-related liver disease has remained abstinent from alcohol for 18 months and is awaiting liver transplantation. At transplant assessment he had ascites, which responded to a combination of furosemide 80 mg and spironolactone 200 mg per day, and hepatic encephalopathy, which was controlled on lactulose 30 ml twice per day. In clinic, 6 weeks after listing for transplantation, he did not have ascites but was noted to be confused again with asterixis. His bilirubin was 63 μmol/l (1–22), albumin 28 g/l (37–49), INR 1.9, ammonia 94 μmol/l (12–55), blood sugar 6.3 mmol/l, sodium 125 mmol/l (137–144), potassium 5.8 mmol/l (3.5–4.9) and creatinine 134 μmol/l (60–110).

   Which of the following is the likely cause of the confusion?

   (a) acute-on-chronic liver failure necessitating priority listing for liver transplantation

   (b) diuretic therapy

   (c) insufficient dose of lactulose

   (d) illicit benzodiazepine usage

   (e) spontaneous bacterial peritonitis (SBP)

9. A 56-year-old woman was diagnosed as having acute alcoholic hepatitis. She was drowsy and had mild ascites.

   Which one of the following approaches is an approved part of the investigative and therapeutic regime?

   (a) corticosteroid therapy at 40 mg prednisolone per day until serum transaminases fall

   (b) high-dose vitamin B complex supplementation

   (c) liver biopsy to confirm the diagnosis

   (d) modest protein restriction (<40 mg/day) to prevent hepatic encephalopathy

   (e) therapeutic paracentesis

10. Among patients with alcoholic liver disease in the UK, which of the following is true?

    (a) comprise 10% of the population

    (b) can reliably be detected early on routine clinical interview

    (c) can be detected by routine liver function tests measuring serum transaminases

    (d) preventive strategies in primary care are of dubious value

    (e) tend to have a high AST:ALT ratio as fibrosis develops