NMS Q&A Family Medicine

Problems of the Liver 105been investigated as well as several others. The latterinclude presence of uncontrolled diabetes, obesity, anddyslipidemia. Every drug on which a patient has beenplaced should be perused for possibilities of elevation ofliver enzymes, and the list is too long to address in thiswork. Chronic hepatitides B and C are common. Hemochromatosisis much more common than appreciateddecades ago. If the ALT is twice that of the AST, then alcoholismshould be suspected. However, that relationship isneither quite sensitive nor specific.9. The answer is C. Ultrasound. Conjugated bilirubinemia(direct-acting bilirubin), when in the absence ofunconjugated bilirubin, indicates extrahepatic obstructivejaundice. Ultrasound is more likely to elucidate thecause than computed tomography, the latter generallygiving more information regarding the parenchyma ofthe liver and of the pancreas. The hepatitides cause moreoften a mixed picture of elevations of both conjugatedand unconjugated bilirubin. Plain x-rays are seldom helpfulin jaundice. ALT and AST levels may be mildly elevatedin obstructive jaundice, but neither confirms nor rulesout obstruction; if obstruction is present, no anatomicdiagnosis will be made from the test.10. The answer is D. PBC occurs more often in womenthan men by a ratio of roughly 4 or 5:1. Steatorrhea istypical, as are xanthelasmas and xanthomas. Patients areasymptomatic for years before beginning complaints ofpruritus, a common symptom of biliary obstruction.Along the way, first alkaline phosphatase and then conjugatedbilirubin become elevated. Antimitochondrial antibodiesare positive in 95% of cases, although the test isnot adequately specific. Alcoholic cirrhosis is not characterizedby the skin manifestations alluded to and is notcharacterized by the symptoms of biliary obstructionfrom early on, as is PBC. Choledocholithiasis, although acause of biliary obstruction, is neither a slowly progressiveprocess nor insidious in onset. The same can be saidfor carcinoma of the pancreas. The latter is noted for“painless jaundice” with a palpable gallbladder (theCourvoisier sign). Gilbert disease (or syndrome) is a mildcondition in which there is an inherited tendency forintermittent elevation of unconjugated bilirubin levels.11. The answer is B. Hepatitis B is more transmissiblethan hepatitis C, although hepatitis C is significantly morelikely to cause chronic hepatitis, once passed (75%), cirrhosis(20% within 20 years), and hepatocellular carcinoma(1% to 4% per year). Hepatitis A never becomeschronic nor does it result in a carrier state, nor does hepatitisE. Hepatitis D occurs only in concert with hepatitis B.12. The answer is E. The answer is E. The combination ofelevated GGT and normal alkaline phosphatase stronglysuggests active drinking. The increased red cell volumewas eye-catching, and alcoholism is associated with macrocytosis,due to nutritional deficiency. The elevation ofAST out of proportion to ALT (typically 2:1) is suggestiveof alcoholic hepatitis, and a lower than expected BUNmay be found in active alcoholism. Examining for thestigmata of cirrhosis is appropriate as well (spiderangiomata, palmar erythema, testicular atrophy, distendedflank veins, etc.). Gallbladder ultrasound study isnot indicated in the absence of abdominal pain and biliaryobstruction. Approximately 15% of patients withlaboratory findings from constant drinking will developcirrhosis even though one-third will have fatty liver at onetime or another. Other tests and procedures can bedeferred to results of further inquiry, and empiric responseto alcohol abstention is known.13. The answer is B. PSC is associated with ulcerative colitisor Crohn colitis in two-thirds of cases, although only 1%to 4% of ulcerative colitis cases have coexisting PSC. As inPBC, pruritus and incidental findings of elevated alkalinephosphatase may precede clinical jaundice. The diagnosis isconfirmed by endoscopic retrograde cholangiography,which usually shows evidence of extrahepatic ductalinflammatory injury or liver biopsy. PSC is most commonlyfound in men more so than women at a ratio of 1.5to 2:1 between the ages of 20 and 30 years. The diagnosisis also confirmed by histopathology in liver biopsy. PSC iscommonly complicated by bacterial ascending cholangitis.PBC is noted for xanthomas and xanthelasmas and isfound in women between the ages of 40 and 60 years (seeQuestion 8 and explanation). Choledocholithiasis isunlikely in the absence of colic and gallstones in the gallbladder.Steatohepatosis (fatty liver) is common in manyasymptomatic conditions such as diabetes, morbid obesity,and alcoholism and in itself would not cause thesymptoms in the vignette. Viral hepatitis is not consideredduring the acute phase without elevations of ASTand ALT that are 50 to 100 times normal.14. The answer is E. Autoimmune hepatitis is initially adiagnosis of exclusion in a patient who manifests evidenceof acute, subacute, or chronic hepatitis without evidenceof viral, chemical, infectious, or pharmacological causation.Presence of SMA and ANA as well as other autoimmunediseases (e.g., thyroiditis in this case) lends furthercircumstantial evidence of autoimmune disease. PSC isless likely because of the absence of colitis.15. The answer is D. A ceruloplasmin level that is lowerthan normal may be indicative of Wilson disease. The diseaseis characterized by copper overload, damaging theliver and kidneys and resulting in central nervous systemabnormalities, most commonly depression. SMA andANA may be connected with autoimmune hepatitis,but the patient is younger than expected for that condition.Iron studies would be appropriate for diagnosis of