Case 1
Alicia Moldovan
Alicia, 26 years of age, has been newly diagnosed with hepatitis C. She is 12 weeks pregnant.
Question 1
Which of the following is TRUE regarding acute hepatitis C:
- approximately 30% of patients with acute hepatitis C will progress to chronic infection
- intranasal illicit drug use populations have no higher risk of hepatitis C infection than population level risk
- patients with symptomatic acute hepatitis C are more likely to progress to chronic infection
- previous hepatitis C infection protects against future infection with the same genotype
- the presence of jaundice is associated with spontaneous clearance of hepatitis C.
Question 2
Regarding vertical transmission of hepatitis C, which statement is CORRECT:
- elective caesarean section reduces the risk of hepatitis C transmission
- hepatitis C in Australia is predominantly acquired via vertical transmission
- it is always safe for mothers with hepatitis C to breastfeed their infants
- maternal hepatitis C antibodies are present in infants for up to 6 months
- mother-to-baby hepatitis C transmission is estimated at 5–7%.
Question 3
Which of the following factors is associated with faster progression of chronic hepatitis C:
- age <16 years at acquisition of infection
- female gender
- marijuana use
- low body mass index
- persistent low grade fevers.
Question 4
Regarding the treatment of hepatitis C, which of the following statements is CORRECT:
- approximately 25% of hepatitis C patients in Australia are currently receiving treatment
- approximately 50% of hepatitis C patients should be considered for active treatment
- patients with poorly controlled substance abuse habits should not be referred for treatment
- patients with decompensated cirrhosis may potentially gain from viral eradication
- patients with HCV PCR negative 6 months after treatment cessation have been cured.
Case 2
Peter Chu
Peter, 64 years of age and a non-drinker, has persistently abnormal liver function tests (LFTs) on routine bloods.
Question 5
In the setting of abnormal LFTs, which of the following investigations is LEAST useful in evaluating differential diagnoses:
- anti-smooth muscle antibody
- coeliac antibodies
- fasting lipids
- iron studies
- thyroid function tests.
Question 6
Regarding the diagnosis of non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steato-hepatitis (NASH), which of the following is most accurate:
- diagnosis of NAFLD requires evidence of liver fatty infiltration on liver biopsy results
- medications such as synthetic oestrogens may be an alternative cause of hepatic steatosis
- NASH is more likely in patient populations in Australia aged more than 40 years
- NASH is more likely where ALT is elevated more than four times the upper limits of normal
- ultrasound for detection of NAFLD has a sensitivity of 97% and specificity of 65%.
Question 7
Which of the following statements is TRUE regarding NAFLD:
- hepatocellular carcinoma may develop in patients with NASH without cirrhosis
- metformin is recommended in the specific treatment of NAFLD
- NAFLD in association with metabolic syndrome is associated with slightly increased mortality
- NASH is more likely in the presence of positive family history and moderate alcohol intake
- simple steatosis is not associated with the development of NASH.
Question 8
Which of the following investigations would exclude the presence of cirrhosis:
- normal albumin
- normal platelets
- normal ultrasound
- normal LFTs
- none of the above.
Case 3
Amala Shah
Amala, 56 years of age, presents with abdominal pains typical of biliary colic. Abdominal ultrasound reveals gallstones and a single polyp attached to the gallbladder wall.
Question 9
Which of the following scenarios is the most concerning:
- polyps larger than 5 mm in patients with inflammatory bowel disease
- polyps detected in younger patients
- polyps detected in patients without gallstones
- polyps with a narrow base
- polyps larger than 2 mm in patients with primary sclerosing cholangitis.
Question 10
In which of the following scenarios would cholecystectomy NOT be considered reasonable:
- asymptomatic gallstones undergoing other abdominal surgery
- asymptomatic gallstones detected in diabetic patients
- calcification in the gallbladder wall detected on ultrasound
- gallbladder wall polyps larger than 10 mm
- chronic acalculous cholecystitis with typical biliary pain with sludge found on ultrasound.
Question 11
Amala is reluctant to undergo cholecystectomy, as her mother suffered with ongoing pain post-cholecystectomy. Which of the following is CORRECT regarding complications associated with cholecystectomy:
- biliary dyskinesia, or spasm of the sphincter of Oddi, commonly occurs within the first week after cholecystectomy
- bile leak occurs in 1–2% of patients undergoing laparoscopic cholecystectomy
- conversion from elective laparoscopic to open cholecystectomy occurs in 10% of patients
- post-cholecystectomy pain may be caused by bile leak, usually about 3–4 weeks after surgery
- studies suggest an incidence of 1–5% of diarrhoea developing post-cholecystectomy.
Question 12
Amala decides to proceed with cholecystectomy and sees you 4 weeks post-operatively. She complains of new onset loose stools. At this stage, which of the following would be the most appropriate management:
- advise Amala to decrease her fibre intake and review her in 4 weeks
- advise Amala to increase her monounsaturated fat intake and review in 4 weeks
- refer Amala for early gastroenterology assessment
- refer Amala for consideration of bile acid therapy
- review in 2 weeks and advise that loose stools usually resolve completely within 6 weeks.
Case 4
Bradley Larson
Bradley, 39 years of age, has hepatitis B and hasn’t attended your clinic for 2 years. Liver ultrasound and other initial investigations performed 2 years ago were unremarkable. Liver biopsy has not been performed.
Question 13
Regarding hepatitis B, which of the following statements is CORRECT:
- healthy hepatitis B carriers maintain a low hepatitis B viral load and normal LFTs
- hepatitis B is estimated to affect approximately 1% of the Australian population
- if not appropriately managed, 35–40% of patients with hepatitis B develop liver disease
- most patients diagnosed with primary liver cancer survive between 1 and 5 years after diagnosis
- two-thirds of Australians with hepatitis B currently remain undiagnosed.
Question 14
Which set of further investigations is most appropriate to determine the phase of hepatitis B infection:
- LFT, HBV viral load and liver ultrasound
- LFT, HBV viral load, FBE, INR and non-invasive testing for fibrosis
- LFT, HBV viral load, HBsAg, anti-HBc and anti-HBs
- LFT, HBV viral load and liver biopsy
- LFT, HBV viral load, HBeAg and anti-HBe.
Question 15
Which one of the following patient groups with hepatitis B is recommended for 6 monthly surveillance liver ultrasounds:
- African females aged over 10 years
- Asian men aged over 30 years
- family history of hepatocellular cancer
- intravenous drug users
- patients with two or more episodes of jaundice per year.
Question 16
Regarding the treatment of hepatitis B, which of the following is TRUE:
- determining the phase of hepatitis B infection is used to make decisions regarding treatment
- evidence shows that 4 years of treatment can decrease the risk of liver cancer by 25%
- first-line oral treatments have good efficacy but cause significant lethargy and nausea
- liver biopsy results demonstrating fibrosis is required for PBS eligibility for treatment
- response to treatment is monitored by hepatitis B viral load, albumin, platelets and INR.