1. A 47-year-old man has noted increasing abdominal enlargement for several months.

Physical examination reveals the presence of no abdominal tenderness, but a fluid wave is present. A paracentesis is performed with removal of 2000 cc of clear, yellow ascitic fluid. This fluid has a protein of 2.1 g/dL. Cytologically, the fluid contains a few mesothelial cells and a few mononuclear cells. Which of the following underlying conditions is he is most likely to have: A. Perforated gastric ulcer B. Acute pancreatitis C. Micronodular cirrhosis D. Crohn's disease

2. A 30-year-old healthy woman goes on a crash diet to lose weight, eating less than 500 calories per day. After two weeks, she notices scleral icterus and sees her physician. Laboratory testing reveals total bilirubin 3.5 mg/dl with direct bilirubin 0.3 mg/dl. The most likely cause for these findings is:

A. Fatty metamorphosis of liver B. Biliary atresia C. Rotor syndrome D. Choledocholithiasis E. Gilbert's syndrome

3. A 1-month-old baby is noted to be increasingly icteric. She has a serum total protein of 6.7 g/dL, albumin 3.1 g/dL, alkaline phosphatase 122 U/L, AST 202 U/L, ALT 212 U/L, and total bilirubin 3.8 mg/dL. A liver biopsy is performed and reveals periportal chronic inflammation with minimal piecemeal necrosis, a few giant cells, and small periportal PAS-positive hyaline globules. The child develops cirrhosis by the age of 10. Which of the following genetic findings is most likely to be present A. C282Y mutation B. Galactose-1-phosphate uridyl transferase deficiency C. DeltaF508 mutation

4. A 44-year-old woman has developed worsening pruritis over the past three months. Laboratory findings include: total protein 5.9 g/dL, albumin 3.4 g/dL, alkaline phosphatase 487 U/L, AST 66 U/L, ALT 55 U/L, total bilirubin 0.9 mg/dL, and direct bilirubin 0.7 mg/dL. A liver biopsy reveals destruction of intrahepatic bile ducts with associated lymphoplasmacytic inflammatory infiltrates of the portal tracts that extend into the adjacent parenchyma. Which of the following disease processes best explains these findings: A. Pancreatic adenocarcinoma B. Viral hepatitis C infection C. Chronic alcoholism

5. A 45-year-old woman has noted increasing bronze pigmentation of the skin even though she has not been out in the sun. She is found to have a fasting serum glucose of 160 mg/dl. Physical examination reveals a palpable spleen tip and a firm liver edge. Arrhythmias are noted on electrocardiogram. The best explanation for these findings is: A.Chronic alcoholism B.Wilson's disease C.Budd-Chiari syndrome D.Hemochromatosis

6. Bone marrow transplantation for acute leukemia was performed in a 23-year-old woman. She received total body radiation with busulfan and cyclophosphamide therapy. Three weeks after transplantation, she had sudden weight gain with hepatic enlargement, ascites, and markedly elevated serum bilirubin. These findings most strongly suggest: A.Acute viral hepatitis B B.Micronodular cirrhosis C.Focal nodular hyperplasia D.Extrahepatic biliary obstruction

7. An 84-year-old woman is found at autopsy to have a cirrhotic liver in which the size of the liver nodules averages 2 to 3 mm. Microscopically, the liver shows regenerative nodules with extensive fibrosis between portal regions along with scattered lymphocytes and bile duct proliferation. Which of the following etiologies best explains the appearance of the cirrhosis in this case A.Alpha-1-antitrypsin deficiency B.Hepatitis B infection C.Biliary atresia D.Veno-occlusive disease E.Chronic alcoholism

8. At autopsy, the liver is slightly enlarged and grossly shows a "nutmeg" pattern on sectioning. The microscopic appearance of the liver demonstrates centrilobular congestion and necrosis, but no inflammation or fibrosis. The patient was a 63-year-old woman who had a 70 pack year history of smoking. She also had a history of chronic arthritis for which she used analgesics. The cause for the liver disease is most likely to be A.Cor pulmonale B.Uncontrolled diabetes mellitus C.Alpha-1-antritrypsin deficiency D.Chronic hepatitis C E.Acetaminophen ingestion

9. A 56-year-old man from Shanghai, China has had a 10 kg weight loss over the past three months and has felt tired. An abdominal CT scan reveals a 10 cm solid mass in the left lobe of a nodular liver. Laboratory testing reveals that he is hepatitis B surface antigen positive, hepatitis C antibody negative, and hepatitis A antibody negative. A liver biopsy of the lesion is most likely to show: A.Metastatic adenocarcinoma B.Large B cell lymphoma

10. A 57-year-old woman is moderately obese and has diabetes mellitus type II. She has increasing malaise for several months. A chemistry panel is performed and reveals: total protein 6.1 g/dL, albumin 4.0 g/dL, alkaline phosphatase 31 U/L, AST 67 U/L, ALT 59 U/L, total bilirubin 1.2 mg/dL, and direct bilirubin 0.3 mg/dL. Her malaise persists for another 9 months. An abdominal CT scan reveals decreased attenuation of the entire liver. No mass lesions are noted, but the liver is diffusely enlarged. A liver biopsy is performed. What is the biopsy most likely to show

A.Hepatocellular carcinoma B.Intracanalicular bile stasis

11. A 26-year-old student incurs a

needlestick injury while starting an IV on a combative patient in the emergency room. About 25 years later, a mass develops in his liver. This mass is most likely to be a(an): A.Hepatoblastoma B.Hepatocellular carcinoma C.Hepatic angiosarcoma D.Cholangiocarcinoma E.Hepatic adenoma

12. A neonate in the second week of life is noted to be increasingly icteric. Physical examination reveals no abdominal distension or masses. There is no tenderness. Bowel sounds are present. Laboratory findings reveal a neonatal bilirubin of 12.2 mg/dL A.Biliary atresia

B.Acute pancreatitis C.Meconium ileus D.Choledocholithiasis E.Pyloric stenosis

13. A 67-year-old man has abdominal pain. The serum calcium is 15.2 mg/dL with a serum albumin of 4.1 g/dL and serum phosphorus of 2.1 mg/dL. The most likely diagnosis is A.Chronic hepatitis B

B.Acute pancreatitis C.Hemochromatosis D.Hepatocellular carcinoma E.Small intestinal obstruction

14. A 66-year-old woman who noted

pale, clay-colored stools is found to have a total bilirubin of 15.4 mg/dL with a direct bilirubin of 12.8 mg/dL. A.Chronic alcoholism with cirrhosis B.Hemoglobinopathy with hemolysis C.Multiple hepatic metastases D.Acute hepatitis A E.Adenocarcinoma of the head of the pancreas

15.

A. B. C. D. E.

A 34-year-old woman has had nausea, vomiting, and fatigue for several months. Serum chemistries reveal that both the aspartate aminotransferase (AST) and alanine aminotransferase (ALT) are moderately elevated. The hepatitis B surface antigen is negative, hepatitis B surface antibody negative, hepatitis B core antibody negative, hepatitis A antibody-IgM negative, and the hepatitis C antibody is positive. These findings most strongly suggest that: She will recover in a few weeks with no sequelae The patient is at risk for development of chronic hepatitis There is no risk for development of hepatocellular carcinoma Infection could not have come from a blood transfusion She was infected via unprotected sexual intercourse a