ABSTRACT
Multiple Choice (choose the one best answer) 1. A 43-year-old woman presents with a 2-year history of
daily right upper quadrant discomfort that is dull and intermittent. She has a body mass index of 38 and no constitutional symptoms. She has been taking oral contraceptives for 15 years. Her only other medication is atorvastatin. Physical examination findings are remarkable for right upper quadrant tenderness which persists and is slightly accentuated when she raises her head off the examination table. A complete blood count and electrolyte studies are normal. A liver panel is remarkable for alanine aminotransferase (ALT) that is 1.5 times the upper limit of normal. The bilirubin and alkaline phosphatase levels are normal. Ultrasonography shows a 0.5-cm nonmobile
gallbladder mass that does not shadow. Doppler studies of the gallbladder mass are negative. The liver displays an increase in echotexture. A 5-cm echogenic mass is present. Computed tomography of the right lobe (Figure) demonstrates decreased density of the liver relative to the spleen and a 6-cm mass in segment 6. Nodular peripheral enhancement is noted on the arterial phase study, with delayed filling of the lesions during the venous phase examination. The most appropriate management of this patient is: a. Referral to a surgeon b. Ultrasonographically guided biopsy of the mass c. Discontinuation of the oral contraceptives, and imaging
studies repeated in 3 months d. Reassurance e. Magnetic resonance imaging of the liver
Question 1
Precontrast Arterial Phase
ribavirin failed. He has been abstinent from alcohol for 4 years. He is fatigued and has noted peripheral edema. His current medications include propranolol for prophylaxis of variceal bleeding (larger varices on endoscopy 2 months ago) and furosemide. Physical examination shows muscle wasting, spider angiomas, splenomegaly, and peripheral edema. The following were reported on laboratory evaluation: albumin 2.9 g/dL, total bilirubin 2.1 mg/dL, international normalized ratio 1.0, hemoglobin 12.1 g/dL, leukocytes 3.1 × 109/L, and platelets 56 × 109/L. Alpha fetoprotein is normal. Ultrasonography of the liver shows a 4-cm mass in the right lobe. No Doppler signal is detected in the right portal vein. Ascites is also noted on ultrasonography. Magnetic resonance imaging demonstrates enhancement in the mass, worrisome for hepatocellular carcinoma. The mass involves the right portal vein. What is the appropriate next step? a. Repeat imaging studies in 2 months, reassure the patient
that he likely has macroregenerative nodules, and see him back in 6 months
b. Reassure the patient that he likely has macroregenerative nodules, and see him back in 6 months
c. Perform endoscopy of the upper gastrointestinal tract and colonoscopy to exclude a source for potential hepatic metastases
d. Make a clinical diagnosis of hepatocellular carcinoma, and refer the patient to a tertiary care center
e. Biopsy the left lobe of the liver
5. A 65-year-old man is referred for evaluation of a liver mass. He has a low-grade fever to 101.3°F, night sweats, and a 12-lb weight loss. He has been ill for 3 weeks. There is no antecedent history of liver disease. He has urinary outflow obstructive symptoms and has been treated in the past for prostatitis. On physical examination, his temperature is 100.5°F, pulse rate 105 beats/min, and blood pressure 128/83 mm Hg. He has tenderness of the right upper quadrant. The prostate is enlarged and soft. Laboratory values include the following: leukocytes 11.5 × 109/L, alkaline phosphatase increased 3-fold, alanine aminotransferase increased 2-fold, and prostate-specific antigen 8 ng/mL (normal, <4.5). Microscopic examination of a urine specimen shows pyuria and bacteria. Computed tomography shows a heterogenous 4-cm mass in the right lobe of the liver. It has peripheral enhancement following intravenous administration of contrast. The next management step should be: a. Prostate biopsy b. Magnetic resonance imaging of the liver to further define
the lesion
2. tion of a liver mass. At age 50, he had right hemicolectomy for colon cancer. He states that no lymph nodes were involved. No adjuvant chemotherapy was given. He has hypertension and is taking enalapril. Aside from a midline abdominal scar, physical examination findings are unremarkable. A complete blood count, liver panel, and electrolyte study are all normal. Colonoscopy shows a 7-mm polyp in the sigmoid colon; it is removed. Ultrasonography of the liver shows a 3-cm isoechoic mass in the right lobe. You order a magnetic resonance imaging study. The mass is isointense on both T1 and T2 studies. Following gadolinium administration, prominent arterial enhancement is observed during the arterial phase studies, with a rapid washout on the venous phase studies. No central scar is present. The appropriate management of this patient is: a. Referral to an oncologist for chemotherapy b. Reassurance c. Fine-needle aspiration of the lesion d. Referral to a radiologist for a radiofrequency ablation
procedure e. Biopsy of the liver away from the mass
3. A 64-year-old woman is referred for evaluation of a liver mass. She has developed progressive anorexia and has lost 15 lb. Her history is remarkable for hypertension, hypothyroidism, and coronary artery disease. Her medications include thyroid hormone and metoprolol. On examination, the left lobe of the liver is palpable. Laboratory studies demonstrated the following: hemoglobin 11.1 g/dL, leukocytes 5.4 × 109/L, and platelets 554 × 109/L. The alkaline phosphatase level is increased 2.5-fold, alanine aminotransferase is 1.5 times the upper limit of normal, and total bilirubin is 0.8 mg/dL. Carcinoembryonic antigen and alpha fetoprotein values are normal, but CA 19-9 is 864 U/L (normal <80). Ultrasonography shows a 7-cm mixed echogenic mass in the left lobe of the liver. On computed tomography, the mass has no arterial enhancement but displays venous phase enhancement. Chest radiography does not show any lung metastases. The best management of this lesion is: a. Referral to a surgeon b. Chemoembolization c. Observation, with repeat imaging in 2 months d. Colonoscopy and endoscopy of the upper gastrointestinal
tract e. Endoscopic ultrasonography
4. A 51-year-old man with hepatitis C and a history of alcohol abuse comes for his semiannual evaluation. Two years
c. d. Further staging studies, including bone marrow exam-
ination to exclude lymphoma
6. A 60-year-old man is brought to the emergency department by his wife, who comments that the patient has a drinking problem and has been complaining of back pain for the past several days. Physical examination findings are notable for spider angiomas and palmar erythema. The liver edge is firm and the span is increased. The spleen is palpable. No ascites or lower extremity edema is appreciated. Laboratory studies demonstrate the following: hemoglobin 11.9 g/dL, leukocytes 12.1 × 109/L, platelets 130 × 109/L, blood urea nitrogen 50 mg/dL, creatinine 2.3 mg/dL, aspartate aminotransferase 4,200 U/L, alanine aminotransferase 5,193 U/L, total bilirubin 3.1 mg/dL, alkaline phosphatase 70 U/L, and international normalized ratio 1.6. Which of the following is the most likely cause of this patient’s liver disease? a. Pancreatic cancer b. Acute hepatitis A c. Acetaminophen toxicity d. Ischemic hepatitis e. Alcoholic hepatitis
7. A 40-year-old man comes to the emergency department complaining of several days of fatigue and abdominal pain. The pain is described as dull, achy, and in the right upper quadrant. He says he does not use intravenous drugs but has infrequently used intranasal cocaine. He notes occasionally having sex with prostitutes, but none in the recent past. He states he does not take any regular medications except 4 to 6 tablets of acetaminophen (Extra-Strength Tylenol) daily because of abdominal pain. He describes himself as a social drinker but denies any problems of alcohol abuse. His wife nods in agreement. On physical examination, he appears fatigued. Temperature is 100.9°F, pulse rate 100 beats/min, and blood pressure 100/65 mm Hg. The sclerae are mildly icteric. Cardiac examination reveals a systolic flow murmur. Abdominal examination is notable for an enlarged, tender liver. There is no asterixis. Laboratory findings are as follows: hemoglobin 12.5 g/dL, mean corpuscular volume 108 fL, platelets 120 × 109/L, leukocytes 15.9 × 109/L with a left shift, blood urea nitrogen 29 mg/dL, creatinine 1.9 mg/dL, aspartate aminotransferase 96 U/L, alanine aminotransferase 60 U/L, γ-glutamyltransferase 430 U/L, alkaline phosphatase 220 U/L, total bilirubin 2.5 mg/dL, and ceruloplasmin 26 mg/dL. Ultrasonography of the liver demonstrates heterogenous echotexture without ascites. Which of the following is the most appropriate treatment option?
