2004

Question 17.
Regarding Hepatitis C:
A. Hepatitis C does not cause acute liver failure
B. there are 7 main genotypes
C. is preventable by vaccination
D. is spread by faecal oral route
E. is an hepadna virus

Question 22.
Regarding hepatitis B:
A. Surface antigen is absent in serum during active replication
B. surface antibody can denote past infection
C. core antigen is detectable in serum
D. precore mutants express g antigen
E. it is a picornavirus

 

Question 26.
Albumin:
A. has a half life of 3 days under normal conditions
B. has a basal production rate of 32 mg per day
C. serum concentration rises in pregnancy
D. is predominantly intracellular
E. can serve as a measure of hepatic synthetic capacity

 

Question 27.
Bilirubin:
A. is a heam breakdown product
B. is conjugated with galactouric acid
C. is water soluble
D. is bound to ligandin in the smooth endoplasmic reticulum
E. is oxidised to biliverdin by cytochrome P450
Question 28.
Phase 2 reactions include:
A. Dichlorination
B. Galactothione conjugation
C. Cytochrome P450 oxidation
D. Glucuronidation
E. Dehydrogenation

Question 31.
Regarding viral hepatitis, select an option that best fits the stem. Each option may be used once, more than once, or not at all.
(5 marks)
Stems
(1) hepatitis B
(2) hepatitis E
(3) hepatitis C
(4) hepatitis D
(5) hepatitis A
Options
A. picorna virus
B. corona virus
C. prion
D. hepadna virus
E. requires hepatitis B co-infection
F. flavivirus
G. causes high mortality in pregnancy

 

Question 8
Which of the following does not normally drain into the portal venous system?
a. The anal canal
b. The head of the pancreas
c. The sigmoid colon
d. The spleen
e. The transverse colon
Question 17
Bile acids are:
a. secreted by the pancreas
b. have hydrophobic and hydrophillic properties
c. important for iron absorption
d. synthesised in the bile duct
e. enzymes which catalyse the hydrolysis of triglycerides
Question 18
Once the keto acids have been formed from amino acids by transamination they may be used for
a. Energy production via the cori cycle
b. Lipid production by the lipolysis process
c. Cholesterol production
d. The synthesis of amino acids needed or not present in the diet
e. Acting on spinal afferent neurones activating sympathetic efferent pathways to the gut
Question 19
Concerning normal liver function:
a. urea is a product of cholesterol metabolism
b. cholic acid is a primary bile acid
c. glycogen is generated by glycogenolysis
d. the fat soluble vitamins are; A,D,E,B
e. conjugation of biliverdin is catalysed by glucuronyl transferse
Question 21
Concerning liver enzymes:
a. Aspartate aminotransferase only a mitochondrial enzyme
b. Clotting factor V is vitamin K dependant
c. Bilirubin is conjugated with glucuronic acid
d. Alcohol is not metabolised cytochrome P450
e. Glucuronidation occurs in the mitochondria
MMED 8221 GASTROINTESTINAL SYSTEM APRIL EXAMINATION 2005 PAGE 9
continued next page…
Question 22
Regarding Hepatitis C:
a. Hepatitis C usually progresses to cirrhosis.
b. Transmission is by the feacal-oral route
c. It is untreatable
d. Initial infection is usually assymptomatic
e. It is a DNA virus
Question 23
Regarding hepatitis B:
a. surface antigen dissapears after 60 days from infection
b. precore mutants do not express e antigen
c. core antigen is detectable in serum
d. surface antibody indicates current infection
e. it is an RNA picornavirus
Question 24
With respect to Hepatitis A:
a. Route of transmission is parenteral
b. It is associated with cirrhosis
c. It is RNA virus
d. It is not preventable by vaccination
e. Is uncommon in third world countries

Question 27
For each of the stems listed below, select an option which best matches. Each option may be used once,
more than once, or not at all.
Stems
(1) autoimmune hepatitis
(2) coeliac disease
(3) primary biliary cirrhosis
(4) hepatitis C
(5) alcoholic hepatitis
Options
a. anti mitochondrial antibodies
b. elevated IgA
c. anti Ro antibodies
d. anti smooth muscle antibodies
e. cold agglutinins
f. anti thyroglobulin antibodies
g. anti nuclear antibodies
h. anti endomysial antibodies
i. cryoglobulins
(5 marks)
Question 28
Regarding viral hepatitis, select an option that best fits the stem. Each option may be used once, more
than once, or not at all.
Stems
(1) hepatitis D
(2) hepatitis B precore mutant
(3) hepatitis C
(4) hepatitis B wild type
(5) hepatitis A is
Options
a. eAg positive
b. eAg negative
c. genotypes 1,2,3,4
d. E IgM antibody
e. requires hepatitis B co-infection
f. picornavirus
g. causes high mortality in pregnancy
(5 marks)

2006
Question 9.
Concerning viral liver disease:
A. Hepatitis A does not cause chronic liver disease
B. More than 60% of people with hepatitis C develop cirrhosis
C. Hepatitis B surface antigen indicates immunity to hepatitis B
D. Hepatitis B is a single stranded RNA virus
E. Hepatitis C is a cause of acute liver failure
Question 10.
Regarding Hepatitis C:
A. Hepatitis C always progresses to chronic liver disease
B. Transmission is by the faecal-oral route
C. Is preventable by vaccination
D. The histological features include portal inflammation, lobular inflammation and fatty change
E. It is a DNA virus
Question 11.
With respect to Hepatitis A:
A. Route of transmission is blood to blood
B. It is associated with chronic liver disease and cirrhosis
C. It is a DNA virus
D. It is preventable with a vaccine
E. Is never associated with fatal hepatitis
Question 12.
Which of the following does not normally drain into the portal venous system?
A. The thoracic esophagus
B. The head of the pancreas
C. The sigmoid colon
D. The spleen
E. The transverse colon
Question 18.
Concerning normal liver function:
A. Urea is a product of cholesterol metabolism
B. Glycogen is generated by glycogenolysis
C. The fat soluble vitamins are; A,D,E,C
D. Chenodeoxycholic acid is a secondary bile acid
E. Conjugation of bilirubin is catalysed by glucuronyl transferse
Question 19.
Concerning liver enzymes:
A. Aspartate aminotransferase is a cytosolic and mitochondrial enzyme
B. Clotting factor III is vitamin K dependant
C. Bilirubin is not conjugated by glucuronyl transferase
D. Alcohol is not metabolised cytochrome P450
E. Glucuronidation occurs in the mitochondria
Question 22.
Regarding hepatitis B:
A. Surface antigen is present in serum during active replication
B. Surface antibody exclusively denotes past infection
C. Core antigen is detectable in serum before core antibody
D Precore mutants express

 

Question 27. (5 marks)
Regarding viral hepatitis, select an option that best fits the stem. Each option may be used once, more
than once, or not at all.
Stems
27.1 Hepatitis B
27.2 Hepatitis E
27.3 Hepatitis C
27.4 Hepatitis D
27.5 Hepatitis A
Options
A. picorna virus
B. corona virus
C. prion
D. hepadna virus
E. requires hepatitis B co-infection
F. flavivirus
G. causes high mortality in pregnancy
Question 28. (5 marks)
For each of the liver functions listed below, select an option which is involved in the process. Each
option may be used once, more than once, or not at all.
Stems
28.1 Removes amino groups off aspartate
28.2 Conjugates bilirubin in the hepatocyte
28.3 Converts ethanol to acetaldehyde
28.4 Is most important in detoxifying paracetomol
28.5 Is a source of sulphate for sulphate conjugation
Options
A. Gamma glutamyl transferase
B. Glucuronyl transferase
C. Alcohol dehydrogenase
D. Uridine diphospho glucuronosyl transferase
E. 3 phosphoadenosine 5 phosphosulphate
F. Glutathione conjugation
G. Cytochrome P450 3A4
H. Alkaline phosphatase
I. Aspartate amino transferase
J. Alanine amino transferase

2007

Mr Eugene Toh is a 55 year old Vietnamese born man who works as a chef at the Lucky Dragon restaurant.
He has lived in Australia for 15 years after immigrating from Vung Tau where he was born. He presents with a 3 month history of increasing difficulty sleeping and more recently has noticed that he bruises easily. His abdomen feels swollen and he has noticed progressive swelling of both legs. He has no abdominal pain.
He receives monthly acupuncture for relief of headaches. He has no history of blood transfusion.
On examination Mr Toh weighs 83kg and is 155 cm tall. Abdominal examination reveals a small liver and splenomegaly. Moderate ascites is detected. Numerous spider naevii are evident on the upper body. There is pitting oedema of the legs bilaterally. He has no tattoos, or piercings. Examination of the hands reveals palmer erythaema and a flap is present.
There are multiple bruises on his back after recent acupuncture.
Question 1. (2 marks)
Identify Mr E Toh's symptoms.
Question 2. (2 marks)
Identify Mr E Toh's clinical signs.
Question 3. (6 marks)
What are the most likely possible causes for liver disease in this man?
Question 4. (4 marks)
What additional history would you obtain?
SECTION A Mini Case - Mr Eugene Toh
Part 2 (Total marks: 10 - Suggested writing time: 10 minutes)
Answer all questions.
Write your answers in booklet marked Section A, Part 2.
Start each question on a new page.
Mr E Toh reports drinking 2 stubbies of light strength (2. %) beer daily whilst working in the kitchen. He has done so for 3 years.
He has never used IV drugs.
Mr Toh does not use traditional medicine, natural therapies or prescription medication.
There is no known family history of liver disease.
INVESTIGATION RESULTS
Normal range
• Complete Blood Picture:
Hb 110g/l 115-155
MCV 109fl 80-99
White cell count 2.1 x 109/l 4-11
Platelets 33 x 109/l 150-450
ESR 10/hr 1-15
• INR: 1.7
• Liver Function Tests
Albumin 24 g/1 37-52
Alk Phos 98 U/l 30-100
Bilirubin 320 μmol/l <20
Gamma GT 186 U/l <50
AST 165 U/l <35
ALT 64 U/l <50
• Alpha Feto Protein: Normal
• Liver Ultrasound:
The liver is small and the surface irregular. The spleen is 17 cm. Ascites is present.
The gallbladder is present. No gall stones are seen. The bile ducts are not dilated.
There are no mass lesions evident in the liver.
Question 5. (10 marks)
Are these results consistent with chronic liver disease? Explain.
SECTION A Mini Case - Mr Eugene Toh
Part 3 (Total marks: 16 - Suggested writing time: 16 minutes)
Answer all questions.
Write your answers in booklet marked Section A, Part 3.
Start each question on a new page.
Additional investigation results are obtained:
• Hepatitis C antibody: negative
• Hepatitis C RNA PCR: negative
• Hepatitis B surface antigen positive
• Hepatitis B serum viral DNA positive
• Hepatitis B surface antibody negative
• Anti-mitochondrial Antibody negative
• Iron studies normal
Question 6. (2 marks)
What are the likely causes for this man’s liver disease?
Question 7. (14 marks)
Discuss the possible complications of cirrhotic liver disease.

Question 8.
Regarding non-alcoholic steatohepatitis (NASH):
A. Usually the AST is greater than 2 times the level of ALT
B. Liver biopsy should be performed in all patients
C. Is not frequently associated with a metabolic syndrome (obesity, hypertension, hyperlipidaemia, insulin resistance/diabetes)
D. The initial treatment of choice is slow weight loss in overweight patients
E. The majority of patients will progress to cirrhosis
Question 9.
Regarding genetic haemochromatosis:
A. Significant iron overload is usually present before 30 years of age
B. Homozygosity for the c282y mutation of the HFE protein accounts for >90 % of patients with iron overload in Australia
C. Patients with cirrhosis have a relative risk for hepatocellular carcinoma of > 20
D. Patients with iron overload should not undergo venesection
E. All complications due to iron overload can be reversed by venesection
Question 18.
Regarding Hepatitis C:
A. Hepatitis C is not associated with hepatocellular carcinoma
B. There are 9 main genotypes
C. Is treated with interferon and ribavirin
D. Spread by an insect vector
E. Is a headman virus
Question 19.
Regarding Hepatitis B:
A. Surface antigen is present in serum during active replication
B. Surface antibody is not protective against reinfection
C. Core antigen is detectable in serum
D Is never transmitted vertically
E. It is a flavivirus
Question 20.
Aspartate aminotransferase:
A. Converts alanine to pyruvic acid
B. Is found in liver cytosol only
C. Is found in skeletal muscle
D. Converts aspartic acid to glutamic acid
E. Can serve as a measure of hepatic synthetic capacity
Question 27.
Which is a clinical marker of hepatic synthetic function:
A. Activated partial thromboplastin time
B. Serum cholesterol
C. Serum creatinine
D. Prothrombin time
E. Serum ferritin
Question 28. (5 marks)
For each of the stems listed below, select an option which best matches. Each option may be used once, more than once, or not at all.
Stems
27.1 Is associated with schlerosing cholangitis
27.2 May be associated with folate deficiency
27.3 Mucosal granuloma are often seen
27.4 Is associated with dermatitis herpetiformis
27.5 Often involves both large and small bowel
Options
A. Gilberts syndrome
B. Eosinophilic oesophagitis
C. Duodenal ulcer
D. Coeliac disease
E. Carolies disease
F. Ulcerative colitis
G. Crohn’s disease
H. Carcinoid syndrome

 

2008

Question 15.
With respect to Hepatitis A, please indicate whether the following statements are True or False:
a) The route of transmission is parenteral.
b) It is associated with cirrhosis.
c) It is an RNA virus.
d) It is not preventable by vaccination.
e) It can lead to fulminant liver failure and death.
(2.5 marks)
Question 16.
A 48 year old lady with known cirrhosis from alcoholic liver disease is taken to the accident and emergency department by her concerned husband. He had found her drowsy and confused at home. She has been abstinent from alcohol for several months now. She is on frusemide and spironolactone for management of ascites but is on no other medication.
On examination she is disorientated and has asterixis. She is afebrile. There is mild jaundice, and moderate ascites but her abdomen is soft and non-tender. Rectal examination reveals only hard stool.
Investigation results from a venous blood sample include:
Na 127 (137-145)
K 2.8 (3.5-4.9)
urea 12.4 (2.7 – 8.0)
creatinine 159 (50-120)
albumin 29 (34-48)
bilirubin 47 (6-24)
INR 2.1 (0.9-1.1)
Please indicate whether the following statements are True or False:
a) This lady has Child’s B cirrhosis.
b) Her encephalopathy may have been precipitated by the diuretics which should now be held.
c) She needs a diagnostic ascitic tap as spontaneous bacterial peritonitis is a possible cause of her encephalopathy.
d) Treatment with neomycin would be a reasonable first line of treatment.
e) Lactulose treats encephalopathy by acidifying the colon and thereby reducing ammonia production by colonic bacteria.
(2.5 marks)
Question 17.
Regarding liver metabolism, please state whether the following sentences are True or False:
a) Phase II reactions are mediated by cytochrome P450 enzymes and include oxidation and dehydrogenation reactions.
b) The majority of bile salts are reabsorbed at the site of the terminal ileum.
c) Deoxycholic acid is the primary bile acid in human bile.
d) Ammonia removal is an important function of hepatocytes that is impaired in liver failure.
e) Glycolysis involves the conversion of glucose to pyruvate with the concomitant production of ATP.
(2.5 marks)
Question 18.
Regarding the enzyme alanine aminotransferase (ALT), which of the following statements are True and which are False:
a) The function of this enzyme is the removal of amino groups from aspartate.
b) The enzyme is present in many body organs, including the liver.
c) The commonest cause of elevation in developed countries in non-alcoholic fatty liver disease.
d) In alcoholic hepatitis ALT is usually higher than the AST.
e) In non-alcoholic liver disease the AST:ALT ratio is usually < 1.
(2.5 marks)

Question 21.
Regarding the liver, please indicate whether the following statements are True or False:
a) The liver moves with respiration.
b) The liver displays haemopoietic activity in the foetus.
c) Histologically, the largest diameter structure within the portal triad is the arteriole.
d) The Quadrate lobe is separated from the Caudate lobe by the Porta Hepatis.
e) The Portal Vein is formed by the union of the Superior Mesenteric and Hepatic Veins.
(2.5 marks)

 

2009

Question 17.
Regarding non-alcoholic fatty liver disease, please indicate which one of the following statements is CORRECT:
a) Raised GGT and an AST to ALT ratio greater than 1 are characteristically seen.
b) Significant liver disease is more likely to occur in diabetic and overweight patients.
c) Liver biopsy is required to confirm diagnosis.
d) Insulin resistance is uncommon.
e) Weight loss does not improve liver histology.
Question 18.
With respect to Hepatitis C infection, please state which of the following statements is TRUE:
a) It is usually cleared following infection.
b) Positive Hepatitis C antibody test confirms current infection.
c) 50% of chronically infected people will develop cirrhosis.
d) Genotype predicts the response to therapy.
e) Current antiviral therapy has an overall cure rate of 95%.
Question 21.
Concerning liver metabolism, please indicate which of the following statements is INCORRECT:
a) Alanine aminotransferase is a cytosolic enzyme.
b) Clotting factor V is not Vitamin K dependent.
c) Bilirubin is conjugated by GGT.
d) Alcohol is metabolised by alcohol dehydrogenase and cytochrome P4502E1.
e) Glucuronidation occurs in the hepatocyte endoplasmic reticulum.
Question 22.
With respect to Hepatitis B, please indicate which of the following statements is TRUE:
a) It is a double shelled DNA virus.
b) It is not associated with persistent infection and cirrhosis.
c) Its route of transmission is exclusively blood borne.
d) The risk of becoming a carrier is greater if the disease is contracted later in life.
e) Surface antibody is not protective against reinfection.
Question 23.
Regarding the protein albumin, please state which one of these statements is CORRECT:
a) Albumin is synthesized by the kidneys.
b) Albumin has a plasma half life of 2 to 3 months.
c) Its synthesis can be depressed by conditions other than liver failure.
d) Levels of albumin rise in pregnancy.
e) Following synthesis, the majority of albumin is stored within hepatocytes.
Question 26.
A 59 year-old man is admitted with haematemesis and at endoscopy is found to have oesophageal varices. An ultrasound is performed and confirms the presence of cirrhosis with portal hypertension. Which of the following is the least likely to be the cause of his chronic liver disease?
a) Alcohol.
b) Hepatitis A.
c) Hereditary haemochromatosis.
d) Hepatitis C.
e) Non-alcoholic Steatohepatitis (NASH).

 

Question 30.
Which ONE of the following is a marker of hepatic synthetic function?
a) Serum creatinine.
b) Serum ferritin.
c) Vitamin K.
d) Aspartate aminotransferase (AST).
e) Serum albumin.