Question 1
What is FALSE about the mechanism of action of ursodeoxycholic acid?
(A) It becomes the predominant bile acid in enterohepatic circulation
(B) It is cytoprotective
(C) It promotes endogenous secretion of bile acids
(D) It increases renal excretion of toxic bile acids
(E) It reduces inflammatory cytokine production
D: Ursodeoxycholic acid has been used in PBC and PSC. In PBS it shows a survival advantage. It is a bile acid that competes with other bile acids for absorption in the terminal ilieum. It may also cross the placenta. High doses in PBC are not effective, nether are low doses, there is a sweet spot in the middle (13 - 15mg/kg). N Engl J Med 2007; 357:1524-1529
Question 2
Which of the following factors is the most important determinant of outcome in non-alcoholic fatty liver disease?
(A) Fibrosis stage
(B) microvascular steatosis
(C) macrovascular steatosis
(D) balooning of hepatocytes
(E) Mallory bodies
A: All of the following are features of the spectrum of NAFLD, however the most important determinant of survival is fibrosis score. Other prognostic markers are age > 50, BMI >28, AST/ALT >1, elevated triglycerides, DM and systemic hypertension. Gastroenterology. 2015 Aug; 149(2): 389-397
Question 3
Which of the following is the most common cause of death in patients with NAFLD according to the community cohort study in the Olmstead county?
(A) Ischaemic heart disease
(B) Infections
(C) Malignancy
(D) Liver disease
(E) Stroke
C: Liver related deaths is the third most common cause of mortality in patients with NAFLD (NASH, NAFL, cirrhosis), but malignancy (28%) and ischaemic heart disease (13%) were the highest contributors. The population sample was 53, and the patients were followed from 1980 to 2000. Gastroenterology. 2005 Jul;129(1):113-21.
Question 4
Which of the following interventions have been shown to have the greatest effect on liver histology in patients with NAFLD?
(A) Weight loss > 7% via life-style reconstruction
(B) Weight loss >7% via bariatric surgery
(C) Vitamin E in non-diabetic patients at dose 800IU/d
(D) Omega 3 fatty acids
(E) Pioglitazone
A: Note that bariatric surgery in morbidly obese patients without cirrhosis has been shown to decrease NASH inflammatory grade and fibrosis stage. Gastroenterology 2012; 142: 1592-1609, RPA course 2015, Gastroenterology 2015; 149: 379-388
Question 5
What is the closest percentage of liver cirrhosis deaths that are attributable to alcohol?
(A) 25%
(B) 35%
(C) 50%
(D) 15%
(E) 65%
C: According to Rehm et al.Global burden of alcoholic Liver diseases, J Hepatol 2013 vol 59 j 160 - 168, 47.9% of liver cirrhosis related deaths are attributable to alcohol.
Question 6
The STOPAH trial examined the effects of prednisolone, pentoxifylline or both for the treatment of severe acute alcoholic hepatitis with a maddrey's discriminant function of 32 or higher. Which of the following is FALSE with regards to the results of this pivotol trial
(A) Patients treated with prednisolone had a higher chance of infections compared to placebo
(B) 28 day mortality in patients treated with pentoxifylline and prednisolone achieved statistical significance favouring combination therapy
(C) There was no statistically significant reduction in 28 day mortality for patients treated with prednisolone
(D) There was no statistically significant reduction in 90 day mortality in patients treated with pentoxifylline
(E) At 1 year, there was no statistically significant change in outcome with prednisolone or placebo
B: OR for prednisolone was 0.72 for 28 day mortality, with p = 0.06, therefore approaching statistical significance in patients treated with prednisolone N Engl J Med 2015; 372: 1619-1628
Question 7
What is the most common viral genotype in hepatitis C in Australia?
(A) Genotype 1
(B) Genotype 2
(C) Genotype 3
(D) Genotype 4
(E) Genotype 5
A: Genotype 1a>1b. Genotype 1 together accounts for 54% of all hepatitis C genotypes, with genotype 3 accounting for 37%. Genotype 5 is not prevalent in Australia. Genotype 6 is highly prevalent in Vietnam, and genotype 3a is the most common in India. Hepatology. 2015 Jan; 61(1): 77–8, RPA course 2015
Question 8
There is a significant gap between patients living with hepatitis C and those that have ever received treatment. What is the percentage of patients who have been diagnosed with hepatitis C who have ever received treatment?
(A) 10%
(B) 25%
(C) 35%
(D) 50%
(E) 75%
B: According to the Kirby Institute, HIV, viral hepatitis, and sexually transmissible infections in Australia Annual Surveillance Report 2015
Question 9
Which of the following genotypes of hepatitis C is most associated with steatosis and increased risk of progression to cirrhosis?
(A) Genotype 1
(B) Genotype 2
(C) Genotype 3
(D) Genotype 4
(E) Genotype 5
C: Genotype 3 is specifically associated with steatosis and may be associated with increased progression to cirrhosis and HCC. RPA course 2015, JAMA Intern Med, 2014; 174(2): 204-212
Question 10
Which of the following is NOT associated with hepatitis C?
(a) Mixed essential cryoglobulinaemia
(B) porphyria cutanea tarda
(C) acute intermittent porphyria
(D) lichen planus
(E) arthritis
C: Nat Med. 2013 Jul; 19(7): 850 - 8
Question 11
Which of the following is NOT a host risk factor associated with a risk of progression to cirrhosis?
(A) Female gender
(B) immunosupression
(C) alcohol use
(D) obesity
(E) type II diabetes
A: Male gender as opposed to female gender portends risk of cirrhosis
Question 12
The current best practice guidelines for hepatitis C genotype 1 treatment are IFN + ribavirin + simepravir. At what time point is the sustained virological response measured?
(A) 12 weeks into treatment
(B) 24 weeks into treatment
(C) 48 weeks into treatment
(D) 12 weeks at the end of treatment
(E) 24 weeks at the end of treatment
D: Note that SVR means undetectable HCV viral RNA, and it equates a cure from chronic HCV. SVR12 is now measured at 12 weeks post end of treatment. SVR can lead to regression of liver fibrosis and cirrhosis in HCV infected patients Liver int 2014; 35: 30 - 36, reduces all cause mortality, liver related mortality, liver failure and HCC JAMA 2012; 308 (24): 2584 - 2593. Furthermore, overall survival of patients with HCV and advanced fibrosis returns to that of age and sex matched population following SVR JAMA 2014 Van der Neer A.
Question 13
What is the percentage of Australians receiving HCV treatment who are infected with HCV?
(A) 0.5%
(B) 2%
(C) 7%
(D) 15%
(E) 25%
B: There are a number of barriers that preclude many patients having IFN based therapy, including medical co-morbidities and psychiatric comorbidities, cytopenias and hepatic decompensation.
Question 14
What is the mechanism of action of simepravir?
(A) NS5A protein inhibitor
(B) NS5B polymerase inhibitor - nucleoside
(C) NS3/4A protease inhibitor
(D) NS5B polymerase inhibitor - non-nucleoside
(E) Interferon inhibitor
C: It is a protease inhibitor and thus inhibits viral protein production, translation and polyprotein processing. N Engl J Med 2013; 368:1907-1917
Question 15
What is the most common hepatitis B genotype in Australia?
(A) Genotype A
(B) Genotype B and C
(C) Genotype D and E
(D) Genotype F
(E) Genotype I
B: As this is the most common in Asia and Australia receives much of the migrant population from Asia. In total there are 10 genotypes (A --> J) of hepatitis B. Clinically this is not tested. Interestingly, B is associated with less active disease, slower progression and lower incidence of HCC than genotype C, F is associated with fulminant liver disease, although this is rare. J Virol 2008; 82: 5657 - 5663, J Hepatol. 2009; 50: 227 - 242
Question 16
A 46 year old male applying for Australian Visa through Cambodia presents to the liver clinic with the following hepatitis serology:
HbSag -
HbSab -
anti-HBc +
anti-Hbs -
What is the correct interpretation?
(A) vaccinated
(B) resolved infection
(C) chronic infection
(D) isolated anti-Hbc status
(E) HBV susceptible patient
D: There are various possibilities. It could represent resolved past infection, HbsAg mutants, occult hepatitis B infection. Evaluation with quantitative HBV DNA is recommended. Liver Int. 2014; 34(7): 991 - 1000
Question 17
Which phases of chronic hepatitis B should you treat a patient?
(A) Immune Tolerance
(B) Immune Clearance and Immune escape
(C) Immune Escape
(D) Immune control
(E) Immune Tolerance and Immune Control
B: Basically, treatment should occur only in the immune clearance or immune escape phase. In immune clearance, there is the beginnings of eAg seroconversion into anti-HbEag, and ALT levels fluctuate. In immune escape, the patient has already seroconverted however the virus escapes immune control and ALT levels fluctuate.
Question 18
In general, how long does Hepatitis B vaccination last?
(A) 5 years
(B) 10 years
(C) 15 years
(D) 20 years
(E) 22 years
C: Vaccine efficacy is defined as a HBSab >10mIU/ml. Lancet Volume 384, Issue 9959, 6–12 December 2014, Pages 2053–2063
Question 19
What is correct regarding the virology of hepatitis B
(A) single stranded, DNA
(B) double stranded, DNA
(C) single stranded, RNA
(D) double stranded, RNA
(E) retrovirus
B: Lancet Volume 384, Issue 9959, 6–12 December 2014, Pages 2053–2063
Question 20
Pegylated interferon alpha may be used to treat hepatitis B. Which genotype is most responsive?
(A) A
(B) B
(C) C
(D) D
(E) E
A: Other predictors of response include low initial HBV DNA and high ALT. It has a defined time line of treatment (one year) as opposed to the viral reverse transcriptase inhibitors tenofovir and entecavir which prevent RNA --> DNA. However cccDNA is not affected thus explaining why relapses may occur after one has stopped reverse transcriptase therapy. In general, patients with immune clearance or immune escape phase should be treated. BUT guidelines do vary internationally, and one should consider treatment in patients who have persistently high HBV DNA load irrerspective of liver histology (evidence of necroinflammation and cirrhosis) or ALT titre. Lancet Volume 384, Issue 9959, 6–12 December 2014, Pages 2053–2063
Question 21
What is the main reason why tenofovir and entacavir are preferred over lamivudine in the treatment of chronic hepatitis B?
(A) Treatments run for shorter duration of time
(B) There is less genetic barrier to resistance with these treatments
(C) There is a higher SVR12 post treatment
(D) There is a higher SVR 24 post treatment
(E) Side-effects occur significantly less so with the third generation antiviral agents compared to lamivudine
B: RPA course and Lancet Volume 384, Issue 9959, 6–12 December 2014, Pages 2053–2063
Question 22
What is the vertical transmission risk to a baby if a pregnant female patient has a high viral load (10^7 IU/mL) in the third trimester of pregnancy?
(A) 10%
(B) 15%
(C) 35%
(D) 40%
(E) 60%
A: In this situation, all babies of HBsAg + mothers will be given HBIG and HB Vax x 3. In additionm a strong case can be made to consider tenofovir from week 30 to 2-3 months post delivery. RPA course 2015
Question 23
What is the recommended HCC surveillance strategy in patients with a diagnosis of cirrhosis?
(A) 6 monthly AFP and U/S
(B) Quad phase CT Abdomen annually
(C) 6 monthly U/S only
(D) Annual U/S
(E) Annual U/S and AFP
C: In accordance to the AASLD Practice Guidelines. Hepatology 2010
Question 24
Which of the following population groups do NOT need to be surveilled for development of HCC?
(A) A 43 year old asian female with chronic hepatitis B
(B) A 35 year old asian male with chronic hepatitis B
(C) A 22 year old African male with chronic hepatitis B
(D) A 22 year old asian male with chronic hepatitis B and a family history of HCC
(E) A 45 year old male with F4 METAVIR cirrhosis secondary to HCV
B: Any asian female with HBV > 50 or male > 40 should be screened, as should any African male >20 or any patient with FHx of HCC. Additionally, any patient with cirrhosis should be screened. Bruix and Sherman. AASLD Practice Guideline. Hepatology 2010. HCC Surveillance increases mean 3 year survival from cancer diagnosis and decreases need for liver transplantation. Am J Med 2008; 121: 119 - 126
Question 25
A 27 year old male with ECOG 1 performance status presents to the liver clinic for review. He is an ex-IVDU, who gave up alcohol 6 months prior to the clinic appointment. He has well controlled type 1 diabetes. His GP performed a blood test which revealed a high titre AFP. A subsequent ultrasound found 2 suspicious liver lesions. A quad-phase CT scan was organised showing 2 lesions enhancing in the arterial phase, measured at 2cm and 2.2cm respectively. The lesions also demonstrate venous and delayed phase washout relative to normal liver parenchyma. Which of the following is an appropriate treatment strategy?
(A) List patient for liver transplantation
(B) Radiofrequency ablation
(C) Liver resection if favourable anatomy
(D) A, B or C
(E) Sorafanib
D: This fulfils the Milan criterion with a single lesion <5cm or max 3 lesions all < 3cm. Radiofrequency ablation is equivalent to surgery for lesions <3cm Annals of Surgery 2009; 249. TACE is a palliative option that does improve survival and involves the delivery f chemotherapy and occlusion of the arterial supply. RPA course 2015. Sorafanib is a multikinase inhibitor with twice daily dosing having antiproliferative and antiangiogenic activity that slows progression rates and increases survival NEJM 2005; 359: 378 - 390
Question 26
A 48 year old female who was previously known to be HLA-DR3 positive from previous tissue typing studies develops fatigue and pruritis. Liver function tests show AST and ALT to be elevated. ANA and IgG are also elevated with raised Anti-LKM and smooth muscle antibodies. With regards to the underlying diagnosis, what is the treatment that is most likely going to result in clinical remission?
(A) Prednisolone
(B) Budesonide
(C) Aathioprine
(D) Mycophenylate mofetil
(E) 6 mercaptopurine
B: Budesonide induces remission more effectively than prednisolone in a controlled trial of patients with autoimmune hepatitis Gastroenterology 2010; 139: 1198 - 1206
Question 27
A 34 week old G1P0 from a remote aboriginal clinic presents for her first antenatal check. HbSAg is positive, and furthermore, she has HBV DNA levels of 10^8 IU/ml. What would you recommend regarding reduction of vertical transmission rates?
(A) HBV immunisation to mother
(B) HBV immunisation of baby as soon as it is delivered
(C) Tenofovir from third trimester and continuation 3 months post partum
(D) Entacavir from third trimester and continuation 3 months post partum
(E) HbIG as soon as baby is born
C: This would be the best answer however I would also vaccinate baby and give passive immunisation. RPA Lectures 2016
Question 28
With their typically high rates of morbidity and mortality, patients with cirrhosis are frequently admitted and readmitted to the hospital. Their 90-day readmission rate has been estimated at as high as 50%. Which of the following risk factors is the greatest predictor of short and medium term hospital readmission?
(A) Presence of hepatic encephalopathy
(B) Previous liver transplant
(C) Presence of oesophageal varices
(D) Ongoing substance abuse
(E) Poor living conditions
A: Among 119,722 unique admissions for cirrhosis, the rates of 30-day and 90-day readmissions were 13% and 21%, respectively, overall, and 24% and 36% among those with three or more complications of cirrhosis. Hepatic encephalopathy was the strongest predictor of readmission (adjusted odds ratio, 1.8). Overall, acute complications of cirrhosis caused about 40% of readmissions in those with a prior complication of cirrhosis (the majority of patients). The second most common cause was substance abuse (25%) in patients with alcoholic liver disease and cancer complications (16%) in those with nonalcoholic liver disease. Clin Gastroenterol Hepatol 2016 Aug 14:1181, taken from NEJM Journal Watch 2016
What is FALSE about the mechanism of action of ursodeoxycholic acid?
(A) It becomes the predominant bile acid in enterohepatic circulation
(B) It is cytoprotective
(C) It promotes endogenous secretion of bile acids
(D) It increases renal excretion of toxic bile acids
(E) It reduces inflammatory cytokine production
D: Ursodeoxycholic acid has been used in PBC and PSC. In PBS it shows a survival advantage. It is a bile acid that competes with other bile acids for absorption in the terminal ilieum. It may also cross the placenta. High doses in PBC are not effective, nether are low doses, there is a sweet spot in the middle (13 - 15mg/kg). N Engl J Med 2007; 357:1524-1529
Question 2
Which of the following factors is the most important determinant of outcome in non-alcoholic fatty liver disease?
(A) Fibrosis stage
(B) microvascular steatosis
(C) macrovascular steatosis
(D) balooning of hepatocytes
(E) Mallory bodies
A: All of the following are features of the spectrum of NAFLD, however the most important determinant of survival is fibrosis score. Other prognostic markers are age > 50, BMI >28, AST/ALT >1, elevated triglycerides, DM and systemic hypertension. Gastroenterology. 2015 Aug; 149(2): 389-397
Question 3
Which of the following is the most common cause of death in patients with NAFLD according to the community cohort study in the Olmstead county?
(A) Ischaemic heart disease
(B) Infections
(C) Malignancy
(D) Liver disease
(E) Stroke
C: Liver related deaths is the third most common cause of mortality in patients with NAFLD (NASH, NAFL, cirrhosis), but malignancy (28%) and ischaemic heart disease (13%) were the highest contributors. The population sample was 53, and the patients were followed from 1980 to 2000. Gastroenterology. 2005 Jul;129(1):113-21.
Question 4
Which of the following interventions have been shown to have the greatest effect on liver histology in patients with NAFLD?
(A) Weight loss > 7% via life-style reconstruction
(B) Weight loss >7% via bariatric surgery
(C) Vitamin E in non-diabetic patients at dose 800IU/d
(D) Omega 3 fatty acids
(E) Pioglitazone
A: Note that bariatric surgery in morbidly obese patients without cirrhosis has been shown to decrease NASH inflammatory grade and fibrosis stage. Gastroenterology 2012; 142: 1592-1609, RPA course 2015, Gastroenterology 2015; 149: 379-388
Question 5
What is the closest percentage of liver cirrhosis deaths that are attributable to alcohol?
(A) 25%
(B) 35%
(C) 50%
(D) 15%
(E) 65%
C: According to Rehm et al.Global burden of alcoholic Liver diseases, J Hepatol 2013 vol 59 j 160 - 168, 47.9% of liver cirrhosis related deaths are attributable to alcohol.
Question 6
The STOPAH trial examined the effects of prednisolone, pentoxifylline or both for the treatment of severe acute alcoholic hepatitis with a maddrey's discriminant function of 32 or higher. Which of the following is FALSE with regards to the results of this pivotol trial
(A) Patients treated with prednisolone had a higher chance of infections compared to placebo
(B) 28 day mortality in patients treated with pentoxifylline and prednisolone achieved statistical significance favouring combination therapy
(C) There was no statistically significant reduction in 28 day mortality for patients treated with prednisolone
(D) There was no statistically significant reduction in 90 day mortality in patients treated with pentoxifylline
(E) At 1 year, there was no statistically significant change in outcome with prednisolone or placebo
B: OR for prednisolone was 0.72 for 28 day mortality, with p = 0.06, therefore approaching statistical significance in patients treated with prednisolone N Engl J Med 2015; 372: 1619-1628
Question 7
What is the most common viral genotype in hepatitis C in Australia?
(A) Genotype 1
(B) Genotype 2
(C) Genotype 3
(D) Genotype 4
(E) Genotype 5
A: Genotype 1a>1b. Genotype 1 together accounts for 54% of all hepatitis C genotypes, with genotype 3 accounting for 37%. Genotype 5 is not prevalent in Australia. Genotype 6 is highly prevalent in Vietnam, and genotype 3a is the most common in India. Hepatology. 2015 Jan; 61(1): 77–8, RPA course 2015
Question 8
There is a significant gap between patients living with hepatitis C and those that have ever received treatment. What is the percentage of patients who have been diagnosed with hepatitis C who have ever received treatment?
(A) 10%
(B) 25%
(C) 35%
(D) 50%
(E) 75%
B: According to the Kirby Institute, HIV, viral hepatitis, and sexually transmissible infections in Australia Annual Surveillance Report 2015
Question 9
Which of the following genotypes of hepatitis C is most associated with steatosis and increased risk of progression to cirrhosis?
(A) Genotype 1
(B) Genotype 2
(C) Genotype 3
(D) Genotype 4
(E) Genotype 5
C: Genotype 3 is specifically associated with steatosis and may be associated with increased progression to cirrhosis and HCC. RPA course 2015, JAMA Intern Med, 2014; 174(2): 204-212
Question 10
Which of the following is NOT associated with hepatitis C?
(a) Mixed essential cryoglobulinaemia
(B) porphyria cutanea tarda
(C) acute intermittent porphyria
(D) lichen planus
(E) arthritis
C: Nat Med. 2013 Jul; 19(7): 850 - 8
Question 11
Which of the following is NOT a host risk factor associated with a risk of progression to cirrhosis?
(A) Female gender
(B) immunosupression
(C) alcohol use
(D) obesity
(E) type II diabetes
A: Male gender as opposed to female gender portends risk of cirrhosis
Question 12
The current best practice guidelines for hepatitis C genotype 1 treatment are IFN + ribavirin + simepravir. At what time point is the sustained virological response measured?
(A) 12 weeks into treatment
(B) 24 weeks into treatment
(C) 48 weeks into treatment
(D) 12 weeks at the end of treatment
(E) 24 weeks at the end of treatment
D: Note that SVR means undetectable HCV viral RNA, and it equates a cure from chronic HCV. SVR12 is now measured at 12 weeks post end of treatment. SVR can lead to regression of liver fibrosis and cirrhosis in HCV infected patients Liver int 2014; 35: 30 - 36, reduces all cause mortality, liver related mortality, liver failure and HCC JAMA 2012; 308 (24): 2584 - 2593. Furthermore, overall survival of patients with HCV and advanced fibrosis returns to that of age and sex matched population following SVR JAMA 2014 Van der Neer A.
Question 13
What is the percentage of Australians receiving HCV treatment who are infected with HCV?
(A) 0.5%
(B) 2%
(C) 7%
(D) 15%
(E) 25%
B: There are a number of barriers that preclude many patients having IFN based therapy, including medical co-morbidities and psychiatric comorbidities, cytopenias and hepatic decompensation.
Question 14
What is the mechanism of action of simepravir?
(A) NS5A protein inhibitor
(B) NS5B polymerase inhibitor - nucleoside
(C) NS3/4A protease inhibitor
(D) NS5B polymerase inhibitor - non-nucleoside
(E) Interferon inhibitor
C: It is a protease inhibitor and thus inhibits viral protein production, translation and polyprotein processing. N Engl J Med 2013; 368:1907-1917
Question 15
What is the most common hepatitis B genotype in Australia?
(A) Genotype A
(B) Genotype B and C
(C) Genotype D and E
(D) Genotype F
(E) Genotype I
B: As this is the most common in Asia and Australia receives much of the migrant population from Asia. In total there are 10 genotypes (A --> J) of hepatitis B. Clinically this is not tested. Interestingly, B is associated with less active disease, slower progression and lower incidence of HCC than genotype C, F is associated with fulminant liver disease, although this is rare. J Virol 2008; 82: 5657 - 5663, J Hepatol. 2009; 50: 227 - 242
Question 16
A 46 year old male applying for Australian Visa through Cambodia presents to the liver clinic with the following hepatitis serology:
HbSag -
HbSab -
anti-HBc +
anti-Hbs -
What is the correct interpretation?
(A) vaccinated
(B) resolved infection
(C) chronic infection
(D) isolated anti-Hbc status
(E) HBV susceptible patient
D: There are various possibilities. It could represent resolved past infection, HbsAg mutants, occult hepatitis B infection. Evaluation with quantitative HBV DNA is recommended. Liver Int. 2014; 34(7): 991 - 1000
Question 17
Which phases of chronic hepatitis B should you treat a patient?
(A) Immune Tolerance
(B) Immune Clearance and Immune escape
(C) Immune Escape
(D) Immune control
(E) Immune Tolerance and Immune Control
B: Basically, treatment should occur only in the immune clearance or immune escape phase. In immune clearance, there is the beginnings of eAg seroconversion into anti-HbEag, and ALT levels fluctuate. In immune escape, the patient has already seroconverted however the virus escapes immune control and ALT levels fluctuate.
Question 18
In general, how long does Hepatitis B vaccination last?
(A) 5 years
(B) 10 years
(C) 15 years
(D) 20 years
(E) 22 years
C: Vaccine efficacy is defined as a HBSab >10mIU/ml. Lancet Volume 384, Issue 9959, 6–12 December 2014, Pages 2053–2063
Question 19
What is correct regarding the virology of hepatitis B
(A) single stranded, DNA
(B) double stranded, DNA
(C) single stranded, RNA
(D) double stranded, RNA
(E) retrovirus
B: Lancet Volume 384, Issue 9959, 6–12 December 2014, Pages 2053–2063
Question 20
Pegylated interferon alpha may be used to treat hepatitis B. Which genotype is most responsive?
(A) A
(B) B
(C) C
(D) D
(E) E
A: Other predictors of response include low initial HBV DNA and high ALT. It has a defined time line of treatment (one year) as opposed to the viral reverse transcriptase inhibitors tenofovir and entecavir which prevent RNA --> DNA. However cccDNA is not affected thus explaining why relapses may occur after one has stopped reverse transcriptase therapy. In general, patients with immune clearance or immune escape phase should be treated. BUT guidelines do vary internationally, and one should consider treatment in patients who have persistently high HBV DNA load irrerspective of liver histology (evidence of necroinflammation and cirrhosis) or ALT titre. Lancet Volume 384, Issue 9959, 6–12 December 2014, Pages 2053–2063
Question 21
What is the main reason why tenofovir and entacavir are preferred over lamivudine in the treatment of chronic hepatitis B?
(A) Treatments run for shorter duration of time
(B) There is less genetic barrier to resistance with these treatments
(C) There is a higher SVR12 post treatment
(D) There is a higher SVR 24 post treatment
(E) Side-effects occur significantly less so with the third generation antiviral agents compared to lamivudine
B: RPA course and Lancet Volume 384, Issue 9959, 6–12 December 2014, Pages 2053–2063
Question 22
What is the vertical transmission risk to a baby if a pregnant female patient has a high viral load (10^7 IU/mL) in the third trimester of pregnancy?
(A) 10%
(B) 15%
(C) 35%
(D) 40%
(E) 60%
A: In this situation, all babies of HBsAg + mothers will be given HBIG and HB Vax x 3. In additionm a strong case can be made to consider tenofovir from week 30 to 2-3 months post delivery. RPA course 2015
Question 23
What is the recommended HCC surveillance strategy in patients with a diagnosis of cirrhosis?
(A) 6 monthly AFP and U/S
(B) Quad phase CT Abdomen annually
(C) 6 monthly U/S only
(D) Annual U/S
(E) Annual U/S and AFP
C: In accordance to the AASLD Practice Guidelines. Hepatology 2010
Question 24
Which of the following population groups do NOT need to be surveilled for development of HCC?
(A) A 43 year old asian female with chronic hepatitis B
(B) A 35 year old asian male with chronic hepatitis B
(C) A 22 year old African male with chronic hepatitis B
(D) A 22 year old asian male with chronic hepatitis B and a family history of HCC
(E) A 45 year old male with F4 METAVIR cirrhosis secondary to HCV
B: Any asian female with HBV > 50 or male > 40 should be screened, as should any African male >20 or any patient with FHx of HCC. Additionally, any patient with cirrhosis should be screened. Bruix and Sherman. AASLD Practice Guideline. Hepatology 2010. HCC Surveillance increases mean 3 year survival from cancer diagnosis and decreases need for liver transplantation. Am J Med 2008; 121: 119 - 126
Question 25
A 27 year old male with ECOG 1 performance status presents to the liver clinic for review. He is an ex-IVDU, who gave up alcohol 6 months prior to the clinic appointment. He has well controlled type 1 diabetes. His GP performed a blood test which revealed a high titre AFP. A subsequent ultrasound found 2 suspicious liver lesions. A quad-phase CT scan was organised showing 2 lesions enhancing in the arterial phase, measured at 2cm and 2.2cm respectively. The lesions also demonstrate venous and delayed phase washout relative to normal liver parenchyma. Which of the following is an appropriate treatment strategy?
(A) List patient for liver transplantation
(B) Radiofrequency ablation
(C) Liver resection if favourable anatomy
(D) A, B or C
(E) Sorafanib
D: This fulfils the Milan criterion with a single lesion <5cm or max 3 lesions all < 3cm. Radiofrequency ablation is equivalent to surgery for lesions <3cm Annals of Surgery 2009; 249. TACE is a palliative option that does improve survival and involves the delivery f chemotherapy and occlusion of the arterial supply. RPA course 2015. Sorafanib is a multikinase inhibitor with twice daily dosing having antiproliferative and antiangiogenic activity that slows progression rates and increases survival NEJM 2005; 359: 378 - 390
Question 26
A 48 year old female who was previously known to be HLA-DR3 positive from previous tissue typing studies develops fatigue and pruritis. Liver function tests show AST and ALT to be elevated. ANA and IgG are also elevated with raised Anti-LKM and smooth muscle antibodies. With regards to the underlying diagnosis, what is the treatment that is most likely going to result in clinical remission?
(A) Prednisolone
(B) Budesonide
(C) Aathioprine
(D) Mycophenylate mofetil
(E) 6 mercaptopurine
B: Budesonide induces remission more effectively than prednisolone in a controlled trial of patients with autoimmune hepatitis Gastroenterology 2010; 139: 1198 - 1206
Question 27
A 34 week old G1P0 from a remote aboriginal clinic presents for her first antenatal check. HbSAg is positive, and furthermore, she has HBV DNA levels of 10^8 IU/ml. What would you recommend regarding reduction of vertical transmission rates?
(A) HBV immunisation to mother
(B) HBV immunisation of baby as soon as it is delivered
(C) Tenofovir from third trimester and continuation 3 months post partum
(D) Entacavir from third trimester and continuation 3 months post partum
(E) HbIG as soon as baby is born
C: This would be the best answer however I would also vaccinate baby and give passive immunisation. RPA Lectures 2016
Question 28
With their typically high rates of morbidity and mortality, patients with cirrhosis are frequently admitted and readmitted to the hospital. Their 90-day readmission rate has been estimated at as high as 50%. Which of the following risk factors is the greatest predictor of short and medium term hospital readmission?
(A) Presence of hepatic encephalopathy
(B) Previous liver transplant
(C) Presence of oesophageal varices
(D) Ongoing substance abuse
(E) Poor living conditions
A: Among 119,722 unique admissions for cirrhosis, the rates of 30-day and 90-day readmissions were 13% and 21%, respectively, overall, and 24% and 36% among those with three or more complications of cirrhosis. Hepatic encephalopathy was the strongest predictor of readmission (adjusted odds ratio, 1.8). Overall, acute complications of cirrhosis caused about 40% of readmissions in those with a prior complication of cirrhosis (the majority of patients). The second most common cause was substance abuse (25%) in patients with alcoholic liver disease and cancer complications (16%) in those with nonalcoholic liver disease. Clin Gastroenterol Hepatol 2016 Aug 14:1181, taken from NEJM Journal Watch 2016