GI Final Exam Review

Multiple Choice

Which of the following is the process of breaking down?

• Catabolism

• Anabolism

• Metabolism

• All of the above

Multiple Choice

Which of the following is the process of building up large proteins from amino acids?

• Catabolism

• Anabolism

• Metabolism

• All of the above

Fill in the Blank

Anabolism + Catabolism = ?

Multiple Choice

Match a term w/ the following definition: A measurement of energy or heat that it takes to raise the temp of 1 gram of water by 1 degree celsius

• Catabolism

• Carbohydrate

• Calorie

• Metabolism

• All of the above

Multiple Choice

Match a term w/ the following definition: A primary energy source

• Catabolism

• Carbohydrate

• Calorie

• Metabolism

• All of the above

Fill in the Blank

A carb (oral) = __ kcal/gm

Fill in the Blank

A unit of dextrose = __ kcal/gm

Multiple Choice

Which of the following is the carb source in parenteral nutrition that is used for our non-diabetics?

• Glycerol

• Dextrose

• Glucose

• Calories

• Carbohydrates

Multiple Choice

Which of the following is the carb source in parenteral nutrition that is used for our diabetics?

• Glycerol

• Dextrose

• Glucose

• Calories

• Carbohydrates

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Fill in the Blank

_____ nutrition: liquid nutrition delivered through catheter tube directly into GI tract, also known as tube feedings

Multiple Choice

T/F: To use enteral nutrition, pt must have functional GI System

• True

• False

Multiple Choice

T/F: Parenteral nutrition should be avoided unless absolutely necessary

**phrase to remember**

• True; if the gut works, use it

• False

Multiple Select

Which of the following conditions mean that enteral nutrition is not appropriate?

Select all that apply

• Mechanical Obstruction

• Intractable Vomiting

• Severe Diarrhea

• Pt Refusal

• Hypovolemic Shock

  + Hypotension

Multiple Choice

When should tube feedings be considered?

• When a pt has inadequate oral nutrient intake for 2-4 days

• When a pt has severe diarrhea

• When a pt has functional GI tract, but cannot meet nutrient needs orally

• When a person has severe, acute pancreatitis

Multiple Select

Hold tube feeds for 1 hour before or 2 hours after administering which of the following?

Select all that apply

• Phenytoin

• Ciprofloxacin

• Tetracycline

• Warfarin

• All of the above

Multiple Choice

Drug-Nutrient interactions associated w/ low INRs is pertaining to which of the following medications?

• Tetracycline

• Warfarin

• Ciprofloxacin

• Phenytoin

Multiple Choice

Drug-Nutrient interactions associated w/ oral suspension not being used due to adhesion to tubing is pertaining to which of the following medications?

Remember: Use IR tablets (crush → make slurry → put down tube)

• Tetracycline

• Warfarin

• Ciprofloxacin

• Phenytoin

Multiple Choice

Drug-Nutrient interactions associated w/ chelation of metals & reduces the drugs availability is pertaining to which of the following medications?

• Tetracycline

• Warfarin

• Ciprofloxacin

• Phenytoin

Multiple Choice

Drug-Nutrient interactions associated w/ drug levels being reduced due to the binding w/ tube feedings is pertaining to which of the following medications?

Note: Important to separate TF and this medication by 2 hrs

• Tetracycline

• Warfarin

• Ciprofloxacin

• Phenytoin

Multiple Choice

Which of the following statements is false in regards to medication administration when dealing w/ tube feedings?

• Medications should be given orally or via IV when possible

• Use liquid formulations, besides Ciprofloxacin

• Do not mix medications w/ feeding formula

• ER and Enteric coated dosage forms are okay to use to bypass the increased risk of developing gastric ulcers

• All of the above are true

Multiple Choice

Which type of parenteral nutrition is administered through peripheral or midlines for short term access (less than a week)

• Peripheral

• Midline

• Central

• Total

Multiple Choice

Which type of parenteral nutrition is administered through central line for long term access (longer than a week)

• Peripheral

• Midline

• Central

• Total

Multiple Select

In which cases should a patient receive TPN?

Select all that apply.

• Patient has GI dysfunction due to recent surgery to remove intestinal tumor​

• Expectant patient is experiencing severe nausea and vomiting and has had nothing to eat or drink for 8 days​

• Malnourished patient with head injury has functioning GI and access is obtained for tube feedings

• Patient with minor bowel obstruction​

Fill in the Blank

The general guideline for fluid is __ - __ ml/kg/day

Multiple Choice

Protein for TPN is provided via ____

• Amino Acid Solution

• Carbohydrate Solution

• 1/2 NaCl Solution

• D5W Solution

Fill in the Blank

10% w/v solution has 10 g of solute per ____ ml

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Multiple Choice

low ______ levels will lead to falsely low serum calcium levels

calcium must be corrected for it

• Phosphorus

• Potassium

• Sodium

• Albumin

• None of the above

Multiple Select

_______ and ______ bind together, precipitate; causing death

• Phosphorus

• Potassium

• Sodium

• Albumin

• Calcium

Multiple Choice

Pertaining to calcium or phosphorus, which is added first?

• Phosphorus

• Calcium

Fill in the Blank

Calcium ________ is less reactive and therefore has a lower risk of precipitation with phosphate

Multiple Choice

Which of the following is true?

• PN formulations do not have to be prepared in accordance with USP Chapter 797 Standards for Sterile Compounding​

• Parenteral nutrition orders reviewed by a pharmacist and determined correct do not need visual inspection before being dispensed

• Solid and liquid precipitates may form in TPN solutions due to incompatibility of salts and phase separation

• PN formulations which are not standardized are more useful due to documented stability and compatibility by manufacturer​

• All of the above

Multiple Choice

T/F: It is NOT ADVISED that drugs be mixed into TPN

• True (due to complex formulation and potential for drug-nutrient interactions)

• False

Multiple Choice

Match the term w/ the following definition: severe complications resulting from overly-aggressive feeding of severely malnourished pts

symptoms include: dyspnea, respiratory failure, confusion, hypotension, weakness

• CaPhos OD

• Refeeding Syndrome

• Amino Acid Solution Precipitates

• None of the above

Fill in the Blank

Pts receiving an IV of this general anesthetic do not have to have lipids added to their TPN

Fill in the Blank

Fred is starting EN therapy. He has past history of T2DM and will be started on Glucerna Shakes.

What percent of calories will he receive from the protein provided in one serving?

__% (# only)

Multiple Choice

Fred is starting EN therapy. He has past history of T2DM and will be started on Glucerna Shakes.

How many calories are being obtained from the fat?

__kcal (# only)

• 60

• 72

• 8

• 180

• None of the above

Fill in the Blank

A 72 yo, 154 lb patient is NPO and needs hydration. She is afebrile and does not have HF, renal disease or ascites. What volume of fluid should the patient receive per day?

____ mls/day

Fill in the Blank

PP is 46 yo male (207 lb, 71 in) admitted for bowel resection. After surgery, he is started on PN and MD wants him to receive 1.3 g/kg/day. Calculate protein required using actual weight.

___ g protein/day

Fill in the Blank

The pharmacy stocks FreAmine 10% AA Solution. A patient requires 122 g protein/day. How many mL of FreAmine will be needed?

___ mls

 

Fill in the Blank

A patient is receiving PN containing 540 mL of 12.5% AA per day. How many grams of nitrogen is patient receiving? Round to the nearest tenth.

___ g N

Multiple Choice

A patient is receiving PN containing 480 mL of 50% dextrose and 50 gm AA plus electrolytes. Calculate the NPC:N ratio for this patient to determine the level of stress that they are experiencing

• Most severe stress

• Severe stress

• No/normal stress

Fill in the Blank

A 44 yo male is receiving 1,235 mL of D30W, 1,010 mL of 8.5% AA, 200 mL of intralipid 20% and 50 mL of electrolytes/minerals in his PN. How many calories is he receiving from dextrose in the TPN?

____ kcal/day

Fill in the Blank

Using a 20% lipid emulsion, how many mL are required to meet 989 calories?

___ mls

Fill in the Blank

A 35 yo female is receiving 325 g dextrose, 85 g AA, and 300 mL of 10% lipids in TPN. What % of total calories is provided by protein?

__ %

Fill in the Blank

The pharmacist is adding 80 mEq Na to a TPN, half will be given as acetate (2 mEq/mL) and half as chloride (4 mEq/mL). How many mL of NaCl are needed?

__ mls

Fill in the Blank

You have calculated that a patient needs 30 mmol of phosphate and 80 mEq of potassium. Pharmacy has stock KPO4 (3 mmol phos with 4.4 mEq of K/mL) and KCl (2 mEq K/mL). How much KPO4 and KCl will be required?

1. Phosphate required

2. Amount of K+ pt will receive from KPO₄

3. The remaining K+ that will be provided by KCl

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Multiple Choice

Hepatitis _ virus DNA polymerase has reverse transcriptase activity similar to retroviruses

• A

• B

• C

• D

• F

Fill in the Blank

Reverse transcriptase transforms ___ to ___.

separate by comma & space

Fill in the Blank

The drug shown here is a protease inhibitor. It exemplifies that protease inhibitors often resemble ______

Multiple Choice

nitrogenous base + sugar = ____

• Nucleotide

• Nucleoside

• Amino Acid

• Peptide

Multiple Choice

nitrogenous base + sugar + phosphate = ____

• Nucleotide

• Nucleoside

• Amino Acid

• Peptide

Multiple Choice

Which class of medications does the following acronym: NRTI belong to?

• Nucleotide Reverse Transcriptase Inhibitors

• Nucleoside Reverse Transcriptase Inhibitors

• None of the above

Fill in the Blank

NRTIs interfere with the actions of _____ ______ (enzyme)

Multiple Choice

Adefovir, depicted here, contains a nucleoside or nucleotide analog?

• Nucleoside

• Nucleotide

Fill in the Blank

Adefovir, depicted here, is a nucleotide analog which is missing what kind of moiety?

Multiple Choice

T/F: The following drug is classified as a Pro-Drug

• True

• False

Multiple Choice

T/F: This drug is a Pro-Drug which is metabolized to its active form in the blood

• True

• False (only converted intracellularly due to steroid hindrance)

Multiple Choice

T/F: Since this drug has the 3' OH, the virus will continue to grow when this drug is given

• True (But since the base is not a normal base in DNA, it will induce mutations that spoil DNA)

• False

Multiple Choice

Which type of metabolism is occuring in the image depicted here?

• Oxidation

• Glucuronic Conjugation

• Hydrolysis

• Carboxylation

• None of the above

Fill in the Blank

Proteases cleave ______ bonds

Fill in the Blank

Which drug class includes the following medications?

adefovir, tenofovir

Fill in the Blank

Which drug class includes the following medications?

ribavirin, lamivudine

Fill in the Blank

Which drug class includes the following medication?

ritonavir

Multiple Choice

Is the following drug based on a purine or pyrimidine analog?

• Purine (one ring)

• Pyrimidine (two rings)

• Pyrimidine (one ring)

• Purine (two rings)

Multiple Choice

Is the following drug based on a purine or pyrimidine analog?

• Purine (one ring)

• Pyrimidine (two rings)

• Pyrimidine (one ring)

• Purine (two rings)

Fill in the Blank

The end amino acid in a peptide with a free NH3+ group:

_ terminal

(answer w/ one letter only)

Fill in the Blank

The end amino acid in a peptide with a free -COO- group:

_ terminal

(answer w/ one letter only)

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Multiple Choice

T/F: Hepatitis C drugs are often given in combination therapy

• True (due to the high number of mutations of virus)

• False (due to the high number of mutations of virus)

Fill in the Blank

Tetracyclines undergo ___ reactions and form insoluble salts at neutral pH

Multiple Select

Tetracyclines should not be given w/ which of the following due to chelation potential?

Select all that apply

• Dairy

• Antacids

• Calcium containing supplements

• All of the above

Multiple Choice

In basic pH, tetracyclines undergo ____ of the center ring

• Phosphorylation

• Hydroxylation

• Oxidation

• Cleavage

Fill in the Blank

If tetracyclines have a chlorine at position c7, they will have this side effect:

Multiple Choice

To prevent resistance, Clavulanic acid is given in combination w/ which of the following antibiotics?

• Augmentin

• Amoxicillin

• Ceftriaxone

• Meropenem

Fill in the Blank

Metronidazole (Flagyl) is depicted here. This drug works via generation of ____ _____ which are harmful to parasites

Fill in the Blank

Sucralfate works by forming a _____ to protect the stomach from the erosive action of pepsin and bile salts; forms coat to protect ulcer surface

Multiple Choice

Which of the following compounds is p-aminophenol? This is the parent compound of acetaminophen and is very toxic.

Multiple Choice

Which of the following is the toxic iminoquinone metabolite of APAP?

Multiple Select

this is the toxic iminoquinone metabolite of acetaminophen. It binds _______ and ______ throughout the body

Select all that apply

• Guanine

• Adenosine

• Cysteines

• Glutathione

Fill in the Blank

What is used for the treatment for APAP overdose

Multiple Select

Aldosterone is shown here. In order to make an antagonist, C__ will be substituted and C__ will be transformed into a lactone ring

Select all that apply

• 7

• 10

• 17

• 3

Multiple Choice

T/F: Spironolactone and eplerenone are both potassium-sparing diuretics

• True

• False

Multiple Choice

Which of the following is an aldosterone antagonist with androgen, glucocorticoid, and progesterone receptor side effects?

• Eplerenone

• Spironolactone

• Finerenone

• None of the above

• All of the above

Multiple Choice

Which of the following is an aldosterone antagonist with epoxide group at C-9, and it was created to overcome side effects of spironolactone

• Eplerenone

• Spironolactone

• Finerenone

• None of the above

• All of the above

Fill in the Blank

Lactulose is what type of drug?

Multiple Choice

T/F: This drug is limited in its actions and only exerts an effect in the GI tract

• True

• False

Fill in the Blank

Swelling and inflammation of the liver is associated w/:

Multiple Choice

Identify the most common cause of Hepatitis

• Moderate amount of alcohol

• APAP

• Hepatitis Virus

• Portobello Mushroom

• All of the above

Multiple Choice

Chronic Hepatitis is caused by which of the following?

• HAV

• HBV

• HCV

• HEV

• Chemical Exposure

Multiple Choice

Which of the following is the most common route of HCV transmission?

• Physical Contact

• Contaminated food ingredients

• Sharing of needles

• Ingestion of cntaminated water

• All of the above

Multiple Choice

Which of the following is most true in regards to Cirrhosis?

• Usually indicates late stage progression of chronic hepatitis.

• A condition caused by significant damage to liver.

• Outcome of long-term infection of hepatotropic virus.

• All of the above

Multiple Choice

Which one is non-enveloped single-stranded RNA virus unrelated to Rubella virus?

• HBV

• HAV

• HDV

• HCV

Multiple Choice

Pathogenesis of hepatitis involves which of the following?

• Destruction of hepatocytes

• Inflammation of parenchyma

• Invasion of lymphocytes

• All of the above

Multiple Choice

A feature of chronic viral hepatitis is:

• Lobular Disarray

• Coagulative Necrosis

• "Ground Glass" Hepatocytes

• Multinucleated Hepatocytes

Multiple Select

Which of the following Hepatitis Viruses lack the lipid envelope, are resistant to degradation by bile acids in the proximal intestine and consist of short incubation and only cause acute infection?

Select all that apply

• A

• B

• C

• D

• E

Multiple Select

Signs of hepatitis include which of the following?

Select all that apply

• Dark urine

• Pale skin

• Pale stools

• Bloody stools

• All of the above

Fill in the Blank

Fluid in the abdomen as a result of hepatitis that can become infected is known as:

Fill in the Blank

Jaundice, caused by hepatitis, changes the color of the skin to:

Multiple Choice

Which of the following forms of Hepatitis is transmitted through consuming food or drink contaminated with the feces of someone with the infection?

• A

• B

• C

• D

• E

Multiple Select

Which of the following forms of Hepatitis is transmitted through contact with the bodily fluids of a person with the infection, usually from the woman to the fetus at birth but occasionally from using contaminated needles or having sex without a condom

Select all that apply

• A

• B

• C

• D

• E

Multiple Choice

Which of the following forms of Hepatitis is transmitted through coming in contact with blood containing the viruses. Mostly spread through needles of IV drug users

• A

• B

• C

• D

• E

Multiple Choice

Which of the following forms of Hepatitis is usually transmitted through consuming undercooked meat or food or drink contaminated with the feces of someone with the infection

also from mom to fetus

• A

• B

• C

• D

• E

Multiple Choice

Which of the following forms of Hepatitis is transmitted through blood containing the virus

• A

• B

• G

• D

• E

Multiple Select

Which of the following are hepatitis virus types which that have lipid envelope and can be degraded by digestive tract secretions, transmitted only by sharing bodily fluids, and are chronic infections which lead to cirrhosis and hepatocellular carcinoma?

Select all that apply

• A

• B

• C

• D

• E

Fill in the Blank

T/F: Features of acute viral hepatitis are identical regardless of infecting virus

Multiple Choice

Lobular disarray is associated w/ which of the following definitions?

• hepatocellular necrosis is spotty or focal

• formation of highly eosinophilic cells called councilman or acidophilic bodies

• swelling of hepatocytes to several times the normal size

• None of the above

Multiple Choice

Coagulative necrosis is associated w/ which of the following definitions?

• hepatocellular necrosis is spotty or focal

• formation of highly eosinophilic cells called councilman or acidophilic bodies

• swelling of hepatocytes to several times the normal size

• None of the above

Multiple Choice

Ballooning degeneration is associated w/ which of the following definitions?

• hepatocellular necrosis is spotty or focal

• formation of highly eosinophilic cells called councilman or acidophilic bodies

• swelling of hepatocytes to several times the normal size

• None of the above

Multiple Choice

Which of the following is not one of the four phases of viral hepatitis infection?

• Incubation

• Postdrome

• Clinical Illness

• Resolution

Fill in the Blank

What is the phase of viral hepatitis marked by malaise and myalgia?

Fill in the Blank

Chronic persistent hepatitis is hepatitis lasting for more than __ months with

minimal-mild necroinflammatory changes

Fill in the Blank

Chronic ____ hepatitis presents continued liver damage that often progresses to cirrhosis

Multiple Choice

Hepatitis __ is associated w/ "ground glass" appearance due to presence of surface antigen in hepatocyte cytosol

• A

• B

• C

• D

• E

Multiple Choice

Hepatitis __ is associated w/ moderate steatosis and dense follicular lymphoid infiltrates around small bile ductules

• A

• B

• C

• D

• E

Fill in the Blank

The symptoms of hepatitis may be mild, but the condition can lead to severe complications. For example, each type of hepatitis can cause ______ hepatic failure, which affects the liver.

Multiple Choice

Select the statement that is false in regards to Hepatitis A.

• Severity of hepatitis A infection increases with age

• Treatment of hepatitis a is largely supportive

• There's no vaccine for hepatitis A

• All of the above are correct

Multiple Choice

Select the statement that is true in regards to Hepatitis B.

• Chronic hepatitis B has been associated with aplastic anemia (blood disorder)

• Acute hepatitis B has been associated with aplastic anemia (blood disorder)

• Liver transplantation is not a treatment of hepatitis B because of recurrence of hep B viral infection

• All of the above are correct

Fill in the Blank

The following medications are all anti-hepatitis _____:

adefovir, adefovir dipivoxil

Multiple Choice

Which of the following medications is:

1. selective to HBV

2. has potential to cause dose-related nephrotoxicity and tubular dysfunction

• adefovir

• adefovir dipivoxil

• ribavirin

• All of the above

Fill in the Blank

______ pertains to cytokines used in the treatment of hepatitis and are enzymes that inhibit viral replication, destroy single-stranded rna/dna, and inhibit protein synthesis in the presences of rna

Multiple Choice

T/F: interferons cannot be administered orally

• True; IM/IV only

• False

Multiple Choice

Attachment of interferons to ____ slows absorption rates, decreases clearance and prolonged, higher serum concentration

• PEG

• AEG

• PBS

• HCV

Multiple Choice

Interferons (both recombinant and natural pegylated) are approved for hepatitis ____ and hepatitis ____

• A + E

• C + D

• C + B

• A + D

Multiple Choice

Presently, the most common treatment for HCV infected patients is the combinations of pegylated interferon and _____ that provide a sustained response

• adefovir

• adefovir dipivoxil

• ribavirin

• All of the above

Fill in the Blank

Only the NS3-NS5B region of the polyprotein is required for genome replication in which hepatitis virus?

Multiple Choice

The following are all new drugs for the treatment of hepatitis __:

telaprevir, boceprevir, grazoprevir, paritaprevir, voxilaprevir, glecaprevir, daklinza

• A

• B

• C

• D

• G

Multiple Choice

Hepatitis D infections normally occur alongside Hepatitis B infections in IV drug users. Prevention of Hepatitis D is vaccination against Hepatitis __

• A

• B

• C

• D

• G

Multiple Choice

T/F: There are currently drugs specifically intended for the treatment of Hepatitis D

• True

• False (no specific drug therapy exists for hepatitis d -> just get vaccinated against hepatitis b)

Fill in the Blank

Prevention of Hepatitis E is with ____ _____

Multiple Select

Which of the following forms of Hepatitis have vaccines available?

Select all that apply

• A

• B

• C

• D

• G

Multiple Choice

Which of the following forms of Hepatitis has chronicity that is related to age?

90% of infections in neonates lead to chronic diseases, but only 5-10% of infections in healthy adults lead to chronic disease

• A

• B

• C

• D

• G

Multiple Choice

T/F: The liver produces most proteins needed by the body

• True

• False

Multiple Choice

 T/F: The liver produces bile

• True

• False

Multiple Choice

T/F: The kidneys produce most of the substances required to regulate blood clotting

• True

• False

Fill in the Blank

T/F: Fibrosis, cirrhosis, cancer, and liver failure are all irreparable damage

Multiple Choice

Acute liver failure typically lasts which of the following durations?

• 2-7 weeks

• 2-3 months

• 1-4 weeks

• 1 year

Multiple Choice

T/F: There is a high mortality rate for chronic liver failure

• True

• False; acute only

Multiple Choice

Which type of liver failure is least common?

• Acute

• Chronic

Multiple Choice

Which type of liver failure presents w/ minimal symptoms at first?

• Acute

• Chronic

Multiple Choice

Pain in the ___ ___ quadrant is a sign of liver issues

• Right upper

• Left upper

• Right lower

• Left lower

Fill in the Blank

The elevation of _____ in the body is what causes hepatic encephalopathy (confusion and drowsiness)

Multiple Choice

T/F: Liver injury is associated with excess blood clotting and pulmonary embolism

• True

• False (easy bruising and excessive bleeding are actually signs)

Multiple Choice

Which of the following terms pertains to abnormal accumulation of acidic fluid in the abdominal cavity; caused by low albumin levels as a result of liver failure

• Elevated albumin

• Ascites

• INR

• Decreased bilirubin

Multiple Choice

Which of the following disease states pertains to the following statement?

AST/ALT (specific ratio) is > 3X's the upper limit of normal

• Chronic Liver Failure

• Acute Liver Failure

• Obstructive Jaundice

• Cholestasis

• All of the above

Fill in the Blank

b/c you're not making clotting factors in severe liver injury, ___ level begins to elevate

Multiple Choice

T/F: The INR elevation associated w/ liver injury is a false elevation

• True

• False (true elevation, pt is really at risk for bleeding)

Multiple Choice

GGT is induced by ethanol & drugs. GGT/ALP above which of the following values suggest alcoholic liver disease?

• 5

• 3.7

• 2.5

• 30

Fill in the Blank

_____ is increased during times of decreased hepatic clearance or increased breakdown of hemoglobin

Multiple Choice

Vitamin __ deficiency/antagonism will increase INR labs

• A

• D

• E

• K

Multiple Choice

Which of the following forms of liver disease requires imaging and surgery consultation?

• Acute Liver Disease

• Chronic Liver Disease

• Obstructive Jaundice

• All of the above

Fill in the Blank

Testing for ____ is necessary in pts who are presenting w/ chronic and/or acute liver disease

Multiple Choice

Which of the following drug levels should be drawn for all cases of drug/alcohol acute liver injury?

• ASA

• Ibuprofen

• APAP

• Lithium

Multiple Choice

Case #1: Pt presents to ER w/ extreme elevation in both AST and ALT. There is also a slight increase in ALP, GGT, bilirubin, and INR.

What could potentially be the causative issue?

• Acute Liver Disease

• Obstructive Jaundice

• Chronic Liver Disease

• Drug/Alcohol Liver Disease

Multiple Choice

Case #2: Pt presents to ER w/ extreme elevation in bilirubin with slight elevation in INR and ALT, w/ a decrease in albumin

What could potentially be the causative issue?

• Acute Liver Disease

• Obstructive Jaundice

• Chronic Liver Disease

• Drug/Alcohol Liver Disease

Multiple Choice

Case #3: Pt presents to ER w/ extreme elevation in ALP, GGT, bilirubin and a slight increase in INR

What could potentially be the causative issue?

• Acute Liver Disease

• Obstructive Liver Disease

• Chronic Liver Disease

• Drug/Alcohol Liver Disease

Multiple Choice

Case #4: Pt presents to ER w/ extreme increases in AST and ALT and GGT levels. Bilirubin and INR levels are normal at first, but then increase

What could potentially be the causative issue?

• Acute Liver Disease

• Obstructive Liver Disease

• Chronic Liver Disease

• Drug/Alcohol Liver Disease

Multiple Choice

T/F: Hepatitis A is transmitted through blood transmission

• True

• False (usually transmitted through

  fecal-oral route)

Multiple Select

Which of the following statements is most true?

Select all that apply

• 70% of children under the age of 6 are symptomatic when they have Hepatitis A

• 70% of children under the age of 6 are asymptomatic when they have Hepatitis A

• 70-80% of adults with Hepatitis A are symptomatic

• 70-80% of adults with Hepatitis A are asymptomatic

Multiple Choice

T/F: Hepatitis A can never progress to chronic liver injury

• True; always just acute

• False; if untreated can progressively get worse

Fill in the Blank

What is the main risk factor for contracting Hepatitis A infection?

Multiple Choice

Which of the following statements is false in regards to Hepatitis A?

• Hepatitis A is often spread through food

• Spreads through fecal-oral route; The CDC has specific food recommendations for those traveling abroad

• The CDC recommends that you avoid salads, unwashed fruits and vegetables, and food from street vendors when traveling abroad

• It is recommended that pts at high risk for Hepatitis A (like msm, homeless, etc) receive an extra dose of the hep a vaccine even if they were vaccinated as children

Fill in the Blank

Hepatitis vaccines are recommended in all kids above ___ year(s) of age

Multiple Choice

Which of the following is a Hepatitis A vaccine that is only given to people 18 and up; it is combined Hepatitis A + B together so it is a 3 dose series

• Havrix

• Twinrix

• Vaqta

• GamaSTAN

Multiple Select

Which of the following are two inactive Hepatitis A vaccines used in children 1-18 years of age; given as 2-dose series

Select all that apply

• Havrix

• Twinrix

• Vaqta

• GamaSTAN

Multiple Choice

Which of the following is the Hepatitis A immune globulin used as pre-exposure or post-exposure prophylaxis? It is used very infrequently b/c is not necessary in people who have at least 1 dose of Hepatitis A vaccine series

• Havrix

• Twinrix

• Vaqta

• GamaSTAN

Multiple Choice

Which of the following statements is most true?

• Treatment of Hep A in-patient is mainly supportive

• Persons with clotting factor disorders are at a lower risk of Hep A

• Hep B is transmitted through fecal-oral route

• Hep B is often initially symptomatic

Multiple Choice

T/F: Hepatitis A + B have both been trending down in their incidence over the past 40 years

• True (due to vaccines being release in the 80s/90s)

• False

Multiple Select

Case #1: TD is a 58 year old female; retired teacher(substitutes part time). PMHx: seasonal allergies, ovarian cyst, chronic Hep C, NKDA, Takes multivitamin, baby aspirin, cetirizine daily, No past surgical history. Travels with her husband throughout the Caribbean/Central America during the winter months, Non-smoker, No illicit drug use, Social drinker- 2 glasses of wine per week

What are TD’S risk factors and reasons to receive Hepatitis A vaccine?

Select all that apply

• None, she does not need to get the vaccine

• Age

• Travel History (central-south america)

• Occupation

• Medical History (Chronic Hep C)

Multiple Choice

What is the main risk factor for death associated w/ Hepatitis B?

• Obesity

• Age

• Hygeine

• All of the above

Fill in the Blank

T/F: Hepatitis B vaccination is given to children at the age of 1

Multiple Select

Which of the following Hepatitis B vaccine(s) are given at birth?

Select all that apply

• Engerix B

• Heplisav B

• Pediarix

• Recombivax HB

Multiple Select

Which of the following Hepatitis B vaccine(s) are given as a two dose series; only in adults (but not given in pregnant pts)?

Select all that apply

• Engerix B

• Heplisav B

• Pediarix

• Recombivax HB

Multiple Choice

Which of the following Hepatitis B vaccine is a combination of Hepatitis B, DTap, and Polio?

• Engerix B

• Heplisav B

• Pediarix

• Recombivax HB

Multiple Choice

T/F: Everyone who tests positive for Hepatitis B should be treated for it

• True

• False (only treat if liver enzymes are elevated and virus is replicating a lot)

Multiple Choice

Which of the following is the preferred Sub-Q treatment for pts with chronic Hepatitis B + D co-infection; cannot be used in decompensated liver failuer

• Peginterferon a2a

• Interferon a 2b

• Heplisav b

• GamaSTAN

Fill in the Blank

What is a abnormal ADE associated w/ Interferons that could ultimately lead to suicide?

Multiple Choice

What would be your interpretation of the following lab data associated w/ HBV Diagnosis?

• Immune due to natural infection

• Immune due to HBV vaccine

• Not immune; should get vaccinated

Multiple Choice

What would be your interpretation of the following lab data associated w/ HBV Diagnosis?

• Immune due to natural infection

• Immune due to HBV vaccine

• Not immune; should get vaccinated

Multiple Select

Which of the following drugs are considered PO tx for Chronic Hepatitis B?

Select all that apply

• entecavir

• tenofovir alafenamide

• tenofovir disoproxil fumarate

• Adefovir

• Telbivudine

Fill in the Blank

_____ Analogs to tx Hepatitis B should not be given to those w/ HIV

Multiple Choice

Which of the following has a finite duration of 48 weeks, dosed once weekly, no resistance, higher rates of seroconversion, as well as only moderate antiviral effects w/ ↑ ADE?

• Nucleosides

• Nucleotides

• Interferons

• None of the above

Multiple Select

Which of the following has potent antiviral effects?

Select all that apply

• Nucleosides

• Nucleotides

• Interferons

• None of the above

Multiple Select

Which of the following can be used in decompensated liver failure, have pretty good tolerance, resistance concerns, indefinite tx duration, but have less side effects?

Select all that apply

• Nucleosides

• Nucleotides

• Interferons

• None of the above

Multiple Choice

Peginterferon A2A is the only effective tx option for Hepatitis _

• A

• B

• D

• E

Multiple Choice

In order for Hepatitis D to be able to replicate, the host must be co-infected w/ Hepatitis _

• A

• B

• D

• E

Fill in the Blank

T/F: There is currently one vaccine available for the prevention of Hepatitis D

Fill in the Blank

T/F: There is currently no vaccine available for the prevention of Hepatitis E in the US

Multiple Choice

What further lab work do you want now to decide if you want to treat WC?

• AST/ALT

• HBeAg

• HBV DNA quantity

• All of the above

Multiple Choice

With lab work complete, do you want to treat W.C.?ALT: 380

HBeAg: (+)

DNA: 55,000 U/mL

Plus he has (+) symptoms

• Yes

• No

• Monitor pt a little longer

• None of the above

Multiple Choice

Do you want to treat W.C.? If yes, which tx option(s) would you want to recommend?

• SubQ Pegasys

• Oral Tenofovir

• Oral Enecavir

• All of the above

Multiple Choice

The most common mode of transmission of Hepatitis C is:

• Contaminated food

• Contaminated water sources

• The use of contaminated needles

• Unprotected intercourse

Multiple Choice

Hepatitis C is usually present alongside which of the following co-infections?

• HPV

• HBV

• HIV

• All of the above

Fill in the Blank

Which genotype is the most common type of Hepatitis C in the US?

Multiple Choice

T/F: There is a vaccine available for Hepatitis C

• True

• False

Fill in the Blank

T/F: The current tx recommendation for acute Hepatitis C is the same as for chronic Hepatitis C

Multiple Choice

Which form of HCV is usually asymptomatic, majority go undiagnosed, have an onset of about 8 weeks, as well as not being common?

• Acute

• Chronic

Multiple Choice

Which form of HCV is associated w/ increased prevalence, progression related to certain factors, untreated infections lead to?

• Acute

• Chronic

Multiple Choice

T/F: All adults should be screened for Hepatitis C at least once in their lifetime

• True

• False

Multiple Choice

Which drug is associated w/ the following side effects?

bone marrow suppression, depression

• Peginterferon

• Ribavirin

• Grazoprevir

• Glecaprevir

Multiple Choice

Which drug belongs to the NS34A inhibitor class, is combined w/ elbasvir, used for HIV co-infection, and can be used in renally impaired + hemodialysis?

• Peginterferon

• Ribavirin

• Grazoprevir

• Glecaprevir

Multiple Choice

Which drug belongs to the NS34A inhibitor class, is combined w/ sofosbuvir and velpatasvir, and is indicated for pts with treatment failure only

• Voxilaprevir

• Sofosbuvir

• Ledipasvir

• Pibrentasvir

Multiple Choice

Which drug belongs to the NS5B inhibitor class, CANNOT use w/ amiodarone, and is used in most combo products?

• Voxilaprevir

• Sofosbuvir

• Ledipasvir

• Pibrentasvir

Multiple Choice

Which drug belongs to the NS5A inhibitor class, combined w sofosbuvir, must hold all acid suppressing medications while on this drug

• Voxilaprevir

• Sofosbuvir

• Ledipasvir

• Pibrentasvir

Multiple Choice

Which drug belongs to the NS5A inhibitor class, combined with glecaprevir, also included in triple therapy for failures, effective for all genotype 1-6 infections

• Voxilaprevir

• Sofosbuvir

• Ledipasvir

• Pibrentasvir

Multiple Choice

T/F: once tx course is completed for HCV, the patient is cured of HCV and no longer needs to be on antivirals

• True (unlike HIV)

• False

Fill in the Blank

Hepatitis C "cure" (goal of therapy):

Multiple Select

HCV genotype 1a and 1b, these are the treatment options:

Select all that apply

• Harvoni

• Zepatier

• Mavyret

• Epclusa

• Vosevi

Multiple Select

HCV genotypes 2 and 3, these are the treatment options:

Select all that apply

• Harvoni

• Zepatier

• Mavyret

• Epclusa

• Vosevi

Multiple Select

HCV genotype 4, these are the treatment options:

Select all that apply

• Harvoni

• Zepatier

• Mavyret

• Epclusa

• Vosevi

Multiple Select

HCV genotypes 5 + 6, these are the treatment options:

Select all that apply

• Harvoni

• Zepatier

• Mavyret

• Epclusa

• Vosevi

Multiple Choice

If pt has prior treatment failure w new agents, this combination product is recommended:

• Harvoni

• Zepatier

• Mavyret

• Epclusa

• Vosevi

Multiple Select

Per the previous case slide, what lab test should RDs doctor send next?

Select all that apply

• HIV

• HCV RNA

• HBV RNA

• HgA1C

• None of the above

Multiple Choice

Per the previous case slide, what is the most likely route of transmission of HCV for RD?

• Intercourse w/ HCV infected person

• Sweat from an HCV positive person he plays racquetball w/

• Blood transfusion from hospital course

• From his dog Boomer

• None of the above

Multiple Choice

Per the previous case slide, R.D.’s labs come back negative for HIV, HCV load of 1.2 million, genotype 1a, and liver biopsy with moderate fibrosis.

What is the appropriate treatment course for RD?

 

• Do not treat, continue monitoring parameters

• PEG/RBV x 48 weeks

• Sofobuvir + Ledipasvir (Harvoni) x 12 weeks

  (Maybe 8 wk tx b/c load < 6 mil)

• Boceprevir + Simeprevir + Whatcham-acallavir

• None of the above

Fill in the Blank

T/F: Up to 40% of cirrhosis pts are asymptomatic

Multiple Choice

Which of the following is the gold standard for diagnosing Cirrhosis?

• Labs

• LFT

• Biopsy

• AST/ALT

Multiple Choice

T/F: Cirrhosis is reversible once offending agents are removed/lifestyle changes are implemented

• True

• False (Cirrhosis is irreversible)

Multiple Choice

T/F: Steatosis is reversible once offending agents are removed/lifestyle changes are implemented

• True

• False (Steatosis is irreversible)

Fill in the Blank

Abnormal accumulation of fluid in the abdomen caused by cirrhosis; secondary hyperaldosteronism

Multiple Choice

Part of the treatment of ascites is discontinuing medications that decrease renal perfusion, including which of the following?

• NSAIDs

• Beta Blockers

• ACEs

• ARBs

• All of the above

Multiple Choice

T/F: As part of the treatment of ascites, pt should increase their sodium intake

• True

• False (sodium restriction is actually what you should do)

Multiple Select

Treatment of ascites is with THIS specific diuretic +/- a diuretic of this class

Select all that apply

• Spironolactone

• Furosemide

• K+ Sparing Diuretics

• Loop Diuretics

• Aldosterone Antagonists

Fill in the Blank

Spironolactone works by blocking the effects of _______, this is why it works to treat ascites

Multiple Choice

Treatment failure of ascites is defined as failing _____ of pharmacologic therapy with max dose spironolactone and furosemide

• 7 days

• 1 month

• 2 weeks

• 8 weeks

• 1 year

Multiple Choice

T/F: Paracentesis is the surgical puncture to remove fluid from the abdomen that is used in treatment of ascites. Sometimes 4-6 liters of fluid is removed. Every time paracentesis is done, you are increasing the patient's chance of developing spontaneous bacterial peritonitis

• True

• False

Fill in the Blank

The major complications of cirrhosis are referred to collectively as: _________

Fill in the Blank

Variceal hemorrhage, one of the cirrhotic sequelae issues mostly due to portal vein HTN, can occur in the esophagus, stomach, or rectum. Rupture causes 1/3 of deaths associated with cirrhosis, and ALL cirrhosis pts should be screened for these ___ per year

Multiple Choice

Which of the following drug classes can be used as PRIMARY prevention of variceal hemorrhage in cirrhosis pts?

• CCB

• ACE/ARB

• BB

• TCAs

Multiple Select

Nonspecific beta blockers which are used in prevention of variceal hemorrhage in cirrhosis pts:

Select all that apply

• Propranolol

• Carvedilol

• Atenolol

• Nadolol

• Labetalol

Multiple Choice

Which of the following is an endoscopic procedure used as SECONDARY prevention of variceal hemorrhage in cirrhosis pts; as effective as beta blocker monotherapy

• Biopsy

• Banding

• TIPS

• SBP

• None of the above

Multiple Choice

Which of the following is a procedure used in cirrhosis pts while they are waiting for liver transplant? Used to lower portal vein hypertension, bypassing liver, problems with metabolism

• Biopsy

• Banding

• TIPS

• SBP

• None of the above

Multiple Choice

Which of the following is a late stage complication of liver disease, bad infection with very high mortality rate, caused by altered gut wall permeability, impaired ability of hepatic/splenic macrophages to clear portal bacteria

• Biopsy

• Banding

• TIPS

• SBP

• None of the above

Multiple Choice

Which of the following is a procedure used to diagnose spontaneous bacterial peritonitis? If findings show PMN count above 250 cells/microliter, pt has spontaneous bacterial peritonitis

• Biopsy

• Diagnostic Paracentesis

• TIPS

• SBP

• None of the above

Multiple Select

Which abx potentially used for spontaneous bacterial peritonitis treatment; anaerobic and gram negative coverage? Select all that apply

• Cefotaxime

• Ceftriaxone

• Ertapenem

• All of the above

Multiple Select

Which abx potentially used for spontaneous bacterial peritonitis prophylaxis

used to prevent recurrence (remember recurrence rates are as high as 70% within 1 year), but resistance issues have arose; select all that apply

• Norfloxacin

• Levofloxacin

• Ciprofloxacin

• Bactrim DS

• All of the above

Fill in the Blank

Normal treatment length for spontaneous bacterial peritonitis with

abx is ____ days

Multiple Choice

Which of the following is a neuropsychiatric disorder caused by hepatic insufficiency leading to ammonia buildup? It is usually reversible, but 1 year survival is only 40%

• Hepatic Insufficiency

• HA

• Hepatic Encephalopathy

• Asterixis

• None of the above

Multiple Choice

Asterixis; aka Liver Flap, a flapping tremor of the hands. When the pt extends the arms & hands in front of the body, the hands rapidly flex & extend is caused by which of the following?

• Hepatic Insufficiency

• HA

• Hepatic Encephalopathy

• Asterixis

• None of the above

Multiple Choice

T/F: It is recommended that cirrhosis pts have decreased protein intake to prevent ascites and other cirrhotic sequelae

• True

• False (pt should be encouraged to have a normal protein intake)

Fill in the Blank

This drug is given to prevent cirrhotic sequelae. It works to increase clearance of ammonia product and prevent its resorption. Creates an acidic environment. ADE associated w/ this medication is diarrhea (3 or more loose stools per day)

Multiple Select

If lactulose is given rectally (in pts who cannot tolerate po), use rectal balloon catheter to retain drug for _________ min(s) every _____ hour(s)

Select one choice for mins and one for hours

• 15-45 minutes

• 30-60 minutes

• 8-12 hours

• 4-6 hours

Multiple Select

Which of the following medications is/are not used in the treatment of hepatic encephalopathy?

Select all that apply

• Rifaximin

• Neomycin

• Flagyl

• Bactrim DS

• Rifampin

Fill in the Blank

Classification of cirrhosis A,B,C (A is the healthiest and has life expectancy of 15-20 years)

Denote the Child Pugh classification from the given data below:

1. 5-6 pts

2. 7-9 pts

3. 10-15 pts

Fill in the Blank

What is used to prioritize pts on liver transplant list - 3 month mortality scoring system. higher number = increased chance of mortality (much more complicated than child pugh classification)

_____ score

Multiple Choice

Which of the following is the gold standard for diagnosing Drug-induced liver disease?

• Labs

• LFT

• Biopsy

• AST/ALT

Multiple Choice

Select the appropriate phase of metabolism in regards to the following term:

catalyzed by the p450 system

• Phase I Metabolism

• Phase II Metabolism

• Phase III Metabolism

• None of the above

Multiple Choice

Select the appropriate phase of metabolism in regards to the following term:

compounds are conjugated

• Phase I Metabolism

• Phase II Metabolism

• Phase III Metabolism

• None of the above

Multiple Choice

Select the appropriate phase of metabolism in regards to the following term:

polar groups are added to lipophilic compounds by oxidation, reduction, or hydrolysis

• Phase I Metabolism

• Phase II Metabolism

• Phase III Metabolism

• None of the above

Multiple Choice

Select the appropriate phase of metabolism in regards to the following term:

compound is becoming inert (losing pharmacologic activity)

• Phase I Metabolism

• Phase II Metabolism

• Phase III Metabolism

• None of the above

Fill in the Blank

T/F: BOTH phase I and phase II metabolism make compounds more polar

Multiple Choice

T/F: All drugs must undergo phase I metabolism before undergoing phase II metabolism

• True

• False (drugs can sometimes just undergo phase ii without ever undergoing phase i, drugs can just undergo phase i without ever undergoing phase ii)

Multiple Choice

T/F: In general, as age increases, severity of liver injury will also increase

• True (With a few exceptions; like reye's disease in kids)

• False

Fill in the Blank

(men/women) have an increased risk of hepatotoxicity

Multiple Choice

Dose-dependent drug induced hepatotoxicity is associated w/ which of the following?

• Shorter latency

• Necrosis

• Increased ALT

• All of the above

Multiple Choice

Dose-independent drug induced hepatotoxicity is associated w/ which of the following?

• Idosyncratic

• Immunoallergy

• Increased autoimmune markers

• All of the above

Multiple Choice

Dose-dependent drug induced hepatotoxicity is associated w/ which of the following medications?

• APAP

• Methotrexate

• Cyclophosphamide

• All of the above

Multiple Select

Dose-independent drug induced hepatotoxicity is associated w/ which of the following medications?

Select all that apply

• APAP

• Anti-convulsants

• Sulfonamides

• All of the above

Fill in the Blank

75% of drug induced hepatotoxicity and 25% of drug death in the US are caused by this drug:

Fill in the Blank

APAP daily doses exceeding ______ (range) g in adults may cause liver injury

Fill in the Blank

APAP daily doses exceeding ______ mg/kg in kids may cause liver injury

Fill in the Blank

Therapeutic levels of APAP are _____ (Range) mcg/ml in the blood

Multiple Choice

T/F: The time of presentation after initial ingestion of APAP is a very important factor for the treatment choice.

• True

• False

Multiple Choice

Chronic alcohol consumption lowers toxic dose threshold of apap by inducing this enzyme

• CYP12A

• CYP3A4

• CYP450

• CYP2E1

Multiple Choice

Which of the following is a metabolite of APAP that covalently binds to liver cell proteins and causes injury --> ultimately liver failure?

It is normally eliminated renally when overdose is not occurring.

• NAC (N-acetyl-cysteine)

• NAPQI (N-acetyl-p-benzoquinone imine)

• Glutathione

• None of the above

Multiple Choice

Which of the following is an agent that is found mostly in the liver parenchymal cells? It is responsible for NAPQI detoxification (remember NAPQI is the toxic metabolite of APAP) and helps to prevent damage to other organs.

• NAC (N-acetyl-cysteine)

• Activated Charcoal

• Glutathione

• None of the above

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Multiple Choice

T/F: APAP intoxication causes widespread liver inflammation

• True

• False (occurs w/ very little inflammation - unlike Hepatitis)

Fill in the Blank

APAP overdose can cause nephrotoxicity via extrahepatic _____ causing acute tubular necrosis

Multiple Choice

T/F: Normally, in the first 24 hours after APAP overdose, there will be very few side effects and patients may think everything is fine and they do not need to seek treatment

• True (This is really dangerous because time is a key factor in properly treating overdose)

• False

Multiple Choice

What stage of APAP induced hepatotoxicity is described below?

72-96 hrs after, stage i symptom typically reappear in addition to jaundice and confusion; liver abnormalities peak during this phase

• Stage III

• Stage IV

• Stage I

• Stage II

Multiple Choice

What stage of APAP induced hepatotoxicity is described below?

first 24 hours, very mild symptoms and very mild aminotransferase increases if any at all

• Stage III

• Stage IV

• Stage I

• Stage II

Multiple Choice

What stage of APAP induced hepatotoxicity is described below?

4 days-2 weeks later, "Recovery Phase," signs of necrosis are still there but lab values normalize slowly over weeks

• Stage III

• Stage IV

• Stage I

• Stage II

Multiple Choice

What stage of APAP induced hepatotoxicity is described below?

24-72 hrs after, symptoms are becoming evident, liver may become enlarged, alt/ast rising, decreased urine output

• Stage III

• Stage IV

• Stage I

• Stage II

Fill in the Blank

25-50% of pt with hepatotoxicity caused by APAP overdose will experience ____ injury

Multiple Choice

Which of the following is true in regards to the nomogram?

• Gap = Buffer

• Anything on or above the dotted line should be treated

• APAP Concentration should be plotted as a factor of time

• All of the above

Fill in the Blank

Initial therapy of APAP toxicity is gastrointestinal decontamination with _______ as a single 1 gm/kg dose

Fill in the Blank

Antidote for APAP Toxicity:

Multiple Choice

Pts with serum APAP levels above the nomogram line should be treated with ___

• NAP

• NAPQI

• NAC

• AST/ALT

• None of the above

Fill in the Blank

Pts w/ unknown time of ingestion and APAP level above ___ mcg/ml should be treated with NAC

Fill in the Blank

If serum APAP levels cannot be drawn within __ hours of ingestion but you suspect pt has had an overdose of APAP, you should treat them with NAC

Multiple Choice

If the pt cannot tolerate NAC due to intractable vomiting, is pregnant, or needs a shorter regimen of 21 hours, you should give NAC via this route:

It is given in 20% solution

• IV

• Oral

• SubQ

• IM

Multiple Choice

A longer regimen of 72 hrs, in 5% solution, but is associated w/ less side effects which is safer/better for the pt.

may be more beneficial in pts who report to the hospital more than 10 hrs after ingestion of apap

• IV

• Oral

• SubQ

• IM

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