KMU Past Paper Practice

Question:

A 48-year-old man with long-standing heavy alcohol use presents with anorexia, tender hepatomegaly and jaundice. AST is 224 U/L, ALT 88 U/L and GGT is elevated. Which finding best supports alcohol-associated hepatocellular injury rather than an acute viral hepatitis pattern?

Disproportionately raised alkaline phosphatase

AST exceeding ALT by more than twofold

Isolated unconjugated hyperbilirubinemia

Normal aminotransferases with low albumin

Predominantly elevated serum creatinine

Correct Answer: AST exceeding ALT by more than twofold

Explanation: Alcohol-associated injury frequently produces an AST:ALT ratio above 2, with moderately elevated enzymes; the result supports but does not independently establish the diagnosis.

Question:

A 39-year-old woman develops pruritus and jaundice three weeks after starting a new medication. ALP is markedly raised, ALT mildly increased and ultrasound shows no duct dilatation. Which clinical interpretation best explains the pattern?

Predominantly hepatocellular necrosis

Isolated impairment of albumin synthesis

Hemolysis with indirect hyperbilirubinemia

Intrahepatic cholestatic drug injury

Extrahepatic bile duct obstruction

Correct Answer: Intrahepatic cholestatic drug injury

Explanation: A cholestatic pattern with a temporal drug exposure and no duct dilatation suggests intrahepatic drug-induced cholestasis; competing causes still require assessment.

Question:

A 44-year-old man with jaundice has total bilirubin 6.0 mg/dL, direct bilirubin 4.8 mg/dL and dark urine. His renal function is normal. What explains the urinary discoloration?

Water-soluble conjugated bilirubin entering urine

Albumin-bound unconjugated bilirubin entering urine

Increased urinary urobilinogen alone

Excess urinary hemoglobin from occult hemolysis

Elevated urinary bile acid synthesis

Correct Answer: Water-soluble conjugated bilirubin entering urine

Explanation: Conjugated bilirubin is water-soluble and can be filtered into urine; unconjugated bilirubin remains albumin-bound and is not filtered.

Question:

A patient with prolonged cholestasis has a raised INR and is being evaluated for worsening liver function. After parenteral vitamin K, the INR improves substantially within the expected response interval. What is the most likely contributor to the initial abnormality?

Increased fibrinolysis from portal hypertension

Reduced platelet sequestration

Chronic splenic enlargement

Acute ammonia accumulation

Vitamin K malabsorption due to cholestasis

Correct Answer: Vitamin K malabsorption due to cholestasis

Explanation: Cholestasis can impair absorption of fat-soluble vitamin K; correction of INR after replacement indicates a reversible deficiency rather than isolated severe synthetic failure.

Question:

A 52-year-old patient with chronic viral hepatitis has no ascites or jaundice. The clinician wants a noninvasive assessment of hepatic fibrosis to guide follow-up. Which test is most directly appropriate?

Serial serum amylase testing

Routine diagnostic laparotomy

Transient elastography

Plain abdominal radiography

Single fasting serum bilirubin

Correct Answer: Transient elastography

Explanation: Transient elastography estimates liver stiffness and is commonly used as a noninvasive aid to assessing advanced fibrosis, interpreted with clinical and laboratory findings.

Question:

A 56-year-old man with established cirrhosis is found on screening endoscopy to have large esophageal varices. He has never experienced upper gastrointestinal bleeding and is hemodynamically stable. Which strategy most directly lowers his risk of a first variceal hemorrhage?

A nonselective beta-blocker where suitable

High-dose proton-pump inhibitor alone

Oral iron supplementation

Empirical broad-spectrum antibiotics

Repeated therapeutic paracentesis

Correct Answer: A nonselective beta-blocker where suitable

Explanation: Nonselective beta-blockade reduces portal pressure and first-bleed risk; endoscopic band ligation is an alternative in appropriate patients.

Question:

A 60-year-old woman with ankle swelling and abdominal distension has a SAAG of 1.4 g/dL. Ascitic total protein is 3.3 g/dL, and examination reveals elevated jugular venous pressure and a displaced apex beat. Which underlying mechanism is most likely?

Tuberculous peritoneal inflammation

Low-pressure pancreatic duct leakage

Peritoneal malignant exudation

Congestive cardiac hepatopathy

Nephrotic hypoalbuminemia alone

Correct Answer: Congestive cardiac hepatopathy

Explanation: High-SAAG ascites with relatively high ascitic protein and systemic venous congestion favors cardiac ascites rather than uncomplicated cirrhotic ascites.

Question:

A 42-year-old woman has abdominal distension, low-grade fever and weight loss. Ascitic analysis reveals SAAG 0.6 g/dL, protein 4.2 g/dL and lymphocyte predominance. Which diagnosis best matches the fluid pattern and symptoms?

Uncomplicated cirrhotic portal hypertension

Tuberculous peritonitis

Cardiac congestive ascites

Portal vein thrombosis

Hepatic venous outflow obstruction

Correct Answer: Tuberculous peritonitis

Explanation: A low-SAAG, protein-rich, lymphocyte-predominant ascites with constitutional symptoms is characteristic of peritoneal tuberculosis and needs confirmatory testing.

Question:

A 64-year-old man with tense cirrhotic ascites needs diagnostic paracentesis to exclude infection. Platelets are 75,000/mm³ and INR is 1.8, with no active bleeding. What is the best procedural decision?

Postpone fluid sampling until INR normalizes

Give prophylactic fresh-frozen plasma in all cases

Proceed with careful ultrasound-guided paracentesis

Replace diagnostic fluid analysis with CT scanning

Start anticoagulation before abdominal puncture

Correct Answer: Proceed with careful ultrasound-guided paracentesis

Explanation: Paracentesis is a low-bleeding-risk procedure in cirrhosis; moderate INR elevation or thrombocytopenia alone generally does not require routine prophylactic correction.

Question:

A patient has recovered from a documented episode of spontaneous bacterial peritonitis and is being discharged with persistent cirrhotic ascites. Which follow-up measure most specifically reduces the chance of another episode?

Routine proton-pump inhibitor therapy

Daily high-dose loop diuretics alone

Long-term corticosteroid therapy

Repeated elective upper endoscopy

Guideline-directed secondary antibiotic prophylaxis

Correct Answer: Guideline-directed secondary antibiotic prophylaxis

Explanation: Previous spontaneous bacterial peritonitis carries a high recurrence risk, so selected patients require guideline-directed secondary antibacterial prophylaxis.

Question:

A man with cirrhosis has mild sleep reversal and difficulty concentrating, but he remains oriented, performs daily activities and has no asterixis. Which West Haven category best fits these early manifestations?

Grade IV: coma

Grade I: subtle cognitive changes

Grade III: marked somnolence

Grade II: obvious disorientation

Grade III: severe agitation

Correct Answer: Grade I: subtle cognitive changes

Explanation: Grade I encephalopathy produces subtle attention and sleep changes without the overt disorientation characteristic of higher grades.

Question:

A hospitalized patient with cirrhosis becomes very somnolent but can be awakened by repeated verbal stimulation. On waking, he is markedly disoriented and cannot cooperate with examination. Which West Haven grade is most consistent?

Grade 0

Grade I

Grade II

Grade III

Grade IV

Correct Answer: Grade III

Explanation: Grade III describes marked somnolence or stupor with arousability and gross disorientation; grade IV is coma.

Question:

A 50-year-old patient with decompensated cirrhosis develops confusion. His ammonia result is within the laboratory reference range, while bedside assessment raises concern for encephalopathy. What is the most appropriate interpretation?

A normal ammonia level should prompt careful diagnostic reassessment

A normal ammonia level confirms advanced encephalopathy

Ammonia alone should determine West Haven grading

Lactulose must be stopped regardless of symptoms

Neuroimaging is unnecessary despite neurological changes

Correct Answer: A normal ammonia level should prompt careful diagnostic reassessment

Explanation: A normal ammonia concentration in a patient thought to have overt hepatic encephalopathy should trigger diagnostic reevaluation rather than reliance on ammonia alone.

Question:

A 31-year-old woman arrives after a deliberate paracetamol overdose. She has nausea, markedly elevated aminotransferases and an evolving coagulopathy. Which treatment specifically addresses the suspected toxic cause?

Oral spironolactone

Intravenous terlipressin

Endoscopic variceal ligation

Long-term rifaximin

N-acetylcysteine

Correct Answer: N-acetylcysteine

Explanation: N-acetylcysteine replenishes glutathione and limits toxic paracetamol metabolite injury; prompt administration is crucial in suspected paracetamol toxicity.

Question:

A 37-year-old man with severe acute hepatitis is admitted with increasing INR but no previous cirrhosis. After initial stabilization, which additional information is most essential for identifying the cause and selecting etiology-specific treatment?

Presence of abdominal striae alone

Serial waist circumference

Medication exposure and viral hepatitis testing

Past history of uncomplicated hemorrhoids

Single measurement of ascitic fluid volume

Correct Answer: Medication exposure and viral hepatitis testing

Explanation: A careful medication and toxin history plus acute viral hepatitis testing identifies common treatable causes of severe acute liver injury.

Question:

A 45-year-old man is newly diagnosed with hepatitis B-related cirrhosis. His spouse and adolescent child have no documented hepatitis B immunization. Which counselling recommendation most directly protects household contacts?

Start rifaximin for all household members

Offer hepatitis B testing and vaccination if susceptible

Avoid all shared meals and handshakes

Begin hepatitis C antiviral therapy for contacts

Use routine antibiotics after close contact

Correct Answer: Offer hepatitis B testing and vaccination if susceptible

Explanation: Household contacts of a patient with hepatitis B should undergo appropriate HBV testing and receive vaccination when susceptible; casual contact does not transmit HBV.

Question:

A 43-year-old woman with chronic hepatitis C asks how to avoid passing the infection to her spouse while awaiting antiviral treatment. Which statement is most accurate?

Hepatitis C spreads efficiently through casual hugging

A licensed hepatitis C vaccine is routinely available

Sharing razors is safe when no blood is visible

Avoid sharing blood-contaminated personal items

Household contacts require prophylactic antibiotics

Correct Answer: Avoid sharing blood-contaminated personal items

Explanation: HCV is transmitted primarily through blood exposure; patients should not share razors or toothbrushes that may be contaminated with blood.

Question:

A 59-year-old man with chronic liver disease has a small liver, ascites and an elevated INR. The clinician wishes to estimate prognosis using a commonly applied score incorporating bilirubin, INR and creatinine. Which is the most suitable score?

MELD score

Glasgow Coma Scale

Wells score

CURB-65 score

CHA₂DS₂-VASc score

Correct Answer: MELD score

Explanation: MELD uses bilirubin, INR and creatinine to estimate severity in advanced liver disease; contemporary variants may include sodium and albumin.

Question:

A 65-year-old patient with decompensated cirrhosis has reduced muscle mass and recurrent mild encephalopathy. His family has eliminated nearly all protein from his meals. What is the best nutritional advice?

Maintain a very-low-protein diet indefinitely

Replace all meals with clear fluids

Stop oral feeding until ammonia normalizes

Avoid late evening snacks

Provide adequate protein and nutrition with regular meals

Correct Answer: Provide adequate protein and nutrition with regular meals

Explanation: Protein restriction promotes sarcopenia and worsens ammonia handling; adequate dietary protein and energy intake are recommended in cirrhosis.

Question:

A 57-year-old man with cirrhosis has increasing abdominal discomfort and early satiety. Ultrasound shows large-volume ascites; he has no fever, abdominal tenderness or renal failure. Which treatment best offers prompt symptom relief while maintaining hemodynamic safety?

Urgent broad-spectrum antimicrobials alone

High-dose intravenous corticosteroids

Therapeutic paracentesis with appropriate albumin

Immediate escalation of sedative therapy

Endoscopic variceal banding before drainage

Correct Answer: Therapeutic paracentesis with appropriate albumin

Explanation: Therapeutic large-volume paracentesis relieves tense ascites; albumin is indicated when more than 5 L are removed to limit circulatory dysfunction.