Cirrhosis: Clinical

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Cirrhosis: Clinical

USMLE® Step 2 questions

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USMLE® Step 2 style questions USMLE

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A 55-year-old man is brought to the emergency department due to confusion. He has not had fevers, vomiting, diarrhea, or epigastric pain. His last colonoscopy was 5 years ago and was notable for benign polyps, which were subsequently resected. Past medical history includes hypertension, hypercholesterolemia, gastroesophageal reflux disease and type 2 diabetes. He has been drinking a half-pint of vodka daily for 30 years. Temperature is 37.0°C (98.6°F), pulse is 80/min, respirations are 20/min, and blood pressure is 135/85 mmHg, BMI is 20 kg/m2. Physical examination reveals erythematous palms. Abdominal distension and shifting dullness is noted on abdominal examination. Neurologic examination is notable for flapping tremors and impaired recent and remote memory. Fecal occult blood test is positive. Which of the following is the mechanism of action of the most appropriate pharmacological agent in this patient? 


Cirrhosis is when chronic inflammation and liver damage causes the liver to become fibrotic and develop scar tissue.

At a cellular level, the hepatocytes become impaired and this leads to hepatic dysfunction and portal hypertension.

Cirrhosis is usually irreversible, so it’s usually called “end-stage” or “late-stage” liver damage, and often requires a liver transplant. However, in some cases, early treatment can slow down and even reverse the cirrhosis.

Compensated cirrhosis is when there are enough healthy cells to make up for the damaged ones, but minor complications like hemorrhoids can still occur.

Decompensated cirrhosis is when healthy cells can no longer keep up with the workload, causing major complications like hepatic encephalopathy, ascites, and esophageal and gastric variceal hemorrhage.

In compensated cirrhosis, although there aren’t any major complications, there may still be some symptoms such as loss of appetite, fatigue, and muscle cramps. There may also be easy bruising and excessive bleeding because there aren’t enough clotting factors produced by the liver.

Cirrhosis can also impair estrogen metabolism, causing amenorrhea and irregular menstrual bleeding in females, and low libido and gynecomastia in males.

On physical exam, there may be hepatomegaly - where the liver can feel firm and nodular, but when there’s a lot of scarring, the liver may be small so that it can’t be felt at all.

Another sign is spider angiomas- or spider nevi- which are swollen blood vessels just beneath the skin surface- on the truck, face and upper limbs.

Palmar erythema- which is redness of the hands- can sometimes be seen.


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