Liver Cirrhosis – Hard Case-based MCQ Quiz (20 Qs)

Child–Pugh • Nutrition

Q1. Decompensated cirrhosis with “protein restriction” confusion

A 52-year-old man with alcohol-related cirrhosis (Child–Pugh C) is admitted for mild hepatic encephalopathy that resolved with lactulose. The resident suggests “strict protein restriction” to prevent recurrence. He is sarcopenic with BMI 18 and no active GI bleed or infection. Which is the MOST appropriate nutritional advice?

A. Restrict protein to <0.5 g/kg/day until MELD <10 B. Maintain 1.2–1.5 g/kg/day protein with late evening snack C. Switch to completely protein-free diet for 3–5 days D. Reduce total calories to <15 kcal/kg/day to prevent ammonia formation

Ascites • SAAG

Q2. New-onset ascites – most likely etiology

A 47-year-old woman with chronic hepatitis B develops new-onset ascites. Diagnostic paracentesis shows: SAAG 1.4 g/dL, total protein 0.9 g/dL, neutrophils 70/mm³. Which is the MOST likely mechanism for her ascites?

A. Peritoneal carcinomatosis due to HCC B. Nephrotic syndrome with hypoalbuminemia C. Portal hypertension due to cirrhosis D. Pancreatic ascites from chronic pancreatitis

Variceal bleed • Resuscitation

Q3. Target hemoglobin in acute variceal bleed

A 56-year-old man with known cirrhosis presents with massive hematemesis. BP 96/60 mmHg, HR 112/min. Hb 6.4 g/dL, platelets 75,000/µL. Endoscopy confirms large esophageal varices with active spurting bleed. What is the MOST appropriate transfusion target for hemoglobin during resuscitation?

A. Maintain Hb > 10 g/dL B. Maintain Hb 7–8 g/dL C. Maintain Hb exactly 9 g/dL D. Avoid transfusion unless Hb <5 g/dL

SBP diagnosis

Q4. Spontaneous bacterial peritonitis – diagnostic threshold

A 60-year-old man with decompensated cirrhosis and tense ascites presents with low-grade fever and diffuse abdominal pain. Ascitic fluid analysis: total WBC 700/mm³, PMN 320/mm³, negative Gram stain. What is the BEST interpretation?

A. Not SBP; PMN must be ≥500/mm³ B. SBP is diagnosed; start empiric antibiotics C. Secondary peritonitis; urgent laparotomy needed D. Culture-negative, non-neutrocytic ascites – no treatment

SBP • Albumin

Q5. Albumin dosing in SBP

A 58-year-old cirrhotic with SBP is started on IV cefotaxime. Creatinine is 1.6 mg/dL, bilirubin 4.2 mg/dL. To reduce the risk of hepatorenal syndrome, which albumin regimen is MOST evidence-based?

A. 0.5 g/kg albumin on day 1 only B. 1.5 g/kg on day 1 and 1 g/kg on day 3 C. 20 g/day albumin for 7 days D. Albumin is not indicated in SBP

Varices prophylaxis

Q6. Non-selective beta-blocker goal

A 45-year-old man with compensated HCV cirrhosis has large esophageal varices without prior bleeding. Propranolol 20 mg BID is started. Which of the following BEST defines an adequate response?

A. HR <40/min regardless of symptoms B. HR 55–60/min without symptomatic hypotension C. Any dose tolerated by the patient D. Complete normalization of portal pressure on Doppler

HE • Precipitant

Q7. Precipitant for hepatic encephalopathy

A 63-year-old man with cirrhosis develops confusion and disorientation over 24 hours. He is afebrile, BP 112/70, HR 88/min. Labs: Na 132 mEq/L, K 3.1 mEq/L, creatinine 0.9 mg/dL, ammonia mildly elevated. Three days earlier, his diuretics were doubled and lactulose dose reduced because of bloating. Which is the MOST likely precipitating factor?

A. Hypernatremia due to diuretics B. Hypokalemic metabolic alkalosis from diuretics C. Acute viral hepatitis superinfection D. Spontaneous portosystemic shunt closure

HRS diagnosis

Q8. Hepatorenal syndrome – key diagnostic step

A 59-year-old man with advanced cirrhosis and tense ascites develops rising creatinine from 1.0 to 2.2 mg/dL over 3 days. BP 94/60 mmHg, no hematuria, bland urine sediment. Ultrasound: normal-sized kidneys. Which initial intervention is MOST appropriate to confirm hepatorenal syndrome before labeling it HRS?

A. Immediate high-dose loop diuretics B. Volume expansion with albumin and stopping diuretics C. Kidney biopsy D. Angiography of renal arteries

MELD • Transplant

Q9. When to refer for liver transplant

A 50-year-old man with NASH-cirrhosis is Child–Pugh B (score 8) with recurrent ascites and one episode of HE controlled on lactulose. His MELD-Na is 17. What is the MOST appropriate step regarding transplant decision?

A. Defer transplant referral until MELD >25 B. Immediate listing is not needed in NASH C. Refer now for transplant evaluation D. Transplant is contraindicated in Child–Pugh B

HCC screening

Q10. Optimal screening interval for HCC

A 48-year-old man with HBV cirrhosis and no known focal lesions is on regular follow up. Which of the following represents the BEST evidence-based screening schedule for HCC?

A. Ultrasound abdomen once every 12 months only B. CT abdomen every 3 months C. Ultrasound ± AFP every 6 months D. MRI every month for the first year

Ascites • Diuretics

Q11. Appropriate weight loss target on diuretics

A 55-year-old man with cirrhosis and moderate ascites is started on spironolactone 100 mg and furosemide 40 mg daily with 2 g/day salt restriction. He has peripheral edema. What is the MOST appropriate maximum daily weight loss target to avoid renal dysfunction?

A. 0.25 kg/day irrespective of edema B. 0.5 kg/day because edema is present C. 1 kg/day as he has peripheral edema D. 3 kg/day in the first week

Child–Pugh

Q12. Child–Pugh class assignment

A patient with cirrhosis has: bilirubin 3.2 mg/dL, albumin 2.7 g/dL, INR 2.1, moderate ascites controlled on diuretics, and no encephalopathy. What is his Child–Pugh class?

A. Class A B. Class B C. Class C D. Cannot be determined without MELD

HE • Treatment

Q13. Role of rifaximin

A 62-year-old man with cirrhosis has had two episodes of overt hepatic encephalopathy in the last 6 months, despite good adherence to lactulose therapy. What is the MOST appropriate next step in long-term therapy?

A. Add rifaximin 550 mg twice daily B. Stop lactulose and use neomycin alone C. Institute strict protein restriction D. Start prophylactic octreotide infusion

Acute variceal bleed

Q14. Antibiotic choice in acute variceal bleed

A 49-year-old cirrhotic presents with upper GI bleed from esophageal varices. Endoscopic band ligation is done. Which antibiotic regimen is MOST appropriate for prophylaxis against infections and SBP in this setting?

A. Ceftriaxone 1 g IV daily for 7 days B. IV vancomycin for 3 days C. Oral azithromycin single dose D. No antibiotics are indicated without fever

Refractory ascites

Q15. Next step in refractory tense ascites

A 57-year-old man with cirrhosis has tense ascites causing dyspnea despite maximal diuretics and sodium restriction. Creatinine is 1.0 mg/dL. There is no active infection or HCC. What is the MOST appropriate next therapeutic intervention?

A. Large-volume paracentesis with albumin replacement B. Immediate TIPS in all cases C. Stop diuretics and observe only D. Emergency liver transplantation

Drug safety

Q16. Analgesic of choice in cirrhosis

A 54-year-old man with Child–Pugh B cirrhosis has chronic knee osteoarthritis pain. Which analgesic strategy is MOST appropriate for long-term use?

A. High-dose NSAIDs regularly B. Paracetamol up to 2 g/day C. Tramadol + NSAIDs combination daily D. No analgesia is safe in cirrhosis

Secondary prophylaxis

Q17. Variceal bleed – secondary prophylaxis

A 51-year-old man recovered from an acute esophageal variceal bleed after band ligation and octreotide infusion. Which combination is the BEST recommended long-term strategy to prevent rebleeding?

Liver Cirrhosis – Hard Case-based MCQ Quiz