A 28-year-old woman at 34 weeks of gestation presents with elevated liver enzymes and pruritus. Labs reveal total bilirubin to be 4.2 mg/dL, AST 480 U/L, ALT 640 U/L, and alkaline phosphatase 232 U/L. Viral hepatitis serologies and ANA are negative. On physical examination, she is jaundiced, but has a normal blood pressure, no edema, and a soft abdomen. The fetus is in no distress. Which of the following is true?

Correct Answer: B

Rationale: The correct answer is B: Symptoms will resolve promptly after delivery. The presentation of elevated liver enzymes, pruritus, and jaundice in a pregnant woman at 34 weeks with no signs of severe preeclampsia suggests cholestasis of pregnancy. This condition typically resolves after delivery. The absence of fetal distress and normal maternal blood pressure indicate that immediate delivery is not necessary. There is a risk of recurrence in subsequent pregnancies, so choice C is incorrect. Screening for LCHAD deficiency is not indicated in this scenario, as the presentation is more consistent with cholestasis of pregnancy.

Correct Answer: A

Rationale: The correct answer is A: He should be treated with a low-protein diet and lactulose. This patient is presenting with hepatic encephalopathy, as evidenced by his altered mental status, ataxia, slurred speech, hyperreflexia, and normal ammonia level. The management of hepatic encephalopathy involves reducing the production of ammonia in the gut. Lactulose is a non-absorbable disaccharide that helps trap ammonia in the gut and promote its excretion in the feces. A low-protein diet is also recommended to decrease ammonia production. Option B is incorrect because lorazepam is not the drug of choice for managing hepatic encephalopathy; it can worsen the condition. Option C is incorrect because gentamicin is not indicated in this scenario. Option D is incorrect because acetaminophen should be avoided in patients with liver disease due to the risk of hepatotoxicity; nonsteroidal anti-inflammatory drugs

Correct Answer: B

Rationale: The correct answer is B: Cytomegalovirus. Cytomegalovirus is a common cause of acute pancreatitis in immunocompromised patients. The virus can infect the pancreas leading to inflammation. HIV (A) can also cause pancreatitis, but it is typically due to opportunistic infections like CMV rather than the virus itself. Dideoxyinosine (ddI) (C) and Pentamidine (D) are medications that can cause pancreatitis, but they are not the primary cause in this case.

Correct Answer: C

Rationale: Rationale: C is false because eradication of H. pylori does not completely prevent adenocarcinoma of the stomach, although it reduces the risk. A is true as H. pylori can invade epithelium. B is true as it can stimulate acid secretion. D is true as H. pylori produces urease. Thus, C is the only false statement.

Correct Answer: B

Rationale: The correct answer is B: Measure serum gastrin in response to secretin infusion. This step is necessary to confirm the diagnosis of gastrinoma. Secretin stimulation test is used to differentiate between Zollinger-Ellison syndrome (gastrinoma) and other causes of hypergastrinemia. If serum gastrin levels remain elevated after secretin infusion, it supports the diagnosis of gastrinoma. Choice A: Refer her for an exploratory laparotomy - This is an invasive procedure and should not be the first step in the investigation of gastrinoma. Choice C: Treat her for H. pylori - This is not indicated in the management of suspected gastrinoma. H. pylori infection is not a likely cause of the symptoms described. Choice D: Obtain a dedicated small bowel series - This test is not typically used in the initial evaluation of gastrinoma. The secretin stimulation test is the preferred method for confirming the diagnosis.