Hepatology Board Review
Scott Gabbard, MD
06/09/2009
Question 1
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A 53-year-old man with hepatitis C and cirrhosis comes for a follow-up office
visit. He feels fatigued but has no other new signs or symptoms. The patient
has a history of alcohol abuse but has been abstinent for 8 months following
a treatment program. He now attends weekly Alcoholics Anonymous
meetings. Complications of the hepatitis C and cirrhosis have included ascites
and encephalopathy, both of which are controlled by medications.
Physical examination discloses mild jaundice, spider angiomata,
splenomegaly, and mild peripheral edema.
Labs: Hgb 13; Plt 80; AST and ALT in the 70s; total bili 3; INR 1.4; Alpha
fetoprotein normal
Abdominal ultrasonography discloses a coarse echotexture of the liver, mild
ascites, and a 2.2-cm hyperechoic hepatic mass that was not seen on
previous imaging studies. A CT scan of the liver shows vascular enhancement
of the mass.
Question 1
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What is the diagnosis?
 Metastatic cancer
 HCC
 Focal nodular hyperplasia
 Cavernous hemangioma
 Regenerative nodule
HCC
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Answer: HCC
Patients with hepatitis C and cirrhosis are at increased risk for
developing hepatocellular carcinoma, and the finding of a new
hepatic mass with vascular enhancement in such patients almost
certainly indicates hepatocellular carcinoma.
Although metastases are the most commonly diagnosed malignant
hepatic masses in patients without cirrhosis, they are uncommon in
patients with cirrhosis, especially those who do not have a history of
another malignancy.
Focal nodular hyperplasia and cavernous hemangiomas are unusual
in patients with cirrhosis and would not explain the finding of a new
lesion.
Regenerative nodules may occur in patients with cirrhosis, but these
nodules usually do not show vascular enhancement.
Question 2
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A 42-year-old woman has a 1-year history of progressive
fatigue without dyspnea, chest pain, or other systemic
symptoms. She sleeps well at night and does not have
features of sleep apnea. The patient has hypothyroidism,
managed with levothyroxine, and dysmenorrhea, treated with
an estrogen/progesterone combination.
On physical examination, the thyroid is slightly enlarged but
nontender. Xanthomas are present on the extensor surfaces.
Abdominal examination discloses mild hepatomegaly.
Labs: CBC normal; AST 25; ALT 35; Alk phos 300; total
bilirubin 1.1
Question 2
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In addition to a fasting serum lipid profile, which of the
following studies would most likely help establish the
diagnosis?
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Antimitochondrial antibody
Serum 25-hydroxyvitamin D
Endoscopic retrograde cholangiopancreatography
Abdominal ultrasonography
Primary biliary cirrhosis
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Answer: Antimitochondrial antibody
This patient most likely has primary biliary cirrhosis.
Key words: fatigue, woman 40-60, other autoimmune disease,
skin findings, metabolic bone disease
Diagnosis: Antimitochondrial antibody titer of 1:40 or more
occur in >90% of patients with primary biliary cirrhosis. Then
proceed with biopsy, which characteristically shows
nonsuppurative cholangitis plus findings ranging from bile
duct lesions to cirrhosis.
Treatment with ursodeoxycholic acid improves the biochemical
profile, reduces pruritus, decreases progression to cirrhosis,
and delays the need for liver transplantation.
Question 3
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A 66-year-old woman comes for her annual physical
examination. She reports only mild fatigue. The patient has
prediabetes that is managed by diet alone. She takes no
medications and drinks one glass of wine each day.
On physical examination, blood pressure is 132/86 mm Hg.
BMI is 32. The remainder of the examination is normal.
Labs: Hgb 13; Plts 80; AST 130; ALT 120; Total Bili 0.8;
Albumin 2.9; Hepatitis serologies negative
Ultrasound demonstrates evidence of mild fatty infiltration of
the liver
Question 3
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In addition to weight loss, which of the following is the most
appropriate next step for managing this patient's liver
chemistry abnormalities?
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Rosiglitasone and repeat LFTs in 6 months
Alcohol counseling
Liver biopsy
Evaluation for liver transplant
NAFLD
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Answer: Liver biopsy
Although a liver biopsy is not required for all patients with
NAFLD, biopsy should be considered for those who are older
than 45 years of age, are obese, have diabetes mellitus, or
have a serum aspartate aminotransferase to serum alanine
aminotransferase ratio (AST:ALT) >1, as these may be
predictors of fibrosis.
Rosiglitazone or pioglitazone may be indicated for patients
with nonalcoholic steatohepatitis and features of the
metabolic syndrome in order to prevent progression of the
liver disease.
Question 4
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A 44-year-old man was recently found to have abnormal
serologic test results for viral hepatitis when he attempted to
donate blood. The patient is asymptomatic. He used injection
drugs and drank alcohol excessively for 2 years 25 years ago
but has not used either drugs or alcohol since. Medical history
is otherwise unremarkable, and he takes no medications.
Physical examination discloses a BMI of 23, no stigmata of
chronic liver disease, and a normal-sized liver.
Labs: AST 50; ALT 70; total bili 0.9; HbsAg negative; anti-HBs
positive; IgG anti-HBc positive; IgM anti-HBc negative; antiHCV positive
Question 4
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Which study should be done next?
Hepatitis B e antigen (HBeAg)
 Hepatitis B virus DNA (HBV DNA)
 Hepatitis C virus RNA (HCV RNA)
 IgM antibody to hepatitis A virus (IgM antiHAV)
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Hepatitis C Virus
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Answer: HCV viral RNA
This patient has elevated serum aminotransferase values and positive
antibodies to hepatitis C virus (anti-HCV). In a patient with a history
of injection drug use, these findings are highly suggestive of
hepatitis C, and an HCV RNA study should be done to confirm the
presence of viremia.
Positive tests for antibody to hepatitis B surface antigen (anti-HBs)
and IgG antibody to hepatitis B core antigen (IgG anti-HBc) are
consistent with immunity from prior infection, and determination of
hepatitis B e antigen (HBeAg) and HBV DNA is therefore not
necessary.
Testing for IgM antibody to hepatitis A virus (IgM anti-HAV) is not
indicated because acute hepatitis A tends to cause systemic
symptoms, jaundice, and more marked elevations in serum
aminotransferase values.
Question 5
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A 30-year-old woman is evaluated because of an abnormal
serum total bilirubin level detected when she had a life
insurance examination. Medical history is unremarkable. Her
only medication is an oral contraceptive agent. Physical
examination is normal.
Labs: Hgb 13; MCV 90; Total bilirubin 2.4; Direct bilirubin 0.2;
AST 23; ALT 25; Alk phos 90
Question 5
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Which of the following is the most appropriate management
at this time?
 Discontinue the oral contraceptive agent
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Repeat the liver chemistry tests in 3 months
Evaluate for the presence of hemolysis
Schedule abdominal ultrasonography
No additional diagnostic studies are indicated
Gilbert’s syndrome
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Answer: Do nothing (very appealing to all the third years here)
This patient has indirect (unconjugated) hyperbilirubinemia, which in
an asymptomatic patient with a normal hemoglobin level and
otherwise normal liver tests is suggestive of Gilbert's syndrome.
Gilbert's syndrome is the most common inherited disorder of bilirubin
metabolism. In adults, it is a benign disorder, and no additional
diagnostic studies or therapy is required at this time.
Cholestasis due to an oral contraceptive agent will cause conjugated
(direct) hyperbilirubinemia and an elevated serum alkaline
phosphatase level
Patients with hemolysis significant enough to cause unconjugated
hyperbilirubinemia generally have a low hemoglobin level and
abnormal values for mean corpuscular volume
Question 6
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A 37-year-old woman has a 1-week history of fatigue,
jaundice, and slight fever. The patient has hypothyroidism for
which she has taken levothyroxine for the past 10 years. She
traveled to Mexico 5 months ago and received one dose of
hepatitis A vaccine before her trip. Physical examination
discloses mild jaundice and hepatomegaly.
Labs: CBC normal; TSH normal; AST 310; ALT 450; Alk phos
180; total bili 2.3
Question 6
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Which will confirm the diagnosis?
 Antimitochondrial antibody
 Antinuclear antibody and anti–smooth muscle antibody
 IgM antibody to hepatitis A virus (IgM anti-HAV)
 Serum acetaminophen
 Endoscopic retrograde cholangiopancreatography
Autoimmune hepatitis
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Answer: ANA and AMSA (and antibody to liver/kidney
microsome type 1)
This patient most likely has autoimmune hepatitis because of
her concomitant autoimmune thyroid disease and abnormal
liver test results. Antinuclear antibody and anti–smooth
muscle antibody titers should therefore be obtained; titers
>1:80 for both assays support the diagnosis.
Key words: woman 20-40; concomitant autoimmune disease
(thyroiditis, UC, synovitis)
Prednisone alone or prednisone plus azathioprine is effective
in inducing remissions in patients with autoimmune hepatitis.
Question 7
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A 23-year-old woman has an 8-month history of dyspnea and
dry cough. Medical history is unremarkable, and her only
medication is an oral contraceptive agent.
On physical examination, vital signs are normal. Crackles are
heard in both lung fields. Cardiac examination is normal.
Abdominal examination discloses mild hepatomegaly.
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Labs: CBC normal; AST 45; ALT 55; Alk phos 430
A chest radiograph shows mild diffuse pulmonary infiltrates.
Heart size is normal. A tuberculin skin test is negative.
Abdominal ultrasonography shows mild hepatomegaly without
bile duct dilatation.
Question 7
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What is the most likely diagnosis?
Amyloid
 Sarcoid
 Tuberculosis
 Primary biliary cirrhosis
 OCP induced cholestasis
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Liver sarcoidosis
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Answer: Sarcoidosis
A high serum alkaline phosphatase level is commonly
associated with an infiltrative liver disorder, and the presence
of pulmonary infiltrates and hepatomegaly are suggestive of
sarcoidosis.
Amyloid is usually accompanied by evidence of other organ
involvement, such as the nephrotic syndrome or neuropathy.
In addition, amyloidosis is rare in patients this young.
Liver biopsy showing noncaseating granulomas will confirm
the diagnosis of sarcoidosis.
The majority of patients are asymptomatic, and thus do not
require specific treatment
Question 8
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A 26-year-old woman who is 36 weeks pregnant is evaluated
because of right-sided abdominal pain. The patient has had
mild preeclampsia for 4 weeks. She vomited twice this
morning but is able to drink liquids. She also developed a
nosebleed this morning.
On physical examination, blood continues to ooze from her
nostrils. Temperature is normal, pulse rate is 105/min, and
blood pressure is 135/85 mm Hg. Abdominal examination
discloses right upper quadrant tenderness and uterine
enlargement consistent with gestational age. There is 2+
bilateral lower extremity edema.
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Labs: Hgb 8; WBC 9.5; Plt 45; AST 160; ALT 170; total bili
4.8; INR 1.0
Question 8
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Which of the following is most
appropriate at this time?
Prompt delivery of the infant
 Endoscopic retrograde
cholangiopancreatography
 Administration of a corticosteroid
 Administration of acyclovir
 Administration of magnesium sulfate
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HELLP
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Answer: Prompt delivery of the infant
This patient has HELLP syndrome (hemolysis, elevated liver
enzymes, low platelets).
HELLP develops in 5% to 10% of pregnancies associated with
preeclampsia or eclampsia.
Diagnosis:
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microangiopathic hemolytic anemia with an abnormal peripheral
blood smear, low serum haptoglobin, and elevated serum indirect
bilirubin and lactate dehydrogenase levels
serum aspartate aminotransferase value greater than twice the
upper limit of normal
thrombocytopenia with a platelet count <100
The treatment of choice is prompt delivery of the infant.
Following delivery, the mother's condition often resolves
within 48 hours
Question 10
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A 42-year-old man is evaluated after an elevated serum
alkaline phosphatase value was noted during a life insurance
examination. The patient does not have pruritus, abdominal
pain, or jaundice. He has had loose bowel movements for
many years and occasionally has rectal bleeding, which he
attributes to hemorrhoids. Physical examination is
unremarkable.
Labs: Hgb 12; MCV 75; AST 45; ALT 55; Alk phos 620; total
bilirubin 2.0; direct bilirubin 1.6
Question 10
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Which of the following diagnostic studies is most
appropriate at this time?
 ERCP
 RUQ US
 CT abd/pelvis
 HIDA scan
 CEA level
Primary sclerosing cholangitis
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Answer: ERCP
Most patients with primary sclerosing cholangitis also have
ulcerative colitis. Because of his chronic loose bowel
movements and rectal bleeding, this patient is also likely to
have this inflammatory bowel disorder.
Key words: men aged 20-30, ulcerative colitis, recurrent
bacterial cholangitis
The diagnosis is confirmed when either endoscopic retrograde
cholangiopancreatography or magnetic resonance
cholangiopancreatography shows a “string of beads” pattern
of the biliary tree
Treatment: supportive until liver transplant
Question 11
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A 22-year-old woman with hepatitis C becomes pregnant for
the first time. She is at 10 weeks gestation, and the
pregnancy has been uneventful. Hepatitis C was diagnosed 5
years ago and was believed to be acquired following blood
transfusions when the patient was 3 years old and was being
treated for hemolytic uremic syndrome. The patient is HCV
genotype 1 and has an HCV RNA viral load of 3 million
copies/mL. Liver biopsy 6 months ago showed grade 1 (mild)
inflammation and stage 0 (no) fibrosis.
Physical examination is normal.
Labs: CBC normal; LFTs normal; albumin normal; INR normal;
HIV negative; HBs negative; anti-HBs positive;
Question 11
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Which of the following is most
appropriate?
Administer pegylated interferon and ribavirin
to the mother now
 Administer pegylated interferon to the
mother now
 Administer pegylated interferon and ribavirin
to the infant soon after birth
 Check the serum HCV RNA in the infant 4
months after birth
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Vertical HCV transmission
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Answer: Check the serum HCV RNA in the infant 4
months after birth
The overall risk of maternal–fetal transmission of
hepatitis C is about 5%.
Mother-to-fetus placental transfer of antibody to
hepatitis C virus (anti-HCV) is common, and antiHCV can be detected in the newborn for up to 15
months.
Question 12
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A 67-year-old man has a 1-year history of idiopathic chronic
pancreatitis. Because of diarrhea, pancreatic enzyme
supplements were started at the time of diagnosis. The
patient currently takes 10,000 units of an enteric-coated
enzyme preparation in one total dose during each meal.
However, his diarrhea has persisted, and he has lost 2.6 kg (6
lb). He does not have lower abdominal pain. Stools are lightcolored, and the patient describes what appears to be “oil” in
the toilet bowl after defecation.
Question 12
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Which of the following is the most
appropriate therapy at this time?
Add omeprazole to the current enzyme
regimen
 Increase his enzymes to 6 pills with each
meal (60,000 units/meal)
 Space enzymes out before, during, and after
each meal (3 pills with each meal)
 Change to another brand of pancreatic
enzyme supplements
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Pancreatic enzymes
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Answer: Space enzymes out before, during, and after each
meal (3 pills with each meal)
Approximately 30,000 units of lipase are required with each
meal for pancreatic enzyme supplementation.
The supplements need to be spaced out before, during, and
after meals to better mimic endogenous enzyme secretion.
Question 13
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A 49-year-old man is evaluated because of progressive
jaundice, mild right upper quadrant abdominal pain, and
weight loss over the last 3 months. The patient has a 25-year
history of primary sclerosing cholangitis but has not seen a
physician for more than 10 years. He takes no medications
and drinks two cans of beer each evening.
On physical examination, he is cachectic and jaundiced.
Abdominal examination discloses a firm liver edge and
moderate ascites.
Labs: Hgb 11; Plts 75; total bili 5.8; AST 75; ALT 82; Alk phos
1000
RUQ US shows a nodular liver with moderate dilatation of the
intrahepatic bile ducts, splenomegaly, and ascites.
Question 13
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Which of the following is the most
likely diagnosis?
Choledocholithiasis
 Metastatic colon cancer
 Pancreatic adenocarcinoma
 Cholangiocarcinoma
 Hepatocellular carcinoma
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Cholangiocarcinoma
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Patients with primary sclerosing cholangitis have a 10% to
30% lifetime risk of developing cholangiocarcinoma.
Approximately 60% to 80% of cholangiocarcinomas arise near
the porta hepatis (Klatskin's tumor), 20% are located in the
distal bile duct, and <5% are intrahepatic
Approximately 90% of patients have obstructive jaundice, and
patients with advanced disease may have hepatomegaly or a
distended palpable gallbladder (Courvoisier's sign)
Treatment: hepatic resection if tumor is confined to
intrahepatic ducts
Question 14
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A 42-year-old woman has a 2-week history of jaundice, low-grade
fever, and fatigue. Medical history is noncontributory. The patient
lives in Honduras but was born in the United States and returned to
this country when she became ill. She has consumed at least one
bottle of rum daily for 15 years and has taken acetaminophen, 1 g
daily, for the past 3 days. She has no history of injection drug use,
blood transfusions, or known exposure to anyone with hepatitis.
On physical examination, temperature is 37.9 °C (102.9 °F), pulse
rate is 100/min and regular, and blood pressure is 110/70 mm Hg.
Jaundice, spider angiomata, and mild muscle wasting are noted.
Abdominal examination shows mild splenomegaly, no hepatomegaly,
and no ascites.
Labs: Hgb 12.8; WBC 4; Plts 90; AST 125; ALT 57; Total bili 6;
Direct bili 4; INR 2.4; Albumin 3.4; IgG anti-HAV positive
Question 14
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Which of the following is the most
likely diagnosis?
Hepatitis A
 Sepsis
 Acetaminophen hepatotoxicity
 Alcoholic hepatitis
 Autoimmune hepatitis
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Alcoholic hepatitis
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Fever, alcoholism, findings consistent with chronic liver
disease, and a serum aspartate aminotransferase to serum
alanine aminotransferase ratio (AST:ALT) >2 are associated
with alcoholic hepatitis.
The discriminant function (DF) uses the patient's prothrombin
time (PT) and serum bilirubin level to estimate disease
severity: (DF = 4.6 [PTpatient - PTcontrol] + serum bilirubin
[mg/dL]). A DF score of >32 identifies patients with a 50%
mortality rate within 30 days.
Treatment options for DF>32: pentoxifylline, prednisolone
Question 15
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A 24-year-old woman comes to the emergency department
because of acute right upper quadrant abdominal pain and
syncope. Medical history is unremarkable. On physical
examination, pulse rate is 124/min and regular, and blood
pressure is 80/60 mm Hg. The abdomen is distended but
nontender. An urgent CT scan demonstrates a 5-cm lesion in
the liver and high-density fluid in the peritoneal cavity,
consistent with blood.
The patient's condition stabilizes following administration of
intravenous fluids and blood transfusions. Physical
examination discloses abdominal distention. There are no
stigmata of chronic liver disease.
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Labs: Hgb 7, WBC 12; Plts 200; AST 34; alpha-fetoprotein 3.5;
alk phos 150
Question 15
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Which of the following is the most
likely diagnosis?
Hepatocellular carcinoma
 Hepatic cyst
 Focal nodular hyperplasia
 Hepatic adenoma
 Cavernous hemangioma
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Liver masses
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Hepatic adenomas are the most likely benign liver tumor to
cause bleeding.
– Hepatic adenomas are estrogen sensitive and should be resected
whenever possible because of their potential for becoming
malignant and their risk for bleeding.
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Cavernous hemangiomas are benign lesions that are found in
2% of the general population.
Pyogenic liver abscesses are most likely due to biliary tract
infection
An amebic abscess to Entamoeba histolytica should be
suspected in a patient from a developing country who
presents with a liver mass and symptoms suggestive of an
infection.
– Treatment: flagyl
References
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MKSAP
UpToDate.com