The management of cirrhosis and its primary complication, portal hypertension, represents one of the most complex areas in gastrointestinal and hepatic medicine. As the irreversible final stage of liver disease, cirrhosis leads to a cascade of life-threatening conditions including esophageal varices, ascites, and hepatic encephalopathy. As a future pharmacist, mastering the pharmacotherapy for these complications is a critical competency, covered in depth in the Patient Care 4 curriculum’s module on the “Management of Portal Hypertension & Cirrhosis”. This quiz will test your knowledge on the evidence-based strategies used to manage these challenging conditions and improve outcomes for patients with advanced liver disease.
1. Portal hypertension is best defined as:
- a. Systemic high blood pressure caused by liver disease.
- b. A sustained increase in pressure within the portal venous system.
- c. High blood pressure localized to the hepatic artery.
- d. Fluid overload caused by kidney failure.
Answer: b. A sustained increase in pressure within the portal venous system.
2. Which of the following is used for primary prophylaxis to prevent a first esophageal variceal bleed?
- a. A proton pump inhibitor (PPI)
- b. An IV octreotide infusion
- c. A non-selective beta-blocker (NSBB) like nadolol or propranolol.
- d. A loop diuretic like furosemide.
Answer: c. A non-selective beta-blocker (NSBB) like nadolol or propranolol.
3. What is the mechanism of action of non-selective beta-blockers in preventing variceal bleeding?
- a. They increase heart rate and cardiac output.
- b. They cause potent systemic vasodilation.
- c. They decrease portal pressure by reducing cardiac output (β1 blockade) and causing splanchnic vasoconstriction (β2 blockade).
- d. They directly cause clots to form in the varices.
Answer: c. They decrease portal pressure by reducing cardiac output (β1 blockade) and causing splanchnic vasoconstriction (β2 blockade).
4. The first-line management for a patient with an acute variceal hemorrhage includes endoscopic therapy and what pharmacologic agent?
- a. A continuous infusion of furosemide.
- a. A continuous infusion of octreotide.
- c. A high dose of an oral beta-blocker.
- d. IV albumin.
Answer: b. A continuous infusion of octreotide.
5. What is the primary goal of diuretic therapy with spironolactone and furosemide in a patient with cirrhosis and ascites?
- a. To cure the underlying liver disease.
- b. To mobilize ascitic fluid and increase urinary sodium excretion.
- c. To lower systemic blood pressure.
- d. To treat hepatic encephalopathy.
Answer: b. To mobilize ascitic fluid and increase urinary sodium excretion.
6. The standard dose ratio for spironolactone to furosemide in the management of ascites is:
- a. 25 mg : 40 mg
- b. 50 mg : 50 mg
- c. 40 mg : 100 mg
- d. 100 mg : 40 mg
Answer: d. 100 mg : 40 mg
7. A patient with ascites undergoes a large-volume paracentesis where 6 liters of fluid are removed. What should be administered to prevent post-paracentesis circulatory dysfunction?
- a. IV furosemide
- b. IV albumin
- c. IV normal saline
- d. IV octreotide
Answer: b. IV albumin
8. Spontaneous Bacterial Peritonitis (SBP) is diagnosed based on what finding in the ascitic fluid?
- a. An absolute neutrophil count (PMN) > 250 cells/mm³
- b. A high protein level
- c. A low glucose level
- d. The presence of red blood cells
Answer: a. An absolute neutrophil count (PMN) > 250 cells/mm³
9. The first-line antibiotic treatment for Spontaneous Bacterial Peritonitis (SBP) is:
- a. Oral ciprofloxacin
- b. IV vancomycin
- c. An IV third-generation cephalosporin (e.g., ceftriaxone)
- d. Oral metronidazole
Answer: c. An IV third-generation cephalosporin (e.g., ceftriaxone)
10. What is the first-line pharmacologic agent for the treatment of hepatic encephalopathy (HE)?
- a. Rifaximin
- b. Lactulose
- c. Metronidazole
- d. Neomycin
Answer: b. Lactulose
11. The “Management of Portal Hypertension & Cirrhosis” is a specific learning module in the Patient Care 4 curriculum.
- a. True
- b. False
Answer: a. True
12. How does lactulose work to treat hepatic encephalopathy?
- a. It directly binds ammonia in the bloodstream.
- b. It is metabolized by gut bacteria to an acid, which traps ammonia in the colon as non-absorbable ammonium.
- c. It sterilizes the gut.
- d. It improves liver function.
Answer: b. It is metabolized by gut bacteria to an acid, which traps ammonia in the colon as non-absorbable ammonium.
13. A patient who has survived an episode of SBP should receive what therapy long-term?
- a. Daily diuretic therapy
- b. A non-selective beta-blocker
- c. Lifelong secondary antibiotic prophylaxis (e.g., ciprofloxacin or TMP-SMX).
- d. No further therapy is needed.
Answer: c. Lifelong secondary antibiotic prophylaxis (e.g., ciprofloxacin or TMP-SMX).
14. What is the therapeutic goal when titrating a non-selective beta-blocker for variceal prophylaxis?
- a. To achieve the maximum tolerated dose.
- b. To keep the blood pressure above 140/90 mmHg.
- c. To reduce the resting heart rate to 55-60 bpm, as tolerated.
- d. To increase the heart rate by 25%.
Answer: c. To reduce the resting heart rate to 55-60 bpm, as tolerated.
15. Which of the following lab abnormalities is characteristic of cirrhosis due to impaired synthetic function?
- a. High serum albumin
- b. Low INR
- c. Low serum albumin and high INR
- d. High platelet count
Answer: c. Low serum albumin and high INR
16. Rifaximin is used as an add-on therapy for hepatic encephalopathy. What is its mechanism?
- a. It is a non-absorbable antibiotic that reduces ammonia-producing gut bacteria.
- b. It is an osmotic laxative.
- c. It is a potent diuretic.
- d. It is a beta-blocker.
Answer: a. It is a non-absorbable antibiotic that reduces ammonia-producing gut bacteria.
17. The Child-Pugh score is used to assess the severity of cirrhosis. Which of the following is NOT a component of the score?
- a. Serum albumin
- b. Serum bilirubin
- c. Serum creatinine
- d. Presence and severity of ascites
Answer: c. Serum creatinine
18. Why is the combination of spironolactone and furosemide preferred for ascites management?
- a. It has a synergistic diuretic effect and helps maintain potassium balance.
- b. It is the cheapest available option.
- c. Furosemide prevents the side effects of spironolactone.
- d. Both drugs work in the proximal tubule.
Answer: a. It has a synergistic diuretic effect and helps maintain potassium balance.
19. A patient with cirrhosis should be counseled to avoid which class of pain medications?
- a. Acetaminophen at therapeutic doses
- b. Opioids
- c. NSAIDs (e.g., ibuprofen, naproxen)
- d. All pain medications are safe.
Answer: c. NSAIDs (e.g., ibuprofen, naproxen)
20. A facilitated case discussion on cirrhosis and heart failure is part of the Patient Care 4 curriculum.
- a. True
- b. False
Answer: a. True
21. What is the most important non-pharmacologic recommendation for a patient with ascites?
- a. A high-sodium diet.
- b. Strict dietary sodium restriction (e.g., <2 g/day).
- c. A high-protein diet.
- d. Complete bed rest.
Answer: b. Strict dietary sodium restriction (e.g., <2 g/day).
22. A patient with cirrhosis presents with confusion, lethargy, and a flapping hand tremor (asterixis). These are signs of:
- a. An acute variceal bleed
- b. Spontaneous bacterial peritonitis
- c. Hepatic encephalopathy
- d. Hepatorenal syndrome
Answer: c. Hepatic encephalopathy
23. Octreotide works to control variceal bleeding by:
- a. Directly causing vasoconstriction of the bleeding varix.
- b. Acting as a somatostatin analog to cause splanchnic vasoconstriction, reducing portal blood flow.
- c. Inhibiting gastric acid secretion.
- d. Increasing cardiac output.
Answer: b. Acting as a somatostatin analog to cause splanchnic vasoconstriction, reducing portal blood flow.
24. Which of the following is a common precipitating factor for hepatic encephalopathy?
- a. Infection
- b. GI bleeding
- c. Constipation
- d. All of the above
Answer: d. All of the above
25. A patient with Child-Pugh Class C cirrhosis has:
- a. Mild, well-compensated disease.
- b. Moderate liver dysfunction.
- c. Severe, decompensated liver disease.
- d. Normal liver function.
Answer: c. Severe, decompensated liver disease.
26. Why are selective beta-1 blockers (like metoprolol) not recommended for variceal prophylaxis?
- a. They do not reduce cardiac output.
- b. They lack the beta-2 blockade necessary for splanchnic vasoconstriction.
- c. They have more side effects.
- d. They are more expensive.
Answer: b. They lack the beta-2 blockade necessary for splanchnic vasoconstriction.
27. The goal of lactulose therapy should be titrated to achieve:
- a. 10-12 loose stools per day.
- b. No bowel movements.
- c. 2-3 soft stools per day.
- d. A normal serum ammonia level.
Answer: c. 2-3 soft stools per day.
28. What is the Serum-Ascites Albumin Gradient (SAAG)?
- a. A test to diagnose SBP.
- b. A calculation (serum albumin – ascitic fluid albumin) used to determine if ascites is due to portal hypertension.
- c. A measure of liver synthetic function.
- d. A score to predict mortality in cirrhosis.
Answer: b. A calculation (serum albumin – ascitic fluid albumin) used to determine if ascites is due to portal hypertension.
29. A SAAG value > 1.1 g/dL is highly suggestive of:
- a. Ascites caused by pancreatitis.
- b. Ascites caused by portal hypertension.
- c. Ascites caused by malignancy.
- d. A normal finding.
Answer: b. Ascites caused by portal hypertension.
30. The “PK Dosing in hepatic dysfunction” module is part of the Patient Care 4 curriculum.
- a. True
- b. False
Answer: a. True
31. Spironolactone can cause which clinically significant side effect, especially in males?
- a. Gynecomastia
- b. Hypokalemia
- c. A dry cough
- d. Tachycardia
Answer: a. Gynecomastia
32. The management of an acute variceal bleed always includes short-term antibiotic prophylaxis to prevent:
- a. Hepatic encephalopathy
- b. C. difficile infection
- c. Spontaneous bacterial peritonitis (SBP)
- d. Further bleeding.
Answer: c. Spontaneous bacterial peritonitis (SBP)
33. In a patient with cirrhosis, the half-life of drugs metabolized by the liver may be:
- a. Decreased
- b. Unchanged
- c. Increased
- d. Unpredictable
Answer: c. Increased
34. A patient with cirrhosis should be advised that the safest analgesic for mild pain is generally:
- a. Ibuprofen
- b. Naproxen
- c. Acetaminophen (at reduced maximal doses, e.g., <2g/day).
- d. Aspirin
Answer: c. Acetaminophen (at reduced maximal doses, e.g., <2g/day).
35. Hepatorenal syndrome (HRS) is a serious complication of cirrhosis characterized by:
- a. Liver failure causing kidney failure.
- b. Kidney failure causing liver failure.
- c. An infection of both the liver and kidneys.
- d. The need for both liver and kidney transplants.
Answer: a. Liver failure causing kidney failure.
36. A key part of managing hepatic encephalopathy is identifying and treating precipitating factors.
- a. True
- b. False
Answer: a. True
37. Secondary prophylaxis for variceal bleeding (preventing a re-bleed) often involves:
- a. A PPI alone.
- b. A non-selective beta-blocker plus endoscopic variceal ligation (banding).
- c. Octreotide therapy for life.
- d. Diuretic therapy.
Answer: b. A non-selective beta-blocker plus endoscopic variceal ligation (banding).
38. The use of benzodiazepines in a patient with cirrhosis should be done with extreme caution because:
- a. They are nephrotoxic.
- b. They can precipitate or worsen hepatic encephalopathy.
- c. They cause severe hypertension.
- d. They interact with diuretics.
Answer: b. They can precipitate or worsen hepatic encephalopathy.
39. An active learning session covering cirrhosis is part of which course?
- a. PHA5784C Patient Care 4
- b. PHA5163L Professional Skills Lab 3
- c. PHA5781 Patient Care I
- d. PHA5782C Patient Care 2
Answer: a. PHA5784C Patient Care 4
40. What is the ultimate, definitive treatment for end-stage liver disease?
- a. Lifelong diuretic therapy
- b. A TIPS procedure
- a. Liver transplantation
- d. Lifelong lactulose therapy
Answer: c. Liver transplantation
41. A patient with ascites has a goal weight loss of 0.5 kg/day. They lose 2 kg in one day. The pharmacist should be concerned about:
- a. Treatment failure.
- b. Intravascular volume depletion and potential for renal injury.
- c. The development of SBP.
- d. The patient not adhering to their sodium restriction.
Answer: b. Intravascular volume depletion and potential for renal injury.
42. The main goal of therapy for hepatic encephalopathy is to:
- a. Cure cirrhosis.
- b. Reduce the production and absorption of ammonia from the gut.
- c. Increase the number of varices.
- d. Lower the patient’s blood pressure.
Answer: b. Reduce the production and absorption of ammonia from the gut.
43. A Transjugular Intrahepatic Portosystemic Shunt (TIPS) is a procedure used to:
- a. Diagnose cirrhosis.
- b. Treat refractory ascites or variceal bleeding by reducing portal pressure.
- c. Remove the gallbladder.
- d. Biopsy the liver.
Answer: b. Treat refractory ascites or variceal bleeding by reducing portal pressure.
44. A major risk of the TIPS procedure is that it can worsen or precipitate:
- a. Portal hypertension
- b. Ascites
- c. Hepatic encephalopathy
- d. SBP
Answer: c. Hepatic encephalopathy
45. Which of the following drugs with high first-pass metabolism would have a significantly increased oral bioavailability in a patient with severe cirrhosis?
- a. Digoxin
- b. Lisinopril
- c. Labetalol
- d. Gentamicin
Answer: c. Labetalol
46. All patients with cirrhosis should be screened for hepatocellular carcinoma (HCC) with an ultrasound every:
- a. 5 years
- b. 2 years
- c. 1 year
- d. 6 months
Answer: d. 6 months
47. A patient on spironolactone should be monitored for which electrolyte abnormality?
- a. Hypokalemia
- b. Hyperkalemia
- c. Hyponatremia
- d. Hypomagnesemia
Answer: b. Hyperkalemia
48. Why is it important for a pharmacist to assess a patient’s alcohol use when managing liver disease?
- a. Continued alcohol use is the primary driver of disease progression in alcoholic liver disease.
- b. To recommend a brand of non-alcoholic beer.
- c. To determine their insurance status.
- d. It is not important for the pharmacist to assess this.
Answer: a. Continued alcohol use is the primary driver of disease progression in alcoholic liver disease.
49. The overall management of a patient with decompensated cirrhosis requires:
- a. A single medication.
- b. Only lifestyle modifications.
- c. A multidisciplinary approach involving hepatologists, pharmacists, dietitians, and nurses.
- d. Treatment of only one complication at a time.
Answer: c. A multidisciplinary approach involving hepatologists, pharmacists, dietitians, and nurses.
50. A pharmacist’s role in managing portal hypertension and cirrhosis is critical for:
- a. Selecting appropriate therapies and doses.
- b. Monitoring for efficacy and toxicity.
- c. Educating patients about their complex disease state and medications.
- d. All of the above.
Answer: d. All of the above.