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A 28-year-old woman is admitted to hospital with acute, severe abdominal pain and vomiting. She had been for a night out with her friends and had consumed approximately 8 units of alcohol. Her friends said that she had been acting strangely all night and seemed disoriented. The patient was unable to give an adequate history, but her friends stated that she had been previously fit and well and that she was not on any regular medication. They were adamant that she had not taken any illicit drugs and were unsure about her family history.
On examination she was unwell, restless and agitated. She was disoriented in time, place and person and was expressing some paranoid ideas. Her temperature was 37.8oC, pulse 120/min and regular, blood pressure 166/92 mmHg, oxygen saturation 96% on air. Cardiorespiratory examination was normal. She had a tense abdomen with generalised tenderness and scanty bowel sounds. She did not co-operate well with neurological examination but there were no obvious focal signs. Her pupils were equal and reactive to light, but fundoscopy was not possible due to her agitation. She had no visible rashes.
Investigation results are below:
Haemoglobin (Hb) 13.8 g/dl
White cell count 14.0 x 109/L
Platelets 350 x 109/L
Mean corpuscular volume (MCV)96 fl
Na+ 142 mmol/l
K+ 3.6 mmol/l
Urea 10.2 mmol/l
Ca2+2.32 mmol/l
Creatinine 100 μmol/l
C-reactive protein (CRP) 42 mg/l
Bilirubin 26 mmol/l
Aspartate transaminase (AST) 62 IU/l

Alkaline phosphatase 90 IU/l
Gamma-glutamyl transferase 78 IU/l
Amylase520 IU/l
Electrocardiogram (ECG)Sinus tachycardia
Urinalysis Protein +
Erect chest radiographNormal
Abdominal radiographNormal
What is the most likely diagnosis?
1- Wilson’s disease
2- Acute pancreatitis
3- Ruptured ectopic pregnancy
4- Acute intermittent porphyria
5- Sepsis from urinary tract infection

Answer: 4- Acute intermittent porphyria

A 40-year old male with celiac disease complains of a recurrence of his symptoms despite he is strictly eat gluten-free diet. What is the most likely cause?

  1. Bacterial overgrowth
  2. Crohn’s disease
  3. Intestinal lymphangiectasia
  4. Intestinal lymphoma
  5. Giardia infection

Answer:4- Intestinal lymphoma

A 23-years-old who is 10 weeks pregnant is reviewed in outpatient clinic at the booking visit.  This is her first pregnancy and she is well apart from some sickness which is worse in the morning. Bloods tests including the full blood count, hepatitis B, C and HIV serology are normal. A slight yellow tinge of her sclera is noticed and liver function tests are ordered:

  •  Total Bilirubin  3 mg/dl (normal value total Bilirubin 0.18–0.94 mg/dL)
  • Unconjugated 2.5 mg/dl
  • Conjugated 0.5 mg/dl
  •          Alkaline phosphatase 100 U/L(normal value 40–125 U/L)
  •         ALT 25 U/L (normal value 10–50 U/L)
  •         Albumin 35 g/L (normal value 35–50 g/L)
  •         What is the most likely diagnosis?
  1. Intrahepatic cholestasis of pregnancy
  2. Gallstones
  3. Acute fatty liver
  4. Gilbert’s syndrome
  5. Primary biliary cirrhosis

Answer: 4- Gilbert’s syndrome

A 62-year-old man is seen in the gastroenterology clinic with a 9-month history of abdominal discomfort and bloating, associated with loose stools that are difficult to flush away and weight loss of 1 stone. He also describes a general deterioration in his health over the last few years with malaise, arthralgia and depression. Recently, he had been more unsteady on his feet and was having problems with co-ordination. He had no significant past medical history, was on no regular medication and had not been abroad recently. He did not smoke or drink alcohol.
On examination he was thin with areas of abnormal cutaneous pigmentation and scattered lymphadenopathy. There was no jaundice or finger clubbing. Cardiorespiratory examination was unremarkable. His abdomen was soft, with mild generalised tenderness and no masses. On neurological examination he had evidence of cerebellar ataxia.
Investigation results are below:
Haemoglobin (Hb) 11.5 g/dl
White cell count 6.0 x 109/L
Platelets470 x 109/L
Mean corpuscular volume (MCV) 90 fl
Erythrocyte sedimentation rate (ESR) 40 mm/h
Na+ 136 mmol/l
K+ 3.5 mmol/l
Urea 5.2 mmol/l
Ca2+ 1.98 mmol/l
Creatinine 120 μmol/l
Bilirubin 15 μmol/lAlkaline transferase (ALT) 40 IU/l
Alkaline phosphatase 120 IU/l
Gamma-glutamyl transferase 50 IU/l
Glucose (random) 5.6 mmol/l
What is the most likely diagnosis?
1- Carcinoid syndrome
2- Whipple’s disease
3- Pancreatic carcinoma with brain metastases
4- Coeliac disease
5- Haemochromatosis

Answer: 2- Whipple’s disease

A 32-year-old man is seen with a long history of anaemia. He denies haematemesis or melaena. His past medical history includes an episode of intussusception 1 year ago. He has been investigated previously with an upper gastrointestinal endoscopy and a colonoscopy which are normal. Lower duodenal biopsies are normal. He has since been started on iron tablets. On examination, the only significant findings are melanin spots on his buccal mucosa and fingers.
Investigation results are below:
Haemoglobin (Hb)9.1 g/dl
Whole blood count (WBC) 6.0 × 109/l
Platelets 192 × 109/l
Mean cell volume (MCV)71 fL
Ferritin 3 μg/l
A barium meal and follow through is abnormal and an enteroscopy shows multiple hamartomatous polyps
What is the most likely diagnosis?
1- Gardner’s syndrome
2- Peutz-Jeghers syndrome
3- Cowden syndrome
4- Familial adenomatosis polyposis
5- Pseudopolyps

Answer: 2- Peutz-Jeghers syndrome

A 70-years-old man who is known to have a trial fibrillation presents with abdominal pain and rectal bleeding. A diagnosis of ischemic colitis is suspected. Which part of the colon is most likely to be affected?

  1. Hepatic flexure
  2. Transverse colon
  3. Splenic flexure
  4. Ascending colon
  5. Rectum

Answer: 3- Splenic flexure

At a routine company medical, it transpires that a solderer, who is otherwise fit and well and has no significant past medical history, has an alcohol intake of 4 pints of beer a day and has been doing so for about 2 years. He is not on any medications and is a non-smoker. The conscientious doctor decides to do some routine laboratory tests and some of the results are shown below:
Hb 12.5 g/dl
WCC 7 x 109/L
PLT 220 x 109/L
MCV 105 fl
Gamma GT 40 U/l
AST 350 U/l
ALT 411 U/l
ALP 218 U/l
Based on these results, what is the most likely diagnosis in this patient?
1- Alcoholic fatty liver
2- Isocyanate exposure
3- Cirrhosis
4- Previous hepatitis A infection
5- Gilbert’s syndrome

Answer: 1- Alcoholic fatty liver

A 52-year-old man presented with an attack of acute upper abdominal pain associated with vomiting. On examination he had epigastric tenderness and guarding. Serum amylase was 1300 IU/l. He was treated with intravenous antibiotics, fluids and analgesia. His pain settled and he made a good recovery and was discharged from hospital several days later. Eight weeks later he was readmitted with malaise and persistent abdominal pain. On examination he had a low-grade pyrexia and there was a tender mass palpable in the upper abdomen.
Investigation results are below:

Haemoglobin (Hb) 11.2 g/dl
White cell count 14 x 109/L
Platelets 390 x 109/L
Mean corpuscular volume (MCV) 82 fl
C-reactive protein (CRP) 200mg/l
Na+ 137 mmol/l
K+ 4.3 mmol/l
Urea 4.8 mmol/l
Creatinine 120 μmol/l
Ca2+ 2.50 mmol/l
Bilirubin 22 μmol/l
Alkaline phosphatase 160 IU/l
Gamma-glutamyl transferase 78 IU/l
Aspartate transaminase (AST) 42 IU/l
Amylase 1000 IU/l
What is the most likely diagnosis?
1- Pancreatic pseudocyst
2- Pyogenic liver abscess
3- Chronic pancreatitis
4- Recurrent attack of acute pancreatitis
5- Pancreatic carcinoma

Answer: 1- Pancreatic pseudocyst

A 60-year-old woman is evaluated for a 5-day history of painful swallowing with both liquids and solids. The pain is worse when swallowing solid foods. She otherwise feels well. She underwent liver transplantation 4 months ago. Her only medication is mycophenolatemofetil, and she recently stopped taking prednisone.On physical examination, vital signs are normal. The oral pharynx appears normal, and abdominal examination reveals no tenderness.

Upper endoscopy finding  show curdy white esophageal plaques seen on upper endoscopy.

Which of the following is the most appropriate treatment?

  1. Acyclovir
  2. Metronidazole
  3. Fluconazole
  4. Swallowed aerosolized fluticasone
  5. Ganciclovir

Answer: 3- Fluconazole

A 64-year-old woman is admitted to hospital with recurrent vomiting. She has been diabetic since the age of 14 years. She usually vomits several times in the evening and the vomitus often contains undigested residues of her morning meal. Apart from her insulin she also takes a statin, and angiotensin-converting enzyme (ACE) inhibitor. Examination is unremarkable other than hypertension. She was given a two week course of erythromycin by her general practitioner (GP) for a chest infection, which she finished a week ago. During her hospitalisation she has an upper gastrointestinal endoscopy, oesophageal manometry and a barium swallow, all of which are reported as normal.
Her blood results are outlined below.
Urea 9.0 mmol/l
Creatinine 140 μmol/l
Sodium 140 mmol/l
Potassium 3.0 mmol/l
Chloride85 mmol/l
Blood glucose 8.0 mmol/l
Haemoglobin A1c (HbA1c) 9.4%
What is the most likely cause of the vomiting?
1- Drug toxicity
2- Renal failure
3- Gastroparesis
4- Addison’s disease
5- Bulimia nervosa

Answer: 3- Gastroparesis

A 45-year-old man is evaluated in follow-up after a recent diagnosis of hepatitis B infection, which was discovered after a blood donation. His medical history is notable for illicit parenteral drug use 10 years ago. He has no family history of hepatitis B infection. He is otherwise well and takes no medications. On physical examination, vital signs are normal, and he appears well. No spider telangiectasia  are noted. The liver span is normal, and the spleen is not palpable. No ascites or edema is present.

Laboratory studies:

Alanine aminotransferase      (Normal )

Hepatitis B serologic studies:

Hepatitis B surface antigen  (Positive)

IgG antibody to hepatitis B core antigen  (Positive)

Hepatitis B e antigen  (Negative)

Antibody to hepatitis B e antigen (Positive)

Hepatitis B virus DNA (low viral load <10 IU/mL)

Which of the following is the most appropriate management?

  1. Entecavir.
  2. Lamivudine.
  3. Pegylated interferon.
  4. Entecavir and Pegylated interferon.
  5. No treatment at this time.

Answer: 5- No treatment at this time

A 26-year-old man is referred for investigation of profuse, watery diarrhoea that had been going on for the past 6 weeks. He had lost one stone in weight over this time, even though his appetite remained good. He had not seen any blood or mucus in the stool and had no abdominal pain, distension or vomiting. Apart from lethargy, he had no other symptoms. He had no significant past medical history and took no regular medication. He did not smoke and drank 10 units of alcohol per week. There was no relevant family history. He had recently spent a year in Australia, travelling back through South East Asia, but had returned home over 6 months ago. His general practitioner had tried him on several anti-diarrhoeal agents that had not worked, and multiple stool cultures had come back negative.
On examination he was thin, but not wasted. There was no lymphadenopathy, jaundice or clubbing. His abdomen was soft and non-tender with no masses, and normal bowel sounds. Digital rectal examination was normal.
Investigation results are below:
Haemoglobin (Hb) 10 g/dl
White cell count 3.4 x 109/L
Platelets 260 x 109/L
Mean corpuscular volume (MCV) 102 fl
Erythrocyte sedimentation rate (ESR) <10 mm/h
Na+ 137 mmol/l
K+ 4.3 mmol/l
Urea 5.2 mmol/l
Creatinine 100 mmol/l
C-reactive protein 8 mg/l
Ca2+ 1.90 mmol/l
Bilirubin 14 mmol/l
Alkaline phosphatase 60 IU/l
Gamma-glutamyl transferase 48 IU/l
Aspartate transaminase (AST) 22 IU/l
Albumin 30 g/l
Serum anti-endomysial antibodies negative
Colonoscopy No abnormality seen, good views to terminal ileum
Small bowel barium follow through Normal
Abdominal ultrasound scan Normal
What would be the next most useful investigation to establish the cause of the diarrhoea?
1- Serum gastrin level
2- HIV test
3- Hydrogen breath test
4- Radio-isotope-labelled white cell scan
5- 24 h urinary 5-hydroxyindoleacetic acid (5-HIAA)

Answer: 2- HIV test

If the result of Serum–Ascites Albumin Gradient (SAAG) is less than  < 11 g/L , this will raises the possibility of all the following except :

  1. portal hypertension.
  2. malignancy.
  3. pancreatic ascites.
  4. Infection (especially tuberculosis).
  5. hepatic venous obstruction.

Answer: 1- portal hypertension.

A 32-year-old chef from Pakistan presents with abdominal pain, abdominal swelling and weight loss. His blood test shows elevated alkaline phosphatase and alanine transaminase enzyme levels. He has clinically detectable ascites.
A diagnostic tap was performed which shows the below results:
Total ascites white cell count 150/ml (< 500/ml)
Serum-ascites albumin gradient 21 g/L (< 11g/L)
What is the most likely cause of his ascites?
1- Tuberculous peritonitis

2- Peritoneal carcinomatosis
3- Pancreatic ascites
4- Biliary ascites
5- Acute portal vein thrombosis

Answer: 5- Acute portal vein thrombosis

Each one of the following is a risk factor for gastric cancer, except:

  1. Smoking
  2. Blood group O
  3. Nitrates in diet
  4. Pernicious anaemia
  5. H. pylori infection

Answer: 2- Blood group O

A 32-year-old chef from Pakistan presents with abdominal pain, abdominal swelling and weight loss. His blood test shows elevated alkaline phosphatase and alanine transaminase enzyme levels. He has clinically detectable ascites.
A diagnostic tap was performed which shows the below results:
Total ascites white cell count 150/ml (< 500/ml)
Serum-ascites albumin gradient 21 g/L (< 11g/L)
What is the most likely cause of his ascites?
1- Tuberculous peritonitis

2- Peritoneal carcinomatosis
3- Pancreatic ascites
4- Biliary ascites
5- Acute portal vein thrombosis

Answer: 5- Acute portal vein thrombosis

All of the following drugs are used in treatment of Primary biliary cirrhosisexcept :

  1. Ursodeoxycholic acid
  2. colestyramine
  3. rifampicin
  4. azathioprine
  5. naltrexone

Answer: 4- azathioprine

The generally accepted diagnostic criteria for Primary sclerosing cholangitis includes all of the followings except :

  1. Most patients are males at age 25-40 years
  2. Generalized beading and stenosis of the biliary system on cholangiography
  3. The patient has history of gall stones
  4. Absence of history of bile duct surgery
  5. Exclusion of bile duct cancer

Answer: 3- The patient has history of gall stones

A 32-year-old woman presents to the emergency department with a sudden onset of severe central abdominal pain and profuse vomiting. She had also passed several loose stools, but these had not been associated with any blood or mucus. She had no other symptoms. On examination, she was pyrexial and tachycardic with generalised abdominal tenderness. She had eaten in a Chinese buffet restaurant 3 h prior to the onset of symptoms. Apart from a neutrophil leucocytosis, her full blood count and serum biochemistry were normal.
What is the most likely causative organism?
1- Campylobacter jejuni
2- Escherichia coli 0157:H7
3- Bacillus cereus
4- Staphylococcus aureus
5- Listeria monocytogenes

Answer: 3- Bacillus cereus

A 77-year-old lady is seen with a 3-h history of cramping abdominal pain, bloody diarrhoea and abdominal distension. The blood is dark and looks mixed with the stool. She has previously been relatively well. She has a history of atrial fibrillation for which she takes warfarin. She also has hypertension and is on a diuretic. She stopped smoking 2 years ago and she occasionally drinks a sherry at night. On examination, she is in pain and has a mild fever, temperature 37.6°C Her pulse is 100 and irregular and blood pressure is 124/76 mmHg. Her abdomen is distended with generalised tenderness on palpation. Abdominal X-ray (AXR) – mild diffuse bowel dilatation.
Bloods:
whole cell count (WCC) 17.2 x 109/L
haemoglobin (Hb) 10.1 g/dl
mean corpuscular volume (MCV) 84.3 fl
platelets 531 x 109/L
INR 1.8
A barium enema is requested which demonstrates thickening of the bowel wall with some evidence of thumb printing.
What is the most likely diagnosis?
1- Acute duodenal ulcer
2- Diverticulitis
3- Mesenteric venous thrombosis
4- Ischaemic colitis
5- Crohn’s colitis

Answer: 4- Ischaemic colitis

A 23-year-old who is 10 weeks pregnant is reviewed in outpatient clinic at the booking visit.

This is her first pregnancy and she is well apart from some sickness which is worse in the morning .Bloods tests including the full blood count, hepatitis B, C and HIV serology are normal. A slight yellow tinge of her sclera is noticed and liver function tests are ordered:

Total Bilirubin ( 3 mg/dl )…(2.5 mg/dl unconjugated+  0.5 mg/dl conjugated) ….(normal value total Bilirubin 0.18–0.94 mg/dL)

Alkaline phosphatase 100 U/L(normal value 40–125 U/L)

ALT 25 U/L (normal value 10–50 U/L)

Albumin 35 g/L (normal value 35–50 g/L)

What is the most likely diagnosis?

  1. Intrahepatic cholestasis of pregnancy
  2. Gallstones
  3. Acute fatty liver
  4. Gilbert’s syndrome
  5. Primary biliary cirrhosis

Answer: 4- Gilbert’s syndrome

A 57-year-old school teacher is found to have abnormal liver function tests at a health screening. Other than tiredness and occasional gritty eyes that she attributes to age she is well. She is postmenopausal and takes hormone replacement therapy (HRT) but no other medication. She smokes 12 cigarettes per day but takes no alcohol. There is nothing to find on examination.
Some of her blood results are shown below:

Albumin 40 g/l (37-49)
Alanine aminotransferase (ALT) 14 U/l (5-35)
Alkaline Phosphatase 300 U/l (45-105)
AMApositive >1:40
Anti-dsDNA weakly positive
Bilirubin 12 mmol/l (1-22)
High-density lipoprotein (HDL) cholesterol 4.0 mmol/l (>1.55)
Liver-kidney microsomal antibody (anti-LKM) negative
Liver transaminase (AST) 10 U/l (1-31)
Low-density lipoprotein (LDL) cholesterol 4.0 mmol/l (<3.36)
Plasma thromboplastin (PT) 12 s (11.5-15.5)
Smooth muscle antibody (SMA) negative
Which of the following would be an appropriate next step?
1- Liver biopsy
2- Ursodeoxycholic acid
3- Referral for liver transplant assessment
4- Azathioprine
5- Withdrawal of HRT Answer & Comments

Answer: 2- Ursodeoxycholic acid

A 19-year-old man is referred to the general medical clinic. For the past six months his family have noted increasing behavioural and speech problems. He himself has noticed that he is more clumsy than normal and reports excessive salivation. His older brother died of liver disease. Given the likely underlying condition what is the most appropriate therapy?

  1. Vitamin B6 supplements
  2. Venesection
  3. Penicillamine
  4. Pulsed methylprednisolone
  5. Ribavirin + interferon alpha

Answer: 3- Penicillamine

A 45-year-old man presents with a recent change in bowel habits. He had a colonoscopy which was normal. He is still concerned about colorectal cancer as a colleague has recently been diagnosed with metastatic colorectal cancer. He would like some advice on prevention.
Which of the following lifestyle measures is least likely to protect against colorectal carcinoma?
1- Plant-based diet
2- Lifelong physical activity
3- Dietary supplement with micronutrient
4- Stop smoking
5- Increase fish consumption rather than meat

Answer: 3- Dietary supplement with micronutrient

A 27-year-old woman with chronic left iliac fossa pain and alternating bowel habit is diagnosed with irritable bowel syndrome. Initial treatment is tried with a combination of antispasmodics, laxatives and anti-motility agents. Unfortunately after 6 months there has been no significant improvement in her symptoms.  what is the most appropriate next step?

  1. Low-dose tricyclic antidepressant
  2. Cognitive behavioural therapy
  3. Refer for sigmoidoscopy
  4. Trial of probiotics
  5. Selective serotonin reuptake inhibitor

Answer: 3- Low-dose tricyclic antidepressant

A 37-year-old social worker is referred to you with a long history of diarrhoea and abdominal discomfort. She was diagnosed with irritable bowel syndrome 10 years ago and takes mebeverine, peppermint tablets and Gaviscon. She is a vegetarian and rarely drinks or smokes. Examination of all systems is normal. Her blood tests show macrocytic anaemia. An upper gastrointestinal endoscopy reveals oesophagitis, hypertrophy of the gastric body and multiple duodenal ulcers.
What is the most likely diagnosis?
1- Untreated peptic ulcer disease
2- Dyspepsia overlapped with irritable bowel syndrome
3- Zollinger-Ellison syndrome
4- Pernicious anaemia
5- Somatostatinoma

Answer: 3- Zollinger-Ellison syndrome

A 66-year-old man is under investigation for recurrent fevers, and arthralgia. He has had episodes of fevers over the last 4 years associated with seronegative non-destructive arthropathies. Episodes have been characterised by elevated C-reactive protein (CRP) and have responded to antibiotics. Blood cultures have been persistently negative. On this admission the patient complains of persistent diarrhoea and weight loss over the last 6 months as well as myalgia. His wife has noticed that he has become more forgetful of late. On examination he is pale and thin and auscultation reveals a systolic murmur in the aortic area. Central nervous system (CNS) examination shows signs of mild ataxia.
Some investigation results are outlined below.
Bilirubin 10 μmol/l (1-22)
Aspartate transaminase (AST) 16 u/l (1-31)
Alkaline transferase (ALT) 21 u/l (5-35)
Albumin 29 g/l (37-49)
CRP82
Erythrocte sedimentation rate (ESR) 76 mm/h
Haemoglobin (Hb) 11.5 g//dl
White cell count (WCC) 10 x 109/L
Platelets 300 x 109/L
Synovial fluid:
No crystals
No organisms
Endoscopy:

Normal appearance of oesophagus and stomach
Slightly thickened duodenal wall
Histology of the duodenum:
Lipid deposition in the lamina propria with foamy macrophages noted containing PAS-staining sickle-like inclusion bodies
What is the most likely diagnosis?
1. Histoplasmosis
2. Whipple’s disease
3. Mycobacterium avium-intercellelare
4. H. pylori infection
5. Sickle cell crisis

Answer: 2- Whipple’s disease

A 44-year-old man with alcoholic liver disease is admitted with pyrexia. He has been unwell for the past threedays and has multiple previous admissions before with variceal bleeding. Examination shows multiple stigmata ofchronic liver disease, ascites and jaundice.

Paracentesis is performed with the following results:

Neutrophils 487 cells/ul

What is the most appropriate treatment?

  1. Intravenous  Amoxicillin
  2. Intravenous cefotaxime
  3. Intravenous vancomycin + metronidazole
  4. Insert an ascitic drain
  5. Intravenous cefotaxime

Answer: 2- Intravenous cefotaxime

A 42-year-old woman presents with pins and needles in her hands and feet. She incidentally describes weight loss and offensive smelling stool. She has a history of diverticular disease and anaemia. She is a non-smoker and non-drinker. She eats red meat. On examination, the power and tone in her legs are normal. There are exaggerated knee jerks and absent ankle jerks. Joint position and vibration sense are absent below her ankles. The plantar responses are extensor.
Investigation results:
Haemoglobin (Hb) 10.3 g/dl
Whole blood count (WBC) 5.0 x 109/L
Platelets 142 x 109/l
Mean cell volume (MCV) 107 fL
Bilirubin 32 μmol/l
Alanine aminotransferase (ALT) 22 U/l (5-35)
Alkaline phosphatase (ALP) 45 U/l (30-150)
Albumin 35 glL
Blood film Macrocytosis and hypersegmented neutrophils
Ferritin 46 μg/l (4-120)
Serum B12 80 ng/l (160-900)
Folate 50 μg/l (3-20)
Schilling test:
Oral labelled Vitamin B12 secreted in urine:
Pre intrinsic factor 3%
Post intrinsic factor 4%
What is the most likely diagnosis?

  1. Terminal ileal Crohn’s disease
  2. Chronic pancreatitis
  3. Bacterial overgrowth
  4. Pernicious anaemia
  5. R-Binder deficiency

Answer: 3- Bacterial overgrowth

A 35-year-old man presents with lethargy and increased skin pigmentation. Blood test reveal deranged liver function tests and impaired glucose tolerance.

what is the most appropriate initial investigation strategy?

  1. Transferrin saturation + ferritin
  2. Haematocrit + ESR
  3. Liver biopsy with Perl’s stain
  4. Serum iron + B 12 levels
  5. Serum iron + haematocrit

Answer: 1- Transferrin saturation + ferritin

A 32-year-old nurse presents with iron-deficiency anaemia. She prefers mainly white meat and fish, but claims that her diet is varied enough. There is frequent diarrhoea. On examination her body mass index (BMI) is 22.
Some blood results are shown below:
haemoglobin Hb 10.4 g/dl
mean cell volume (MCV) 80 fl (76-96)
serum ferritin 14 μg/l (15-300)
serum folate 1.4 μg/l (2-11)
albumin 34g/l (37-49)
IgG 15 g/l (6-13)
IgA 3.8 g/l (0.8-3.0)
IgM 2.6 g/l (0.4-2.5)

Small bowel follow-through is suggestive of subtotal villous atrophy.
What is the most likely diagnosis?
1- Coeliac disease
2- Crohn’s disease
3- Whipple’s disease
4- Dietary vitamin and mineral deficiency
5- Ulcerative colitis

Answer: 1- Coeliac disease

A 31-year-old man with a known history of alcoholic liver disease is reviewed following a suspected oesophagealvaricealhaemorrhage. He has been resuscitated and intravenous terlipressin has been given. His blood pressure is now 105/60 mmHg and his pulse is 84/min. What is the most appropriate intervention?

  1. Transjugular Intrahepatic Portosystemic Shunt
  2. Surgical referral
  3. Endoscopic variceal band ligation
  4. Sengstaken-Blakemore tube
  5. Endoscopic sclerotherapy

Answer: 3- Endoscopic variceal band ligation

A 44-year-old man presents with a 10-month history of pain in his lower back, hips, ankles and feet. He has tried osteopathy, acupuncture and diclofenac, but had no relief. He has also been feeling increasingly tired and breathless on walking up steep inclines. He had lost 10 kg in the last 6 months despite eating reasonable meals. He had no dysphagia, change in bowel habit or night sweats. He smokes 30 cigarettes/day and drinks two pints of beer 3x week. His past history includes hypothyroidism for which he takes thyroxine and his mother is tablet-controlled diabetic. On examination, his clothes fit loosely and he looks pale. He has no clubbing or lymphadenopathy. He had normal cardiac, chest and abdominal examinations. On joint examination there was pain when moving each joint but no obvious focus of the pain. CXR – normal, fibre optic bronchoscopy (FOB) positive.
Bloods:
Sodium 136 mmol/l
Potassium 3.8 mmol/l
urea 4.6 mmol/l
creatine 71 μmol/l
calcium (corrected) 1.82 mmol/l
Albumin 26 g/l
whole cell count (WCC) 6.5 x 109/L
haemoglobin (Hb) 7.1 g/dl
mean corpuscular volume (MCV) 71.2 fl
platelets 512 x 109/L
INR 1.5
parathyroid hormone (PTH) 251 pmol/l (0.9-5.4)
What is the most likely diagnosis?
1- Crohn’s disease
2- Metastatic caecal carcinoma
3- Coeliac disease
4- Whipple disease
5- Intestinal lymphangiectasis

Answer: 3- Coeliac disease

A 45-year old female was referred for preoperative checkup her investigation showed hepatitis B serology:HB s Ag positive;  HB s Ab negative ;  HB core Ab positive;   HB e Ag positive ;  HB

e Ab negative.

Which of the following is true regarding the patient’s hepatitis B status?

  1. Recent primary infection
  2. Persistent carrier, low infectivity
  3. Pre-core mutant carrier
  4. Spontaneously cleared infection
  5. Persistent carrier, high infectivity

Answer:5 Persistent carrier, high infectivity

A 55-years old male presented with a 4-weeks history of tenesmus and rectal bleeding . His bowel habit has not significantly changed. Rectal examination reveals a granular mucosa and a sigmoidoscopy reveals touch bleeding on a background of diffuse erythema; above 10 cm the mucosa appears to be normal. Rectal biopsies show generalized mucosal inflammation with crypt abscesses. The most appropriate initial therapy is?

  1. Oral prednisolone
  2. Oral mesalazine
  3. Oral sulfasalazine
  4. Rectal steroids
  5. Rectal mesalazine

Answer:5 Rectal mesalazine

A 17-year-old art student is referred with the following blood results. He recently had a upper respiratory tract infection. His mother has autoimmune hepatitis. His last travel was 4 months ago to Brazil for a school trip. Physical examination is normal. He is concerned that he may have the same liver disorder as his mother.
Liver function test results:
Bilirubin (unconjugated) 57 μmol/l
Alanine aminotransferase (ALT) 20 U/l (5-35)
Alkaline phosphatase (ALP) 75 U/l (30-150)
Gamma GT (GGT) 34
What is the most likely diagnosis?

1- Infectious mononucleosis
2- Cytomegalovirus hepatitis
3- Gilbert’s syndrome
4- Chronic active hepatitis
5- Criggler Najjar Type II

Answer: 3- Gilbert’s syndrome

As the medical registrar, you are asked for an opinion by the surgical house officer on a 72-year-old woman who is 24 hours post abdominal aneurysm repair. All the other members of the surgical team are occupied in theatre at the present time. The patient is complaining of severe constant abdominal pain, mainly localised to the right iliac fossa, but on examination no abdominal signs are elicited. Apart from hypertension, she has no other significant past medical history. The patient is tachycardic and has a blood pressure of 95/61 mmHg. Urgent bloods, including ABG, are requested as well as an AXR. Fluid replacement is commenced. The AXR is reported by the duty registrar as showing a gasless abdomen. The relevant blood results are outlined below:
Hb 18.0 g/dl
WCC 14 g/dl
Platelets 420 x 109/L
Amylase 270 U/l
pH 7.31
pa(CO2) 3.5 kPa
pa(O2) 14.0 kPa
Standard bicarbonate 12mmol/l (normal range 22-28 mmol/l)

The patient undergoes a single contrast barium assessment the next day. The provisional report suggests that there is thumbprinting of the bowel walls.
On the basis of these results, what is the most likely diagnosis?
1- Acute pancreatitis
2- Acute ischaemic colitis
3- Ulcerative colitis
4- Crohn’s disease
5- Acute bowel obstruction

Answer: 2- Acute ischaemic colitis

An elderly man who has undergone a previous emergency partial gastrectomy 9 months ago is presented with abdominal bloating , mild abdominal distension , flatulence and intermittent diarrhea. On examination he looks pale, his blood pressure 130/70 mmHg, his pulse rate 85 BpM regular, Abdominal examination is unremarkable apart from a midline scar consistent with his partial gastrectomy. His investigations:

Hb: 10 g/dl,

MCV 106 fl,

WBC 5.9 *10^9/L,

Platelets  150*10^9 /L,

Na+ 141 mmol/L ,

K+ 4.6 mmol/L,

Creatinine 100Micromol/L.

Which of the following is the most appropriate next investigation?

  1. Barium follow through
  2. Endoscopy of the gastric remnant
  3. Glucose hydrogen breath test
  4. General stool examination
  5. Glucose tolerance test

Answer: 3- Glucose hydrogen breath test

A 55-year-old bank worker presents to his GP after her husband noticed that her eyes were mildly yellow. She had a hysterectomy over twenty years ago for endometriosis and had required a blood transfusion at the time. She does not drink alcohol, has no history of foreign travel and is otherwise reasonably well, though has noticed increasing lethargy over the past six months.
She has no other past medical history and is not on any medications:
ALT 50 iu/l (normal 5-30 iu/l)
AST 65 iu/l (normal 10-40 iu/l)
Bilirubin 30 μmol/l (normal < 20 μmol/l
ALP 120 u/l (normal 25-115 iu/l)
You suspect a diagnosis of hepatitis C.
Which of the following is true?

1- Treatment of hepatitis C if indicated involves oral ribavirin and interferon alpha
2- The severity of liver damage due to the hepatitis is reflected in the blood transaminase levels
3- The sequelae of chronic hepatitis due to hepatitis C are similar to the sequelae of chronic hepatitis due to hepatitis B
4- The gold standard test for hepatitis C is PCR for hepatitis C DNA
5- Treatment of hepatitis C is based on clinical symptoms and serum transaminase levels

Answer: 3- The sequelae of chronic hepatitis due to hepatitis C are similar to the sequelae of chronic hepatitis due to hepatitis

A 54-years old male patient presents with indigestion. He denies alcohol intake and he is non-smoker . On examination he looks well only has mild epigastric tenderness. Endoscopy was done to him with biopsy shows area of low grade mucosa associated lymphoid tissue lymphoma.

Which of the following most appropriate management of this patient?

  1. Gastrectomy
  2. Chemotherapy
  3. H. pylori eradication
  4. long term proton pump inhibitor
  5. partial gastrectomy

Answer: 3- H. pylori eradication

A 35-year-old woman is referred to you for the investigation of anaemia discovered when she attended her regular blood donation session.. She feels fit and well apart from feeling tired occasionally which she attributes to the stress of her high-powered job. On specific questioning she denies weight loss or dyspepsia and there is no change of bowel habit. She is not pregnant and has noticed no change in her menses.
She is slightly concerned as her father died of colorectal cancer at the age of 55 years.
Some initial investigations are outlined below.
Haemoglobin (Hb) 10.0 g//dl
Mean corpuscular volume (MCV) 75 fl
White cell count (WCC) 10 x 109/L
Mean corpuscular haemoglobin (MCH) 22 pg
Platelets 300 x 109/L
Ferritin 12 mg/l
B12 450 ng/l
Serum folate 7 μg/l
Which of the following is an appropriate next step?

1- Prescription of ferrous sulphate and 3-month review
2- Upper gastrointestinal (GI) endoscopy
3- Barium enema

4- Colonoscopy
5- Blood film

Answer: 1- Prescription of ferrous sulphate and 3-month review

A 35-year-old Israeli student was admitted to hospital on a number of occasions with abdominal and joint pain and fever. Previous medical history included apendicectomy and choecystitis. Pain was often associated with constipation that became diarrhoea when the pain resolved. Clinical examination revealed a pyrexia of 38.5°C with generalised rebound tenderness in the abdomen and diminished bowel sounds. Bilateral swollen knees were noted and clear fluid was aspirated from each joint. Computed tomography (CT) examination was unremarkable.
Tests revealed:
Bilirubin 10 μmol/l (1-22)

Aspartate transaminase (AST) 16 u/l (1-31)
Alkaline transferase (ALT) 21 u/l (5-35)
Albumin 40 g/l (37-49)
C-reactive protein (CRP) 72 mg/l
Erythrocyte sedimentation rate (ESR) 50 mm/h
Haemoglobin (Hb) 13.5 g//dl
White cell count (WCC) 10 x 109/L
Platelets 300 x 109/L
CEA Normal
α-fetoprotein (AFP) Normal
Synovial fluid:
No crystals
No organisms
Neutrophils 80/ml
Urinalysis protein +++
Urinary porphyrins Normal
What is the most likely diagnosis?

1- Familial Mediterranean fever
2- Tuberculous peritonitis
3- Spontaneous bacterial peritonitis
4- Hepatocellular carcinoma
5- Acute intermittent porphyria

Answer: 1- Familial Mediterranean fever

Folic acid deficiency may occur in all of the following Except:

  1. Crohn’s disease
  2. Coeliac disease
  3. Decrease intake of folic acid rich diet
  4. Tropical sprue
  5. Bacterial overgrowth syndrome

Answer: 5- Bacterial overgrowth syndrome

A 55-year-old man was found on the street by the police. He complains of right upper quadrant pain and anorexia. He works at a building site but has recently lost his job. On examination, he smells very strongly of alcohol. He is tanned with icteric sclera. His temperature is 37.6°C. There is spider naevi and palmar erythema. Heart sounds and chest examination are unremarkable. Abdominal examination reveals dull flanks and a tender hepatomegaly with a soft hepatic bruit. There is no focal neurology but a hepatic flap is present.
Investigation results are as below:
Haemoglobin (Hb) 12.1 g/dl
White blood count (WBC) 17.0 x 109/L
Platelets 80 x 109/l
Mean cell volume (MCV) 103 fL
International normalised ratio (INR) 1.6
Na+ 132 mmol/l
K+ 3.3 mmol/l

Urea 1.7 mmol/l
Creatinine 70 μmol/l
Albumin 35 glL
Bilirubin 102 μmol/l
Alanine aminotransferase (ALT) 45 U/l (5-35)
Aspartate aminotransferase (AST) 100 U/l (10-40)
Alkaline phosphatase (ALP) 156 U/l (30-150)
Ferritin 987 μg/l
Hepatitis and autoimmune serology Negative
What is the most likely diagnosis?

1- Hepatoma
2- Alcoholic hepatitis
3- Choledocholithiasis
4- Spontaneous bacterial peritonitis
5- Haemochromatosis

Answer: 2- Alcoholic hepatitis

If the result of Serum–Ascites Albumin Gradient (SAAG) is less than  < 11 g/L , this will raises the possibility of all the following Except:

  1. Portal hypertension
  2. Malignancy
  3. Pancreatic ascites
  4. Infection (especially tuberculosis)
  5. Hepatic venous obstruction

Answer: 1- Portal hypertension

A 28-year-old woman presents to the gastroenterology clinic complaining of intermittent diarrhoea and constipation. Full blood count and viscosity were normal. Flexible sigmoidoscopy was unremarkable.
What is the next most appropriate management step?

  1. Full colonoscopy
  2. Barium enema
  3. Wheat-free diet
  4. High-fibre diet
  5. Caffeine supplementation

Answer: 4- High-fibre diet

A young male patient with known alcoholic cirrhosis presents saying that he has had black foul smelling stool after a week of binge drinking. He has had two such episodes. He has never had melaena before, but on ultrasound one year ago he was found to have mild splenomegaly and has had drainage of ascites recently. He is refusing an oesophageo-gastro-duodenoscopy (OGD) as he had a ‘bad experience’ before. However he will have other investigations as necessary and will have an OGD if you can determine that he has had an upper gastrointestinal bleed.
Which of the following would you use to confirm an upper gastrointestinal (GI) bleed?

1- Repeat ultrasound abdomen
2- Serum urea: creatinine ratio
3- Serial haemoglobin measurements
4- Insert a nasogastric tube (NGT)
5- Measure lying and standing blood pressure

Answer: 4- Insert a nasogastric tube (NGT)

You determine that his Child Pugh’s grade is C. Which of the following is true?

1- Child Pugh criteria includes prothrombin time (PT)
2- Child Pugh’s criteria A predicts a life expectancy of about five years
3- The size of the liver relative to the spleen is helpful in prognosis prediction
4- Raised serum sodium is a bad prognostic feature
5- Child Pugh grading only applies to alcoholic cirrhosis

Answer: 1- Child Pugh criteria includes prothrombin time (PT)

The generally accepted diagnostic criteria for Primary sclerosing cholangitis includes all of the followings Except :

  1. Most patients are males at age 25-40 years
  2. Generalized beading and stenosis of the biliary system on cholangiography
  3. The patient has history of gall stones
  4. Absence of history of bile duct surgery
  5. Exclusion of bile duct cancer

Answer: 3- The patient has history of gall stones

You review a 27-year-old man who has recently moved house and is referred by his GP for investigation of jaundice. His blood results reveal raised conjugated bilirubin with normal haptoglobins. He is liver biopsied. Review of the biopsy reveals a number of dark granules within the hepatocytes.
What diagnosis fits best with this clinical picture?

1- Dubin-Johnson syndrome
2- Crigler-Najjar syndrome type I
3- Crigler-Najjar type II
4- Gilbert’s syndrome
5- Haemolytic anaemia

Answer: 1- Dubin-Johnson syndrome

A 50-year-old male who is known to abuse alcohol is seen in clinic. He complains of abdominal discomfort and being generally unwell. He has never had hematemesis or melaena. He is an asthmatic and uses a salbutamol inhaler as required in addition to twice daily inhaled corticosteroid. On examination he was noted to have several spider naevi on his upper chest. He had gynaecomastia and examination of his abdomen revealed hepatosplenomegaly. You arrange an upper gastrointestinal endoscopy to screen for varices and the endoscopist reports the presence of 3 small non-tortuous varices and portal hypertensive gastropathy. In this patient which of the following would you use to prevent variceal hemorrhage?

  1. Isosorbide mononitrate
  2. Atenolol
  3. Ppropranolol
  4. Terlipressin
  5. Octreotide

Answer: 1- Isosorbide mononitrate

A 17-year-old female is sent to you for assessment, as she is profoundly depressed. She has features of anhedonia and anorexia over the last 6 months. Before this, she has always been an excellent student and has many friends. She has no known medical problems but her mother has a history of schizophrenia. She does not smoke or drink and both she and her parents deny that she has used drugs.
On examination, she is well dressed but does not keep eye contact. She tells you that she is hearing second person auditory hallucinations and has done so for 3 months. She has an expressionless face and when writing a sentence she has small cramped handwriting. Her gait is slow and there is some increased tone in her right arm.
Bloods:
Albumin 36 g/l
alanine aminotransferase (ALT) 201 U/l
alkaline phosphatase (ALP) 121 U/l
bilirubin 28 μmol/l
What is the most likely diagnosis?

1- Abuse of clozapine
2- Chronic abuse of LSD
3- Ganser’s disease
4- Othello’s syndrome
5- Wilson’s disease
Answer: 5- Wilson’s disease
A 60-year-old retired teacher presents with an itchy rash on her trunk and elbows. She has a 20-year history of coeliac disease and claims to be on a gluten-free diet. She had a thyroidectomy 10 years ago. She drinks two cans of beer per day. On examination, she has xanthelasma and excoriation marks on her body. There are no stigmata of chronic liver disease. The rest of the physical examination is normal.
Her blood tests show
Haemoglobin (Hb) 10.7 g/dl
Whole blood count (WBC) 3.7 x 109/L
Platelets 148 x 109/l
Mean cell volume (MCV) 76 fL
Bilirubin 29 μmol/l
Alanine aminotransferase (ALT) 308 U/l (5-35)
Alkaline phosphatase (ALP) 1063 U/l (30-150)
Gamma GT (GGT) 520
Albumin 36 glL
Erythrocyte sedimentation ratio 81 mm/hr
Lactate dehydrogenase 459 U/l
Anti-smooth muscle antibody (ASMA) Negative
Anti-mitochondrial antibody (AMA) Positive (1 in 80)
Ultrasound scan of liver Normal
What is the most appropriate treatment?
1- Penicillamine
2- Ursodeoxycholic acid
3- Phenobarbitone
4- Corticosteroids
5- Azathioprine
Answer: 2- Ursodeoxycholic acid
A 59-year-old man presents to his GP complaining of difficulty in swallowing. This problem had initially been for solids and the patient had thought it was related to his episodes of heart burn, but he has recently started having problems swallowing liquids as well. Consequent to this problem, he has lost about 8 kg of weight in the last 2 months. His other symptoms include pain in the retrosternal area and bouts of coughing at night. He is otherwise fit and well and apart from taking self medication in the form of Gaviscon for heartburn, he is on no other medications. He is a smoker of a pack of cigarettes per day and has been for about 20 years.
Which of the following imaging investigations would be LEAST useful in this patient?
1- Barium swallow
2- Oesophagogastroduodenoscopy
3- Abdominal and chest CT scans
4- Bronchoscopy
5- Endoscopic ultrasound
Answer: 4- Bronchoscopy
A 36-year-old woman with a 15-year history of severe ileo-colonic Crohn’s disease is admitted for assessment and management of a severe flare-up of her disease. Her symptoms are severe lower abdominal pain, diarrhoea, weight loss and lethargy. She has also recently developed a vesico-colic fistula. She is currently taking mycophenolate mofetil (MMF) which had been controlling her symptoms for the last few months, but was now losing its efficacy. Her treatment history consists of multiple courses of steroids which, when tapered off resulted in severe disease recurrence. She also failed on azathioprine and 6-mercaptopurine and an elemental diet. She had an ileal segmental resection with end-to-end anastomosis 8 years ago and a strictuloplasty more recently. Her blood tests show a normochromic normocytic anaemia, leucocytosis, elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) and a low albumin.
What is most appropriate next line in management?
1- Oral ciclosporin
2- Intravenous infliximab
3- Total colectomy with ileo-anal pouch formation
4- Alpha-interferon therapy
5- Intravenous cyclophosphamide
Answer: 2- Intravenous infliximab
A 31-year-old previously fit and healthy lady is knocked over by a cyclist on the pedestrian crossing. She is admitted to hospital and has an abdominal computed tomography scan. This shows that the spleen and liver are normal except for a cyst in the pancreas. The cyst shows features of serous cystadenoma.
Which of the following is the most appropriate management?
1- Do nothing
2- Annual computed tomography scan
3- Resection of cyst alone
4- Resection of tail of pancreas
5- Resection of whole pancreas
Answer: 1- Do nothing
A 60-year-old lady undergoes investigation after presenting with intermittent diarrhoea alternating with constipation over a period of several months. In addition she complains of cramping abdominal pains. Her weight is steady. Her general practitioner has checked her routine bloods: haemoglobin is 9.8 g/dl, erythrocyte sedimentation rate 20 mm/h and electrolytes and liver function tests are normal.
A view obtained at colonoscopy is shown below:
Image courtesy of Dr Hans Bjorknas, Gastrolab, Vasa, Finland.
What is the most likely cause of the anaemia?
1- Vitamin B12 deficiency
2- Vitamin B12 and folate deficiency
3- Iron deficiency
4- Folate deficiency
5- Ferritin deficiency
Answer: 3- Iron deficiency
A 59 lady presents who is is undergoing investigations in hospital for an episode of diarrhoea, rectal blood loss, and abdominal pain. Her barium enema is shown below.
Image courtesy of Ian Maddison, London South Bank University
What is the most likely diagnosis?
1- Ulcerative colitis (UC)
2- Crohn’s disease
3- Coeliac disease
4- Diverticulosis
5- Colonic carcinoma
Answer: 1- Ulcerative colitis (UC)
A 65-year-old man is seen in clinic after he presents to his general practitioner (GP) with a year’s history of tiredness, and is found to be anaemic. He has no previous medical history and takes no medication. He reports no weight loss and denies a change in bowel habit. He has a varied diet including red meat. There is nothing to find on examination.
Blood tests taken by the primary physician are shown below.
Haemoglobin (Hb) 11.5 g//dl
Mean corpuscular volume (MCV) 70 fl
White cell count (WCC) 10 x 109/L
Mean corpuscular haemoglobin (MCH) 20 pg
Platelets 300 x 109/L
Ferritin 10 mg/l
B12 500 ng/l
Serum folate 9 μg/l
Which of the following investigations should not be requested?
1- Urinalysis
2- Upper gastrointestinal (GI) endoscopy
3- Barium enema
4- Faecal occult blood
5- Anti-endomysial antibody
A 25-year-old art student is brought into the casualty department by her flatmates following one cupful of haematemesis. She has been vomiting earlier that day after an alcohol binge over the weekend. There is no past medical problem and she is on the oral contraceptive pill. She drinks 15 units of alcohol per week, mainly during the weekends. Her mother suffers from primary biliary cirrhosis. On examination, her heart rate is 82/minute and her blood pressure is 124/70 mmHg. There is mild epigastric discomfort. The rest of the examination is normal.
Her blood tests are as below:
Haemoglobin (Hb) 12.0 g/dl
Whole blood count (WBC) 6.0 x 109/L
Platelets 192 x 109/l
Mean cell volume (MCV) 85 fL
International normalised ratio (INR) 1.1
Na+ 133 mmol/l
K+ 3.2 mmol/l
Urea 6.0 mmol/l
Creatinine 61 μmol/l
Bilirubin 14 μmol/l
Alanine aminotransferase (ALT) 24 U/l (5-35)
Alkaline phosphatase (ALP) 140 U/l (30-150)
Gamma GT (GGT) 104
Albumin 38 glL
Upper gastrointestinal endoscopy shows no source of bleeding. There is no evidence of blood in the oesophagus, stomach or duodenum.
What is the most appropriate step of management?
1- Check autoantibody screen
2- Liver ultrasound
3- High dose proton-pump inhibitor for 4 weeks
4- Repeat endoscopy in 2 weeks
5- Discharge home with General Practitioner follow-up
Answer: 5- Discharge home with General Practitioner follow-up
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