Archives: MRCP Part 2

MRCP2-2156

A 27-year-old woman presents to the gastroenterology clinic with a flare of ulcerative colitis. She reports experiencing bloody diarrhoea for the past week, with up to 6 bowel movements per day. She denies having a fever and reports compliance with her mesalazine enemas, which have not been effective. She has no significant medical history, occasional smoking habits, and drinks alcohol once or twice a week. Her last menstrual period was 3 weeks ago.

On physical examination, she is afebrile, with normal vital signs except for mild hypotension, which is her baseline. Her abdomen is soft, with mild tenderness in the left iliac fossa.

Laboratory tests reveal a hemoglobin level of 118 g/L (normal range for females: 115-160 g/L), platelet count of 250 * 109/L (normal range: 150-400 * 109/L), white blood cell count of 11.7 * 109/L (normal range: 4.0-11.0 * 109/L), and an erythrocyte sedimentation rate of 25 mm/hr (normal range: <10mm/hr). A pregnancy test is negative. An abdominal X-ray is unremarkable. A flexible sigmoidoscopy is scheduled for the next day, which reveals mild inflammation. A previous colonoscopy showed colitis up to the ileocaecal valve. Based on the patient’s clinical history, what interventions should be considered?

MRCP2-2123

A 35-year-old man presents to the Emergency Department for review. He is experiencing increasing difficulty with heartburn and acid reflux. He has tried elevating his head while sleeping, but this has not provided relief. On examination, his blood pressure is 120/80 mmHg and his pulse is 80 bpm and regular. His abdomen appears normal.
Investigations:
Investigations Results Normal Values
Haemoglobin (Hb) 140 g/l 130–170 g/l
White cell count (WCC) 6.5 × 109/l 4–11 × 109/l
Platelets (PLT) 200 × 109/l 150–400 × 109/l
Sodium (Na+) 142 mmol/l 135–145 mmol/l
Potassium (K+) 4.2 mmol/l 3.5–5.0 mmol/l
Creatinine 80 µmol/l 60–110 µmol/l
Glucose 5.0 mmol/l 3.5–5.5 mmol/l
Urine: Protein negative, blood negative

What is the most appropriate course of action for this patient?

MRCP2-2124

A 35-year-old construction worker with a 4-year history of chronic liver disease secondary to alcohol abuse presents with increased abdominal pain, swelling and confusion.
On examination, there is jaundice with spider naevi and finger clubbing. His temperature is 37.0 °C with a blood pressure of 120/80 mmHg. There is gynaecomastia with obvious abdominal distension due to ascites. This was surprising as he had therapeutic drainage of his ascites a few days earlier.
He has been using occasional ‘painkillers’ for his pain. He is unsure of any allergies.
Investigations reveal the following:
Haemoglobin (Hb) 140 g/l 135–175 g/l
White cell count (WCC) 8.5 × 109/l 4.0–11.0 × 109/l
Platelets (PLT) 180 × 109/l 150–400 × 109/l
Sodium (Na+) 137 mmol/l 135–145 mmol/l
Potassium (K+) 4.0 mmol/l 3.5–5.0 mmol/l
Creatinine (Cr) 80 µmol/l 50–120 µmol/l
Glucose 5.2 mmol/l 3.9–7.1 mmol/l
Bilirubin 95 µmol/l 2–17 µmol/l
Aspartate aminotransferase (AST) 145 IU/l 10–40 IU/l
Alanine aminotransferase (ALT) 125 IU/l 5–30 IU/l
Alkaline phosphatase (ALP) 440 IU/l 30–130 IU/l
Gamma glutamyl-transferase (γGT) 490 IU/l 5–30 IU/l
Amylase 450 U/l < 200 U/l
Urea 6.8 mmol/l 2.5–6.5 mmol/l
Ascitic tap revealed a neutrophil count of 300 cells per mm3 in the ascitic fluid.
Which of the following represents the best initial management for this patient?

MRCP2-2125

A 28-year-old woman with a history of ulcerative colitis presents with worsening symptoms over the past six weeks. She reports passing bloody stools up to 10 times a day and experiencing severe fatigue. Upon examination, her pulse is 102 bpm and her temperature is 37.9°C. Blood tests reveal a low hemoglobin level, low potassium level, and elevated C-reactive protein. Based on the 2007 European Crohn’s and Colitis Organisation consensus guidelines, what is the most appropriate initial treatment for this patient?

MRCP2-2126

A 65-year-old man is suffering from irritable bowel syndrome. Despite undergoing all necessary investigations and attempting dietary modifications, he has not experienced much relief from various laxatives and antimotility agents. What would be your recommendation for a second line treatment?

MRCP2-2127

A 42-year-old female with type 2 diabetes presents to the outpatient clinic with complaints of lethargy and joint pains for the past two months. Upon investigation, her ferritin levels are found to be elevated at 1800 ng/ml and transferrin saturation is at 61%. Genetic testing reveals that the patient is homozygous for the HFE C282Y gene.

What would be the most suitable course of action for managing this patient?

MRCP2-2128

A 40-year-old man presents to an outpatient gastroenterology clinic for follow-up of his ulcerative colitis. During his last visit, he reported good symptom control with only one or two bowel movements per day and no mucous or blood. However, he now complains of intense itching and yellowing of his eyes. He also reports darker urine and paler stools. The patient has no other medical issues besides ulcerative colitis, which is being managed with mesalazine and azathioprine.

After his last appointment, the physician ordered blood tests and a magnetic resonance cholangiopancreatography (MRCP). The results of the tests are as follows:

– Hb 116 g/L (115 – 160)
– Platelets 352 * 109/L (150 – 400)
– WBC 5.5 * 109/L (4.0 – 11.0)
– CRP 10 mg/L (< 5)
– Bilirubin 75 µmol/L (3 – 17)
– ALP 250 u/L (30 – 100)
– ALT 45 u/L (3 – 40)
– γGT 79 u/L (8 – 60)
– Albumin 32 g/L (35 – 50)

The MRCP revealed three small gallstones in the gallbladder but no common bile duct dilation. It also showed multiple segmental strictures of the biliary tree. Based on this information, what is the most likely diagnosis?

MRCP2-2129

A 32-year-old male presents with a four month history of bloody diarrhoea. On average he has five bowel motions a day and there is associated urgency and abdominal cramps.

He reports occasional pus mixed with the stool. He denies vomiting but has been intermittently febrile. There is no travel history. On direct questioning he admits he has lost 4 kg in weight over the last few months.

On examination he appears dehydrated and there is mild generalised abdominal tenderness but no guarding or rebound tenderness and bowel sounds are normal.

His GP has sent several stool cultures, the results of which are all negative.

His blood results are as follows:

Hb 100 g/L (130-180)
MCV 77 fL (80-96)
WBC 18.2 ×109/L (4-11)
Neutrophils 11.5 ×109/L (1.5-7)
Platelets 496 ×109/L (150-400)
Na 138 mmol/L (137-144)
K 3.5 mmol/L (3.5-4.9)
Urea 9.5 mmol/L (2.5-7.5)
Creatinine 85 µmol/L (60-110)
ESR 30 mm/hour (0-15)
CRP 48 mg/L (<10)
Amylase 30 U/L (60-180)

Abdominal x ray demonstrates faecal loading. A subsequent flexible sigmoidoscopy is performed and demonstrates diffusely erythematous and friable mucosa which bleeds on contact. Biopsies are taken and the histology is reported as showing distorted crypt architecture and goblet cell depletion.

Which of the following features is not related to the activity of the underlying disease?

MRCP2-2130

A 42 year-old man, working as a pastry chef, presents to his GP with a complaint of pale, foul-smelling stools and a recent weight loss of 6 kg over the past two months. He has a medical history of occasional acid reflux, for which he was recently prescribed omeprazole. He reports drinking several glasses of wine daily and has a smoking history of five packs per year.

Upon conducting blood tests, the following results were obtained:

– Hemoglobin (Hb): 9.9 g/dL
– Mean corpuscular volume (MCV): 115 fl
– Platelets: 280 * 109/l
– White blood cells (WBC): 7.1 * 109/l
– Sodium (Na+): 136 mmol/l
– Potassium (K+): 4.0 mmol/l
– Urea: 3.2 mmol/l
– Creatinine: 52 mol/l
– Bilirubin: 15 mol/l
– Alkaline phosphatase (ALP): 140 u/l
– Alanine transaminase (ALT): 50 u/l
– Gamma-glutamyl transferase (γGT): 210 u/l
– Albumin: 39 g/l
– Vitamin B12: 120 ng/l
– Faecal elastase: 98 g/g (normal > 200)

What is the most appropriate next investigation?

MRCP2-2131

A 45-year-old teacher presents with iron deficiency anaemia. She mainly consumes white meat and fish but insists that her diet is diverse enough. She also complains of frequent diarrhoea and has lost 8 kg in the past year.
During examination, her BMI is 23, but no other abnormalities are detected.
The following investigations are conducted:
Haemoglobin (Hb) 102 g/l 115–155 g/l
Mean corpuscular volume (MCV) 82 fl 76–98 fl
Serum ferritin 12 µg/l 10–120 µg/l
Serum folate 1.8 µg/l 2.0–11.0 µg/l
Albumin 36 g/l 35–55 g/l
Immunoglobulin G (IgG) 14 g/l 5–16 g/l
IgA 4.2 g/l 1.0–4.0 g/l
IgM 2.8 g/l 0.5–2.0 g/l
An OGD is performed, which reveals mild duodenitis. Small bowel biopsies are taken and are reported as showing subtotal villous atrophy.
What is the most probable diagnosis?