Archives: MRCP Part 2

MRCP2-2108

A 50-year-old man with alcoholic liver cirrhosis presents with increasing abdominal distension and pain over the past week. He is currently taking thiamine 100mg BD, vitamin B co-strong one OD, spironolactone 100mg OD, and omeprazole 20 mg OD. He has no known drug allergies.

Upon examination, his temperature is 38.2ºC, pulse rate is 120 beats per minute, and blood pressure is 100/60 mmHg. His sclera is icteric, and there are multiple bruise marks all over his body. Examination of his abdomen reveals a distended abdomen that is generally tender all over on palpation. There are reduced breath sounds at his lung bases on auscultation.

The following investigations were conducted:

Hb 90 g/l Na+ 129 mmol/l Bilirubin 60 µmol/l
Platelets 78 * 109/l K+ 3.6 mmol/l ALP 110 u/l
WBC 13.5 * 109/l Urea 1.2 mmol/l ALT 40 u/l
Neuts 10.5 * 109/l Creatinine 35 µmol/l γGT 150 u/l
Lymphs 1.0 * 109/l Albumin 24 g/l
Eosin 0.1 * 109/l

An ascitic tap was performed and showed:

Neutrophil count 600 neutrophils/mm3
Fluid protein <10 g/L
Serum albumin-ascites gradient >11

The patient was treated with piperacillin-tazobactam for spontaneous bacterial peritonitis (SBP). What antibiotic should be considered for long-term prophylaxis to prevent recurrence of SBP?

MRCP2-2109

A 42-year-old accountant presents with dyspepsia and an upper endoscopy reveals a duodenal lesion. Biopsies confirm the presence of MALT lymphoma. What is the most appropriate initial treatment approach?

MRCP2-2110

A 32-year-old man 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)

No faecal shadows are seen on the plain abdominal x ray.

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.

What radiological finding on abdominal x ray would be indicative of toxic megacolon in this patient?

MRCP2-2111

A 58-year-old man comes to the gastroenterology clinic for follow-up. He has recently been diagnosed with haemochromatosis and is scheduled to begin regular venesection. His medical history includes cirrhosis with transaminitis, arthralgia due to arthritis, and hypogonadism. Which of his conditions is expected to improve the most with treatment?

MRCP2-2112

A 65-year-old man presents with portal hypertension. What would be a possible indication for a transjugular intrahepatic portosystemic shunt?

MRCP2-2113

A 55-year-old man visited his GP complaining of epigastric discomfort that had been bothering him for two months. He found some relief with antacids. He had no significant medical history and was not taking any regular medication. The GP referred him for an outpatient upper gastrointestinal endoscopy, which revealed moderate duodenitis but no signs of peptic ulceration. The test for Helicobacter pylori was positive, and he was prescribed a seven-day course of omeprazole, amoxicillin, and clarithromycin. When he returned to the clinic four weeks later, he reported being completely symptom-free.

What is the recommended course of action for managing this patient further?

MRCP2-2114

A 28-year-old woman presents with severe abdominal pain, nausea, and vomiting. She has a history of poorly-controlled asthma. Upon questioning, she reports no unusual behavior except for starting a low-carb diet two weeks ago. She has been taking paracetamol and aspirin for her abdominal pain in addition to her regular asthma medication. On examination, she has peritonism and appears to have some proximal muscle weakness. The nurses note that her urine is dark and changes color on standing. Tests reveal elevated urea and urinary ketones. Given the likely diagnosis, what is the most appropriate treatment option?

MRCP2-2115

A 38-year-old woman with a history of ulcerative colitis is admitted to the hospital. She is currently taking azathioprine and receiving iv hydrocortisone. After showing initial improvement on treatment for 3 days, her clinical condition worsens. Biopsies from a flexible sigmoidoscopy reveal evidence of ulcerative colitis as well as a significant number of inclusion bodies. What is the most effective treatment to improve her condition?

MRCP2-2116

A 50-year-old man presents to the Emergency Department with fresh haematemesis. He has a history of alcoholic liver disease and was found to have grade 1 oesophageal varices on endoscopy three years ago. His only medication is thiamine. On examination, he is unwell with a blood pressure of 90/50 mmHg and a heart rate of 120 bpm. Investigations reveal a low haemoglobin level, elevated white cell count, and low platelet count. He is actively resuscitated with fluids and blood products while awaiting urgent upper gastrointestinal endoscopy. During endoscopy, band ligation is performed to control the bleeding, but it is unsuccessful. What is the next best therapeutic option to control this patient’s acute variceal bleed?

MRCP2-2117

A 39-year-old man who is homeless and has a history of alcohol abuse presents at the hospital with gradual abdominal swelling. He reports feeling full quickly and experiencing discomfort due to the distension. Upon examination, his abdomen is significantly distended with shifting dullness. An ascitic tap is performed and the fluid is sent for analysis. Based on the British Society of Gastroenterology guidelines for ascites management, what is the recommended initial treatment for his ascites?