Archives: MRCP Part 2

MRCP2-1822

An elderly 75-year-old man presents to the hospital with profuse watery diarrhoea lasting for three days. He had a previous episode of Clostridium difficile diarrhoea eight weeks ago, which was successfully treated with oral vancomycin. He has a medical history of hypertension and takes regular amlodipine.

Observations:

Heart rate: 88 beats per minute
Blood pressure: 120/77 mmHg
Respiratory rate: 18/minute
Oxygen saturations: 96% on room air
Temperature: 37.8°C

On examination, he has mild abdominal tenderness with no peritonism. Plain radiography of the abdomen is normal.

Blood tests:

Hb: 136 g/L (Male: 135-180, Female: 115-160)
Platelets: 189 * 109/L (150-400)
WBC: 4.2 * 109/L (4.0-11.0)
Na+: 137 mmol/L (135-145)
K+: 4.2 mmol/L (3.5-5.0)
Urea: 5.2 mmol/L (2.0-7.0)
Creatinine: 66 µmol/L (55-120)
CRP: 33 mg/L (<5) A stool sample confirms the presence of toxin associated with C. difficile. What is the appropriate management for this 75-year-old patient?

MRCP2-1823

A 30-year-old male presents to the clinic with a newly diagnosed chronic hepatitis B infection. He reports engaging in unprotected sexual activity with multiple partners over the past two years. Laboratory results indicate that he is negative for HIV, HCV antibodies, and HBeAg. His liver function tests are as follows, and there is no evidence of decompensated liver disease upon examination:

– Bilirubin: 18µmol/L
– ALT: 52 iu/L
– AST: 38 iu/L
– ALP: 190 iu/L
– Albumin: 30g/L
– Protein: 93g/L
– HBV viral load: 2,000 IU/mL

What is the recommended first-line treatment option for this patient?

MRCP2-1824

A 30-year-old man presents with lower abdominal pain, fevers, and bloody diarrhea. His father was diagnosed with colorectal cancer at the age of 52. After an initial colonoscopy, which revealed extensive ulceration in his distal colon with mild active inflammation, the gastroenterologist discusses the need for colonic surveillance. What is his risk of developing colorectal cancer?

MRCP2-1825

A 50-year-old man presents to the gastroenterology clinic with a flare of ulcerative colitis. He has been experiencing bloody diarrhoea for the past three weeks, with bowels opening up to 5 times per day. He denies any fevers but has been feeling nauseous with reduced appetite and feels he has lost around 3kg in weight whilst unwell. He experienced a similar episode six months ago which settled with oral steroids, and he is keen to try this again. He has been compliant with mesalazine orally and has continued his rectal mesalazine most nights. He has type 2 diabetes mellitus and takes metformin.

On examination, he is afebrile, basic observations are within normal limits, and his abdomen is soft with moderate lower abdominal tenderness.

Blood tests show:
Hb 150 g/L Male: (135-180)
Platelets 340 * 109/L (150 – 400)
WBC 12.0 * 109/L (4.0 – 11.0)
ESR 31 mm/hr (<10) An abdominal X-ray is unremarkable. A flexible sigmoidoscopy is arranged for the following day and shows mild-moderate inflammation. Based on the clinical history, what interventions should be considered for this patient during his acute flare?

MRCP2-1826

A 46-year-old man with a history of alcoholic cirrhosis presents to the acute medical unit complaining of upper abdominal pain that worsens after meals. He denies any changes in bowel habits or the presence of dark, sticky, or foul-smelling stools. An oesophagogastroduodenoscopy (OGD) is scheduled, and the results are as follows:

– Oesophagus: Grade 1 varices with no evidence of recent or active bleeding
– Stomach: Moderate non-haemorrhagic gastritis
– Duodenum: Unremarkable

The patient has no prior history of oesophageal varices. What is the most appropriate management plan for his condition?

MRCP2-1827

A 56-year-old man presents to gastroenterology clinic after an incidental finding of hepatic steatosis on an abdominal ultrasound. He had previously been diagnosed with biliary colic and was scheduled for a laparoscopic cholecystectomy. The patient is concerned about the risk of developing serious liver disease and reports feeling well aside from occasional attacks of biliary colic. Physical examination is unremarkable, and basic blood tests are within normal limits. What is the next appropriate investigation to assess the patient’s risk of developing liver disease due to hepatic steatosis?

MRCP2-1828

A 70 year old man presents with a two month history of recurrent post-prandial vomiting and a 10 kg weight loss. He is urgently referred for upper gastrointestinal endoscopy. On examination, he appears cachectic but otherwise unremarkable. His medical history includes hypertension and a right-sided carotid endarterectomy following a transient ischaemic attack 8 years ago. He takes bendroflumethiazide, clopidogrel and simvastatin regularly. He is a retired teacher, a non-smoker and drinks minimal amounts of alcohol.

During endoscopy, a 3 cm ulcer is found in the body of the stomach. Histology confirms adenocarcinoma with penetration of the tumour into the subserosal connective tissue. Further staging investigations reveal a 3 cm mass in the body of the stomach along the greater curve of the stomach, enlargement of the right and left gastro-epiploic lymph nodes, and no abnormalities in the liver, gallbladder, spleen or kidneys. PET shows no evidence of distant metastasis or nodal involvement, and staging laparoscopy reveals no evidence of peritoneal or metastatic disease.

What is the most appropriate initial treatment for this patient?

MRCP2-1829

A 56-year-old woman presents with abdominal pain localized to her central abdomen. The pain started earlier in the day and has been progressively worsening. She reports feeling nauseous and has vomited twice, but the vomit was not bilious. The pain initially subsides after vomiting but returns shortly after. She has a medical history of recurrent cholecystitis and is awaiting a laparoscopic cholecystectomy. On examination, her abdomen is tender throughout but not distended. She has no fever.

Lab results:

– Hemoglobin: 132 g/L
– Platelets: 584 * 10^9/L
– White blood cells: 14.2 * 10^9/L
– Neutrophils: 10.1 * 10^9/L
– Lymphocytes: 2.2 * 10^9/L
– Sodium: 138 mmol/L
– Potassium: 3.8 mmol/L
– Bilirubin: 42 µmol/L
– Alkaline phosphatase: 152 U/L
– Alanine transaminase: 52 U/L
– Gamma-glutamyl transferase: 124 U/L
– Creatinine: 48 µmol/L
– Urea: 6.2 mmol/L
– Albumin: 38 g/L
– Amylase: 198 U/L

Abdominal ultrasound shows pneumobilia and a common bile duct diameter of 8.2mm. Chest x-ray shows no evidence of pneumoperitoneum, and abdominal x-ray shows dilated loops of small bowel.

What is the most likely diagnosis?

MRCP2-1830

A 57-year-old man presents to the hospital with sudden onset severe central abdominal pain that radiates to his back. He is jaundiced, tachycardic, and has central and epigastric abdominal tenderness. Blood tests reveal elevated white cell count, neutrophils, amylase, ALT, AST, ALP, LDH, glucose, sodium, urea, and creatinine. An abdominal ultrasound shows the presence of a common bile duct stone, several stones in the gallbladder, and intrahepatic duct dilatation. Based on the British Society of Gastroenterology guidelines on the management of common bile duct stones (2008), what is the most appropriate course of action for managing his biliary disease?

MRCP2-1810

A 65-year-old man is experiencing reflux and is currently on multiple medications for various health issues. Which of the following drugs has the potential to decrease the pressure of the lower esophageal sphincter?