A 45-year-old male with a 12-year history of ulcerative colitis (UC) presented with right upper quadrant pain and pruritus. He has noticed pale stools recently. He is currently taking sulfasalazine and has had two minor relapses in the past. On examination, he has five spider naevi on the upper trunk, a 5 cm hepatomegaly, and a tippable spleen, but no ascites. Laboratory investigations revealed thrombocytopenia, prolonged prothrombin time, elevated serum bilirubin, aspartate aminotransferase, alanine aminotransferase, and alkaline phosphatase. Hepatitis B surface antigen was negative. What is the most likely diagnosis?
MRCP2-1763
A 65-year-old man with a history of hypertension, gastric ulceration, and partial gastrectomy 12 years ago presents to accident and emergency with upper abdominal pain, nausea, and diarrhea that has been ongoing for 4 days. He has been admitted to the hospital twice in the past 8 months with similar symptoms and has lost approximately 5 kg in weight over this time. His current medication includes atenolol 50 mg once daily and omeprazole 20 mg once daily. Blood tests reveal elevated white cell count, low platelets, low potassium, high random glucose, and elevated alkaline phosphatase. His 3-day fecal fat excretion is also elevated. What is the most likely cause of his symptoms?
MRCP2-1764
A 45-year-old teacher returns from a trip to South America, where she volunteered at a local school, presenting with severe bloody diarrhea. She is admitted through the Emergency Department with abdominal swelling, dehydration, and a fever of 38.6 °C. Her blood pressure is 112/64 mmHg with a 25 mmHg drop upon standing, resulting in an increased heart rate. The following investigations were conducted: Haemoglobin (Hb) 102 g/l 135 – 175 g/l Erythrocyte sedimentation rate (ESR) 90 mm/h 1 – 20 mm/h Albumin 30 g/l 35 – 55 g/l pANCA (Perinuclear Antineutrophil Antibodies) Positive Abdominal X-ray Dilated large bowel with evidence of mucosal oedema Stool Negative microscopy and culture
What is the most likely diagnosis based on this clinical presentation?
MRCP2-1765
A 57-year-old woman with a history of alcoholic liver disease and chronic hepatitis C virus infection presented to the clinic. Despite previous failed interferon alpha therapy and continued alcohol consumption, she attended regular check-ups every six months for liver ultrasounds and alpha fetoprotein levels. Recently, she reported a decreased appetite and increasing lethargy. The patient also had a long-standing history of depression following her mother’s death from ovarian cancer fifteen years ago, which led to increased alcohol consumption and job loss as a primary school teacher.
During examination, the patient appears cachectic and pale, but not jaundiced, with no liver flap. Her pulse was 90 beats per minute, blood pressure was 110/65 mmHg, and heart sounds were normal. The abdomen was soft and non-tender, with marked hepatomegaly and shifting dullness.
Further investigations revealed a low haemoglobin level, high MCV, low white cell count and platelets, high international normalised ratio, low serum albumin, high serum total bilirubin, high serum alkaline phosphatase, high serum gamma-GT, and extremely high serum alpha-fetoprotein levels. Additionally, the patient had elevated serum CA-125 and CA19-9 levels.
What is the most likely diagnosis?
MRCP2-1766
You are requested to assess a 56-year-old female patient who underwent a 4-unit blood transfusion a week ago for an acute upper GI haemorrhage related to a duodenal ulcer. She has developed several petechial haemorrhages and her platelet count has dropped to 35 x109/l from 152 x109/l post-surgery. Her blood pressure is 121/82 mmHg, pulse is regular at 75/min. She has an abdominal laparotomy scar with dressing and active bowel sounds. There is a widespread petechial rash on her abdomen and bruises on her arms and legs. What is the most probable diagnosis?
MRCP2-1767
A 39-year-old male patient arrives with a complaint of frank haematemesis. Due to a language barrier, obtaining a medical history is not possible. Upon examination, the patient is in shock with a heart rate of 110 beats per minute and a blood pressure of 95/70 mmHg. Palmar erythema and spider naevi are present. Abdominal examination reveals ascites and splenomegaly with epigastric tenderness. What is the probable diagnosis?
MRCP2-1768
A 67-year-old woman complains of right upper quadrant pain, chills, a fever of 38.5 °C and abnormal liver function tests. An ultrasound of the abdomen reveals no gallstones in the common bile duct, but there are enlarged intra- and extrahepatic bile ducts. What is the probable diagnosis?
MRCP2-1769
A 75-year-old man presents to the Emergency department with abdominal pain and distension. He has a past history of ischaemic heart disease.
On examination he is confused, his pulse is 124 bpm and irregular, blood pressure is 87/40 mmHg, his abdomen is distended, firm and tender with shifting dullness.
His blood tests reveal:
Haemoglobin 93 g/L (130 – 180)
White cell count 24.7 ×109/L (4 – 11)
Platelets 322 ×109/L (150 – 400)
Bilirubin 21 µmol/L (1 – 22)
ALP 145 IU/L (45 – 10)
ALT 34 IU/L (5 – 35)
AST 49 IU/L (1 – 31)
Amylase 205 IU/L (60 – 180)
Albumin 32 gl/L (37 – 49)
C reactive protein 263 mg/L (<10)
INR 1.2 (< 1.4)
An ascitic tap is performed and bloody fluid is aspirated from the abdominal cavity. Analysis of the fluid reveals:
Red cell count 21,385/mm3
White cell count 6,734/mm3
90% neutrophils
Albumin 23 g/L
A Gram stain reveals Gram negative bacilli and Gram positive cocci.
What is the most likely cause of his ascites?
MRCP2-1750
A 68-year-old woman presents with right upper quadrant pain and jaundice. An abdominal ultrasound reveals a gallstone in the common bile duct and intrahepatic bile duct dilatation. She is scheduled for an endoscopic retrograde cholangiopancreatography (ERCP) to remove the stone. Based on the 2008 British Society of Gastroenterology guidelines for common bile duct stone management, what is the most frequent complication associated with this procedure?
MRCP2-1751
A 45-year-old man with primary biliary cirrhosis and worsening liver function is in need of a liver transplant.
What is a factor that would make him ineligible for the procedure?