A 50-year-old carpenter presents to the clinic with a complaint of central chest discomfort that has been ongoing for the past seven months. He describes the pain as a burning sensation that often occurs at night and is accompanied by an acidic taste in his mouth. He has tried over-the-counter antacids and was prescribed omeprazole by his GP, but the symptoms persist. He denies any weight loss, vomiting, or difficulty swallowing. On examination, he appears well and is not anemic. His vital signs are within normal limits, and his physical exam is unremarkable except for some tenderness in the chest area. An upper gastrointestinal endoscopy is performed, which reveals a 10 cm area of non-inflamed Barrett’s epithelium with columnar lined mucosa and intestinal metaplasia. No dysplasia is seen on biopsy. What advice should be given to the patient?
MRCP2-1708
A 70-year-old man presents to gastroenterology clinic for follow-up after an upper gastrointestinal endoscopy. The patient was referred by his primary care physician for screening of Barrett’s esophagus due to long-standing and severe gastroesophageal reflux symptoms, associated with obesity and current smoking status. The patient reports suffering from severe heartburn after eating for the past 10 years and has been a regular user of over-the-counter antacid preparations. He sought medical advice recently after a close friend was diagnosed with gastric cancer.
The patient’s medical history includes obesity, hypertension, type 2 diabetes mellitus, and gout. He takes ramipril, allopurinol, metformin, and gliclazide regularly and denies any drug allergies or intolerances. His father underwent a partial gastrectomy for peptic ulcer disease, but there is no family history of Barrett’s esophagus or esophageal adenocarcinoma.
The patient is a retired school teacher who lives with his wife. He has smoked 10 cigarettes per day throughout his adult life and abstains from alcohol.
After initial clinic assessment, an upper gastrointestinal endoscopy was arranged, and the patient was initiated on high-dose proton-pump inhibitor therapy, which significantly improved his reflux symptoms.
The upper gastrointestinal endoscopy report shows no evidence of hiatus hernia, an 8 cm segment of circumferential salmon-colored epithelium extending above the gastroesophageal junction (quadrant biopsies taken as per protocol), no mass lesion or ulceration throughout the esophagus, stomach, or first-part duodenum, and mild-moderate esophagitis and mild gastritis.
Histology from endoscopic biopsies reveals flat intestinal metaplasia present in 15 of 16 samples and no evidence of dysplasia or carcinoma.
What is the appropriate management for this patient’s Barrett’s esophagus, in addition to continued proton-pump inhibitor treatment?
MRCP2-1709
A 45-year-old woman with a history of Sjogren’s syndrome presents with fatigue and pruritus. She has not started any new medications or traveled recently. During the examination, a palpable liver edge is detected. Further investigations reveal the following results:
Anti-mitochondrial antibodies are positive, while anti-smooth muscle antibodies are negative. Additionally, she is positive for anti-HBs, negative for HBsAg and HBcAg, and negative for hepatitis C.
What is the most probable diagnosis?
MRCP2-1710
A 26-year-old female presents to the clinic with a few weeks of diarrhoea, passing mucous, feeling tired, and experiencing abdominal discomfort that is relieved by defecation. A blood test is ordered and reveals the following results:
Which medication would be the most appropriate for her?
MRCP2-1711
A 75 year-old man presents with a 4 month history of generalised abdominal pain and a change in bowel habit. The abdominal pain is colicky in nature and does not radiate anywhere. He also reports increasing distension of his abdomen and 2 episodes of blood in the rectum several weeks ago. He has recently undergone colonoscopy, which did not reveal anything abnormal. His past medical history includes diabetes type 2 and a heart attack three years ago, for which he needed three stents. His mother died of a stroke when he was 60 and his father died of a heart attack at the age of 55. His current medications include ramipril, aspirin, atenolol, atorvastatin and metformin. He has a 35 year pack history and drinks on average 10 units per day.
Apart from an abdominal x-ray, what is the most suitable investigation?
MRCP2-1712
A 43-year-old female patient visits the gastroenterology clinic for follow-up after being discharged from the hospital. She had been admitted due to a six-week history of frequent bloody diarrhea and abdominal pain accompanied by multiple mouth ulcers. During her hospital stay, she underwent several tests, and a short course of intravenous steroids followed by oral prednisolone was prescribed. The patient reported significant improvement in her symptoms and expressed her desire to continue with medication to maintain remission.
The investigations conducted during her hospitalization revealed no organisms in stool microscopy and culture. Colonoscopy showed patchy inflammation with a cobblestone appearance affecting the ascending and transverse colon and terminal ileum. Colonic histology revealed chronic transmural inflammation, crypt abscesses, and submucosal fibrosis. CT abdomen showed no evidence of intra-abdominal collection, structuring, or abnormal fistulation.
What is the most appropriate medication to maintain disease remission in this 43-year-old female patient?
MRCP2-1713
A 45-year-old man presents to the outpatient department with a 5 month history of fatigue and pruritus. He reports excessive daytime sleepiness and difficulty concentrating at work as an auditor. The itching worsens in hot climates and when he uses a blanket while sleeping. He has a medical history of asthma and dry eyes, and takes beclometasone and antihistamines for the itching. He has no known allergies and no family history of any conditions. He does not smoke and drinks 5-10 units of alcohol per week.
During examination, mild jaundice of the sclera and scratch marks over his upper torso and arms are observed. His abdomen reveals a slightly enlarged spleen and liver, both by 1 cm. Blood tests show elevated bilirubin and alkaline phosphatase (ALP). Autoantibody screening reveals the presence of antimitochondrial antibodies (AMA) and antinuclear bodies (ANA).
What is the most appropriate management strategy to alleviate his symptoms?
MRCP2-1714
A 50-year-old woman presents to the gastroenterology clinic complaining of malaise and itching. Her GP had previously found a persistently elevated alkaline phosphatase over the last year. The patient has a history of rheumatoid arthritis. The results of her anti-mitochondrial antibodies and smooth muscle antibodies tests are positive. What further test is necessary to confirm the diagnosis?
MRCP2-1715
A 50-year-old male with a history of alcohol abuse and liver disease presents with confusion. He drinks at least 40 units of alcohol per week. On examination, he has a Glasgow coma scale of 14 and slight hand flapping. He is jaundiced with spider naevi and palmar erythema. Abdominal examination reveals slight distension but no organomegaly. His lab results show elevated liver enzymes and bilirubin levels. He is started on a rapid detoxification program with diazepam but later found collapsed in the bathroom. Which medication is most likely to improve his level of consciousness?
MRCP2-1716
A 45-year-old woman presents with eye irritation that has been ongoing for a few weeks. She attributes this to the recent sunny weather and high pollen levels. She has a history of primary biliary cirrhosis and is currently being treated with ursodeoxycholic acid. She wears contact lenses for myopia and changes the washing solution regularly. On examination, both eyes are red with conjunctival injection, but there is no exudate or photophobia. Her visual acuity is 6/6 bilaterally, and the slit lamp exam is normal. Fluorescein staining shows no abrasion. She has a fine tremor, and there are no palpable neck lumps. Laboratory results show elevated bilirubin, ALP, ALT, and γGT levels, as well as low albumin and positive rheumatoid factor. Her TSH level is within normal limits. What is the most likely diagnosis?