A. Granulomatous changes of hepatocytes
B. Fatty changes of the liver parenchyma
C. Piecemeal necrosis and fibrosis around portal veins
D. Collagen layering around bile ducts
E. Lymphocyte infiltrates causing biliary duct destruction
8. Which one of the following best describes the faecal immunochemical test (FIT)?
A. The antibodies in this test bind to the haem portion of human haemoglobin
B. FIT has a higher clinical sensitivity in detecting occult blood at lower concentrations compared to the guaiac-based faecal occult blood test (gFOBT)
C. Digested blood from the upper gastrointestinal tract is often detected by FIT
D. Patients have to observe dietary restrictions before collecting a stool sample
E. FIT has a higher false-positive rate than gFOBT
Theme: Pathological and clinical features of chronic liver disease (for Questions 9 and 10)
A. Alcoholic hepatitis
B. Autoimmune hepatitis
C. Chronic hepatitis B
D. Haemochromatosis
E. Hepatocellular carcinoma
F. Primary biliary cirrhosis
G. Primary sclerosing cholangitis
H. Wilson disease
For each patient with abnormal liver biochemistry and biopsy, select the most likely diagnosis.
9. A 42-year-old woman presented with fatigue, nausea, abdominal pain and arthralgia. She does not drink any alcohol. Her aspartate and alanine aminotransferase are markedly elevated, above three times the upper limit of normal. Her viral hepatitis serology is negative. Caeruloplasmin level is normal. Her liver biopsy shows dense portal and periportal predominance of plasma cell infiltrate with some lymphocytes.
10. A 35-year-old woman with a history of hypothyroidism, on adequate thyroxine replacement, presented with fatigue and pruritus. She has jaundice and enlarged liver on examination. Her alkaline phosphatase has been elevated for more than 6 months. Her liver biopsy shows portal inflammation and destruction of the intrahepatic bile ducts.
Theme: Nutritional issues after bariatric surgery (for Questions 11 and 12)
A. Thiamine
B. Folic acid
C. Vitamin A
D. Vitamin B12
E. Vitamin C
F. Vitamin D
G. Vitamin E
H. Vitamin K
Deficiency of which micronutrient is the most likely cause of the following clinical scenarios?
11. A 45-year-old man presents with confusion and nausea. He had a Roux-en-Y gastric bypass surgery 2 years prior to this presentation. He has not been adherent to nutritional recommendations after the surgery. On examination he has tachycardia and bilateral pitting oedema of his legs.
12. A 50-year-old woman presents with visual disturbance 8 years after having a Roux-en-Y gastric bypass surgery for morbid obesity. She does not have type 2 diabetes. On examination she has reduced visual acuity and bilateral conjunctival keratinisation with superficial punctuate keratopathy in the cornea.
Clinical
13. A 38-year-old woman has had a 10-year history of heartburn but has not received any treatment. Over the past 4 months, she has had progressive difficulty swallowing large bits of solid food. She has no difficulty with soft foods or liquids, and she has not lost weight. Which one of the following is the most likely explanation for her symptoms?
A. Adenocarcinoma in the lower third of the oesophagus
B. Barrett oesophagus in the distal oesophagus
C. Stricture of the distal oesophagus
D. Schatzki ring of the distal oesophagus
E. Squamous carcinoma in the mid-third of the oesophagus
14. A 65-year-old woman with recently diagnosed renal cell cancer presents to hospital with abdominal pain and abdominal distension. She states that her abdomen has become more distended and painful over a 3-week period and that she was afraid to come into hospital as she thought this was further spread of the cancer. On examination she has a tender distended abdomen with moderate hepatomegaly and evidence of ascites. The hepatojugular reflux is absent. The abdominal veins are dilated in the flanks and over the back, along with pedal oedema. Which one of the following diagnoses is the most likely?
A. Alpha-1-anti-trypsin deficiency
B. Budd–Chiari syndrome
C. Constrictive pericarditis
D. Cytomegalovirus hepatitis
E. Epstein–Barr virus infection
15. A 28-year-old woman was found to have an elevated total bilirubin level on her pre-operative blood test. She has no other significant medical history. She is only taking an oral contraceptive pill and no other over-the-counter medications. Her physical examination is unremarkable. Her hepatitis A, B and C serology are all negative. Her other investigation results are shown below. Which is the most appropriate next step in her management?
| Value | Reference ranges | |
|---|---|---|
| Haemoglobin (g/L) | 139 | 120–140 |
| Serum bilirubin (mmol/L) | 39 | 2–24 |
| Alkaline phosphatase (U/L) | 65 | 30–110 |
| Aspartate aminotransferase (U/L) | 34 | <45 |
A. Investigation for the presence and cause of haemolysis
B. An abdominal ultrasonography before surgery
C. Discontinuation of the oral contraceptive pill permanently
D. Half of the recommended paracetamol dose post surgery
E. Recommended dose of morphine peri-operatively
16. Which one of the following is a predictor of a favourable response to pegylated interferon (PEG-IFN) plus ribavirin therapy in previously untreated immunocompetent patients with chronic hepatitis C infection?
A. HCV genotype 1
B. High hepatitis C RNA levels
C. Absence of cirrhosis
D. Age over 50 years
E. Normal aminotransferase levels
17. A 27–year-old woman who has not travelled abroad in the last 2 years presents with a 8-month history of abdominal discomfort and diarrhoea up to 4 times a day. There is no history of rectal bleeding or weight loss. Her full blood examination, C-reactive protein, electrolytes and coeliac serology are normal. She has tried a lactose-free diet for the last 2 months with no improvement. What is the next most appropriate step?
A. Colonoscopy
B. Hydrogen breath test
C. Pancreatic function testing
D. Trial of anti-spasmodic therapy
E. Computed tomography of the abdomen and pelvis
18. A 60-year-old woman has epigastric pain for several months and is referred for endoscopy. Gastric biopsy confirms mucosa-associated lymphoid tissue (MALT) lymphoma and the presence of Helicobacter pylori. Further evaluation confirms only gastric involvement. What is the next most appropriate treatment?
A. Amoxycillin, clarithromycin and omeprazole
B. Oral cyclophosphamide
C. Radiotherapy
D. Rituximab therapy
E. Total gastrectomy
19. A 52-year-old woman presents with an 8-month history of chronic non-bloody watery diarrhoea. Faecal leucocytes are present but stool cultures are negative. C-reactive protein is mildly elevated. Barium enema and colonoscopy were normal but biopsy reveals increased intraepithelial lymphocytes within the surface epithelium. What is the most likely diagnosis?
A. Microscopic colitis
B. Crohn disease
C. Ulcerative colitis
D. Pseudomembranous colitis
E. Irritable bowel syndrome
20. A 60-year-old man presents with a 1-week history of non-specific epigastric pain. His medical history includes hypertension, gout, hypercholesterolemia and obesity with a BMI of 38 kg/m2. He is currently taking ramipril 10 mg daily, allopurinol 300 mg daily and atorvastatin 40 mg daily. He does not drink any alcohol. His physical examination is normal and liver function test results are within the normal reference ranges. Liver ultrasound revealed features of hepatic steatosis. What is the next appropriate step in his management?
A. Liver biopsy
B. Commence metformin
C. Commence ursodeoxycholic acid
D. Immediate referral for bariatric surgery
E. Continue atorvastatin
21. A 73-year-old man presents with a 2-month history of regurgitating food and foul-smelling breath. He describes the regurgitated food as slightly changed but denies any blood or pain when he eats. He has not lost any weight recently. He is otherwise fit and well. Which of the following diagnoses is most likely?
A. Gastric outlet obstruction
B. Mallory–Weiss tear
C. Oesophageal carcinoma
D. Pharyngeal pouch
E. Plummer–Vinson syndrome
22. The earliest phenotypic manifestation of idiopathic hereditary haemochromatosis is:
A. Post-prandial increase in serum iron concentration
B. Elevated serum ferritin level
C. Slate-grey pigmentation of skin
D. Increased transferrin saturation
E. Jaundice
23. A 45-year-old man presents with lethargy, abdominal discomfort, jaundice and pruritus. The results of investigations are shown below. Anti-nuclear antibody and anti-mitochondrial antibody is negative. Ultrasound of the abdomen shows normal intrahepatic and extrahepatic bile ducts. The gallbladder is mildly enlarged and liver parenchyma show prominent periportal echogenicity. Which one of the following is the likely diagnosis?
| Value | Reference range | |
|---|---|---|
| Bilirubin (μmol/L) | 86 | 2–24 |
| Albumin (g/L) | 35 | 34–48 |
| Alkaline phosphatase (U/L) | 1200 | 30–110 |
| Alanine aminotransferase (U/L) | 150 | <55 |
A. Autoimmune hepatitis
B. Cholangiocarcinoma
C. Chronic active viral hepatitis
D. Primary biliary cirrhosis
E. Primary sclerosing cholangitis
24. Which of the following patients with acute non-typhoid Salmonella gastroenteritis requires antibiotic treatment?
A. Has fever for more than 48 h
B. Has diarrhoea for more than 48 h
C. Has constant abdominal pain for 24 h
D. Has sickle-cell disease
E. International travel a month prior to presentation
25. A 50-year-old man with a 7-year history of cirrhosis caused by hepatitis C and alcohol is seen regularly in the liver clinic. What is the most appropriate surveillance for hepatocellular carcinoma?
A. Aminotransferase measurements every 3 months
B. Serum alpha-fetoprotein every 6 months
C. Liver ultrasonography every 12 months
D. Serum alpha-fetoprotein and liver ultrasonography every 6–12 months
E. Computed tomography of the abdomen every 12 months
26. A 62-year-old man presented with melaena, dizziness and abdominal discomfort. On examination, his blood pressure was 85/40 mmHg and heart rate was 105 beats/min. After initial resuscitation and assessment, he underwent an urgent endoscopy which revealed a duodenal ulcer and a non-bleeding vessel was visible. He was treated with epinephrine (adrenaline) injection and thermal therapy. Gastric biopsy was positive for H. pylori infection. Which one of the following statements concerning his management is correct?
A. The risk of further bleeding is high because he did not receive pre-endoscopic pantoprazole
B. He should receive oral pantoprazole 40 mg twice a day for 3 days
C. He should have a repeat endoscopy 24 h after initial endoscopic haemostatic therapy
D. He should be fasted for 72 h after endoscopy
E. After confirmation of eradication of H. pylori, long-term usage of pantoprazole is not recommended
27. A 45-year-old woman has rectal bleeding during bowel movements for 10 weeks. She has intermittent diarrhoea and severe lower abdominal pains. Her appetite is poor and she has also lost 7 kg in weight. On examination she has a tender left lower abdomen and active bowel sounds. Rectal examination reveals a small streak of blood. Her investigations results are shown below. A rigid sigmoidoscopy shows inflammatory changes with multiple ulceration and numerous areas of petechial haemorrhages. Elevated sessile reddish nodules (small and multiple) appear on the flat surface. There are multiple confluent ulcers leading to denudation of the mucosa.
Which treatment should be administered?
Which treatment should be administered?
| Value | Reference ranges | |
|---|---|---|
| Haemoglobin (g/L) | 111 | 135–175 |
| White cell count (cells/L) | 13.5 × 109 | 4.0–11.0 × 109 |
| Platelet count (cells/L) | 600 × 109 | 150–450 × 109 |
| Urea (mmol/L) | 6.0 | 2.7–8.0 |
| Creatinine (μmol/L) | 100 | 50–100 |
| C-reactive protein (mg/L) | 80 | <10 |
A. Intravenous hydrocortisone
B. Intravenous metronidazole
C. Intravenous 5-aminosalicylate
D. Intravenous anti-TNF-α antibody infusion
E. Intravenous gamma globulin infusion
28. A 65-year-old man complains of fevers, weight loss, joint pains and diarrhoea. A jejunal biopsy reveals flattened mucosa containing periodic acid–Schiff (PAS) positive macrophages. What is the most likely diagnosis?
A. Campylobacter jejuni infection
B. Coeliac disease
C. Giardiasis
D. Small bowel amyloidosis
E. Tropheryma whipplei infection
29. Which one of the following tests provides the most useful early information about possible ascitic fluid infection in a patient with cirrhosis, abdominal pain and fever?
A. Gram stain of ascitic fluid
B. Neutrophil count of ascitic fluid
C. Albumin gradient of ascitic fluid compared to serum
D. Total protein in ascitic fluid
E. Bacterial culture of ascitic fluid
30. Which one of the following laboratory results is most likely to be observed in patient with severe small intestinal bacterial overgrowth?
Theme: Treatment of inflammatory bowel disease (for Questions 29–33)
A. Azathioprine
B. Cholestyramine
C. Infliximab
D. Mesalazine suppository
E. Methotrexate
F. Metronidazole
G. Oral mesalazine
H. Prednisolone
For each of the following scenarios, select the most appropriate treatment.
31. A 24-year-old woman with a 6-month history of severe diarrhoea is newly diagnosed with primary eosinophilic colitis.
32. A 52-year-old man with Crohn disease has recently been diagnosed with an enteroenteric fistula. He is already being treated with azathioprine.
33. A 38-year-old woman with ulcerative colitis presents with mild bloody diarrhoea and is found to have mild-to-moderate proctitis only on colonoscopy.
34. A 65-year-old man with a long-standing history of Crohn disease, which has been in remission for the past 10 years, presents with acute diarrhoea. Exotoxin from an anaerobic Gram-positive rod is detected in his stool specimen.
35. A 46-year-old woman with a 10-year history of Crohn disease presents with a non-healing leg wound. She has been on a course of prednisolone for a month and maintenance dose of azathioprine.
Answers
Basic Science
1. Answer D
The four major cell types that determine the body iron content and distribution are:
Duodenal enterocytes absorb approximately 1–2 mg of iron/day to offset losses. Absorbed iron circulates bound to transferrin and is used primarily by erythroid precursors in the synthesis of haem. Reticuloendothelial macrophages clear senescent red blood cells and release the iron from haem to export it to the circulation or store it in ferritin. Hepatocytes are another site of iron storage as ferritin and the principal site of production of the peptide hormone hepcidin. Hepcidin blocks the release of iron from enterocytes and reticuloendothelial macrophages by degrading the iron exporter ferroportin. Microfold cells are epithelial cells that overlie Peyer’s patches and other large lymphatic aggregations. They are relatively flat and their surface is thrown into folds, rather than microvilli. They endocytose antigens and transport them to the underlying lymphoid cells where immune responses to foreign antigens can be initiated (Fleming and Ponka, 2012).
The four major cell types that determine the body iron content and distribution are:
- Duodenal enterocytes affecting dietary iron absorption
- Erythroid precursors affecting iron utilisation
- Reticuloendothelial macrophages affecting iron storage and recycling
- Hepatocytes affecting iron storage and endocrine regulation.
Duodenal enterocytes absorb approximately 1–2 mg of iron/day to offset losses. Absorbed iron circulates bound to transferrin and is used primarily by erythroid precursors in the synthesis of haem. Reticuloendothelial macrophages clear senescent red blood cells and release the iron from haem to export it to the circulation or store it in ferritin. Hepatocytes are another site of iron storage as ferritin and the principal site of production of the peptide hormone hepcidin. Hepcidin blocks the release of iron from enterocytes and reticuloendothelial macrophages by degrading the iron exporter ferroportin. Microfold cells are epithelial cells that overlie Peyer’s patches and other large lymphatic aggregations. They are relatively flat and their surface is thrown into folds, rather than microvilli. They endocytose antigens and transport them to the underlying lymphoid cells where immune responses to foreign antigens can be initiated (Fleming and Ponka, 2012).
Fleming, R.E. and Ponka, P. (2012). Iron overload in human disease. N Engl J Med 366, 348–359.
2. Answer A
Bile salts aid fat absorption in the duodenum and jejunum and are reabsorbed in the distal ileum as part of enterohepatic circulation, so that usually only approximately 0.5 g/day are lost in the faeces. One of the consequences of surgical resection of the distal ileum is the reduced absorption of bile salts.
Iron, folate, vitamin C and calcium are absorbed mainly in the proximal jejunum. The only vitamin absorbed in the distal ileum is vitamin B12, which also requires the presence of intrinsic factor, a glycoprotein produced by gastric parietal cells.
Bile salts aid fat absorption in the duodenum and jejunum and are reabsorbed in the distal ileum as part of enterohepatic circulation, so that usually only approximately 0.5 g/day are lost in the faeces. One of the consequences of surgical resection of the distal ileum is the reduced absorption of bile salts.
Iron, folate, vitamin C and calcium are absorbed mainly in the proximal jejunum. The only vitamin absorbed in the distal ileum is vitamin B12, which also requires the presence of intrinsic factor, a glycoprotein produced by gastric parietal cells.
3. Answer C
Fructose is a simple sugar, a monosaccharide that is present primarily in added dietary sugars, honey and fruit. Fructose is absorbed by facilitated diffusion utilising the sodium-independent insulin-independent transporter (GLUT-5). Worldwide, dietary fructose intake is increasing. It is obtained primarily from added sugars, including sucrose and high fructose corn syrup, and this correlates epidemiologically with the rising prevalence of metabolic syndrome and hypertension worldwide (Madero et al., 2011). The administration of fructose to animals and humans increases blood pressure and the development of metabolic syndrome. These changes occur independently of caloric intake because of the effect of fructose on adenosine triphosphate (ATP) depletion and uric acid generation. Fructose ingestion may also be a risk factor for kidney disease with glomerular hypertension, renal inflammation and tubulointerstitial injury seen in animals. Fructose intolerance is due to fructose-1-phosphate aldolase deficiency and can present in infancy with hypoglycaemia and vomiting. Fructose malabsorption may play a role in the symptoms of coeliac disease and, potentially, irritable bowel syndrome.
Fructose is a simple sugar, a monosaccharide that is present primarily in added dietary sugars, honey and fruit. Fructose is absorbed by facilitated diffusion utilising the sodium-independent insulin-independent transporter (GLUT-5). Worldwide, dietary fructose intake is increasing. It is obtained primarily from added sugars, including sucrose and high fructose corn syrup, and this correlates epidemiologically with the rising prevalence of metabolic syndrome and hypertension worldwide (Madero et al., 2011). The administration of fructose to animals and humans increases blood pressure and the development of metabolic syndrome. These changes occur independently of caloric intake because of the effect of fructose on adenosine triphosphate (ATP) depletion and uric acid generation. Fructose ingestion may also be a risk factor for kidney disease with glomerular hypertension, renal inflammation and tubulointerstitial injury seen in animals. Fructose intolerance is due to fructose-1-phosphate aldolase deficiency and can present in infancy with hypoglycaemia and vomiting. Fructose malabsorption may play a role in the symptoms of coeliac disease and, potentially, irritable bowel syndrome.
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