MRCP Part 1 Gastroenterology and Hepatology — Questions and Answers
Question 1: A 45-year-old woman presents with jaundice, pruritus, and fatigue. Blood tests show raised ALP (450 U/L), mildly raised ALT (65 U/L), and positive anti-mitochondrial antibodies (AMA). What is the most likely diagnosis?
- Primary biliary cholangitis (Correct answer)
- Primary sclerosing cholangitis
- Autoimmune hepatitis
- Drug-induced liver injury
Correct answer: Primary biliary cholangitis
Primary biliary cholangitis (PBC, formerly primary biliary cirrhosis) characteristically presents in middle-aged women with cholestatic liver enzymes (raised ALP) and positive anti-mitochondrial antibodies (AMA), which are present in over 95% of cases. Pruritus and fatigue are common symptoms.
Question 2: A 60-year-old man with a history of alcohol excess presents with haematemesis. Endoscopy shows oesophageal varices with active bleeding. After resuscitation, what is the most appropriate acute pharmacological intervention?
- Intravenous terlipressin (Correct answer)
- Oral propranolol
- Intravenous omeprazole
- Oral lactulose
Correct answer: Intravenous terlipressin
Terlipressin (a vasopressin analogue) reduces portal pressure by causing splanchnic vasoconstriction and is the recommended first-line vasoactive drug for acute variceal bleeding. It should be started as soon as variceal bleeding is suspected, even before endoscopy, according to NICE guidelines.
Question 3: Which serological marker is most specific for coeliac disease?
- Anti-tissue transglutaminase IgA antibodies (Correct answer)
- Anti-gliadin IgG antibodies
- Anti-endomysial IgG antibodies
- Anti-nuclear antibodies
Correct answer: Anti-tissue transglutaminase IgA antibodies
Anti-tissue transglutaminase (anti-tTG) IgA antibodies are the recommended first-line serological test for coeliac disease, with sensitivity >95% and specificity >95%. Total IgA should be checked simultaneously as IgA deficiency is more common in coeliac disease and causes false negatives.
Question 4: A patient with ulcerative colitis presents with 8 bloody stools per day, pulse 110 bpm, temperature 38.5 degrees C, and CRP of 85 mg/L. How would you classify this flare according to the Truelove and Witts criteria?
- Severe (Correct answer)
- Mild
- Moderate
- In remission
Correct answer: Severe
Truelove and Witts criteria classify UC flares as severe when patients have 6 or more bloody stools per day PLUS at least one systemic feature: pulse >90 bpm, temperature >37.8 degrees C, Hb <10.5 g/dL, or ESR/CRP >30. This patient meets multiple severe criteria.
Question 5: A 35-year-old man presents with epigastric pain and a duodenal ulcer is found on endoscopy. CLO test is positive. What is the recommended first-line eradication therapy in the UK?
- PPI, amoxicillin, and clarithromycin for 7 days (Correct answer)
- PPI and amoxicillin for 14 days
- Bismuth quadruple therapy
- PPI, metronidazole, and levofloxacin
Correct answer: PPI, amoxicillin, and clarithromycin for 7 days
NICE recommends triple therapy with a PPI, amoxicillin 1g BD, and clarithromycin 500mg BD for 7 days as first-line H. pylori eradication in the UK. If penicillin allergic, metronidazole replaces amoxicillin.
Question 6: Which investigation is the gold standard for diagnosing chronic pancreatitis when cross-sectional imaging is equivocal?
- Endoscopic ultrasound (EUS) (Correct answer)
- Serum amylase
- Faecal elastase
- Plain abdominal X-ray
Correct answer: Endoscopic ultrasound (EUS)
Endoscopic ultrasound (EUS) is the most sensitive investigation for diagnosing chronic pancreatitis, capable of detecting early parenchymal and ductal changes that CT and MRI may miss. It uses the Rosemont classification criteria for standardised diagnosis.
MRCP Part 1 Gastroenterology and Hepatology
A 45-year-old woman presents with jaundice, pruritus, and fatigue.
Blood tests show raised ALP (450 U/L), mildly raised ALT (65 U/L), and positive anti-mitochondrial antibodies (AMA).
What is the most likely diagnosis?