MRCP Part 1 Gastroenterology & Neurology 1 — Questions and Answers
Question 1: A 45-year-old woman presents with jaundice, pruritus, elevated ALP, and positive anti-mitochondrial antibodies (AMA). What is the diagnosis?
- Primary sclerosing cholangitis
- Autoimmune hepatitis
- Primary biliary cholangitis (Correct answer)
- Wilson's disease
Correct answer: Primary biliary cholangitis
Primary biliary cholangitis (PBC, formerly called primary biliary cirrhosis) is an autoimmune cholestatic liver disease characterised by elevated ALP, positive AMA (especially anti-M2), pruritus, and jaundice. It predominantly affects middle-aged women.
Question 2: Which score is used to assess severity and 30-day mortality in acute upper GI bleeding?
- Child-Pugh score
- Glasgow-Blatchford score (Correct answer)
- Maddrey's discriminant function
- MELD score
Correct answer: Glasgow-Blatchford score
The Glasgow-Blatchford score (GBS) uses clinical and biochemical parameters (blood urea, haemoglobin, pulse, systolic BP, history of liver disease/heart failure, and syncope/melaena) to assess the need for clinical intervention and risk of mortality in acute upper GI bleeding.
Question 3: A 30-year-old man presents with profuse watery diarrhoea, terminal ileum disease on colonoscopy, and perianal fistulae. What is the most likely diagnosis?
- Ulcerative colitis
- Crohn's disease (Correct answer)
- Coeliac disease
- Microscopic colitis
Correct answer: Crohn's disease
Crohn's disease is characterised by transmural, discontinuous ('skip lesions') inflammation that can affect any part of the GI tract from mouth to anus, with predominance for the terminal ileum and colon. Perianal disease (fistulae, abscesses) occurs in up to one-third and is highly characteristic of Crohn's.
Question 4: In a patient with oesophageal varices and acute variceal haemorrhage, which pharmacological agent should be given immediately alongside resuscitation?
- IV ranitidine
- IV terlipressin (Correct answer)
- IV omeprazole
- IV metoclopramide
Correct answer: IV terlipressin
Terlipressin (or octreotide where terlipressin is unavailable) is a vasoconstrictor that reduces portal hypertension by constricting splanchnic vasculature. It should be given immediately in suspected variceal haemorrhage, before endoscopic confirmation, alongside IV fluids, antibiotics (ciprofloxacin/ceftriaxone), and blood products.
Question 5: A patient with long-standing ulcerative colitis undergoes surveillance colonoscopy. Dysplasia is found in a flat non-polypoid area. What is the recommended management?
- Repeat colonoscopy in 6 months
- Argon plasma coagulation of the dysplastic area
- Colectomy (Correct answer)
- Enhanced surveillance with narrow-band imaging annually
Correct answer: Colectomy
The detection of flat (non-polypoid) dysplasia in the context of long-standing ulcerative colitis carries a high risk of synchronous or subsequent colorectal cancer. Current guidelines recommend proctocolectomy (colectomy) when flat dysplasia is confirmed by two independent pathologists.
Question 6: What is the mechanism of action of rifaximin in hepatic encephalopathy?
- Reduces gut motility
- Minimally absorbed antibiotic that alters gut flora to reduce ammonia production (Correct answer)
- Increases renal ammonia clearance
- Acts as a GABA receptor antagonist
Correct answer: Minimally absorbed antibiotic that alters gut flora to reduce ammonia production
Rifaximin is a minimally absorbed antibiotic that acts locally in the gut to alter the gut microbiome, reducing ammonia-producing bacteria. This lowers portal and systemic ammonia levels, which is thought to be the primary driver of hepatic encephalopathy.
MRCP Part 1 Gastroenterology & Neurology 1
A 45-year-old woman presents with jaundice, pruritus, elevated ALP, and positive anti-mitochondrial antibodies (AMA).
What is the diagnosis?