MRCP Part 1 Gastroenterology and Hepatology 2 — Questions and Answers
Question 1: A 50-year-old man with known cirrhosis presents with increasing abdominal distension. Diagnostic ascitic tap shows a serum-ascites albumin gradient (SAAG) of 18 g/L and ascitic fluid neutrophil count of 350 cells/mm3. What is the most likely diagnosis?
- Spontaneous bacterial peritonitis (Correct answer)
- Portal hypertensive ascites without infection
- Tuberculous peritonitis
- Pancreatic ascites
Correct answer: Spontaneous bacterial peritonitis
Spontaneous bacterial peritonitis (SBP) is diagnosed when ascitic fluid neutrophil count exceeds 250 cells/mm3 in the absence of a surgically treatable intra-abdominal source. The high SAAG (>11 g/L) confirms portal hypertension as the cause of ascites. SBP requires immediate empirical antibiotics (IV cefotaxime).
Question 2: A patient presents with dysphagia to solids and liquids from onset, with a bird's beak appearance on barium swallow. Manometry shows absent peristalsis and failure of LOS relaxation. What is the diagnosis?
- Achalasia (Correct answer)
- Oesophageal carcinoma
- Diffuse oesophageal spasm
- Benign oesophageal stricture
Correct answer: Achalasia
Achalasia presents with dysphagia to both solids and liquids from onset (unlike mechanical obstruction which starts with solids). The bird's beak sign on barium swallow, absent peristalsis, and failure of lower oesophageal sphincter (LOS) relaxation on manometry are diagnostic.
Question 3: Which liver condition is most commonly associated with ulcerative colitis?
- Primary sclerosing cholangitis (Correct answer)
- Primary biliary cholangitis
- Autoimmune hepatitis
- Non-alcoholic fatty liver disease
Correct answer: Primary sclerosing cholangitis
Primary sclerosing cholangitis (PSC) is strongly associated with ulcerative colitis, with approximately 70-80% of PSC patients having coexisting UC. PSC causes progressive fibrosis and stricturing of intra- and extrahepatic bile ducts, shown by the characteristic beaded appearance on MRCP.
Question 4: A 40-year-old woman presents with abdominal pain and diarrhoea. Colonoscopy shows skip lesions with cobblestoning and non-caseating granulomas on biopsy. Where else might you expect to find disease?
- Anywhere from mouth to anus (Correct answer)
- Colon and rectum only
- Small bowel only
- Oesophagus only
Correct answer: Anywhere from mouth to anus
Crohn's disease can affect any part of the gastrointestinal tract from mouth to anus, though the terminal ileum and colon are most commonly affected. The skip lesions (normal bowel between affected segments), cobblestoning, and non-caseating granulomas are characteristic histological features.
Question 5: A patient with known hepatitis B has the following serology: HBsAg positive, HBeAg negative, anti-HBe positive, HBV DNA 1500 IU/mL, ALT normal. What phase of hepatitis B is this?
- Inactive carrier (HBeAg-negative chronic infection) (Correct answer)
- Immune tolerant phase
- Immune active phase (HBeAg-positive chronic hepatitis)
- HBeAg-negative chronic hepatitis
Correct answer: Inactive carrier (HBeAg-negative chronic infection)
The inactive carrier phase is characterised by HBsAg positive, HBeAg negative, anti-HBe positive, low HBV DNA (<2000 IU/mL), and persistently normal ALT. These patients have low risk of disease progression but require regular monitoring as reactivation can occur.
Question 6: What is the most appropriate surveillance strategy for a patient with Barrett's oesophagus without dysplasia?
- Endoscopy with quadrantic biopsies every 2-3 years (Correct answer)
- Annual CT scan of the chest
- No surveillance needed
- Endoscopy every 6 months
Correct answer: Endoscopy with quadrantic biopsies every 2-3 years
BSG guidelines recommend surveillance endoscopy with Seattle protocol (quadrantic biopsies every 2 cm) every 2-3 years for Barrett's oesophagus without dysplasia. More frequent surveillance is indicated if dysplasia is found. This aims to detect progression to oesophageal adenocarcinoma.
MRCP Part 1 Gastroenterology and Hepatology 2
A 50-year-old man with known cirrhosis presents with increasing abdominal distension.
Diagnostic ascitic tap shows a serum-ascites albumin gradient (SAAG) of 18 g/L and ascitic fluid neutrophil count of 350 cells/mm3.
What is the most likely diagnosis?