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Arab Board IM Final Written study materials
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Arab Board IM Final Written practice questions

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Question 1Cardiology

A 58-year-old man with a history of hypertension presents with sudden-onset tearing chest pain radiating to the back. Blood pressure is 185/100 mmHg in the right arm and 150/90 mmHg in the left arm. Which is the most appropriate initial imaging study to confirm the diagnosis?

  1. Transthoracic echocardiography
  2. CT angiography of the aorta Correct answer.
  3. Coronary angiography
  4. Chest radiograph

Explanation

Interarm blood pressure differential with tearing pain suggests aortic dissection, and CT angiography of the aorta is the first-line confirmatory study with high sensitivity and specificity. Echocardiography is useful in unstable patients but is less reliable for the entire aorta.

Question 2Cardiology

Which finding on the electrocardiogram is most characteristic of hyperkalemia?

  1. Tall peaked T waves Correct answer.
  2. Delta waves
  3. Prolonged QT interval
  4. Prominent U waves

Explanation

Hyperkalemia characteristically produces tall, peaked, narrow-based T waves, followed by QRS widening and loss of P waves as potassium rises. The other findings relate to hypokalemia, hypocalcemia, or ventricular pre-excitation.

Question 3Cardiology

A 70-year-old woman with heart failure with reduced ejection fraction (ejection fraction 30%) remains symptomatic despite optimal doses of an ACE inhibitor, beta-blocker, and mineralocorticoid receptor antagonist. Which medication should be added to reduce mortality?

  1. Furosemide
  2. Dapagliflozin Correct answer.
  3. Amlodipine
  4. Digoxin

Explanation

SGLT2 inhibitors such as dapagliflozin reduce cardiovascular mortality and heart failure hospitalization and are recommended as part of guideline-directed medical therapy in HFrEF. Furosemide, amlodipine, and digoxin provide symptom or hemodynamic benefit but have not been shown to reduce mortality in this setting.

Question 4Cardiology

Which finding on physical examination is most specific for severe aortic stenosis?

  1. Systolic ejection murmur at the left sternal border
  2. Bounding peripheral pulses
  3. Slow-rising, low-amplitude carotid pulse Correct answer.
  4. Wide pulse pressure

Explanation

Severe aortic stenosis produces a fixed outflow obstruction with a low-amplitude, slowly rising carotid pulse (pulsus parvus et tardus). Wide pulse pressure and bounding pulses are features of aortic regurgitation, not stenosis.

Question 5Cardiology

A 30-year-old man is found in a narrow-complex, irregular tachycardia with a pulse and a blood pressure of 95/60 mmHg. He is alert but pale and diaphoretic. What is the most appropriate next step?

  1. Intravenous amiodarone bolus
  2. Unsynchronized defibrillation
  3. Vagal maneuvers followed by adenosine
  4. Synchronized cardioversion Correct answer.

Explanation

Unstable tachyarrhythmias with hypotension or signs of poor perfusion require immediate synchronized cardioversion. Pharmacologic rate control and vagal maneuvers are reserved for hemodynamically stable patients.

Question 6Cardiology

Which of the following is a major criterion in the Duke criteria for the diagnosis of infective endocarditis?

  1. Positive blood cultures with typical organisms in two separate cultures Correct answer.
  2. Predisposing valvular disease
  3. Fever above 38°C
  4. Elevated C-reactive protein

Explanation

Persistently positive blood cultures with typical organisms in two separate cultures is a major Duke criterion, along with evidence of endocardial involvement on echocardiography. Fever, predisposing heart disease, and inflammatory markers are minor criteria.

Question 7Cardiology

A 65-year-old man with a history of myocardial infarction presents with recurrent ventricular tachycardia and an ejection fraction of 30% despite optimal medical therapy. Which intervention has been shown to improve survival?

  1. Permanent pacemaker
  2. Empiric antiarrhythmic therapy with amiodarone
  3. Radiofrequency ablation of the atrioventricular node
  4. Implantable cardioverter-defibrillator Correct answer.

Explanation

An implantable cardioverter-defibrillator reduces mortality in patients with reduced ejection fraction and prior myocardial infarction who are at risk of sudden cardiac death. Amiodarone may suppress arrhythmias but does not improve survival in this population.

Question 8Cardiology

Which of the following is the most important modifiable risk factor for the development of coronary artery disease?

  1. Male sex
  2. Family history of premature coronary disease
  3. Cigarette smoking Correct answer.
  4. Advancing age

Explanation

Cigarette smoking is a major modifiable risk factor for coronary artery disease. Male sex, family history, and age are important but non-modifiable risk factors.

Question 9Cardiology

A patient with acute decompensated heart failure presents with dyspnea, bibasilar crackles, and elevated jugular venous pressure. Which intravenous agent is most appropriate for immediate symptom relief in the absence of hypotension?

  1. Furosemide Correct answer.
  2. Adenosine
  3. Metoprolol
  4. Diltiazem

Explanation

Intravenous loop diuretics such as furosemide relieve congestion and are first-line for acute decompensated heart failure with volume overload. Beta-blockers and calcium channel blockers can worsen acute decompensation.

Question 10Cardiology

Which of the following is the most common cause of myocarditis in developed countries?

  1. Radiation therapy
  2. Bacterial infection
  3. Hypersensitivity reaction
  4. Viral infection Correct answer.

Explanation

Viral infection, particularly with enteroviruses, is the most common cause of myocarditis in developed countries. Bacterial causes are less frequent, and hypersensitivity or radiation-induced myocarditis is rare.

Question 11Cardiology

A 55-year-old woman with mitral stenosis presents with hemoptysis and atrial fibrillation. Which complication is most directly related to the atrial fibrillation in this setting?

  1. Acute mitral regurgitation
  2. Aortic root dilation
  3. Left atrial thrombus and systemic embolism Correct answer.
  4. Right ventricular hypertrophy

Explanation

Atrial fibrillation in mitral stenosis causes blood stasis in a dilated left atrium, predisposing to thrombus formation and systemic embolization. Anticoagulation is therefore indicated.

Question 12Cardiology

Which of the following is the recommended initial treatment for a patient with symptomatic bradycardia and hemodynamic instability unresponsive to atropine?

  1. Synchronized cardioversion
  2. Intravenous amiodarone
  3. Transcutaneous pacing Correct answer.
  4. Intravenous adenosine

Explanation

Symptomatic bradycardia unresponsive to atropine requires transcutaneous pacing as a bridge to definitive therapy. Adenosine, cardioversion, and amiodarone are treatments for tachyarrhythmias.

Question 13Cardiology

Which ECG finding is most suggestive of acute pericarditis?

  1. Sawtooth flutter waves
  2. Delta wave with short PR interval
  3. Focal ST elevation with reciprocal depression
  4. Diffuse concave ST-segment elevation with PR depression Correct answer.

Explanation

Acute pericarditis classically produces widespread concave ST elevation with PR depression. Focal ST elevation with reciprocal changes suggests myocardial infarction, while delta waves and flutter waves indicate other arrhythmias.

Question 14Cardiology

A 45-year-old man with a mechanical mitral valve is being counseled about anticoagulation. Which regimen is most appropriate?

  1. Clopidogrel
  2. Aspirin 81 mg daily
  3. Warfarin with a target INR of 2.5 to 3.5 Correct answer.
  4. Dabigatran

Explanation

Mechanical mitral valves require warfarin with a higher target INR of 2.5 to 3.5 because of the high thrombotic risk. Direct oral anticoagulants are contraindicated in patients with mechanical valves.

Question 15Cardiology

Which finding on echocardiography is diagnostic of cardiac tamponade?

  1. Right ventricular diastolic collapse Correct answer.
  2. Eccentric mitral regurgitation
  3. Left ventricular hypertrophy
  4. Aortic sclerosis

Explanation

Cardiac tamponade produces right ventricular diastolic collapse as intrapericardial pressure exceeds right ventricular filling pressure. Left ventricular hypertrophy, mitral regurgitation, and aortic sclerosis are unrelated findings.

Question 16Cardiology

Which of the following is the most appropriate initial pharmacologic therapy for a patient with stable angina and no contraindications?

  1. Digoxin
  2. Loop diuretic
  3. Calcium channel blocker of the dihydropyridine class
  4. Beta-blocker Correct answer.

Explanation

Beta-blockers are first-line antianginal therapy because they reduce myocardial oxygen demand by lowering heart rate and contractility. Dihydropyridine calcium channel blockers are alternatives or add-on agents, while diuretics and digoxin have no antianginal role.

Question 17Cardiology

A patient with a history of hypertension and diabetes presents with an acute ST-elevation myocardial infarction. Which reperfusion strategy is preferred if he presents within 90 minutes of symptom onset at a facility with a catheterization laboratory?

  1. Sublingual nitroglycerin alone
  2. Primary percutaneous coronary intervention Correct answer.
  3. Fibrinolysis with alteplase
  4. Oral aspirin alone

Explanation

Primary percutaneous coronary intervention is the preferred reperfusion strategy for STEMI when it can be performed promptly at a PCI-capable facility. Fibrinolysis is reserved for situations where timely PCI is unavailable.

Question 18Cardiology

Which of the following best characterizes the murmur of mitral regurgitation?

  1. Holosystolic murmur at the apex radiating to the axilla Correct answer.
  2. Early diastolic decrescendo murmur at the left sternal border
  3. Crescendo-decrescendo systolic murmur at the right upper sternal border
  4. Mid-diastolic rumble at the apex

Explanation

Mitral regurgitation produces a holosystolic murmur at the apex that radiates to the axilla. The other descriptions correspond to aortic stenosis, aortic regurgitation, and mitral stenosis.

Question 19Cardiology

A 60-year-old man with chronic heart failure is started on spironolactone. Which laboratory parameter should be monitored most closely?

  1. Serum potassium and creatinine Correct answer.
  2. Serum amylase
  3. Serum calcium
  4. Serum bilirubin

Explanation

Spironolactone is a potassium-sparing diuretic that can cause hyperkalemia and worsening renal function, particularly when combined with ACE inhibitors. Potassium and creatinine should be checked shortly after initiation and after dose changes.

Question 20Cardiology

Which of the following is the most common cause of sudden cardiac death in young athletes?

  1. Mitral stenosis
  2. Aortic dissection
  3. Constrictive pericarditis
  4. Hypertrophic cardiomyopathy Correct answer.

Explanation

Hypertrophic cardiomyopathy is the leading cause of sudden cardiac death in young athletes, often presenting with exertion-related syncope or arrhythmia. Aortic dissection, mitral stenosis, and constrictive pericarditis are much less common causes in this population.

Question 21Pulmonology

A 24-year-old man is brought to the emergency department with sudden-onset pleuritic chest pain and breathlessness. He is tall and thin. Examination shows reduced breath sounds and hyper-resonance on the right, with tracheal deviation to the left. Which is the most appropriate immediate management?

  1. Intravenous antibiotics and observation
  2. Urgent CT thorax with contrast
  3. Urgent needle decompression followed by intercostal chest drain Correct answer.
  4. Immediate bronchoscopy and lavage

Explanation

Tension physiology with haemodynamic compromise and mediastinal shift demands immediate decompression before any imaging. Needle decompression in the safe triangle is followed by a definitive intercostal drain. Imaging must never delay decompression in a tension pneumothorax.

Question 22Pulmonology

Which finding on arterial blood gas most directly indicates that a patient with an acute exacerbation of COPD needs ventilatory support rather than controlled oxygen alone?

  1. PaO2 of 60 mmHg on room air
  2. PaCO2 of 70 mmHg with pH 7.20 Correct answer.
  3. Bicarbonate of 30 mmol/L
  4. PaCO2 of 50 mmHg with pH 7.35

Explanation

Acute ventilatory failure is defined by hypercapnia with acidaemia, so a rising CO2 accompanied by a low pH signals failure of alveolar ventilation. Chronic compensation raises bicarbonate and keeps pH nearer normal. The pH, not the absolute CO2, determines acuity and the need for NIV.

Question 23Pulmonology

Which organism is the most frequent cause of community-acquired pneumonia requiring hospital admission in adults?

  1. Legionella pneumophila
  2. Mycoplasma pneumoniae
  3. Streptococcus pneumoniae Correct answer.
  4. Haemophilus influenzae

Explanation

Streptococcus pneumoniae remains the single commonest pathogen isolated in community-acquired pneumonia across all severities. Atypical organisms and Haemophilus are important but less frequent overall. Empiric therapy is therefore always designed to cover pneumococcus.

Question 24Pulmonology

A 58-year-old woman has a 6-month history of progressive exertional breathlessness. Examination reveals fine end-inspiratory crackles at both bases and finger clubbing. High-resolution CT shows peripheral, basal, subpleural reticulation with honeycombing. Which is the most likely diagnosis?

  1. Idiopathic pulmonary fibrosis Correct answer.
  2. Pulmonary tuberculosis
  3. Chronic obstructive pulmonary disease
  4. Bronchiectasis

Explanation

Bibasal crackles with clubbing and a CT pattern of peripheral, basal, subpleural reticulation and honeycombing is the classic presentation of usual interstitial pneumonia, most often idiopathic pulmonary fibrosis. Honeycombing indicates established fibrosis.

Question 25Pulmonology

A patient with asthma uses a short-acting beta-2 agonist inhaler more than three times a week and wakes at night once weekly. Which step of management does this represent according to the Global Initiative for Asthma approach?

  1. Occupational asthma requiring allergen avoidance only
  2. Uncontrolled asthma requiring immediate hospital admission
  3. Well controlled asthma requiring no change
  4. Partly controlled asthma needing step-up of controller therapy Correct answer.

Explanation

Night waking and frequent reliever use are markers of inadequate control, and this pattern falls into the partly controlled category. The correct response is to review adherence and inhaler technique and step up controller therapy. Admission criteria depend on acute severity, not chronic control alone.

Question 26Pulmonology

Which feature of the pleural fluid best distinguishes an exudate from a transudate using Light's criteria?

  1. Pleural fluid lactate dehydrogenase below two-thirds of the upper limit of normal serum
  2. Pleural fluid protein to serum protein ratio greater than 0.5 Correct answer.
  3. Pleural fluid glucose below serum glucose
  4. Pleural fluid pH below 7.30

Explanation

Light's criteria classify fluid as exudative when the pleural-to-serum protein ratio exceeds 0.5, the pleural-to-serum LDH ratio exceeds 0.6, or pleural LDH exceeds two-thirds of the upper normal serum limit. Any single criterion is sufficient. Low glucose and low pH suggest complicated infection but are not part of the exudate definition.

Question 27Pulmonology

A 35-year-old man has recurrent episodes of wheeze, flushing and diarrhoea. CT shows a central mediastinal mass. Which mediator is most likely responsible for his bronchospasm?

  1. Acetylcholine
  2. Leukotriene B4
  3. Histamine Correct answer.
  4. Bradykinin

Explanation

This presentation suggests a carcinoid tumour secreting serotonin and other vasoactive substances; histamine released from tumour tissue causes bronchospasm, flushing and diarrhoea. Carcinoid syndrome is the classic paraneoplastic cause of episodic wheeze with a mediastinal mass.

Question 28Pulmonology

Which is the most appropriate first-line investigation for suspected obstructive sleep apnoea?

  1. Overnight polysomnography or home sleep apnoea testing Correct answer.
  2. CT of the upper airway
  3. Daytime multiple sleep latency test
  4. Awake arterial blood gas

Explanation

The diagnosis of obstructive sleep apnoea is confirmed by measuring apnoea-hypopnoea events during sleep, either with full polysomnography or validated home testing. The apnoea-hypopnoea index determines severity and guides therapy such as CPAP.

Question 29Pulmonology

A 70-year-old smoker presents with haemoptysis and a 3 cm spiculated peripheral lung mass with ipsilateral hilar enlargement but no distant lesions. Which investigation is required to establish the diagnosis and subtype before treatment?

  1. Sputum cytology alone
  2. PET-CT as a substitute for tissue
  3. Empirical radiotherapy without histology
  4. CT-guided percutaneous core biopsy Correct answer.

Explanation

Tissue diagnosis with histological subtyping and molecular testing is mandatory before definitive therapy for a potentially curable lung mass. A peripheral lesion is well suited to CT-guided core biopsy, which yields adequate material for immunohistochemistry and mutation analysis.

Question 30Pulmonology

Which statement best describes the mechanism of action of tiotropium in COPD?

  1. It inhibits phosphodiesterase-4 in inflammatory cells
  2. It stimulates beta-2 receptors on airway smooth muscle
  3. It blocks cysteinyl leukotriene receptors
  4. It blocks M3 muscarinic receptors, reducing vagally mediated bronchoconstriction Correct answer.

Explanation

Long-acting muscarinic antagonists competitively block M3 receptors on airway smooth muscle, reducing cholinergic bronchomotor tone and mucus secretion. Their effect lasts over 24 hours, allowing once-daily dosing. They are a cornerstone of maintenance bronchodilation in COPD.

Question 31Pulmonology

A patient with a large left-sided pleural effusion undergoes thoracentesis. After 1.5 L is drained, he develops cough, chest tightness and hypotension. Which is the most appropriate immediate action?

  1. Give intravenous furosemide and restrict fluids
  2. Proceed to immediate chest drain insertion on the same side
  3. Stop drainage, give oxygen and intravenous fluids, and monitor Correct answer.
  4. Continue drainage to completion to relieve compression

Explanation

These features indicate re-expansion pulmonary oedema, a complication of rapid or large-volume drainage. Management is to stop the procedure and provide supportive care with oxygen and haemodynamic support. Drainage should be limited, typically to about 1.5 L per session.

Question 32Pulmonology

Which pulmonary function pattern is characteristic of a patient with moderate persistent asthma between attacks?

  1. Reduced FEV1 with a reduced FEV1/FVC ratio that improves after bronchodilator Correct answer.
  2. Normal FEV1 with a reduced FEV1/FVC ratio that does not change after bronchodilator
  3. Reduced FVC with a normal or raised FEV1/FVC ratio
  4. Raised total lung capacity with a normal FEV1/FVC ratio

Explanation

Asthma produces variable airflow obstruction, so spirometry shows a reduced FEV1/FVC ratio with significant reversibility after a bronchodilator. Demonstrating reversibility is central to confirming the diagnosis. A fixed ratio reduction points towards COPD instead.

Question 33Pulmonology

Which clinical feature most strongly suggests a pulmonary embolism rather than a simple pneumothorax in a breathless patient?

  1. Sudden pleuritic pain with a normal chest radiograph Correct answer.
  2. Unilateral reduced tactile vocal fremitus with a pleural rub
  3. Hyper-resonance with absent breath sounds on one side
  4. Tracheal deviation away from the affected side

Explanation

Pulmonary embolism commonly causes pleuritic pain and breathlessness with a normal or non-diagnostic chest radiograph. Pneumothorax produces the physical signs of pleural air on examination. A normal radiograph therefore raises the relative likelihood of embolism.

Question 34Pulmonology

A patient with known cavitating pulmonary tuberculosis has a sudden large haemoptysis and remains haemodynamically stable but is coughing blood continuously. Which immediate measure is most appropriate?

  1. Start high-dose systemic corticosteroids
  2. Give intravenous heparin
  3. Position the patient with the bleeding side dependent and arrange urgent bronchial artery embolisation Correct answer.
  4. Perform immediate lung resection

Explanation

Massive haemoptysis is managed by protecting the unaffected lung through dependent positioning of the bleeding side, securing the airway, and arranging definitive control, usually by bronchial artery embolisation. Surgery is reserved for failure of embolisation and is not a first step.

Question 35Pulmonology

Which is the most common cause of hospital-acquired pneumonia in ventilated patients?

  1. Streptococcus pneumoniae
  2. Mycobacterium tuberculosis
  3. Gram-negative bacilli such as Pseudomonas aeruginosa Correct answer.
  4. Mycoplasma pneumoniae

Explanation

Ventilator-associated pneumonia is usually caused by aerobic gram-negative bacilli and Staphylococcus aureus, reflecting oropharyngeal colonisation in critically ill patients. Empiric therapy must therefore cover these organisms according to local resistance patterns.

Question 36Pulmonology

A 45-year-old non-smoker has a 3-month history of dry cough, breathlessness and weight loss, with bilateral hilar lymphadenopathy and erythema nodosum. Which is the most likely diagnosis?

  1. Lung adenocarcinoma
  2. Sarcoidosis Correct answer.
  3. Tuberculosis
  4. Hypersensitivity pneumonitis

Explanation

Bilateral hilar lymphadenopathy with erythema nodosum in a young to middle-aged adult is a classic presentation of sarcoidosis, often Löfgren syndrome. The combination of symmetrical hilar adenopathy and cutaneous findings is highly suggestive.

Question 37Gastroenterology and Hepatology

A 45-year-old man has recurrent epigastric pain relieved by meals and a positive urea breath test. What is the most appropriate first-line management?

  1. Daily low-dose aspirin and lifestyle modification
  2. Helicobacter pylori eradication with PPI-based triple therapy Correct answer.
  3. Proton pump inhibitor twice daily for 4 weeks alone
  4. Endoscopic clipping of the gastric mucosa

Explanation

Helicobacter pylori infection is the commonest cause of peptic ulcer disease, and eradication reduces recurrence and complications. Standard first-line therapy combines a PPI with two antibiotics for 10-14 days. Acid suppression alone leaves the infection untreated and ulcers recur.

Question 38Gastroenterology and Hepatology

Which serum marker is the most sensitive for detecting recent alcohol intake over the preceding few weeks?

  1. Alanine aminotransferase
  2. Serum albumin
  3. Carbohydrate-deficient transferrin Correct answer.
  4. Alkaline phosphatase

Explanation

Carbohydrate-deficient transferrin rises with sustained heavy alcohol use and reflects intake over roughly 2-3 weeks, giving it higher sensitivity and specificity than conventional liver enzymes. Transaminases and alkaline phosphatase are nonspecific and may be normal in alcoholic liver disease. Albumin reflects synthetic function rather than recent drinking.

Question 39Gastroenterology and Hepatology

A 30-year-old woman has a 3-month history of bloody diarrhoea and urgency. Colonoscopy shows continuous mucosal inflammation from the rectum to the splenic flexure. Which feature best distinguishes ulcerative colitis from Crohn disease?

  1. Transmural inflammation with fistulae
  2. Presence of skip lesions
  3. Continuous involvement of the rectum Correct answer.
  4. Granulomas on biopsy

Explanation

Ulcerative colitis characteristically begins in the rectum and extends proximally in a continuous fashion. Crohn disease is patchy with skip lesions, transmural inflammation, and non-caseating granulomas. Recognising the distribution pattern is the key discriminator.

Question 40Gastroenterology and Hepatology

A 62-year-old man with cirrhosis presents with haematemesis. After resuscitation, endoscopy shows actively bleeding oesophageal varices. In addition to endoscopic band ligation, which agent reduces mortality by lowering portal pressure?

  1. Octreotide
  2. Omeprazole
  3. Propranolol
  4. Terlipressin Correct answer.

Explanation

Terlipressin, a vasopressin analogue, splanchnic vasoconstriction reduces portal inflow and has been shown to reduce mortality in acute variceal bleeding when combined with endoscopic therapy. Propranolol is used for prophylaxis rather than the acute bleed. Octreotide is an alternative vasoactive agent but the mortality benefit is best established for terlipressin.

Question 41Gastroenterology and Hepatology

Which finding is most consistent with spontaneous bacterial peritonitis in a patient with ascites?

  1. Serum-ascites albumin gradient of 1.0 g/dL
  2. Ascitic fluid polymorphonuclear cell count of 400 cells/mm3 Correct answer.
  3. Ascitic fluid glucose of 120 mg/dL
  4. Ascitic fluid total protein of 3.5 g/dL

Explanation

A polymorphonuclear cell count of 250 cells/mm3 or more in ascitic fluid is diagnostic of spontaneous bacterial peritonitis and warrants empirical antibiotics. Low total protein and a high serum-ascites albumin gradient indicate portal hypertension rather than infection. Ascitic glucose falls with infection rather than rising.

Question 42Gastroenterology and Hepatology

A 25-year-old woman has right upper quadrant pain, jaundice, and fever. Ultrasound shows a dilated common bile duct with a stone. What is the most appropriate definitive management after antibiotics and resuscitation?

  1. Endoscopic retrograde cholangiopancreatography with stone extraction Correct answer.
  2. Percutaneous transhepatic cholangiography
  3. Long-term ursodeoxycholic acid
  4. Elective laparoscopic cholecystectomy alone

Explanation

Choledocholithiasis with cholangitis requires biliary decompression and stone clearance, which is achieved by ERCP with sphincterotomy and extraction. Cholecystectomy alone does not clear the duct. Ursodeoxycholic acid dissolves cholesterol stones only slowly and is not appropriate for infected obstructed ducts.

Question 43Gastroenterology and Hepatology

Which serological pattern is characteristic of autoimmune hepatitis?

  1. Anti-smooth muscle antibodies with raised IgG Correct answer.
  2. Anti-mitochondrial antibodies
  3. Anti-tissue transglutaminase antibodies
  4. Anti-neutrophil cytoplasmic antibodies with IgM deficiency

Explanation

Autoimmune hepatitis is characterised by hypergammaglobulinaemia, particularly raised IgG, together with autoantibodies such as anti-smooth muscle antibody (type 1) or anti-LKM1 (type 2). Anti-mitochondrial antibodies indicate primary biliary cholangitis. Anti-tTG indicates coeliac disease.

Question 44Gastroenterology and Hepatology

A patient with known hepatitis B cirrhosis has a serum alpha-fetoprotein of 900 ng/mL and a 3 cm arterial-enhancing liver lesion with washout on multiphase CT. What is the diagnosis?

  1. Hepatocellular carcinoma Correct answer.
  2. Focal nodular hyperplasia
  3. Hepatic haemangioma
  4. Pyogenic liver abscess

Explanation

In a cirrhotic liver, a lesion larger than 1 cm showing arterial hyperenhancement with portal venous or delayed washout is diagnostic of hepatocellular carcinoma, and markedly raised alpha-fetoprotein supports the diagnosis. Haemangiomas show peripheral nodular enhancement with centripetal fill-in. Focal nodular hyperplasia has a central scar and does not wash out.

Question 45Gastroenterology and Hepatology

Which is the most common mode of transmission of hepatitis A in developed countries?

  1. Faecal-oral contamination of food or water Correct answer.
  2. Sexual transmission through mucosal contact
  3. Percutaneous exposure to blood
  4. Vertical transmission from mother to infant

Explanation

Hepatitis A is an RNA virus spread predominantly by the faecal-oral route through contaminated food, water, or close contact. Blood-borne and vertical transmission are not characteristic. Sexual transmission can occur in specific outbreaks but is not the principal route.

Question 46Gastroenterology and Hepatology

A 40-year-old man with chronic hepatitis C genotype 1 has compensated liver disease. Which statement about modern direct-acting antiviral therapy is correct?

  1. Treatment must be lifelong to suppress viral replication
  2. Cure is defined by undetectable HCV RNA 12 weeks after completing therapy Correct answer.
  3. Sustained virological response requires interferon-based regimens
  4. Ribavirin monotherapy achieves cure in most patients

Explanation

With direct-acting antivirals, a sustained virological response, defined as undetectable HCV RNA at 12 weeks after treatment completion, equates to cure in over 95% of patients. Interferon is no longer required and ribavirin monotherapy is ineffective. Therapy is time-limited rather than lifelong.

Question 47Gastroenterology and Hepatology

A 55-year-old woman has fatigue, pruritus, and jaundice. Investigations show a raised alkaline phosphatase and positive anti-mitochondrial antibodies. What is the first-line treatment?

  1. Ursodeoxycholic acid Correct answer.
  2. Liver transplantation
  3. Prednisolone and azathioprine
  4. Colestyramine as monotherapy

Explanation

Primary biliary cholangitis is treated first-line with ursodeoxycholic acid, which improves cholestasis and slows progression. Immunosuppression is used for autoimmune hepatitis rather than PBC. Colestyramine relieves pruritus but does not treat the disease. Transplantation is reserved for end-stage disease.

Question 48Gastroenterology and Hepatology

A 28-year-old man has chronic diarrhoea, weight loss, and iron deficiency anaemia. Duodenal biopsy shows villous atrophy and intraepithelial lymphocytosis. Which antibody is most useful for monitoring adherence to a gluten-free diet?

  1. Anti-mitochondrial antibody
  2. Anti-tissue transglutaminase IgA Correct answer.
  3. Anti-nuclear antibody
  4. Anti-smooth muscle antibody

Explanation

Coeliac disease is diagnosed and monitored with IgA anti-tissue transglutaminase antibodies, which fall with adherence to a gluten-free diet. Anti-smooth muscle, anti-mitochondrial, and anti-nuclear antibodies are markers of other autoimmune liver diseases and are not used to monitor coeliac disease.

Question 49Gastroenterology and Hepatology

A 70-year-old man presents with painless obstructive jaundice and weight loss. Imaging shows a mass at the head of the pancreas with a dilated pancreatic duct and common bile duct. Which finding is most consistent with this presentation?

  1. A serum-ascites albumin gradient above 1.1 g/dL
  2. Low serum CA 19-9
  3. Markedly raised alpha-fetoprotein
  4. A double-duct sign on imaging Correct answer.

Explanation

A pancreatic head tumour obstructs both the common bile duct and the main pancreatic duct, producing the double-duct sign. CA 19-9 is typically elevated rather than low. Alpha-fetoprotein is a marker of hepatocellular carcinoma. The serum-ascites albumin gradient relates to portal hypertension, not pancreatic malignancy.

Question 50Gastroenterology and Hepatology

Which is the most common cause of acute pancreatitis worldwide?

  1. Gallstones Correct answer.
  2. Endoscopic retrograde cholangiopancreatography
  3. Alcohol
  4. Hypertriglyceridaemia

Explanation

Gallstones and alcohol are the two leading causes of acute pancreatitis, with gallstones being the most common overall. Hypertriglyceridaemia and post-ERCP pancreatitis are less frequent causes. Identifying the aetiology guides management such as cholecystectomy for gallstone disease.