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MRCP(UK) Part 1 study materials
MRCP(UK) Part 1 study resources

MRCP(UK) Part 1 practice questions

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Question 1Cardiology

A 68-year-old white British man is newly diagnosed with stage 1 hypertension. He has no diabetes, no chronic kidney disease and no evidence of target-organ damage. According to UK national guidance, which is the most appropriate first-line antihypertensive?

  1. Spironolactone
  2. Bendroflumethiazide
  3. Amlodipine Correct answer.
  4. Ramipril

Explanation

UK guidance selects step 1 therapy by age and ethnicity: a calcium channel blocker (or thiazide-like diuretic) for people aged 55 or over, or of Black African or Caribbean family origin, and an ACE inhibitor or ARB for younger patients. This man is over 55, so a dihydropyridine calcium channel blocker is the recommended starting drug.

Question 2Cardiology

Which finding on cardiovascular examination is most characteristic of severe aortic stenosis?

  1. Pansystolic murmur at the apex radiating to the axilla
  2. Slow-rising, low-volume carotid pulse Correct answer.
  3. Early diastolic murmur at the left sternal edge
  4. Collapsing pulse with a wide pulse pressure

Explanation

Fixed left ventricular outflow obstruction means the ventricle must generate a high gradient slowly, producing a low-amplitude, slowly rising pulse (pulsus parvus et tardus). The associated ejection systolic murmur characteristically radiates to the carotid arteries.

Question 3Cardiology

Worldwide, which is the commonest cause of mitral stenosis?

  1. Systemic lupus erythematosus
  2. Mitral annular calcification
  3. Rheumatic heart disease Correct answer.
  4. Previous infective endocarditis

Explanation

Rheumatic fever produces commissural fusion, leaflet thickening and chordal shortening, and remains by far the dominant cause of mitral stenosis globally. Non-rheumatic causes are uncommon and usually produce regurgitation rather than stenosis.

Question 4Cardiology

A 28-year-old man has sharp central chest pain that is worse on inspiration and eases when he sits forward. ECG shows widespread concave ST elevation with PR segment depression. Which is the most likely diagnosis?

  1. Acute anterior STEMI
  2. Acute pericarditis Correct answer.
  3. Pulmonary embolism
  4. Benign early repolarisation

Explanation

Inflammation of the whole epicardial surface produces widespread concave ST elevation together with PR depression, and the pain is pleuritic and positional. These features distinguish it from territorial ischaemia or benign variants.

Question 5Cardiology

Which electrolyte disturbance most strongly predisposes to digoxin toxicity?

  1. Hypochloraemia
  2. Hyperkalaemia
  3. Hypernatraemia
  4. Hypokalaemia Correct answer.

Explanation

Digoxin binds the sodium-potassium ATPase at a site that competes with potassium, so low extracellular potassium increases drug binding and toxicity even at therapeutic digoxin levels. Hyperkalaemia instead reflects severe acute toxicity and is a consequence rather than a cause.

Question 6Cardiology

A 58-year-old man presents 90 minutes after the onset of central chest pain. ECG shows 3 mm ST elevation in leads II, III and aVF. The nearest PCI centre is 3 hours away and transfer cannot be completed within 120 minutes of first medical contact. Which is the most appropriate reperfusion strategy?

  1. Immediate intravenous thrombolysis Correct answer.
  2. Conservative management with aspirin alone
  3. Await transfer for primary PCI
  4. Elective coronary angiography as an inpatient

Explanation

When primary PCI cannot be delivered within 120 minutes of first medical contact and symptoms began within 12 hours, prompt fibrinolysis is the recommended reperfusion strategy. Delay in order to transfer forfeits myocardial salvage.

Question 7Cardiology

A 72-year-old man with paroxysmal atrial fibrillation has a CHA2DS2-VASc score of 2 (hypertension and age 65-74 years). He has no contraindication to anticoagulation. What is the most appropriate management?

  1. Aspirin 75 mg daily
  2. No antithrombotic therapy
  3. Oral anticoagulation Correct answer.
  4. Clopidogrel 75 mg daily

Explanation

A CHA2DS2-VASc score of 2 or more in a man indicates a stroke risk high enough to warrant oral anticoagulation, using a DOAC or warfarin according to patient factors. Antiplatelet drugs are not an adequate substitute.

Question 8Cardiology

Which drug has been shown to reduce all-cause mortality in patients with heart failure and reduced ejection fraction?

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

Explanation

Beta-blockers such as bisoprolol, carvedilol and metoprolol succinate reduce mortality in heart failure with reduced ejection fraction through favourable effects on remodelling and arrhythmic death. They are a cornerstone of disease-modifying therapy alongside ACE inhibitors, ARBs or ARNI and mineralocorticoid receptor antagonists.

Question 9Cardiology

A 24-year-old man with hypertrophic cardiomyopathy has an ejection systolic murmur at the left sternal edge. Which manoeuvre would be expected to increase the intensity of the murmur?

  1. Passive leg raising
  2. Valsalva manoeuvre Correct answer.
  3. Squatting
  4. Isometric handgrip

Explanation

Manoeuvres that reduce left ventricular end-diastolic volume, such as the Valsalva manoeuvre or standing, worsen the dynamic outflow gradient and make the murmur louder. Manoeuvres that raise preload or afterload have the opposite effect.

Question 10Cardiology

A 62-year-old hypertensive man has sudden severe tearing chest pain radiating to the back. He is haemodynamically stable. Chest radiograph shows a widened mediastinum. Which is the most appropriate imaging investigation?

  1. CT angiography of the aorta Correct answer.
  2. Exercise treadmill testing
  3. Transthoracic echocardiography
  4. Coronary angiography

Explanation

CT angiography of the aorta is the first-line investigation for suspected acute aortic dissection in a stable patient, offering rapid acquisition with high sensitivity and specificity. It also defines the extent of dissection and involvement of branch vessels.

Question 11Cardiology

An ECG shows a regular ventricular rate of 38 beats per minute with narrow QRS complexes. P waves are present at 90 beats per minute with no fixed relationship to the QRS complexes. Which is the most likely diagnosis?

  1. Mobitz type I (Wenckebach) block
  2. Complete (third-degree) heart block Correct answer.
  3. First-degree heart block
  4. Sinus bradycardia with sinus arrhythmia

Explanation

Complete heart block produces atrioventricular dissociation, so P waves and QRS complexes occur independently at their own rates. The ventricles are driven by an escape rhythm, which may be junctional (narrow) or ventricular (broad).

Question 12Cardiology

Which finding is most typical of mitral regurgitation?

  1. Early diastolic murmur at the left sternal edge
  2. Ejection systolic murmur radiating to the carotids
  3. Mid-diastolic rumble with an opening snap
  4. Pansystolic murmur radiating to the axilla Correct answer.

Explanation

The regurgitant jet in mitral regurgitation is directed anteriorly and laterally, producing a pansystolic murmur loudest at the apex that radiates to the axilla. The murmur is generated by flow across the incompetent valve throughout systole.

Question 13Cardiology

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

  1. Elevated C-reactive protein
  2. Fever above 38 degrees Celsius
  3. Typical organisms in two blood cultures Correct answer.
  4. Predisposing heart condition or intravenous drug use

Explanation

The Duke criteria classify persistently positive blood cultures with typical organisms, and evidence of endocardial involvement on imaging, as major criteria. Clinical features such as fever and predisposing conditions are minor criteria.

Question 14Cardiology

Statins lower LDL cholesterol by which mechanism?

  1. Inhibition of intestinal cholesterol absorption
  2. Inhibition of HMG-CoA reductase Correct answer.
  3. Sequestration of bile acids in the gut
  4. Activation of lipoprotein lipase

Explanation

Statins competitively inhibit HMG-CoA reductase, the rate-limiting enzyme of hepatic cholesterol synthesis. The fall in intracellular cholesterol upregulates hepatic LDL receptors, increasing clearance of LDL from plasma.

Question 15Cardiology

A 55-year-old woman with a large pericardial effusion develops worsening breathlessness. Blood pressure is 88/70 mmHg, the JVP is elevated and heart sounds are soft. Which finding on examination would best support cardiac tamponade?

  1. Pulsus paradoxus Correct answer.
  2. Pulsus bisferiens
  3. Pulsus parvus et tardus
  4. Pulsus alternans

Explanation

In tamponade, raised pericardial pressure exaggerates the normal inspiratory fall in systolic blood pressure, and a fall of more than 10 mmHg defines pulsus paradoxus. Hypotension, raised JVP and muffled heart sounds form the classic clinical triad.

Question 16Cardiology

A 34-year-old woman with a long-standing ventricular septal defect develops cyanosis and clubbing. Echocardiography shows pulmonary artery pressure equal to systemic pressure, with right-to-left shunting across the defect. Which term best describes this?

  1. Persistent ductus arteriosus
  2. Tetralogy of Fallot
  3. Tricuspid atresia
  4. Eisenmenger syndrome Correct answer.

Explanation

A long-standing left-to-right shunt causes pulmonary vascular remodelling, and once pulmonary vascular resistance exceeds systemic resistance the shunt reverses, producing cyanosis and clubbing. This acquired shunt reversal with pulmonary hypertension is termed Eisenmenger syndrome.

Question 17Cardiology

A 55-year-old smoker attends after an episode of chest pain that has now resolved. He is pain-free and troponin is normal. ECG shows deep biphasic T wave inversion in leads V2 and V3. What is the most appropriate management?

  1. Repeat ECG in 24 hours
  2. Exercise stress testing
  3. Urgent coronary angiography Correct answer.
  4. Discharge with follow-up in one week

Explanation

Wellens' pattern in a pain-free patient reflects a critically stenosed proximal LAD and carries a high risk of extensive anterior infarction. Urgent inpatient angiography is required, and stress testing must be avoided because it can precipitate occlusion.

Question 18Respiratory Medicine

Which spirometric finding confirms persistent airflow obstruction in chronic obstructive pulmonary disease?

  1. Total lung capacity above 80% of predicted
  2. Post-bronchodilator FEV1/FVC below 0.70 Correct answer.
  3. FEV1 below 80% of predicted with a normal FVC
  4. A 12% rise in FEV1 after a bronchodilator

Explanation

COPD is confirmed by a post-bronchodilator FEV1/FVC ratio below 0.70, demonstrating persistent airflow obstruction. Significant reversibility may occur in COPD and does not exclude the diagnosis. FEV1 alone and total lung capacity do not define obstruction.

Question 19Respiratory Medicine

Which inhaled regimen is recommended as initial maintenance therapy for a patient with asthma who has symptoms on most days?

  1. Salbutamol as required alone
  2. Low-dose inhaled corticosteroid Correct answer.
  3. Oral theophylline
  4. Long-acting beta-2 agonist alone

Explanation

Frequent daytime symptoms indicate the need for regular anti-inflammatory treatment, and a low-dose inhaled corticosteroid is the standard initial maintenance therapy. A short-acting beta-2 agonist is used for symptom relief only. Long-acting beta-2 agonists should not be used as monotherapy in asthma.

Question 20Respiratory Medicine

What oxygen saturation target is recommended for a patient with COPD who is at risk of hypercapnic respiratory failure?

  1. 88-92% Correct answer.
  2. 94-98%
  3. 90-94%
  4. 85-88%

Explanation

Patients with COPD who are at risk of hypercapnia should receive controlled oxygen to a target saturation of 88-92%. Higher saturations may worsen hypercapnia through loss of hypoxic vasoconstriction and the Haldane effect. Lower saturations risk tissue hypoxia.

Question 21Respiratory Medicine

According to Light's criteria, which finding classifies a pleural effusion as exudative?

  1. Pleural fluid LDH/serum LDH ratio above 0.3
  2. Pleural fluid glucose/serum glucose ratio above 0.5
  3. Pleural fluid protein/serum protein ratio above 0.5 Correct answer.
  4. Pleural fluid protein concentration above 25 g/L

Explanation

Light's criteria classify an effusion as exudative if the pleural fluid protein/serum protein ratio exceeds 0.5, the pleural fluid LDH/serum LDH ratio exceeds 0.6, or the pleural fluid LDH exceeds two-thirds of the upper limit of normal serum LDH. Meeting any one criterion is sufficient.

Question 22Respiratory Medicine

Which organism is the most common cause of community-acquired pneumonia in adults?

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

Explanation

Streptococcus pneumoniae remains the most frequently identified cause of community-acquired pneumonia in adults. Atypical organisms such as Mycoplasma are less common overall. Haemophilus influenzae is more often seen in patients with underlying COPD.

Question 23Respiratory Medicine

In a haemodynamically stable patient with suspected pulmonary embolism and a low Wells score, which investigation is recommended next?

  1. D-dimer testing Correct answer.
  2. Ventilation-perfusion scanning
  3. Transthoracic echocardiography
  4. CT pulmonary angiography

Explanation

With a low pretest probability, D-dimer testing is the next step; a negative result safely excludes pulmonary embolism in this setting. Imaging is reserved for a positive D-dimer or a high pretest probability. Echocardiography is not a diagnostic test for stable pulmonary embolism.

Question 24Respiratory Medicine

Which variable completes the CURB-65 score when added to confusion, respiratory rate, blood pressure and age 65 years or older?

  1. Urea above 7 mmol/L Correct answer.
  2. Confusion
  3. Age 65 years or older
  4. Respiratory rate of 30 breaths/min or more

Explanation

CURB-65 stands for Confusion, Urea above 7 mmol/L, Respiratory rate of 30 breaths/min or more, Blood pressure (systolic below 90 mmHg or diastolic 60 mmHg or less), and age 65 years or older. Urea is the variable that distinguishes CURB-65 from CRB-65.

Question 25Respiratory Medicine

Which pattern of emphysema is most characteristic of alpha-1 antitrypsin deficiency?

  1. Basal panacinar emphysema Correct answer.
  2. Apical centriacinar emphysema
  3. Apical paraseptal emphysema
  4. Diffuse centriacinar emphysema

Explanation

Alpha-1 antitrypsin deficiency typically causes early-onset panacinar emphysema with a lower-lobe predominance. Smoking-related emphysema is more often centriacinar and affects the upper lobes. The distribution is useful in deciding whom to test for alpha-1 antitrypsin deficiency.

Question 26Respiratory Medicine

Which organism is most likely in a patient with pneumonia, diarrhoea, confusion and hyponatraemia?

  1. Streptococcus pneumoniae
  2. Mycoplasma pneumoniae
  3. Legionella pneumophila Correct answer.
  4. Chlamydophila psittaci

Explanation

Legionella pneumonia classically causes gastrointestinal symptoms, confusion, hyponatraemia and lobar consolidation. These systemic features reflect the extrapulmonary effects of the organism. Pneumococcus more typically presents with abrupt fever, pleuritic pain and rusty sputum.

Question 27Respiratory Medicine

Which treatment is first-line for moderate-to-severe obstructive sleep apnoea with excessive daytime sleepiness?

  1. Nocturnal oxygen therapy
  2. Continuous positive airway pressure Correct answer.
  3. A mandibular advancement device
  4. Uvulopalatopharyngoplasty

Explanation

Continuous positive airway pressure is first-line therapy for moderate-to-severe obstructive sleep apnoea with symptomatic daytime sleepiness. It splints the upper airway open and reduces apnoeas and arousals. Mandibular advancement devices are generally used for mild disease or when CPAP is not tolerated.

Question 28Respiratory Medicine

Which sweat chloride result is diagnostic of cystic fibrosis when confirmed on two separate samples?

  1. Above 30 mmol/L
  2. Above 40 mmol/L
  3. Above 60 mmol/L Correct answer.
  4. Above 80 mmol/L

Explanation

A sweat chloride concentration above 60 mmol/L on two occasions is diagnostic of cystic fibrosis. Values between 30 and 59 mmol/L are intermediate and require further genetic or clinical assessment. Values below 30 mmol/L are generally considered normal.

Question 29Respiratory Medicine

Which bronchoalveolar lavage finding supports a diagnosis of sarcoidosis?

  1. Eosinophil predominance
  2. CD4/CD8 ratio above 3.5 Correct answer.
  3. CD4/CD8 ratio below 1
  4. Neutrophil predominance

Explanation

Sarcoidosis typically produces a lymphocytic bronchoalveolar lavage with a CD4/CD8 ratio above 3.5. This finding supports the diagnosis but is not required, and the diagnosis still rests on compatible clinical, radiological and histological features.

Question 30Respiratory Medicine

What is the typical latency period between asbestos exposure and the development of malignant mesothelioma?

  1. 5 to 10 years
  2. 10 to 20 years
  3. 30 to 40 years Correct answer.
  4. 1 to 3 years

Explanation

Malignant mesothelioma usually develops after a long latency of about 30 to 40 years following asbestos exposure. This long interval means that occupational exposure may have occurred decades earlier. Shorter latencies are not typical for mesothelioma.

Question 31Respiratory Medicine

A smoker with a central lung mass develops hyponatraemia due to SIADH. Which histological type is most likely?

  1. Small cell carcinoma Correct answer.
  2. Squamous cell carcinoma
  3. Large cell carcinoma
  4. Adenocarcinoma

Explanation

Small cell lung cancer is typically central and is the histological type most associated with paraneoplastic syndromes, including SIADH and ectopic ACTH secretion. Adenocarcinoma is more often peripheral. Squamous cell carcinoma is more associated with hypercalcaemia.

Question 32Respiratory Medicine

An adult with COPD has pH 7.32, PaCO2 70 mmHg and bicarbonate 34 mmol/L. Which acid-base disturbance is most likely?

  1. Chronic respiratory acidosis Correct answer.
  2. Acute-on-chronic respiratory acidosis
  3. Metabolic alkalosis with respiratory compensation
  4. Acute respiratory acidosis

Explanation

The raised PaCO2 with a raised bicarbonate and only mild acidaemia indicates renal compensation, which takes days and therefore reflects chronic respiratory acidosis. In acute respiratory acidosis, bicarbonate would be close to normal. Acute-on-chronic acidosis usually shows a more marked acidaemia for the degree of hypercapnia.

Question 33Respiratory Medicine

Which arterial blood gas finding in acute severe asthma most suggests impending respiratory failure?

  1. PaCO2 of 3.5 kPa
  2. PaO2 of 9 kPa
  3. PaCO2 of 5.0 kPa Correct answer.
  4. pH of 7.48

Explanation

Early acute severe asthma causes hyperventilation and a low PaCO2. A normal or rising PaCO2 indicates that the patient can no longer maintain hyperventilation and is at risk of respiratory failure. This is a more ominous sign than mild hypoxaemia or respiratory alkalosis.

Question 34Respiratory Medicine

Which autoantibody is most strongly associated with pulmonary arterial hypertension in limited cutaneous systemic sclerosis?

  1. Anti-centromere Correct answer.
  2. Anti-Scl-70
  3. Anti-Jo-1
  4. Anti-RNA polymerase III

Explanation

Anti-centromere antibodies are associated with limited cutaneous systemic sclerosis, which predisposes to pulmonary arterial hypertension. Anti-Scl-70 is more associated with diffuse cutaneous disease and interstitial lung disease. Patients with limited cutaneous systemic sclerosis should be screened for pulmonary hypertension.

Question 35Gastroenterology (including Hepatology)

A 30-year-old woman has a six-month history of diarrhoea, bloating and weight loss. Which is the most appropriate first-line serological test for coeliac disease?

  1. IgA tissue transglutaminase Correct answer.
  2. Anti-smooth muscle antibody
  3. IgG deamidated gliadin peptide antibody
  4. Antimitochondrial antibody

Explanation

IgA tissue transglutaminase is the recommended first-line serological test, having high sensitivity and specificity for coeliac disease. Total IgA must be measured at the same time, because selective IgA deficiency causes false-negative IgA-based tests. Duodenal biopsy remains confirmatory in adults.

Question 36Gastroenterology (including Hepatology)

Which histological feature is most characteristic of ulcerative colitis?

  1. Perianal fissures and skin tags
  2. Skip lesions with transmural granulomatous inflammation
  3. Deep transmural inflammation with fistulae and abscesses
  4. Continuous mucosal inflammation starting in the rectum Correct answer.

Explanation

Ulcerative colitis produces continuous, symmetrical inflammation that always involves the rectum and extends proximally without skip areas. The inflammatory infiltrate is confined to the mucosa and submucosa, which is why fistulae and strictures are uncommon.

Question 37Gastroenterology (including Hepatology)

A 60-year-old man with cirrhosis becomes confused and drowsy after an upper gastrointestinal bleed. He is haemodynamically stable and ascitic fluid analysis shows no infection. Which is the most appropriate first-line treatment?

  1. Rifaximin monotherapy
  2. Oral neomycin
  3. Oral metronidazole
  4. Oral lactulose Correct answer.

Explanation

Lactulose is first-line for overt hepatic encephalopathy; it acidifies the colon so that ammonia is trapped as non-absorbable ammonium and is excreted in stool. Rifaximin is added for secondary prophylaxis after a further episode rather than used alone acutely. Any precipitant such as bleeding must also be treated.

Question 38Gastroenterology (including Hepatology)

A 40-year-old man completes a course of eradication therapy for Helicobacter pylori infection. Which test is best for confirming eradication?

  1. H. pylori IgG serology
  2. Rapid urease test on antral biopsy
  3. 13C urea breath test Correct answer.
  4. Histology of antral biopsies

Explanation

The urea breath test detects active infection and is the preferred non-invasive method for confirming eradication. It should be performed at least four weeks after completing treatment and two weeks after stopping a proton pump inhibitor, since these reduce sensitivity.

Question 39Gastroenterology (including Hepatology)

A 45-year-old man presents with severe epigastric pain radiating to the back. Which finding best supports a diagnosis of acute pancreatitis?

  1. Serum alanine aminotransferase five times the upper limit of normal
  2. Serum C-reactive protein of 40 mg/L
  3. Serum alkaline phosphatase twice the upper limit of normal
  4. Serum lipase three times the upper limit of normal Correct answer.

Explanation

Acute pancreatitis is diagnosed when two of three criteria are met: characteristic pain, a lipase or amylase level more than three times the upper limit of normal, and typical cross-sectional imaging. Lipase is more sensitive and specific than amylase and remains elevated for longer.

Question 40Gastroenterology (including Hepatology)

A blood donor is found to be HBsAg positive, HBeAg positive and anti-HBe negative. What does the HBeAg result indicate?

  1. Immunity to hepatitis B virus
  2. Chronic infection with low infectivity
  3. High-level viral replication with increased infectivity Correct answer.
  4. Co-infection with hepatitis D virus

Explanation

HBeAg positivity reflects active viral replication with high circulating HBV DNA and therefore high infectivity. Seroconversion from HBeAg to anti-HBe usually signals a switch to low-level replication, the inactive carrier state.

Question 41Gastroenterology (including Hepatology)

A 30-year-old woman has fatigue and jaundice. Alanine aminotransferase is 400 U/L, serum IgG is raised, ANA titre is 1:320 and antimitochondrial antibody is negative; biopsy shows interface hepatitis. Which is the most appropriate initial treatment?

  1. Ursodeoxycholic acid alone
  2. Azathioprine as monotherapy
  3. Mycophenolate mofetil as monotherapy
  4. Prednisolone, with or without azathioprine Correct answer.

Explanation

Type 1 autoimmune hepatitis is treated with corticosteroids as induction, usually combined with azathioprine as a steroid-sparing agent. Budesonide is an alternative in non-cirrhotic disease. Ursodeoxycholic acid has no role here.

Question 42Gastroenterology (including Hepatology)

Which antibody is most characteristic of primary biliary cholangitis?

  1. Anti-liver-kidney microsomal antibody
  2. Anti-mitochondrial antibody Correct answer.
  3. Perinuclear antineutrophil cytoplasmic antibody
  4. Anti-smooth muscle antibody

Explanation

Anti-mitochondrial antibodies, principally the M2 subtype, are found in around 90 to 95 per cent of patients with primary biliary cholangitis and are its serological hallmark. They are accompanied by a cholestatic enzyme pattern with a raised alkaline phosphatase.

Question 43Gastroenterology (including Hepatology)

A 52-year-old man has diabetes, arthralgia and skin bronzing. Transferrin saturation is 62 per cent and ferritin 1200 µg/L; HFE testing shows C282Y homozygosity. Which treatment improves survival?

  1. Subcutaneous desferrioxamine
  2. Regular venesection Correct answer.
  3. Dietary iron restriction alone
  4. Oral penicillamine

Explanation

Regular venesection is the treatment of choice in HFE-related haemochromatosis and improves survival by mobilising and removing the excess iron load. Chelation is reserved for transfusional iron overload or when venesection is not feasible. Early treatment also prevents progression to cirrhosis and diabetes.

Question 44Gastroenterology (including Hepatology)

A 22-year-old man has a tremor, deranged liver tests and a low serum caeruloplasmin. Which finding would best confirm a diagnosis of Wilson disease?

  1. Serum ferritin of 900 µg/L
  2. 24-hour urinary copper excretion above 100 µg Correct answer.
  3. Serum caeruloplasmin concentration of 0.15 g/L
  4. Positive antimitochondrial antibody

Explanation

Markedly increased 24-hour urinary copper excretion, typically above 100 µg, is a key confirmatory test for Wilson disease in a compatible clinical setting. A low caeruloplasmin supports the diagnosis but lacks specificity and can be normal, particularly in acute liver failure. Liver biopsy copper quantification or genetic testing may be needed in equivocal cases.

Question 45Gastroenterology (including Hepatology)

A 40-year-old man has emphysema and deranged liver tests. Serum alpha-1 antitrypsin is markedly reduced. Which liver biopsy finding is characteristic?

  1. Steatosis with Mallory-Denk bodies and neutrophil infiltration
  2. PAS-positive diastase-resistant periportal globules Correct answer.
  3. Florid bile duct lesions with non-caseating granulomas
  4. Interface hepatitis with plasma cells and rosette formation

Explanation

Alpha-1 antitrypsin deficiency causes retention of the mutant protein in the endoplasmic reticulum of periportal hepatocytes, seen as PAS-positive, diastase-resistant globules. The globules are most prominent in the periportal zone. Emphysema results from uninhibited neutrophil elastase in the lung.

Question 46Gastroenterology (including Hepatology)

A 58-year-old man with long-standing alcohol excess has ascites. Serum albumin is 30 g/L and ascitic fluid albumin is 12 g/L. What does the calculated serum-ascites albumin gradient indicate?

  1. Tuberculous peritonitis
  2. Portal hypertension Correct answer.
  3. Peritoneal carcinomatosis
  4. Pancreatic ascites

Explanation

The serum-ascites albumin gradient is serum albumin minus ascitic albumin, here 30 minus 12, giving 18 g/L. A gradient of 11 g/L or more indicates that ascites is driven by portal hypertension, as in cirrhosis or cardiac failure.

Question 47Gastroenterology (including Hepatology)

A 55-year-old man with alcohol-related cirrhosis has medium oesophageal varices on endoscopy and has never bled. Which is the most appropriate primary prophylaxis?

  1. A non-selective beta-blocker Correct answer.
  2. Transjugular intrahepatic portosystemic shunt
  3. Long-acting oral nitrates alone
  4. A proton pump inhibitor

Explanation

Non-selective beta-blockers such as propranolol or carvedilol lower portal pressure and are first-line primary prophylaxis against variceal bleeding in patients with medium or large varices. Endoscopic band ligation is the alternative where beta-blockers are contraindicated or not tolerated.

Question 48Gastroenterology (including Hepatology)

A 68-year-old woman has a six-week history of watery diarrhoea. Colonoscopy is macroscopically normal but biopsies show a thickened subepithelial collagen band. Which is the most appropriate first-line drug treatment?

  1. Loperamide as required
  2. Oral budesonide Correct answer.
  3. Oral mesalazine
  4. Oral prednisolone

Explanation

Budesonide is first-line treatment for collagenous colitis because extensive first-pass hepatic metabolism gives high local gut activity with fewer systemic steroid effects than prednisolone. It induces clinical and histological remission in most patients. Offending drugs such as NSAIDs should also be stopped.

Question 49Gastroenterology (including Hepatology)

A 48-year-old man has recurrent peptic ulcers and diarrhoea. Fasting serum gastrin is markedly raised and gastric pH is 2. Which investigation best confirms Zollinger-Ellison syndrome?

  1. H. pylori stool antigen test
  2. Twenty-four-hour ambulatory oesophageal pH monitoring
  3. Secretin stimulation test with a rise in serum gastrin Correct answer.
  4. Basal acid output of 5 mmol/hour

Explanation

Zollinger-Ellison syndrome is confirmed by a paradoxical rise in serum gastrin during secretin stimulation, in a patient with hypergastrinaemia and gastric acid hypersecretion with a pH below 2. The low gastric pH distinguishes it from hypergastrinaemia caused by acid suppression or atrophic gastritis.

Question 50Gastroenterology (including Hepatology)

A 55-year-old man with cirrhosis and ascites has a diagnostic tap showing 400 neutrophils per mm3. He is started on intravenous cefotaxime. Which additional intervention reduces mortality?

  1. Oral rifaximin
  2. Intravenous terlipressin
  3. Continuous furosemide infusion
  4. Intravenous human albumin Correct answer.

Explanation

In spontaneous bacterial peritonitis, adding intravenous albumin to antibiotics reduces the incidence of type 1 hepatorenal syndrome and improves survival, with the greatest benefit in those with renal impairment or bilirubin above 68 µmol/L. Albumin is given on the day of diagnosis and again on day three.