MRCP 2 Masterclass – Gastroenterology

A 58-year-old woman with autosomal dominant polycystic kidney disease presents with increasing abdominal discomfort and distention. A CT scan of her abdomen is
shown below.

What does this show?

A 68-year-old man with a past history of severe seropositive rheumatoid arthritis presents with difficulty swallowing, such that on a couple of occasions he has ‘almost choked’ after eating bread. He has lost about a stone in weight over the last couple of months. On examination he has musculoskeletal deformities due to his rheumatoid arthritis and he looks unwell and a bit pale, but there are no other abnormalities. His barium swallow is shown.

What is the likely diagnosis?

A 47-year-old man presents with a 1 day history of increasing confusion, drowsiness and jaundice. He has been suffering from depression for the last 6 months, but
has no other significant past medical history.

The two most likely causes of his acute liver failure are:

A 35-year-old white English woman presents with abdominal pain and vomiting. She has been unwell for about six weeks with anorexia, nausea and weight loss.
Examination reveals a tender palpable mass in the right iliac fossa.

The two most likely diagnoses are:

You are called to review a 67-year-old man admitted 4 days ago with central abdominal pain. A diagnosis of acute pancreatitis was made clinically and biochemically, and the surgeons have managed him conservatively. A few small gallbladder stones were noted on ultrasonography, but the common bile duct was not dilated and no stones
were seen in the duct. A CT scan has been requested. He is a strict Muslim whose only other past medical history is ulcerative colitis, for which he is on treatment with prednisolone and azathioprine.

The two most likely causes of his pancreatitis are:

A 35-year-old woman, otherwise fit and well, presents with isolated transaminitis. She denies excess alcohol use and ultrasound of her liver reveals only fatty change. Her
standard liver screen is negative.

Which statement best reflects this clinical scenario?

A 43-year-old man presents with an acute colitic illness and is passing between five and ten bloody stools per day. 

Which one of the following statements is true?

An 83-year-old man is about to be discharged home, having spent 3 weeks in hospital being treated for C. difficile diarrhoea associated with pseudomembranous colitis.
Unfortunately, the nursing staff report that he has had a recurrence of profuse, malodorous, greenish diarrhoea. He has already had one course of oral metronidazole
therapy.

Which of the following is the most appropriate treatment?

A 21-year-old student develops abdominal pain, fever and diarrhoea 12 hours after eating a chicken sandwich that had been in his fridge for a week. 

The most likely cause is:

A 30-year-old woman with long standing medically treated Crohn’s disease presents to clinic with increasing abdominal pain associated with intermittent vomiting
and bloating. Her inflammatory markers are normal. 

Which is the most likely cause of her symptoms?

A 70-year-old woman presents with watery diarrhoea. Flexible sigmoidoscopy is reported as normal but histology shows a lymphocytic infiltration.

Which of the following best describes optimum management and complications?

A previously fit 35-year-old man presents with pyrexia and tachycardia, severe bloody diarrhoea and mucus per rectum. His symptoms have been present for three weeks.

The most likely diagnosis is:

A 35-year-old woman presents with abdominal bloating, change in the form of her stool with nocturnal diarrhoea, abdominal pain relieved by defaecation, and marked gastrocolic reflex. 

Which one of these features is NOT a feature of Irritable Bowel Syndrome:

A 60-year-old man with known ulcerative colitis and diverticular disease comes to clinic complaining of passing faeces per urethra. Cystoscopy confirms a fistula
between his bladder and bowel.

Which treatment is most likely to be effective?

A 70-year-old man presents to casualty with lower abdominal pain and fever. He is not jaundiced and blood analysis reveals only a raised white cell count, with normal
liver function tests. Previous upper GI endoscopy is reported as normal and urinalysis and MSU are normal.

What is the most likely diagnosis?

You are asked to review a 45-year-old man recovering from a road traffic accident, just off intensive care. Although able to eat and drink small amounts he remains generally weak and has lost 20% of his pre-morbid weight. His bowels are working normally. The orthopaedic team ask your advice regarding his nutrition.

What do you recommend?

A 28-year-old man complains of a 3-year history of difficulty swallowing both solids and liquids. A barium meal shows a slightly dilated oesophagus and subsequent endoscopy is normal apart from oesophageal candidiasis.

The next best investigation is: 

A 65-year-old man complains of epigastric pain and difficulty swallowing. At endoscopy Grade I reflux oesophagitis is seen.

Which one of the following statements is NOT true?

70-year-old man with dysphagia is seen in clinic. He is unable to swallow any solids or fluids.

What is the best course of action?

A 78-year-old woman is admitted on take because she is unable to cope at home. She says that she feels ‘a bit weak’ but admits to no other symptoms. On examination she
looks as though she has lost a lot of weight and is jaundiced, but there are no other abnormal physical signs.

The most likely diagnosis is:

A 55-year-old man is still anaemic, has some loose stools and has failed to regain weight several months after starting a gluten-free diet for coeliac disease.

Which of the following is the commonest cause of failure to respond to treatment?

A 68-year-old woman presents with a six-month history of diarrhoea and weight loss. Extensive investigation eventually culminates in the finding of multiple diverticula
on a small bowel enema.

The first-line treatment should be:

A 30-year-old woman is seen with weight loss and diarrhoea. Three years ago she spent 6 months in Egypt. Previous investigations have included negative endomysial antibodies, normal hydrogen breath test and normal barium follow through.

Which method is the most appropriate way of diagnosing chronic giardiasis?

A 46-year-old man presents with jaundice. Dipstick testing of his urine reveals the presence of bilirubin but no urobilinogen.

This means that:

A 58-year-old man presents with diarrhoea and weight loss. Amongst many investigations he has a lactulose breath test.

The reason for the test is to detect:

A 55-year-old man diagnosed with total ulcerative colitis at the age of 20 
presented with a 3-month history of rectal bleeding. He was opening his bowels twice a day, passing formed stool. His colitis had been well-controlled for the last 10 years with oral mesalazine 400mg bd.

His blood tests were as follows:

What is the most appropriate next step?

Four weeks after returning from a trip to the Indian subcontinent, a 44-year-old woman presented to A&E complaining that she had been feeling unwell for about a week with symptoms of nausea and anorexia. She did not drink alcohol, look no regular medications and had had only one sexual partner for the last few years. There was no past medical history of note.

Examination revealed a tender liver, palpable to 4 cm below the costal margin. The spleen was also just palpable. Blood results were as follows:

Which of the following is the most likely diagnosis?

A 24-year-old lady with an 8-year history of ileocolonic Crohn’s disease presented with a 2-day history of shortness of breath. She had smoked 10 cigarettes a day for the last 10years. Her Crohn’s disease had been difficult to-control and she had recently been started on oral prednisolone, 40mg per day, in addition to her usual medications of oral mesalazine and methotrexate, both of which she had been taking for many years.

On examination she had a respiratory rate of 22 breaths/minute and her pulse was 110 bpm. Auscultation of her chest was unremarkable.

Which of the following tests is the most appropriate?

A 31-year-old lady presents with a 2-month history of malaise and anorexia. She drinks 21 units of alcohol a week and returned from a holiday in South-East Asia 3 months previously. She is on no regular medication and has not had any recent sexual contacts.

Her investigations were as follows:

What is the most likely diagnosis?

A 64-year-old lady presented with a 2-day history of melaena and epigastric pain. She had a history of osteoarthritis for which she took diclofenac. 

On admission she had a pulse of 125 bpm. Her blood pressure was 110/70 mmHg lying and 100/50 mmHg when sitting. She was resuscitated with intravenous colloid. At endoscopy, she was found to have a stricture in the mid-oesophagus which prevented passage of the endoscope. She continued to have melaena and accordingly had angiography performed which is shown below.

What is the most likely source of her bleeding?

A 42-year-oldmanis referred to Outpatients with a history of tiredness. He had previously had a prophylactic colectomy with ileostomy formation for a family history of colorectal carcinoma. 

The specimen from this operation is shown below. His ileostomy is functioning normally and external examination is unremarkable.

What is the most likely diagnosis?

A 28-year-old woman of Irish descent was referred to hospital with a history of malaise and tiredness for 6 months. She complained that her bowels had always been erratic but were more so recently; she had been passing semi-formed stools three times a day for the last few months. There was no history of foreign travel and, other than the oral contraceptive pill, she was on no regular medications.

Examination revealed that she was pale and undernourished. Her laboratory investigations were as follows:

Anti-endomysial Ab negative

What is the most appropriate test?

A 74-year-oldwoman presented with a 4-month history of anorexia and weight loss. She had previously been fit and well and, apart from some mild epigastric pain, had no other symptoms.

On examination she was clinically anaemic and had an area of abnormal
pigmentation on the back (see below).

What is the most likely diagnosis?

A 35-year-oldwoman was referred to hospital with a 6-month history of diarrhoea. She described the passage of watery stool up to five times a day with associated cramping lower abdominal pain and bloating. There was no history of foreign travel or of weight loss, and she did not take any regular medications.

Examination of the perianal region revealed some excoriation but digital
rectal examination and rigid sigmoidoscopy were normal. Her investigations were as follows:

What is the most likely diagnosis?

A 42-year-old lady presented to A&E with a 4-week history of fevers, malaise, headache and a cough productive of yellow sputum. She had also noted occasional fevers and had lost 3 kg in weight. She had a 20-year history of small-bowel and perianal fistulating Crohn’s disease for which she was taking azathioprine (2 mg/kg) and had recently had her second infusion of anti-tumour necrosis factor-cc antibodies. Her diarrhoea and abdominal pain had improved and the perianal fistulae had become less active. She smoked20cigarettes a day and had done so for 15 years.

On examination, her temperature was 37.4 °C and her chest had occasional scattered wheezes throughout. Her abdomen was soft and non-tender. Her chest X-ray is shown below. 

What is the likely diagnosis?

A 55-year-oldman was referred by his CP with recent onset of dysphagia. Although able to swallow most of the time, he found that food stuck if he did not chew it adequately. He had a long history of gastro-oesophageal reflux for which he took a proton pump inhibitor, but he had never had an upper gastrointestinal endoscopy. He was otherwise asymptomatic. He had smoked 15 cigarettes a day for the last 40 years and drank two
measures of whisky each night before bed.

Examination of his abdomen was unremarkable and all his blood tests were normal. A barium swallow was performed:

Which of the following is the most likely diagnosis?

A 44-year-olclman was referred by his GP with a 2-month history of foul-smelling, greasy stools. He had recently returned from an 8-week trip to Vietnam, his symptoms having developed about halfway through his stay. His weight had decreased by 4 kg over the last 4 weeks. He was opening his bowels up to six times per day and had accompanying abdominal pain, bloating and nausea. He drank 28 units of alcohol per
week and took multivitamins. External examination was unremarkable.

His GP had sent a stool sample for microscopy and culture, the results of which were normal.

Which of (he following organisms is most likely to account for his symptoms?

A 56-year-old Chinese woman presented to Outpatients with a history of nausea, upper abdominal pain, abdominal swelling and weight loss. There was no history of change in bowel habit or rectal bleeding and she had no past history of note. 

Examination revealed jaundice, 4-cm, irregular hepatomegaly, and gross ascites. No other masses were palpable in her abdomen.

Serum tumour markers were as follows:

A CT scan of her abdomen is shown below.

What is the most likely diagnosis?

A 33-year-old lady presented to A&E with a 2-week history of nausea and vomiting, malaise and headache. She was 36 weeks pregnant and had had three uncomplicated pregnancies previously.

Examination revealed that she was normotensive and had mild peripheral oedema. Palpation of her abdomen revealed a gravid uterus consistent with the duration of her pregnancy and mild tenderness in her right upper quadrant. Her urine was negative for protein. Her blood tests were as follows:

Which of the following is the most likely diagnosis?

A 52-year-oldgentleman was admitted with a history of haematemesis. He had drunk ten cans of strong lager a day for the last 10 years. 

Examination revealed that he was lachycardic (110 bpm)and hypotensive (95/60mmHgsupine). He was jaundiced and had multiple spider naevi on his chest wall. His spleen was palpable on inspiration and shifting dullness was detectable.

Blood results were as follows:

Which of the following is not appropriate as part of your immediate management?

A 19-year-old Bangladeshi man was referred to Outpatients with a history of slight weight loss, crampy abdominal pain and, occasionally bloody diarrhoea. He smoked 20 cigarettes a day, drank 14 units of alcohol per week and worked as a mechanic. There was no past history of note. He had started taking ibuprofen for his abdominal pain and loperamide for his diarrhoea.

On examination he was well, apyrexial and not tachycardic. He had mild tenderness in his right iliac fossa but no masses were palpable in his abdomen. His barium follow-through is shown below. 

Which three of the following are most appropriate as part of your initial management?

A 22-year-oldstudent, who had recently returned from a holiday in South-East Asia, presents to A&E complaining of worsening abdominal pain following a 7-day history of bloody diarrhoea.

Examination revealed that he was pyrexial at 37.8 °C, sweaty and tachycardic at 105 bpm. His blood pressure was 95/55 mmHg and palpation of his abdomen revealed that he was diffusely tender. His plain abdominal X-ray is shown below.

What should his subsequent management be?

A 19-year-old woman was brought into hospital by her mother who had recently returned home to find that her daughter was unwell. Two days previously, the daughter had split up from her boyfriend and had taken about 50paracetamoltablets after drinking a quarter of a bottle of spirits. She was not known to be a heavy drinker and had no past history of liver disease. Other than the oral contraceptive pill, she was on no regular medications.

On examination, her temperature was 37.1 °C. She was tearful and withdrawn, but alert and orientated. Aggressive fluid resuscitation and treatment with N-acetylcysteine were initiated.

Which one of the following tests, taken the following day, should prompt referral to a specialist liver unit?

A 65-year-old lady presented with a 6-month history of intermittent epigastric pain radiating to the back. For the past 2 weeks she had noticed that her stools had become pale and her urine dark. An ultrasound of her upper abdomen revealed that her common bile duct and intrahepatic ducts were dilated. She had had a cholecystectomy 15 years previously for cholelithiasis.

An image from endoscopic retrograde cholangiopancreatography (ERCP) is shown below.

What is the most likely diagnosis?

A 78-year-old woman was referred to Outpatients for an opinion. She lived in a nursing home and, along with many of the other residents, had had an attack of diarrhoea 10 weeks previously. However, her symptoms had persisted and she was still opening her bowels eight times a day and was now passing bloody stools. Over the last few days, lesions had been noted on her legs.

What is the lesion shown?

A 78-year-old woman was referred to Outpatients for an opinion. She lived in a nursing home and, along with many of the other residents, had had an attack of diarrhoea 10 weeks previously. However, her symptoms had persisted and she was still opening her bowels eight times a day and was now passing bloody stools. Over the last few days, lesions had been noted on her legs.

What is the most likely diagnosis?

A 3 1-year-old lawyer was referred by his GP who had investigated him for tiredness. As part of a screen of blood tests he had been found to have abnormal liver function tests. He had occasionally used intravenous drugs as a student but had not done so recently. He was married and had had no other sexual partners for the last 4 years. Other than feeling tired, he was asymptomatic. He took no regular medications and drank 40 units of alcohol a week.

Blood tests were as follows:

Which one of the following is not part of the initial management?

A 78-year-old retired banker was reviewed in the Outpatients Department after a recent admission with right lower lobe pneumonia. She had had two similar episodes, managed by her CP, over the last 2 years. She had mild angina for which she was taking aspirin and atenolol. Otherwise she was fit and well. She smoked 15 cigarettes a day from the age of 20, and drank 15 units of alcohol per week. Throughout her life, she had travelled widely in Africa and Asia.

Examination revealed no abnormal signs and her blood tests were unremarkable.
Her plain chest X-ray is shown below.

Which of the following is the most likely diagnosis?

A 58-year-oldCreek lady attended A&E with a 4-week history of discomfort in the right upper quadrant. 

Examination revealed that she was mildly tender in the right upper quadrant and had 4-cm hepatomegaly. She had a previous laparotomy scar, having had a duodenal ulcer oversewn 20 years previously. 

Liver function tests were normal, as was the full blood count. Her abdominal X-ray is shown below.

What is the most likely diagnosis?

A 32-year-oldpsychiatric patient was found to have iron deficiency anaemia on routine blood testing and was referred for an opinion. She complained of anorexia, fullness in her abdomen and, more recently, vomiting after eating solids. She was not vegetarian and said that she ate a varied diet, although she did suffer from menorrhagia. She had lost a little weight recently.

Examination revealed that she had a large mass in her upper abdomen. This was found to be non-tender, non-pulsatile and not to move on ventilation. Other than pale conjunctivae and thinning hair, no other signs were found. Her blood tests confirmed iron deficiency anaemia, but were otherwise normal.

Her plain abdominal X-ray is shown below.

Which of the following is the most likely diagnosis?

A 19-year-old woman presented to A&E with abdominal pain and vomiting. She had a long history of intermittent cramping abdominal pain, as did her younger brother, and her father had had two laparotomies. 

Examination and investigation revealed signs of small-bowel obstruction. A picture of her mouth is shown below.

What is the diagnosis?

A 55-year-old woman with a known history of coeliac disease was reviewed in Outpatients complaining of watery diarrhoea ten times per day and abdominal ramping pains of 10months’duration. There was no accompanying weight loss. She claimed to have been adhering to her gluten-free diet and gave no history of foreign travel or changes in her medication. She took aspirin and digoxin for chronic atrial fibrillation and ibuprofen for osteoarthritis. 

Examination revealed a well-looking lady who was in rate-controlled atrial fibrillation. No other abnormalities were noted. 

Full blood count, electrolytes, serum calcium, immunoglobulins, CRP and
the ESR were normal. IgA anti-endomysial antibodies were negative.

The colonic mucosa looked normal at colonoscopy. A biopsy specimen taken at the time is shown below.

What is the diagnosis?

A 27-year-old woman recently diagnosed with inflammatory bowel disease attended A&E. with severe upper abdominal pain. She also had epilepsy which was difficult to control, requiring recent manipulation of her drug therapy.

On examination she was tachycardic (1 10 bpm), hypotensive (95/55 mmHg) and had marked epigastric tenderness.

Blood results were as follows:

Which of the following drugs that she is taking is least likely lo be the cause?

A 79-year-old man was referred by his GP with a 4-month history of dysphagia. He was unable to pinpoint the site of his symptoms accurately but noted that his dysphagia worsened as he ate. At times he would regurgitate food during his meals, which would temporarily relieve his symptoms. According to his GP, who had weighed him, he had lost 1 kg in weight over the past 2 months. His medications included
bendroflumethiazide for hypertension and ranitidine, which he took intermittently for symptoms of gastro-oesophageal reflux disease. 

A barium swallow is shown below.

What is the diagnosis?

A 17-year-old Turkish girl presented to A&E with a 4-hour history of severe abdominal pain. The onset was rapid and without preceding symptoms. She described no change in her bowel habit or urinary symptoms. She had had an appendectomy 6 months previously and an exploratory laparotomy 2 months ago for similar episodes. At neither operation was any abnormality found other than a small amount of peritoneal fluid.

On examination she was pyrexial at 39.2 “C and tachycardic at 105 bpm. Her abdomen was diffusely tender with guarding in the right upper quadrant. Bowel sounds were reduced. A painful erythematous rash was noted on the lower limbs.

Investigations were as follows:

Which of the following is the most likely diagnosis?

A 27-year-old lady who was 16 weeks pregnant was referred for an opinion by the obstetricians because of recurrent vomiting. She had started vomiting early in her pregnancy and had not responded to treatment with anti-emetics. She now weighed 5kg less than when she became pregnant.Nasogastric and nasojejunal feeding were unsuccessful due to recurrent regurgitation of the tubes. Accordingly, total parenteral nutrition (TPN) was commenced. She also required supplemental intravenous fluids due to continued vomiting.

Her blood tests were checked 72 hours after initiating TPN and were as follows: 

What is the most likely explanation for these results?

A 44-year-old gentle man with a long history of diarrhoea presented with a painful lesion on his leg. He had noticed what he thought was an insect bite some days previously, which rapidly progressed to the lesion depicted. He had started feeling unwell with the development of the lesion and described general malaise and arthralgia.

A picture of the lesion and a barium enema are shown below.

What two diagnoses are shown?

A 55-year-old lady was admitted via A&E complaining of intermittent epigastric pain. She had had a cholecystectomy 1 year ago for these symptoms but continued to have pain after the procedure. The pain was severe, typically came on when she was eating, radiated to the back and was accompanied by nausea and sometimes vomiting. It tended to last for several hours and did not vary in intensity. She had had five attacks over the last year.

Blood results at the time of her admission are shown:

Bilirubin – 21 umol/L
AST – 100 U/L
ALT –  110 U/L
ALP – 176 U/L
Amylase – 220 U/L

An ultrasound scan showed a moderately dilated common bile duct (12 mm) but no stones were seen. Consequently, she underwent an endoscopic retrograde cholangiogram which, again, showed mildly dilated ducts. A sphincterotomy was performed along with trawling of the bile duct, again revealing no cause. Post-procedure she developed acute pancreatitis from which she recovered with conservative management. Subsequently, her symptoms resolved

Which of the following is the most likely diagnosis?

A 56-year-old gentleman is brought to the hospital after collapsing in the street. On arrival he is alert but disorientated and smells strongly of alcohol. He complains of a sore tongue.

Examination reveals that he is unkempt and malnourished, with angular stomatitis and glossitis. A picture of his hands is shown below.

What are the changes on his hands most likely due to?

A 55-year-old gentleman attended A&E with haematemesis half an hour previously. He was visiting the UK from Africa but had been well prior to presentation. On arrival he was shocked and pale and therefore underwent upper gastrointestinal endoscopy after adequate resuscitation.

Blood tests on arrival were as follows:

Examination of the oesophagus revealed large varices with stigmata of recent bleeding. No blood was seen but two red worms, about 10 mm in length, were noted adherent to the mucosa in the duodenum.

Which two agents is he most likely to be infected with?

A 45-year-old lady attended A&E with a 4-hour history of acute severe central abdominal pain that was colicky in nature and associated with nausea and vomiting. Other than hypertension, for which she had recently started a Beta-blocker and an angiotensin-converting enzyme inhibitor, she was fit and well with no past medical or surgical history and no family history of note.

Her plain abdominal X-ray is shown below.

What is the most likely diagnosis?

A 42-year-old man presented to his GP complaining of lethargy, pruritus, right upper quadrant discomfort and dry mouth and eyes. Otherwise he was asymptomatic and had no previous history of note. He drank 24 units of alcohol per week.

On examination, he had two-finger hepatomegaly and his spleen was just palpable. No signs of chronic liver disease were present.

Blood tests were as follows:
Sodium 132 mmol/L
Potassium 4.4 mmol/L
Urea 2.4 mmol/L
Creatinine 70 umol/L
Albumin 34 g/L
Bilirubin 25 umol/L
AST 44 U/L
ALT 41 U/L
ALP 556 U/L
GCT 1021 U/L
Serum LDL cholesterol 3.22 mmol/L
Serum HDL cholesterol 5.56 mmol/L
Serum IgM 6.5 g/L

What is the most likely diagnosis?

A 65-year-old woman is brought to A&E by her husband, complaining of upper abdominal and lower chest pain radiating to the back. As part of their fortieth wedding anniversary celebrations, they had been out for a large meal at which they had consumed more alcohol than they were normally used to. On returning home,  she had become nauseated and had vomited three times. Concurrently, she developed upper abdominal and lower chest pain and, subsequently, shortness of breath.

On examination, she was tachycardic at 105 bpm, tachypnoeic at 25 breaths per minute and was pyrexial at 37.8 °C. She had firmness in the upper abdomen and a plain chest X-ray confirmed the clinical findings of a left pleural effusion.

Which of the following is the most likely diagnosis?

A 67-year-old gentleman of Irish descent presented to Outpatients with a 10-month history of right iliac fossa abdominal pain and watery diarrhoea up to 15 times a day. He had been a heavy drinker in the past, consuming 40 pints of beer a week, but had cut back to pint a day for several years. He had recently noticed that his symptoms became worse when he drank alcohol and so had now stopped completely. His wife had noticed that he had lost weight recently but he was unable to quantify this. He had never smoked but his wife had noticed that he had had some attacks of wheeziness.

Examination of his abdomen revealed 3-cm hepatomegaly and an indistinct mass in the right iliac fossa. Urea and electrolytes, liver function tests and full blood count were normal, but a small-bowel barium examination revealed a submucosal mass in the ileum.

What is the likely diagnosis?

A 44-year-old woman attended A&E. complaining of shortness of breath and tiredness. She had recently started oral treatment for an intensely itchy, vesicular rash on the elbows, knees, buttocks and back. She also gave a history of mild diarrhoea and abdominal bloating, and had lost a stone in weight.

Her blood results were as follows (RDW, red cell distribution width):

Which two of the following are most likely to be contributing to her anaemia?

A 47-year-old woman attends Outpatients asking for advice. She has a family history of colorectal carcinoma. Her family tree is shown below (patient arrowed).

What is the most likely explanation for the family’s history?

A 69-year-old gentleman presented to A&E claiming to have swallowed a foreign object 2 hours previously. He had a long history of mental health problems and had presented with a similar history in the past. He denied any dysphagia, odynophagia or abdominal pain, and physical examination was unremarkable.

His plain abdominal X-ray is shown below.

What course of action would you advise?

A 28-year-old male presented with a six-month history of weight loss of 8 kg, generalized abdominal discomfort and diarrhoea. On examination he was pale and slim, but there were no other significant abnormalities.

Investigations are shown.

What is the diagnosis?

A 38-year-old English male was investigated after he was found to have an abnormal liver function test during a health insurance medical check. He worked in an
information technology firm. Apart from occasional fatigue he was well. He consumed less than 20 units of alcohol per week. The patient had only travelled out of
Europe twice and on both occasions he had been to North America. He took very infrequent paracetamol for aches and pains in his ankles and knees. There was no
history of hepatitis or transfusion or blood products. He had been married for 5 years. Systemic enquiry revealed infrequent episodes of loose stool for almost 4 years.

On examination he appeared well. There were no stigmata of chronic liver disease. Abdominal examination revealed a palpable liver edge 3 cm below the costal
margin. There were no other masses. Examination of the central nervous system was normal.

Investigations were as shown.

What is the most probable diagnosis?

A 16-year-old girl presented with intermittent episodes of lower colicky abdominal pain for six months. In the interim she had lost almost 6.4 kg in weight. Her
appetite was not impaired. There was no history of diarrhoea, although the patient had complained of intermittent constipation and abdominal bloating. The patient was English in origin. She had no family history of note. She had last travelled abroad to Barbados on holiday a year ago. The only other past medical history included a short episode of painful ankles associated with circular erythematous skin lesions.

On examination she was thin and mildly clubbed. The heart rate was 90 beats/min and regular. The blood pressure measured 100/55 mmHg. There was evidence of a BCG scar on inspection of the left upper arm. Both heart sounds were normal and the chest was clear. Abdominal examination revealed vague tenderness

affecting the hypogastrum and right iliac fossa.

Investigations are shown.

What is the diagnosis?

A 13-year-old girl was admitted with a two-day history of lower abdominal pain and blood-stained diarrhoea. Three days later, she developed pains in her ankles and right
elbow and felt nauseous. Positive findings on examination were a purpuric rash affecting the arms and legs, periorbital oedema and a blood pressure of 150/95 mmHg. Investigations are shown.

What is the most probable diagnosis?

A 13-year-old girl was admitted with a two-day history of lower abdominal pain and blood-stained diarrhoea. Three days later, she developed pains in her ankles and right
elbow and felt nauseous. Positive findings on examination were a purpuric rash affecting the arms and legs, periorbital oedema and a blood pressure of 150/95 mmHg. Investigations are shown.

List two investigations that would be most useful in confirming the diagnosis.

A 51-year-old accountant presented with a six-month history of persistent dull right upper quadrant pain and fever. The pain did not radiate elsewhere, but was exacerbated on lying on her right side. During this period she had intermittent pale bulky stool which was difficult to flush, and episodic dark urine. More recently, her
appetite was reduced and she had lost approximately 1 kg in weight during the past month. Over the past week she had difficulty sleeping due to itching all over her body,
and her colleague at work commented on a yellowish pigmentation in her eyes. Six months before this, she had been relatively well. She had a past history of a cholecystectomy for cholesterol stones at the age of 32 and subsequently had an ERCP and removal of sludge from the common bile duct six years ago. She consumed
10 units of alcohol per week. She was married with two sons, aged 20 and 18. Three months ago she had been on holiday in Scotland. She was not taking any regular
medication. 

On examination, she was slightly icteric. Inspection of her hands is shown (33).

There were spider naevi on her arms neck and face and scratch marks around her trunk and lower limbs. She had a temperature of 39°C (102.2°F). Her heart rate was
120 beats/min and blood pressure 140/80 mmHg. There were a few inspiratory crackles on auscultation of the right lung base. Abdominal examination demon –
strated firm, slightly tender hepatomegaly 4 cm below the costal margin, and a moderately enlarged spleen. There were no other abdominal masses, and there was no
evidence of shifting dullness. Rectal examination was normal.

Investigations are shown.

What investigation would you perform to ascertain the cause of her illness?

A 51-year-old accountant presented with a six-month history of persistent dull right upper quadrant pain and fever. The pain did not radiate elsewhere, but was exacerbated on lying on her right side. During this period she had intermittent pale bulky stool which was difficult to flush, and episodic dark urine. More recently, her
appetite was reduced and she had lost approximately 1 kg in weight during the past month. Over the past week she had difficulty sleeping due to itching all over her body,
and her colleague at work commented on a yellowish pigmentation in her eyes. Six months before this, she had been relatively well. She had a past history of a cholecystectomy for cholesterol stones at the age of 32 and subsequently had an ERCP and removal of sludge from the common bile duct six years ago. She consumed
10 units of alcohol per week. She was married with two sons, aged 20 and 18. Three months ago she had been on holiday in Scotland. She was not taking any regular
medication. 

On examination, she was slightly icteric. Inspection of her hands is shown (33).

There were spider naevi on her arms neck and face and scratch marks around her trunk and lower limbs. She had a temperature of 39°C (102.2°F). Her heart rate was
120 beats/min and blood pressure 140/80 mmHg. There were a few inspiratory crackles on auscultation of the right lung base. Abdominal examination demon –
strated firm, slightly tender hepatomegaly 4 cm below the costal margin, and a moderately enlarged spleen. There were no other abdominal masses, and there was no
evidence of shifting dullness. Rectal examination was normal.

Investigations are shown.

What is the cause of her current presentation?

A 38-year-old male was investigated for abnormal liver function tests following investigation of intermittent episodes of diarrhoea. He was generally fit and well. He
consumed no more than 10 units of alcohol per week. He did not take any medications. He had a past history of jaundice after a visit to India 8 years previously, which had resolved spontaneously.

Investigations are shown.

What is the cause of the raised alkaline phosphatase?

A 55-year-old male was admitted with a three-month history of abdominal pain that was dull in nature and often radiated to his back. The pain was precipitated by
meals and started 2 hours after eating. The patient had intermittent diarrhoea productive of foul, bulky stool, and had lost almost 3 kg in weight in three months. He
had been diagnosed as having non-insulin-dependent diabetes mellitus six years ago, and had an inferior myocardial infarction two years later. He smoked 20
cigarettes per day and had never consumed alcohol. There was a strong family history of ischaemic heart disease. A barium meal and ultrasound scan of the
hepatobiliary system were normal.

On examination, he was thin. The external appearance of his eyes is shown (75). There was no pallor, clubbing or lymphadenopathy. His heart rate was 98 beats/min
and blood pressure 140/90 mmHg. The heart sounds were normal and his chest was clear. He had a soft left carotid bruit. On examination of his abdomen he was
tender in the epigastrum and umbilical area. There were no abdominal bruits. Neurological examination was normal.

What is the diagnosis?

A 55-year-old male was admitted with a three-month history of abdominal pain that was dull in nature and often radiated to his back. The pain was precipitated by
meals and started 2 hours after eating. The patient had intermittent diarrhoea productive of foul, bulky stool, and had lost almost 3 kg in weight in three months. He
had been diagnosed as having non-insulin-dependent diabetes mellitus six years ago, and had an inferior myocardial infarction two years later. He smoked 20
cigarettes per day and had never consumed alcohol. There was a strong family history of ischaemic heart disease. A barium meal and ultrasound scan of the
hepatobiliary system were normal.

On examination, he was thin. The external appearance of his eyes is shown (75). There was no pallor, clubbing or lymphadenopathy. His heart rate was 98 beats/min
and blood pressure 140/90 mmHg. The heart sounds were normal and his chest was clear. He had a soft left carotid bruit. On examination of his abdomen he was
tender in the epigastrum and umbilical area. There were no abdominal bruits. Neurological examination was normal.

How would you confirm the diagnosis?

A 36-year-old woman presented with a four-week history of intermittent upper abdominal pain and vomiting. Her bowel movements were unaffected and were normal. There was no blood or mucus in the stool. Her appetite was reduced. She had lost 2 kg in weight. She had a past medical history of ulcerative colitis which was diagnosed at the age of 14 years, and was stable on sulphasalazine. In the past she had received several courses of steroids for acute exacerbation of her colitis. Her only other drug history was that she was currently on the contraceptive pill. She had been married for 10 years and had two children, aged 7 and 3 years. She smoked 15 cigarettes per day and consumed 1–2 units of alcohol per week.

On examination, she appeared unwell. Her tongue was dry and there was loss of skin turgor. She had mild lower limb pitting oedema. The heart rate was 98 beats/min and blood pressure was 100/65 mmHg. The temperature was 36.8°C (98.2°F). The abdomen was slightly distended, and there was generalized tenderness.
The liver was palpable 4 cm below the costal margin, and was tender. There was no evidence of a palpable spleen or any other palpable masses in the abdomen. Percussion of the abdomen revealed shifting dullness. Rectal examination was normal. Examination of the respiratory and cardiovascular system was normal.

Investigations are shown.

What is the diagnosis?

A 17-year-old boy was referred to the local paediatrician because he had not grown very much in the past four years. Apart from feeling more lethargic than his school friends, he gave no other history of note. He measured 1.53 m. He had never needed to shave. His younger brother, aged 16, measured 1.73 m and had already started shaving. There were no other siblings. Both parents were well. The father
was 1.76 m tall and the mother was 1.63 m tall.

On examination, he was slightly pale. He did not have any facial hair. He was below the third centile for height and was just at the 10th centile for weight. He did not
have any evidence of secondary sexual characteristics, and his testes were small. The blood pressure was 115/70 mmHg.

Investigations are shown.

List two possible diagnoses.

A 22-year-old male was admitted to hospital after an episode of haematemesis preceded by profuse vomiting. The patient had been on an alcoholic binge drinking
session 12 hours previously. On examination his heart rate was 90 beats/min. The blood pressure was 100/60 mmHg. The Hb was 15 g/dl. An upper gastrointestinal endoscopy performed 24 hours after admission was normal.

What is the next management step?

A 48-year-old female had an 11-month history of abdominal cramps and diarrhoea. She moved her bowels twice daily; the stool was loose and foul-smelling. There
was no history of bleeding per rectum or tenesmus. Her appetite was unchanged, but she had lost 8 kg in weight. Two years ago she had a total abdominal hysterectomy
and salpingo-oophorectomy for carcinoma of the cervix, followed by a course of external radiotherapy. She had been followed up regularly by her gynaecologist, and was free from recurrence of the malignancy. She was married with two sons, aged 10 and 12. She worked as a secretary. She consumed 1 unit of alcohol daily and was a
non-smoker. There was no history of travel abroad. She had a long history of Raynaud’s phenomenon. She took paracetamol for very infrequent headaches.

On examination she was thin. There was no pallor, clubbing, lymphadenopathy or oedema. The temperature was normal. Inspection of the oral cavity revealed two
small, non-tender, shallow ulcers. The abdomen was thin. There was a lower, midline scar. Mild tenderness was elicited on palpation of the right iliac fossa. Rectal
examination was normal. Investigations are shown.

What is the diagnosis?

A 48-year-old female had an 11-month history of abdominal cramps and diarrhoea. She moved her bowels twice daily; the stool was loose and foul-smelling. There
was no history of bleeding per rectum or tenesmus. Her appetite was unchanged, but she had lost 8 kg in weight. Two years ago she had a total abdominal hysterectomy
and salpingo-oophorectomy for carcinoma of the cervix, followed by a course of external radiotherapy. She had been followed up regularly by her gynaecologist, and was free from recurrence of the malignancy. She was married with two sons, aged 10 and 12. She worked as a secretary. She consumed 1 unit of alcohol daily and was a
non-smoker. There was no history of travel abroad. She had a long history of Raynaud’s phenomenon. She took paracetamol for very infrequent headaches.

On examination she was thin. There was no pallor, clubbing, lymphadenopathy or oedema. The temperature was normal. Inspection of the oral cavity revealed two
small, non-tender, shallow ulcers. The abdomen was thin. There was a lower, midline scar. Mild tenderness was elicited on palpation of the right iliac fossa. Rectal
examination was normal. Investigations are shown.

Which investigation would you perform to reach a diagnosis?

A 44-year-old female was persuaded to come into hospital after she was seen in the out-patient clinic with jaundice. She was diagnosed as having auto-immune
CAH five months ago and was successfully treated with high-dose steroids, which had gradually been withdrawn. She had not been taking any medication before admission
and denied alcohol consumption. On examination, she was thin and deeply jaundiced. She was alert and orientated, and did not demonstrate any signs of cognitive impairment. Abdominal examination was essentially normal. Investigations on admission are shown. Two days following admission, the patient
became suddenly very aggressive, and soon after collapsed and was comatosed.

Which urgent investigation would be most useful in determining the cause of collapse?

A 60-year-old obese male was referred to a gastroenterologist with a 4-month history of right upper quadrant pain and abnormal liver function tests. He did not have nausea, vomiting or steatorrhoea. He consumed 24 units of alcohol per week. He had an 8-year history of non-insulin-dependent diabetes mellitus and had been diagnosed as having hypertension 1 year previously. He had chronic pain in both knees that was attributed to osteoarthritis.

On examination he was obese. He measured 1.8 m and weighed 105 kg. He was not jaundiced and there were no peripheral stigmata of chronic liver disease. The
heart rate was 70 beats/min and regular. The blood pressure measured 150/90 mmHg. Both heart sounds were normal and the chest was clear. Abdominal
examination revealed a palpable liver edge 4 cm below the costal margin. The spleen was not palpable.

Investigations are shown.

What is the most probable diagnosis?

A 69-year-old woman attended her GP complaining of lethargy and pruritus. She also complained of difficulty on climbing stairs because she felt her thighs could not
carry her. She had always led a very healthy lifestyle and was not taking any medications. On examination she appeared slightly icteric and had xanthelasma. There were several scratch marks on the skin. The heart rate, temperature and blood pressure were normal. The liver was palpable 3 cm below the costal margin and the
spleen could just be felt. There was no evidence of lymphadenopathy.
Investigations are shown.

Give two explanations for the raised alkaline phosphatase.

A 56-year-old woman presented with a four-day history of breathlessness, cough and a high fever. She gave a long history of indigestion and intermittent dysphagia to solids
and fluids. On several occasions undigested food would be regurgitated back shortly after she had eaten. She would often wake at night with episodes of coughing and
spluttering. There was no history of weight loss.

On examination, she had a temperature of 39°C (102.2°F). The respiratory rate was 30/min, and the heart rate was 102 beats/min. Chest expansion was moderate and symmetrical. On auscultation of the lung fields there were coarse bilateral basal crackles. 

The chest X-ray demonstrated bilateral lower lobe consolidation.

What is the cause of this patient’s illness?

A 56-year-old woman presented with a four-day history of breathlessness, cough and a high fever. She gave a long history of indigestion and intermittent dysphagia to solids
and fluids. On several occasions undigested food would be regurgitated back shortly after she had eaten. She would often wake at night with episodes of coughing and
spluttering. There was no history of weight loss.

On examination, she had a temperature of 39°C (102.2°F). The respiratory rate was 30/min, and the heart rate was 102 beats/min. Chest expansion was moderate and symmetrical. On auscultation of the lung fields there were coarse bilateral basal crackles. 

The chest X-ray demonstrated bilateral lower lobe consolidation.

What investigation would be most useful in identifying the cause of her presentation?

A 17-year-old girl with insulin-dependent diabetes mellitus was investigated for weight loss andamenorrhoea. 

Investigations are shown.

What is the most probable cause for the weight loss?

A 49-year-old male with alcohol-related liver disease presented with burning epigastric pain and loss of appetite. An upper gastrointestinal endoscopy revealed
gastritis and he had very small oesophageal varices that had not bled. There was no previous history of haematemesis or malena. The patient was haemodynamically stable. 

What is the most effective prophylactic therapy to prevent a variceal bleed in this particular situation?

A 58-year-old man presented with recent onset of epigastric burning that was precipitated by hunger or after a heavy meal. His appetite was unchanged and his
weight was stable. He was a non-smoker and did not consume alcohol. The patient took paracetamol only for a painful left hip.

Investigations are shown.

The patient was treated with H. pylori eradication therapy and was completely asymptomatic when reviewed six weeks later. The Hb was 13 g/dl.

What is the next management step?

A 72-year-old woman underwent upper gastrointestinal endoscopy for epigastric discomfort, which revealed mild antral gastritis. She had a history of transient ischaemic attacks for which she was taking aspirin 75 mg daily. The patient also took regular diclofenac for arthritis. The urease breath test for H. pylori was negative.

What is the best management of her epigastric symptoms?

A 78-year-old female patient presented with acute abdominal pain and vomiting. A plain abdominal film is shown.

What is the diagnosis?

A 64-year-old male presented with a three-month history of copious diarrhoea associated with lower abdominal cramps and weight loss. The patient moved his bowel up to 20 times per day. There was no blood in the stools. He had a past history of gallstones, for which he underwent a cholecystectomy five years ago. He had not experienced any episodes of biliary colic since surgery. The patient was also in the process of being investigated for intermittent dizziness that usually occurred after meals and was preceded by a burning sensation over the
face, neck and chest. According to his wife he developed a red complexion during these episodes, which lasted for 30–60 seconds at a time. On two occasions he had almost lost consciousness when he stood suddenly during these episodes. The patient had not travelled abroad for over eight months. He was not taking any medication. His father had ulcerative colitis and his paternal nephew
had gluten sensitive enteropathy.

On examination he had several telangiectasiae on his face, neck and upper trunk. The JVP was raised with prominent V waves. On auscultation of the precordium,
there was a soft systolic murmur. The chest was clear. Abdominal examination revealed a palpable liver edge 5 cm below the costal margin that had a firm and
irregular consistency. Rectal examination was normal.

Investigations are shown.

What is the diagnosis?

A 44-year-old man presented with recent onset of epigastric burning that was precipitated by hunger or after a heavy meal. His appetite was unchanged and his weight was stable. He consumed 21 units of alcohol per week but was
a non-smoker. The patient was not on any medication. There was no family history of carcinoma of the stomach. The urease breath test for Helicobacter pylori was positive.

What is the next management step?

A 50-year-old man presented with a 24-hour history of heamatemesis and malena. There was no preceding history of abdominal discomfort. He consumed
80–100 units of alcohol per week.

On examination he was pale. His heart rate was 110 beats/min and blood pressure measured 90/60 mmHg.

Investigations are shown.

The patient was resuscitated with 2 units of blood and 2 litres of dextrose 5% and underwent urgent endoscopy, which revealed a bleeding oesophageal varix.

What is the best treatment to prevent further bleeding?

A young alcoholic who is well known to the local Accident and Emergency Department was admitted to hospital after being found collapsed. On examination, he was unrousable. His temperature was 36.5°C (97.7°F). His heart rate was weak pulse volume. The blood pressure was 80/40 mmHg. The heart sounds were normal. Auscultation of the lung fields revealed a few crackles at both lung bases. The abdomen was rigid and bowel sounds were absent. Rectal examination demonstrated soft brown stool. Examination of the fundi
was normal.

Investigations are shown.

What is the diagnosis?