Gastroenterology RACP MCQs

Question 1

RACP 2022 Q13

13.A 56 year old woman has autoimmune hepatitis, hypertension and hyperlipidemia on azathioprine, perindopril and atorvastatin. She develops acute joint pain in her left MTP. Joint aspirate showed calcium pyrophosphate (?) crystals. What is your initial management?
a. Allopurinol
b. Probenicid
c. Feboxustat
d. Benzbromarone

Answer 1

Given that the primary goal is to manage the acute inflammatory symptoms, the correct answer is not explicitly listed in the provided options. The initial management for pseudogout typically includes:

Non-steroidal anti-inflammatory drugs (NSAIDs): Such as indomethacin or naproxen.
Colchicine: Effective for treating acute attacks of pseudogout.
Corticosteroids: If NSAIDs are contraindicated or not tolerated.
Since none of these options (NSAIDs, colchicine, or corticosteroids) are listed, and given that all the provided choices are primarily for urate management, there is no appropriate option for the acute management of pseudogout in this list.

Question 2

RACP 2022 Q45.

A patient has a new diagnosis of diffuse large B cell lymphoma. He is about to start chemo with RCHOP. As part of his initial work up, his hepatitis B serology shows Hep B surface antigen negative, Hep B core antibody
positive, Hep B surface antibody positive. How would you manage this?
a. Do nothing as patient is immune
b. Check Hep B E antibody
c. Start antivirals

Answer 2

A
Patient is fully cured from past infection and no further intervention is required
(refer to Hepatitis powerpoint - JK)

Question 3

RACP 2022 Q79

79.”A 64yo M is found to have large cell lymphoma, he is planned to commence
on cyclophosphamide, doxorubicin, vincristine(?), prednisone, and rituximab.
He was screened pre-treatment for hepatitis B, his results are as follows:
HbsAg negative
HbsAb positive
HbcAb positive
Viral load not detected
What is the most appropriate step before commencing chemotherapy?
a. antiviral medications
b. check hepatitis B e antibody
c. hepatitis B vaccine
d. no further treatment

Answer 3

D
Patient is fully cured from previous Hep B infection
(refer to Hepatitis powerpoint - JK)

Question 4

RACP 2022 Q 85.EMQ:

A patient has been started on isoniazid for pulmonary tuberculosis. What nutritional supplementation does this patient need?
a. B1 (thiamine)
b. B2
c. B3 (niacin)
d. B4
e. B6 (pyridoxine)
f. B12
g. C
h. D

Answer 4

E

Question 5

RACP 2022 86.EMQ:

A patient has been eating shaved ice for a month after having bariatric surgery. He now presents with ophthalmoplegia, ataxia and nystagmus. What nutritional supplementation does this patient need?
a. B1 (thiamine)
b. B2
c. B3 (niacin)
d. B4
e. B6 (pyridoxine)
f. B12
g. C
h. D

Question 6

RACP 2022b 6

6. What is the pathophysiology of malabsorption in coeliac disease?
   A. reduced intestinal surface area
   B. reduced brush border dissacharidases
   C. increased enteric amylase
   D. increased unabsorbed carbohydrates

Answer 6

A

Reduced Intestinal Surface Area (A):

In coeliac disease, the ingestion of gluten leads to an inflammatory response that damages the villi in the small intestine. Over time, this results in villous atrophy, which decreases the surface area available for absorption.
This option is correct because a reduced intestinal surface area directly impacts nutrient absorption, leading to malabsorption.

Question 7

RACP 2022 Q40.

A patient has macrocytic anaemia and you suspect pernicious anaemia. What is the
most Specific Antibody test?
A. Intrinsic factor
B. Methymalone acid
C. Parietal cell
D. Vitamin B 12

Answer 7

Answer: A. Intrinsic factor

Explanation:
In the context of suspected pernicious anemia, which is a type of macrocytic anemia caused by Vitamin B12 deficiency due to impaired absorption, the most specific antibody test is the Intrinsic Factor antibody test.

Pernicious anemia is characterized by the autoimmune destruction of gastric parietal cells, leading to a lack of intrinsic factor, a protein necessary for the absorption of vitamin B12 in the intestines. Consequently, the presence of antibodies against intrinsic factor is a key indicator of this condition.

Here’s a breakdown of the options:

1. Intrinsic Factor Antibody (A):
   
   • This test specifically detects antibodies against intrinsic factor, which is crucial in diagnosing pernicious anemia. A positive result indicates the presence of autoimmune activity that inhibits vitamin B12 absorption. This test is considered the most specific for pernicious anemia.
   • Guidelines such as those from the American Society of Hematology recommend testing for intrinsic factor antibodies when pernicious anemia is suspected.
2. Methylmalonic Acid (B):
   
   • Elevated levels of methylmalonic acid are seen in Vitamin B12 deficiency but are not specific to pernicious anemia alone. While it can help assess Vitamin B12 deficiency, it does not confirm pernicious anemia specifically.
3. Parietal Cell Antibody (C):
   
   • This test detects antibodies against gastric parietal cells. While positive in some cases of pernicious anemia, it is less specific compared to intrinsic factor antibodies.
4. Vitamin B12 (D):
   
   • While low levels of vitamin B12 can indicate deficiency, this test does not specify the underlying cause of the deficiency, such as whether it is due to pernicious anemia or dietary insufficiency.

Question 8

RCAP 2022 Q48

48. What is the mechanism of action of lactulose when used as a laxative?
    A. Not broken down by intestinal enzymes and remains in lumen, causing water to
    remain in lumen
    B. Stimulates intestinal cells to contract, increases intestinal motility
    C. Cause increased secretion of fluid into the intestinal lumen and add bulk to stool
    D. Reduces surface tension to allow more water to enter stool

Answer 8

Answer: A. Not broken down by intestinal enzymes and remains in lumen, causing water to remain in lumen

Explanation:
Lactulose is a synthetic disaccharide that is not absorbed in the gastrointestinal tract. Its mechanism of action as a laxative involves the following:

1. Non-absorption: Lactulose is not broken down by intestinal enzymes, which means it passes through the intestines unchanged.
2. Osmotic Effect: As lactulose remains in the lumen, it draws water into the intestines by osmosis. This influx of water increases the volume of the intestinal contents.
3. Increased Stool Bulk and Softness: The increase in water content causes the stool to soften and swell, promoting peristalsis and facilitating bowel movements.
4. Prebiotic Effects: Additionally, lactulose is fermented by colonic bacteria into short-chain fatty acids, which may also contribute to its laxative effect, although the primary mechanism is its osmotic action.

Conclusion:
Thus, the correct mechanism of action of lactulose as a laxative is that it is not broken down by intestinal enzymes and remains in the lumen, causing water to remain in the lumen. This osmotic effect is what promotes laxation and relief from constipation.

Question 9

RACP 2022 Q50

50. What electrolyte abnormalities occur in refeeding syndrome?
    A) K decrease, PO4 decrease, Mg decrease
    B) K increase, PO4 decrease, Mg decrease
    C) K increase, PO4 increase, Mg increase
    D) K decrease, PO4 increase, Mg increase

Answer 9

A

Low PHOSPHATE, low POTASSIUM, low MAGNESIUM
- Caused in prolonged starvation = reduced insulin production causes shrinking of cell as water flows out of cell along with Potassium, Phosphate, Mg
- When starts eating again, there is excessive insulin release = rush of electrolytes and water back into cells = decreased serum concentrations
○ Increased insulin levels also causes ADH release = fluid retention = dilution hypoalbuminemia
○ Increased insulin levels causes reduced thiamine
Need to restart feeding slowly (high fat, low carb diet), monitor and replace

Question 10

RACP 2022 66. EMQ:
What receptor does this antiemetic act on? Ondansetron
A. 5-HT3
B. Dopamine
C. NK-1
D. Histamine
E. Acetylcholine

Answer 10

Answer: A. 5-HT3

Explanation:
Ondansetron is an antiemetic medication that specifically acts as a selective antagonist of the 5-HT3 receptor, which is a subtype of serotonin receptor. Here’s how it works:

1. 5-HT3 Receptor Mechanism:
   
   • The 5-HT3 receptors are located in the central nervous system (CNS) and the gastrointestinal tract.
   • When serotonin (5-HT) binds to these receptors, it can trigger nausea and vomiting.
   • Ondansetron blocks these receptors, thereby preventing the action of serotonin and effectively reducing the sensation of nausea and the occurrence of vomiting.
2. Clinical Use:
   
   • Ondansetron is commonly used to prevent nausea and vomiting caused by chemotherapy, radiation therapy, and surgery.

Conclusion:
Thus, the correct answer is that Ondansetron acts on the 5-HT3 receptor to exert its antiemetic effects.

Question 11

RACP 2022 67. EMQ: What receptor does this antiemetic act on? Aprepitant
A. 5-HT3
B. Dopamine
C. NK-1
D. Histamine
E. Acetylcholine

Answer 11

Answer: C. NK-1

Explanation:
Aprepitant is an antiemetic that primarily acts as an antagonist of the NK-1 receptor (Neurokinin-1 receptor). Here’s how it works:

1. NK-1 Receptor Mechanism:
   
   • The NK-1 receptor is primarily activated by substance P, a neuropeptide involved in the vomiting reflex.
   • Aprepitant inhibits the binding of substance P to the NK-1 receptor in the central nervous system, which helps to prevent nausea and vomiting.
2. Clinical Use:
   
   • Aprepitant is commonly used in combination with other antiemetics (such as 5-HT3 antagonists) to prevent acute and delayed nausea and vomiting associated with chemotherapy.

Conclusion:
Thus, the correct answer is that Aprepitant acts on the NK-1 receptor to provide its antiemetic effects.

Question 12

RACP 2021a Q36.

A 60 year old man presents with a two week history of pruritis, jaundice, dark urine, pale stools, and 6kg weight loss, but nil abdominal pain. In the month prior, he had a course of augmentin duo forte for a chest infection. He has a background history of a caecal cancer treated with right sided hemicolectomy. He smokes 20 cigarettes per day and drinks 2 standard drinks per day. His observations are: HR 88, BP 125/88, RR 12, temp 36.8C.
An abdominal ultrasound shows a dilated gallbladder with nil stones, dilated CBD to the level of the duodenum, and increased echogenicity throughout the liver. His LFTs are as follows:
Bilirubin 210
Albumin 34
ALT 40
ALP 610
GGT 340
What is the most likely diagnosis?
A. Drug induced liver injury related to Augmentin
B. Alcoholic liver disease
C. Widespread colorectal cancer
D. Head of pancreas cancer

Answer 12

Answer: D. Head of pancreas cancer

Reasoning:

1. Clinical Presentation:
   
   • The patient presents with pruritus, jaundice, dark urine, pale stools, and significant weight loss over two weeks. These symptoms are consistent with cholestasis (the impairment of bile flow).
   • The absence of abdominal pain can be notable in cases of pancreatic cancer, especially when the tumor obstructs the bile duct without causing immediate pain.
2. Laboratory Findings:
   
   • The liver function tests (LFTs) show:
     
     • Elevated bilirubin (210 µmol/L), which is indicative of cholestasis.
     • Elevated alkaline phosphatase (ALP) (610 U/L) and gamma-glutamyl transferase (GGT) (340 U/L) suggest cholestatic liver disease, often due to obstruction of the bile duct.
     • The ALT is mildly elevated, which is less typical for pure obstructive pathology but can be seen in cases of biliary obstruction.
   • Albumin levels are normal, which is indicative of the liver’s synthetic function still being intact at this stage.
3. Imaging Findings:
   
   • The abdominal ultrasound shows:
     
     • A dilated gallbladder and dilated common bile duct (CBD), indicating that bile is not able to flow properly, likely due to an obstruction.
     • The absence of gallstones suggests that the obstruction is not due to stones but potentially due to a mass.
     • Increased echogenicity throughout the liver can indicate liver disease, and may suggest metastasis or infiltrative processes.
4. History of Colorectal Cancer:
   
   • The patient has a history of caecal cancer treated with a right-sided hemicolectomy. Given his history, the possibility of recurrence or metastasis is significant.
   • Cancers of the colon can metastasize to the liver or other structures, and a mass in the head of the pancreas could obstruct the CBD leading to the symptoms presented.
5. Exclusion of Other Options:
   
   • A. Drug-induced liver injury related to Augmentin: While possible, it typically would present with more diffuse liver dysfunction, elevated transaminases, and would not usually cause significant obstruction of bile flow leading to jaundice and pale stools.
   • B. Alcoholic liver disease: Given the patient’s low alcohol intake (2 standard drinks per day) and acute presentation with obstruction, this is less likely.
   • C. Widespread colorectal cancer: While this is a consideration, the specific symptomatology (especially the biliary obstruction signs and jaundice) aligns more closely with a mass effect typically seen in head of pancreas cancer.

Conclusion:
The combination of the patient’s clinical presentation, lab findings, imaging results, and history supports the diagnosis of head of pancreas cancer, likely causing obstruction of the common bile duct leading to jaundice, pruritus, and pale stools.

Question 13

RACP 2021b Q46.

A nurse has been exposed to a needlestick injury when caring for a patient. The patient has bloods with
serology is as follows: Hepatitis B surface antigen positive, HIV serology negative and Hepatitis C serology negative. The nurse’s blood tests from an earlier in the year show: Hepatitis B core negative, HIV negative, Hepatitis C negative and Hepatitis B surface antibody > 1000 IU.
What treatment do you suggest?
A. Prophylactic Entacavir
B. Hepatitis B immunoglobulin
C. Reassure and do no investigations
D. Hepatitis surface antigen serology at 6 and 12 weeks

Answer 13

C

Question 14

RACP 2021a Q71

Q75. What is the histology at GOJ biopsy in Barrett’s oesophagus?
A. Goblet cell hyperplasia
B. Inflammation
C. Intestinal metaplasia
D. (Rhubarb)

Answer 14

C - intestinal metaplasia +/- acid-mucin–containing goblet cells

Question 15

RACP 2021a Q88

Q88. You review a 24-year-old male who has Crohn’s disease with stricturing ileal disease. He underwent a
resection of bowel including the terminal ileum with primary anastomosis 2 years ago. His current medications
include azithromycin and infliximab.
He now comes to you with persistent diarrhea. You performed further investigations to assess the cause. His
faecal calprotectin was within normal limits. Colonoscopy including biopsy showed a patent ileocolonic anastomosis with no evidence of active inflammation. MRI of the abdomen showed normal bowel calibre without any active inflammation.
What is the most likely cause of his persistent diarrhea?
A. Bile salt malabsorption
B. Clostridium difficile infection
C. Coeliac disease
D. Short gut syndrome

Question 16

RACP 2021b Q105

Q105. Persistence of which viral component prevents hepatitis B cure?
A. Covalently closed circular DNA
B. Hepatitis B surface antigen
C. Precore protein
D. Pregenomic RNA

Answer 16

A
(refer to Hepatitis powerpoint - JK)

Question 17

RACP 2021b Q108

Q108. In which part of the gastrointestinal tract are bile salts absorbed?
A. Duodenum
B. Stomach
C. Ileum
D. Jejunum

Answer 17

C - distal ileum

Question 18

RACP 2021 Q145. What is the most specific autoantibody for diagnosis of autoimmune hepatitis?
A. Anti smooth muscle (anti SMA)
B. Anti liver cytosol 1 (anti LC1)
C. Anti liver kidney microsomal (anti LKM)
D. Anti soluble liver antigen/liver pancreas (anti SLA/LP)

Answer 18

A

Question 19

RACP 2021 Q148. Acute opioid withdrawal has been reported in patients with end stage liver disease when administered oxycodone-naloxone combination. This is best explained by:
A. Augmentation of endogenous partial agonists
B. Increased absorption due to gastric hyperaemia and gut oedema
C. Increased volume of distribution
D. Shunting of portal circulation to systemic circulation

Question 20

RACP 2021 Q169 – Which protein releases iron into blood stream from enterocytes?
A. Ferritin
B. Hepcidin
C. Ferroportin
D. Transferrin
E. onwards - rhubarb

Answer 20

Answer: C. Ferroportin

Explanation:
Ferroportin is the key protein responsible for the release of iron from enterocytes (intestinal cells) into the bloodstream. Here’s a breakdown of each option:

1. A. Ferritin:
   
   • Ferritin is a protein that stores iron within cells. It sequesters iron to prevent its free circulation and potential toxicity, but it does not release iron into the bloodstream.
2. B. Hepcidin:
   
   • Hepcidin is a hormone produced by the liver that regulates iron homeostasis. It decreases iron absorption by promoting the internalization and degradation of ferroportin, thus preventing iron release from enterocytes and macrophages. While it plays a crucial role in iron regulation, it does not release iron.
3. C. Ferroportin:
   
   • Ferroportin is the only protein that allows iron to be exported from enterocytes into the blood. When iron is absorbed from the diet, it is stored as ferritin within enterocytes, and ferroportin mediates its transport into the circulation when needed. This action is essential for maintaining systemic iron levels.
4. D. Transferrin:
   
   • Transferrin is a transport protein that binds iron in the bloodstream and delivers it to various tissues, but it does not facilitate the release of iron from enterocytes.

Conclusion:
The protein that releases iron into the bloodstream from enterocytes is C. Ferroportin. This understanding aligns with current knowledge of iron metabolism and regulation in the body.

Question 21

RACP 2021 Q6. A 70 year old male with a history of Parkinson’s disease presents with nausea and vomiting. Which of the
following medications would most likely cause an exacerbation of the patient’s Parkinson’s disease?
A. Cyclizine
B. Metoclopramide
C. Domperidone
D. Ondanestron

Answer 21

Answer: B. Metoclopramide

Explanation:
In patients with Parkinson’s disease, certain medications can exacerbate symptoms due to their effects on dopamine receptors. Here’s a breakdown of the options provided:

1. A. Cyclizine:
   
   • Cyclizine is an antihistamine used to treat nausea and motion sickness. It has anticholinergic properties and does not typically exacerbate Parkinson’s disease symptoms.
2. B. Metoclopramide:
   
   • Metoclopramide is a dopamine receptor antagonist primarily used to treat nausea and gastroparesis. It blocks D2 dopamine receptors in the central nervous system, which can worsen Parkinson’s disease symptoms by reducing dopaminergic activity. Therefore, this medication is known to exacerbate motor symptoms in patients with Parkinson’s disease.
3. C. Domperidone:
   
   • Domperidone is also a dopamine antagonist, but it primarily works peripherally (in the gastrointestinal tract) and does not cross the blood-brain barrier to the same extent as metoclopramide. It is generally considered safer for patients with Parkinson’s disease compared to metoclopramide.
4. D. Ondansetron:
   
   • Ondansetron is a 5-HT3 receptor antagonist used for nausea and vomiting, especially in chemotherapy. It does not have significant effects on dopaminergic pathways and is not known to exacerbate Parkinson’s symptoms.

Conclusion:
Given the potential for metoclopramide to worsen Parkinson’s disease symptoms due to its central D2 receptor antagonism, the most likely medication to cause an exacerbation of the patient’s Parkinson’s disease is B. Metoclopramide.

Question 22

RACP 2021 Q25. A 70 year old man has a history of chronic constipation. He presents with abdominal swelling and distension,
abdo pain and vomiting. His abdominal x-ray is shown below. Exact image included in paper.

What is the most likely diagnosis?
A. Obstructive tumour
B. Pseudo obstruction
C. Faecal loading
D. Sigmoid volvulus

Question 23

RACP 2021
Q55. What is the most likely explanation for persisting malabsorptive symptoms and villous atrophy in patients
with proven coeliac disease?
A. Ongoing dietary gluten intake
B. Pancreatic malabsorption
C. Intestinal Crohn’s disease
D. Collagenous atrophy

Question 24

RACP 2021
Q97. Which of the listed immunosuppressive medications cause chronic diarrhoea?
A. Anti-thymocyte globulin
B. Tacrolimus
C. Cyclosporin
D. Sirolimus
E. Mycophenolate mofetil
F. Basiliximab
G. (Rhubarb)
H. (Rhubarb)

Question 25

RACP 2021o
Q11. Markers in wilson disease
A. copper increased/ceruloplasmin reduced/ increased ALT:AST
B. Copper level increased/ceruloplasmin reduced/decreased ALT:AST ratio
C. Copper level decreased /ceruloplasmin increased/ increased ALT:AST
ratio
D. Copper level decreased/ ceruloplasmin increased/ decreased ALT:AST
ratio

Answer 25

B

AST > ALT in wilsons

Question 26

RACP 2021o
42. Question describes faecal calprotectin being highly specific (or maybe
sensitive) in patients with IBD. What would happen to the negative predictive
value if the prevalence of IBD was found to be higher - such as in an IBD clinic?
a. NNP increased
b. NNP decreased
c. No change to NNP

Question 27

RACP 2020a 4. A 35 year old male has chronic hepatitis, managed with tenofovir. Dipstick urinalysis show glycosuria and proteinuria. Which of the following findings are most consistent with tenofovir-induced Fanconi syndrome?
A) Hypocalcaemia
B) Hypomagnesaemia
C) Hypophosphataemia
D) Hypouricaemia

Answer 27

C

Question 28

RACP 2020a
14. Patients with chronic liver disease feel more dyspnoea when standing up as opposed to lying down (orthodeoxia). An increase in what parameter explains this phenomenon?
A) Left ventricular preload
B) Cardiac output
C) Intra-abdominal pressure
D) Pulmonary capillary vasodilation

Question 29

RACP 2020a 15. What is the most common side effect of osteltamivir?
A) Hepatitis
B) Rash
C) Nausea and vomiting
D) Confusion

Question 30

RACP 2020a 24. A 36 year old male is admitted with 2 weeks of bloody diarrhoea associated with mild abdominal pain and tenesmus. On Examination his heart rate is 105. His Hb is 114 and WCC 14, with a CRP of 40. Stool culture is negative. A flexible sigmoidoscopy shows inflammation pass the splenic flexure. Biopsy demonstrated active inflammation consistent with ulcerative colitis. He is given 3 days of IV hydrocortisone 100mg QID with no improvement. Which of the following will increase his chance of recovery and minimise his risk of colectomy?
A) Methylprednisone
B) Azathioprine
C) Infliximab
D) Methotrexate

Question 31

RACP 2020a
Q 39. A 50 year old female was recently in hospital and diagnosed with a 3cm gastric ulcer in the antrum. This was treated with adrenaline injections and diathermy coagulation. She has no medical history and takes ibuprofen/codeine (2 tablets a month) for headaches. On review 8 weeks later, she is well with no further symptoms. What is the next step in management? (Specifically NO mention of biopsy or H pylori testing in stem)
A) Discharge to GP’s care
B) Perform repeat gastroscopy
C) Urea breath test
D) Fructose hydrogen breath test

Question 32

RACP 2020a
48. A 58 year old male admitted with bleeding duodenal ulcer secondary to NSAIDs. He is treated endoscopically, NSAIDs ceased, commenced on PPI. H pylori is negative. What should the optimal duration of PPI be?
A) 1 month
B) 2 months
C)12 months
D) Indefinitely

Question 33

RACP 2020
56. EMQ Stem: What investigation would most likely lead to the diagnosis? A 30 year old female with primary sclerosing cholangitis presenting with 6 months of blood diarrhoea and bloating. She has not lost weight. She has a family history of small bowel lymphoma.
A) ACE Inhibitors
B) Calcium Channel Blockers
C) Vasopressin receptor, V2 antagonist
D) Anti-CD20 antibody
E) Terminal complement inhibitor
F) Loop diuretic
G) Cyclophosphamide
H) Corticosteroid

Question 34

RACP 2020
57. EMQ Stem: What investigation would most likely lead to the diagnosis? 28 year old girl with RIF pain. History of perianal fistula and Iron Deficiency Anaemia.
A) CT colonoscopy
B) Pelvic MRI
C) Small bowel MRI
D) Colonoscopy
E) Capsule endoscopy
F) Stool MCS
G) Red cell scan

Question 35

RACP 2020
66. What is the mechanism of liver injury in alpha-1 antitrypsin deficiency?
A) Excess protease activity
B) Lack of elastase inhibition
C) Mitochondrial dysfunction
D) Protein accumulation

Question 36

RACP 2020
75. When therapeutic dose of paracetamol is administered, the blood concentration usually takes 2 hours to peak. If someone is overdosed on paracetamol e.g. taken 50g, it takes more than 6 hours to peak. What is the reason for this?
A) Given NAC
B) Given charcoal
C) Delayed absorption
D) Delayed elimination

Question 37

RACP 2020
80. Needlestick injury of a nurse from a patient with HbSag positive blood. Nurse’s HbSAb titre >100IU/L
A) Hepatitis B Immunoglobulin
B) No treatment
C) Hepatitis B vaccination
D) Re-test hepatitis B antigen after 3 months

Answer 37

B
The nurse has immunity to Hep B virus
(refer to Hepatitis powerpoint - JK)

Question 38

RACP 2020
2. Which gene for haemachromatosis
A. C282Y
B. DeltaF508
C. H63D
D. Useless wrong one

Question 39

RACP 2020 6. Needlestick injury of patient with HbSag positive blood. Doctors HbAb titre >100
A. Hb immunoglobulin
B. Monitor at baseline and 6 months
C. Do nothing
D. Hep B booster vaccine

Answer 39

B
The doctor has immunity to Hep B virus
(refer to Hepatitis powerpoint - JK)

Question 40

RACP 2020
37. An 87-year-old man presents for an outpatient appointment for 4 months history of poor appetite, eating only 1/4 of his meals and 5kg weight loss. He has a history of moderate-severe dementia with MMSE 10/30 and his wife makes his meals for him. He is on nutritional supplements. He weighs 55kg (BMI 19.5). What is the best management?
A) CT abdomen
B) Gastroscopy
C) Start olanzapine
D) Cease donepezil

Question 41

RACP 2019a Question 1
What is the response rate of ledipasvir + sofosbuvir in Hepatitis C genotype 1?

A. 65%
B. 75%
C. 85%
D. 95%

Question 42

RACP 2019a Question 29
A 45 year old lady develops abdominal pain and diarrhoea 15 minutes after every meal. She has a history of gastric Roux-en-y and depression for which she is on desvenlafaxine. What is the most likely cause of her symptoms?

A. Carcinoid syndrome
B. Dumping syndrome
C. Insulinoma
D. VIPoma

Question 43

RACP 2019a Question 37
A 35 year old male has chronic hepatitis, managed with tenofovir. Dipstick urinalysis show glycosuria and proteinuria. Which of the following findings are most consistent with tenofovir-induced Fanconi syndrome?

A. Hypocalcaemia
B. Hypomagnesaemia
C. Hypophosphataemia
D. Hypouricaemia

Question 44

RACP 2019a Question 46
A 30 year old man presents with a three month history of bloody diarrhoea associated with mucous, tenesmus and three kilograms of weight loss. He last travelled to Thailand six months ago. Blood tests revealed an anaemia with Hb 115 g/L, CRP 80 mg/L, ESR 25 mm/Hr. WCC, B12, iron and folate were normal. What is the most likely diagnosis?

A. Crohn’s disease
B. Ulcerative Colitis
C. Ischaemic colitis
D. Salmonella enteritis

Question 45

RACP 2019 Question 65
A patient has the following hepatitis B serology: HBsAg negative, HBsAb positive, HBcAb positive (i.e. past infection). Which medication is has the highest risk of reactivation?

A. Rituximab
B. Tocilizumab
C. Prednisolone
D. Infliximab

Question 46

RACP 2019 Question 73
A 45 year old man presents with pruritus and scleral icterus, but no abdominal pain. He has recently received a course of Augmentin DF for an infection. He has a history of colorectal cancer with hemicolectomy several years ago. He also has a history of heavy alcohol use. Vital signs are normal, and he is afebrile.

Bloods show:
High bilirubin, GGT, ALP, normal AST.
Normal Hb, WCC, PLT
Cannot recall if CRP, INR was given.

Abdominal US showed empty but dilated gallbladder, dilated common bile duct to the level of the duodenum, and increased homogeneous echogenicity of the liver.

What is the most likely diagnosis?

A. Antibiotic-induced cholestasis
B. Common bile duct stone-induced cholestasis
C. Disseminated colorectal cancer
D. Head of pancreas cancer

Question 47

RACP 2019a
Question 79
In a patient with a background of decompensated cirrhosis and sarcopenia, with no previous episodes of hepatic encephalopathy, what is the recommended dietary intervention?

A. High calorie, high protein
B. High calorie, low protein
C. Low calorie, high protein
D. Low calorie, low protein

Question 48

RACP 2019a Question 87
38yo female presents with haematemesis on a background of chronic osteoarthritis managed with ibuprofen. Endoscopy found a 3cm x 2cm bleeding antral ulcer which was successfully treated with adrenaline injection and diathermy. She was discharged on appropriate proton pump inhibitor therapy. She presents for follow up 2 months later, and is asymptomatic.
What is the most appropriate management?
A. Repeat Endoscopy
B. Urea breath test
C. Discharge to GP
D. Hydrogen breath test

Question 49

RACP 2019b Question 31
The most common extra-intestinal manifestation of inflammatory bowel disease involves the:

A. Skin
B. Joints
C. Eyes
D. Liver

Question 50

RACP 2019b Question 53
What is the role of transcobalamin II?

A. Binds intrinsic factor
B. Brings B12 to liver
C. Brings B12 to peripheries
D. Brings B12 to terminal ileum

Question 51

RACP 2019b Question 57
What is the biggest risk factor for developing inflammatory bowel disease?

A. First degree relative with inflammatory bowel disease
B. 20 pack year smoking history
C. Previous Campylobacter enteritis
D. Previous fluoroquinolone use

Question 52

RACP 2019b
Question 58
What is the mechanism of cirrhosis in alpha1 anti-trypsin deficiency?
A. Reduced inhibition of elastase
B. Increased protease
C. Protein accumulation in cells
D. Increased elastase

Question 53

RACP 2018a Q 20

20.
.
A 19-year-old female with no other medical conditions presents to hospital after ingestion of 20 grams of paracetamol (immediate release formulation) combined with alcohol. Appropriate blood tests are obtained on admission and intravenous acetylcysteine is commenced immediately.
Results of investigations obtained 6 hours post-ingestion include serum paracetamol 150 mg/L (1000 μmol/L) and blood alcohol concentration 0.07% w/v (70 mg/100 mL or 15.2 mmol/L).
The paracetamol nomogram is shown:
What is the risk of this patient developing hepatitis due to paracetamol poisoning?
A. < 5%
B. 5–10%
C. 11–20%
D. 21–50%
E. > 50%

Question 54

RACP 2018a Q39
39. A 33-year-old lady with known ulcerative colitis is now 9 days post-admission having failed hydrocortisone and infliximab. She has a temperature of 38 °C, 12 bloody bowel actions a day, abdominal discomfort and anorexia despite ciprofloxacin and metronidazole. Stool testing is
negative for viral, bacterial, protozoal and parasitic causes. Abdominal x-ray shows a colonic diameter of less than 5 cm.
What is the most appropriate next step in managing her ulcerative colitis?
A. Add meropenem.
B. Commence methylprednisolone.
C. Commence total parental nutrition.
D. Refer for colectomy.
E. Switch to cyclosporine.

Question 55

RACP 2018a Q43
43. A 35-year-old Somalian lady with chronic hepatitis B is seen in clinic. Her liver function tests are normal. Her hepatitis B surface antigen is positive and surface antibody negative. An upper abdominal ultrasound reveals a liver of normal echotexture and size, with no splenomegaly or portal hypertension. A 2 cm hypoechoic lesion is noted in the right hepatic lobe.
What is the most appropriate next step to investigate the lesion?
A. Positron emission tomography scan.
B. Quadruple phase computed tomography.
C. Repeat ultrasound in 6 months.
D. Targeted liver biopsy.
E. Transient elastography.

Question 56

RACP 2018a Q55
55. A 28-year-old male presents with an itchy, symmetrical, erythematous and vesicular rash in clusters over the shoulder, elbow, knees and buttocks. Which of the following conditions is most likely associated with his presentation?
A. Primary Biliary Cirrhosis
B. Autoimmune Hepatitis
C. Ulcerative Colitis
D. Coeliac Disease
E. Hepatitis C Infection

Answer 56

D - Coeliac disease

This patient likely has dermatitis herpetiformis (vesicular rash) which is associated with coeliac disease

Question 57

RACP 2018a Q78

78. A 90-year-old resident of a nursing home develops offensive diarrhoea after a 7-day period of constipation. He is being treated with paracetamol and a transdermal opioid for chronic persistent pain and has also received long-term coloxyl with senna two tablets daily. He had a 5-day course of cephalexin for a urinary tract infection 5 days ago. What is the most likely cause for the diarrhoea?
    A. Clostridium difficile.
    B. Diverticulitis.
    C. Drug-induced colitis.
    D. Laxative abuse.
    E. Overflow diarrhoea.

Question 58

RACP 2018a Q89
89. Which antibiotic should be used in addition to lactulose for the management of refractory hepatic encephalopathy?
A. Metronidazole.
B. Neomycin.
C. Rifaximin.
D. Sulfamethoxazole.
E. Vancomycin.

Answer 58

C

Question 59

RACP 2018b Q139
138.In patients with hepatic encephalopathy, lactulose may be beneficial by increasing the amount of non-absorbable ammonium (NH4) formation in the colon. Which indirect mechanism of lactulose within the colon likely mediates this effect?
A. Decreases formation of acetic acid.
B. Decreases nitrogen excretion.
C. Decreases pH.
D. Increases disaccharidase activity within enterocytes.
E. Increases pH.

Question 60

RACP 2018b Q144
144.Where in the gastrointestinal tract are bile acids actively reabsorbed?
A. Colon.
B. Duodenum.
C. Ileum.
D. Jejunum.
E. Rectum.

Question 61

RACP 2018b Q167
167.Which hormone released from intestinal L cells can lead to delayed gastric emptying,
increased post-prandial insulin release and improved satiety?
A. Cholecystokinin.
B. Gastrin.
C. Ghrelin.
D. Glucagon.
E. Glucagon-like peptide-1 (GLP-1).
F. Histamine.
G. Peptide YY.
H. Secretin.

Question 62

RACP 2018b Q168
168.Which hormone binds a plasma membrane-bound G-protein coupled receptor, leading to
increased glycogenolysis?
A. Cholecystokinin.
B. Gastrin.
C. Ghrelin.
D. Glucagon.
E. Glucagon-like peptide-1 (GLP-1).
F. Histamine.
G. Peptide YY.
H. Secretin.

Question 63

RACP 2018b Q152
152.Where are chronic peptic ulcers associated with Helicobacter pylori infection most commonly located?
A. Duodenum.
B. Gastric antrum.
C. Gastric body.
D. Gastric fundus.
E. Gastro-oesophageal junction.

Question 64

RACP 2017
A 40-year-old man receives treatment with oral Metronidazole for C. difficile diarrhoea which resolves his symptoms. He has repeat culture on a formed stool sample one week later, which is still positive for C. difficile toxin. What treatment do you give?
A. Fidaxomicin
B. Metronidazole
C. Vancomycin
D. No treatment is required
E. Faecal microbiota transplantation

Question 65

RACP 2017
A 62-year-old woman is admitted for surgical management of fractured femur and her post-operative course was significant for hospital-acquired pneumonia requiring IV antibiotics. Later in her admission she develops profuse watery diarrhoea, opening her bowels up to 10 times per day. Her BP was 100/60 mm Hg, HR was 100bpm and temperature was 38.9oC. Her abdomen was mildly distended and tender. Blood tests revealed a total WCC 18.9, Hb 101, platelets 410, albumin 28, bilirubin 5, ALP 42, GGT 65, ALT 23 and AST 33. Colonoscopy is performed and the macroscopic appearance is depicted below

What is the most appropriate treatment?

a) Azathioprine
b) Infliximab
c) Metronidazole
d) Prednisolone
e) Vancomycin

Question 66

RACP 2017
A 62-year-old female presents with 15 hours of severe epigastric pain. She drinks 70g of alcohol daily. There is no personal or family history of pancreatitis and she is on no regular medications.

Investigations reveal the following:
Urea 12
Creatinine 170
Bilirubin 48
GGT 128
Lipase 6000 / Amylase 4000
ALP & ALT within normal limits
WCC 19
CRP 150
CT abdomen, MRCP and Abdominal Ultrasound reveal gallstones in the gallbladder without features of cholecystitis or biliary dilatation.

Which of the following will improve her mortality in the first 24 hours?
A. Laparoscopic cholecystectomy
B. IV fluids
C. IV antibiotics
D. IV corticosteroids
E. ERCP

Question 67

RACP 2017
A 65-year-old male presents with a two-week history of jaundice, dark urine and pale stools. He has lost 6 kg and has had a reduced appetite. His past history includes twenty pack years of smoking, IHD and a resected right sided colorectal cancer 5 years prior. On examination, he is non-tender in the RUQ and is icteric. 
His bloods demonstrate:
Bili 100
ALT 47
GGT 546
ALP 123
His Liver US demonstrates a dilated gallbladder and common bile duct with dilatation seen all the way to the duodenum. The liver is also echogenic. What is the most likely cause of his symptoms?

A. Recurrent Colorectal Cancer
B. Alcoholic Liver Disease
C. Cancer of the Pancreatic Head
D. Cholecystitis
E. Cholangitis

Question 68

RACP 2017

In addition to a Proton Pump Inhibitor, which of the following regimes makes up the primary treatment of Helicobacter pylori infection in Australia?

A. Doxycycline and Ciprofloxacin
B. Amoxicillin and Moxifloxacin
C. Metronidazole and Rifabutin
D. Amoxicillin and Clarithromycin
E. Metronidazole and Ciprofloxacin

Question 69

RACP 2017
A 60-year-old man presents with pain on defecation over the last two days which is associated with bright red blood on toilet paper. The patient has a few years of intermittent constipation and diarrhoea. His grandmother had bowel cancer diagnosed at the age of 76. What is the most likely diagnosis in this patient?

A. Rectal Cancer
B. Anal fissure
C. Irritable Bowel Syndrome
D. Ulcerative Colitis
E. Pseudomembranous Colitis

Question 70

RACP 2017
What substrate is used for the hydrogen/methane test in the diagnosis of small intestinal bacterial overgrowth?

A. Glucose
B. Fructose
C. Lactose
D. Mannitol
E. Sorbitol

Question 71

RACP 2017
A 38-year-old woman with longstanding GI disease presents with diarrhea. Lab tests are as follows:
pH 7.09
pCO2 22
Na 134
Bicarb 8
Cl 98
K 2.6
Which of the following is the most correct interpretation of the above results?

A.High anion gap metabolic acidosis
B. High anion gap respiratory acidosis
C. Normal anion gap mixed respiratory acidosis metabolic acidosis
D. Normal anion gap respiratory acidosis
E. Normal anion gap metabolic acidosis 

Question 72

RACP 2017
Which of the following is most likely to be associated with a normal faecal calprotectin?
A. Colorectal Cancer
B. Diverticulitis
C. Ulcerative Colitis
D. Crohn’s disease
E. Irritable Bowel Syndrome

Answer 72

E

Question 73

RACP 2017
Which feature shown on the hepatic biopsy below is most characteristic of Non-alcoholic steatohepatitis?

A. Hepatocyte ballooning
B. Piecemeal necrosis
C. Hepatic Steatosis
D. Bridging fibrosis
E. Stellate cell activation

Question 74

RACP 2017

What is the role of trans-cobalamin II in vitamin B12 metabolism?

A. To bind to liberated vitamin B12 in the stomach
B. To co-operate with intrinsic factor
C. To transport vitamin B12 to the terminal ileum
D. To transport vitamin B12 to the peripheral tissues
E. To transport vitamin B12 to the liver

Question 75

RACP 2016a Question 2

A 51yo lady was found to have deranged LFTs. She has a BMI of 29 and drinks 10g of alcohol every 2 days. Her medical background is notable for HTN and GORD, treated with perindopril and pantoprazole respectively. Abdominal exam was normal. LFTs described below:
AST Normal
ALT Normal
ALP 300 (~3xULN)
GGT 90 (~1.5x ULN)
Ferritin 660
INR 1.0
Bilirubin 8
Anti-smooth muscle Negative
Anti-LKM1 negative
Anti-mitochondrial antibody positive

What is the most likely cause for her LFT derangement?
A. Alcoholic hepatitis
B. Non-alcoholic steatohepatitis
C. Primary Biliary Sclerosis
D. Autoimmune hepatitis
E. Haemochromatosis

Question 76

RACP 2016
Question 8
A 52 year old female presents with abdominal pain and jaundice. She has a background history of asthma, urticaria and obesity. She uses 3g Paracetamol per day for chronic back pain.
Her LFTs are as follows:
Bilirubin 67
Amylase 100
Lipase 108
ALT 346
AST 1400
GGT 380
What is the cause of her presentation?
A. NASH
B. Alcoholic liver disease
C. Choledocolithiasis
D. Paracetamol toxicity
E. PBC

Question 77

RACP 2016a Question 32
A young man presents to you concerned regarding the possibility of having acquired hepatitis C. He admits to having used iv amphetamines over the past 6 months. What is the best test for ACTIVE hepatitis C?
A. IgG Hep C
B. IgM Hep C
C. P24 Hep C
D. Hep C RNA PCR
E. Western Blot

Question 78

RACP 2016b Question 7

25 Male with pneumonia, treated with IV benzylpenicillin and PO azithromycin. His pneumonia improves but becomes very confused, with oedema on his CT brain 
You suspected a defect with the urea cycle. If the diagnosis is correct which test is most likely to be abnormal?
A. Ammonia
B. Homocysteine 
C. Lactate
D. Calcium
E. Very long chain lipids

Question 79

RACP 2016b Question 20

Faecal microbiota transplant is a proven therapy in which of the following?
A. Pseudomembranous colitis
B. IBD
C. IBS
D. Pancreatitis
E. Microscopic colitis

Question 80

RACP 2016b Question 33

A 40 yo alcoholic man who smokes 40 cigarettes per day presents with malaena, he takes regular esomeprazole 20mg and ibuprofen. He is found to have a 11mm clean based duodenal ulcer. Antral biopsies are negative for H pylori. What is the most likely cause of his gastric ulcer?
A) ibuprofen
B) H pylori
C) cigarette smoking
D) alcohol
E) Gastrinoma

Question 81

RACP 2015 Q11
Most causes of hepatocellular injury are associated with elevated liver aminotransferases with
ALT>AST. Aside from Alcoholic Hepatitis, which condition most commonly causes an
increased AST:ALT ratio (i.e. AST>ALT)?
A. Ischaemic Hepatitis
B. EBV-Induced Hepatitis
C. Paracetamol Overdose
D. Hepatic Vein Thrombosis
E. Non-Alcoholic Fatty Liver Disease

Question 82

RACP 2015
You are called to the ward to see a 48 year old woman with hepatitis B associated liver
cirrhosis. There is no documented history of recent alcohol use. She is agitated and
delirious. What is the preferred medication for this setting?
A. Diazepam
B. Haloperidol
C. Oxazepam
D. Risperidone
E. Rhubarb

Question 83

RACP 2015
Question 42
A 42 year old female with T1DM is diagnosed with autoimmune hepatitis based on liver
biopsy and blood tests. Bloods shown: mildly deranged LFTs around 1.5-2x ULN, bilirubin 8, INR normal, elevated
CRP, positive anti-LKM Ab, HbA1c 12.6%
Biopsy results: mild changes of AIH (can’t remember exactly) plus marked steatosis
What treatment would you recommend for her autoimmune hepatitis?
A. Azathioprine
B. Mycophenolate
C. Observation
D. Prednisone
E. Vitamin E

Question 84

RACP 2015
A 50 year old female with a background of liver cirrhosis presents with shortness of breath. On standing her Sp02 is 84%, this improves to 94% when she lays flat. What is the cause of
her SOB?
A. Intrapulmonary Shunt
B. Ascites
C. Diaphragmatic weakness
D. Pulmonary Effusion
E. Long QT syndrome

Question 85

RACP 2015
Question 39
Bile acids undergoes enterohepatic circulation. In which part of the intestine bile acids are absorbed to return to the liver:
A. Ascending colon
B. Descending colon
C. Duodenum
D. Jejunum
E. Ileum

Question 86

RACP 2015 Q98
Question 98:
55 year old male with chronic untreated hepatitis B. He was hypertensive to 180/100 on examination. Investigations showed normal renal function. He had a history of recurrent abdominal pain and fever. He also episodes of frank haematuria. What is the likely cause of hypertension?
A. IgA glomerulonephritis
B. Phaeochromocytoma
C. Polyarteritis Nodosa
D. Polycystic kidney disease
E. Primary hyperaldosteronism
F. Reflux nephropathy
G. Renal arterial fibromuscular dysplasia
H. Scleroderma

Question 87

RACP 2015 Question 29
What is the pathophysiological mechanism for excessive flatulence?
A. Fermentation of carbohydrate by gastrointestinal microbes
B. Sphincter incompetence
C. Peristaltic dysfunction
D. Increased motility
E. Diverticular disease

Question 88

RACP 2015
42 M presents with heartburn and dyspepsia. No other significant pmhx. Non smoker and non drinker. Gastroscope shows acute on chronic changes on biopsy with 20 eosinophils on high power. What is the next best management.
A. Budesonide slurry for eosinophilic esophagitis
B. CCB for dismotility
C. Fluconazole for candidiasis
D. Start on PPI and repeat scope
E. Refer for Nissen fundoplication

Question 89

RACP 2015
45M diagnosed with colorectal cancer after colonoscopy. No family hx of cancer. Immunohistochemistry of biopsied specimens showed mismatch repair mutations in MLH 1, MSH2 and MSH6 both in th tumour and adjacent normal tissue. What is the most likely cause for his cancer?
A. Lynch syndrome
B. Familial adenomatous polyposis
C. Familial colorectal cancer
D. Microsatellite instability
E. Sporadic colon cancer

Question 90

67 M with alcoholic Child Pugh C cirrhosis admitted with hepatic encephalopathy complicated by agitated delirium. What is the agent of choice for management of agitation in this setting?
A. Respiridone
B. Haloperidol
C. Diazepam
D. Oxazepam
E. Quetiapine

Question 91

RACP 2014 a
Question 1:

A 56 year old male presents to hospital with confusion. He was recently discharged from hospital after an admission for acute pancreatitis, that was complicated by a pseudocyst, steatorrhea and glucose intolerance. He was discharged home on insulin, candesartan and pancreatic enzymes. On examination, he is confused and clammy. HR=97, BP=120/80 and temp 36.5. What is the most likely cause of his symptoms?

A. Dehydration
B. Malnutrition.
C. Sepsis
D. Pancreatitis
E. Hypoglycemia

Question 92

RACP 2014 Question 11

A 25 year old female undergoes workplace screening for haemochromatosis. She is found to be homonymous for the HFE gene. She is currently asymptomatic with a normal clinical examination.

Laboratory findings:
Hb 120 (N 120-150)
Ferritin 145 (N 25-400)
Transferin 49% (N <45%)
What is the next best management?

A. Echocardiogram
B. Liver biopsy
C. Regular venesection
D. Reduction in dietary iron consumption
E. Repeat iron studies in 12 months.

Question 93

RACP 2014
Question 48
A 28 year old male was diagnosed with Crohn’s disease several years ago. He had been anaemic at the time of diagnosis. Capsule endoscopy at the time showed extensive small bowel disease. He had a good clinical response to infliximab and blood tests normalised. He now complains of severe abdominal pain, distension and vomiting. Table of blood results given (normal, incl. CRP). Small bowel study shows jejunal stricture with proximal dilatation.

What would be the next best management option?
A. Add mesalazine
B. Change AZA to 6MP
C. Change infliximab to adalimumab
D. Surgery
E. Restart prednisolone

Question 94

RACP 2014
Middled aged woman, overweight (BMI 32 or 36). Routine blood tests show abnormal LFTs.
Alcohol infrequent. Nil family history of liver disease. Only medications, perindopril for HTN and pantoprazole for GORD.
Raised BR, GGT, ALP, AST and ALT. Ferritin 638. Transferrin saturation <15%.
AMA, LKM Ab negative.
What is the most likely Dx?
A. Haemochromatosis
B. Alcoholic liver disease
C. Autoimmune hepatitis
D. Drug induced liver injury
E. Fatty liver disease

Question 95

RACP 2014
What supplement is most likely to cause hepatotoxicity?
A. Fish oil
B. Chondroitin
C. Glucosamine
D. Valerian
E. Co-enzyme Q10

Question 96

RACP 2014
Type 1 diabetes is commonly associated with coeliac disease. In a 23 year old woman with Type 1 diabetes, which nutritional deficiency will prompt you to do coeliac screening?
a) B12
b) Folate
c) Iron
d) Calcium
e) Vitamin D

Question 97

RACP 2014
Q47. Gentleman with Child Pugh C cirrhosis - which benzodiazepine is most appropriate for treatment of alcohol withdrawal?
A. Clonazepam
B.Diazepam
C. Oxazepam
D. Nitrazepam
E. Chlordiazepoxide

Question 98

RACP 2013a Q3
In a patient with cirrhosis, which of the following is most likely to precipitate encephalopathy?
A) Hypokalemia
B) Hypomagnesemia
C) Hyponatremia
D) Hypocalcaemia
E) Hypophosphotaemia

Question 99

RACP 2013a Question 21
Hemachromatosis is a result of HFE mutation. It is inherited as an autosomal recessive disease with 25% penetrance. 1:10 in the population are carriers of this mutation. What is the likelihood of developing clinical phenotype of hemachromatosis in a male whose father was affected?

A) 1/4
B) 1/16
C) 1/20
D) 1/40
E) 1/80

Question 100

RACP 2013 Question 36
In non-alcoholic fatty liver disease, which of the following is the single greatest predictor of advanced disease?

A. Cardiovascular disease
B. High serum triglycerides
C. Hypertension
D. Impaired fasting glucose
E. Type 2 diabetes

Question 101

RACP 2013a
In a patient with NASH, what is the most important factor causing progression to fibrosis?

A. Hepatitis B viral load
B. HIV coinfection
C. Obesity
D. High alcohol intake
E. Smoking

Question 102

RACP 2013
Question 38
Which of the following conditions has the strongest association with cryoglobulinaemia and normal complement levels?
A. HBV
B. HCV
C. Waldenstrom’s macroglobulinaemia
D. Tuberculosis
E. EBV

Question 103

RACP 2013a
Question 39
A serum ascites to albumin gradient of 12 is most likely to be caused by which of the following?
A) Malignant ascites
B) Nephrotic syndrome
C) Pancreatitis
D) Portal hypertension
E) Tuberculous ascites

Question 104

RACP 2013a Question 40
A 40yo male patient is admitted with recurrent pancreatitis. A CT scan reveals no pancreatic mass, but evidence of widespread lymphadenopathy. Dedicated liver imaging reveals a stricture in the common bile duct but no stones. He also has a history of parotiditis. What is the most likely diagnosis?
A. Lymphoma
B. IgG4 disease
C. Pancreatic cancer
D. Biliary malignancy
E. Primary sclerosing cholangitis

Question 105

RACP 2013a Question 42
Where is the centre for control of appetite and satiety?
A. Amygdala
B. Hypothalamus
C. Frontal lobe
D. Pons
E. Anterior pituitary

Question 106

RACP 2013a Question 53
Which of the following foods should be avoided in irritable bowel syndrome (to prevent diarrhoea)?

A. Fat
B. Protein
C. Sorbitol
D. Spicy food
E. Fructose

Question 107

RACP 2013b Question 16
58 year old patient was admitted for bowel obstruction 3 months ago, treated with bowel rest, and after several days commenced on IV TPN. Her current medications include pantoprazole 40mg daily, paracetamol 1g QID, morphine 3.5mg S/C PRN & perindopril 5mg day.
Hb 130 WCC 6.7 Platelet 140
Na 135 K 3.4 Cr 114
Alb 30
Bilirubin 27 ALP 150 GGT 180 ALT 3280 AST 3400 APTT 33sec
INR 1.7
USS abdomen is unremarkable.

What is the likely cause of her abnormal blood tests?
A) Paracetamol toxicity
B) Choledocholithiasis
C) Ischaemic hepatitis
D) Budd-chiari syndrome
E) Autoimmune hepatitis

Question 108

RACP 2013b Question 29
An 88M is admitted to ICU with sepsis secondary to community acquired pneumonia. He has a past history of AF, CCF and Parkinson’s disease. In ICU he is noted to have abdominal distension. His AXR is shown below:
What is the likely Dx?
A. Colonic pseudo-obstruction
B. Colon cancer
C. SBO secondary to adhesions
D. Diverticulitis
E. Sigmoid volvulus

Question 109

RACP 2013b Question 44
A 45yo male is found to have an adenocarcinoma of the sigmoid colon. The rest of his colonoscopy was normal. He has no other family or personal history of cancer. Immunohistochemistry of the tumour showed mismatch repair mutations in MLH1, MSH2, and MSH6 in the tumour and adjacent normal tissue. What would be the surveillance recommendations for his children?

A. FOBT yearly from age 50
B. Colonoscopy 5 yearly from age 35
C. No surveillance
D. Yearly colonoscopy from age 25
E. Second yearly colonoscopy from age 45

Question 110

RACP 2013b Question 69
A middle-aged patient presents with large volume, non-bloody, watery diarrhoea. Colonoscopy is normal, and a biopsy reveals a lymphocyte infiltration. What is the likely diagnosis?
A. Coeliac disease
B. Crohn’s disease
C. Ulcerative colitis
D. Microscopic colitis
E. TB

Question 111

RACP 2013b Question 70
A patient with a mitral valve replacement is about to attend a gastroscopy with esophageal dilatation. He has no current active GIT infection. What endocarditis prophylaxis is recommended?
A. None
B. Erythromycin PO 30 min pre-procedure
C. Ciprofloxacin PO 30 min pre-procedure
D. IV ampicillin at time of surgery
E. IV cefazolin at time of surgery

Question 112

RACP 2013b Question 84
56yo female, recurrent pancreatitis. Does not drink alcohol. Nil regular medications. She currently has acute pancreatitis. (Investigations consistent with acute pancreatitis)
CT abdomen NAD
MRCP NAD

What is the next best investigation?
A. ERCP
B. Endoscopic ultrasound
C. HIDA scan
D. Faecal fat collection for 3 days
E. CT abdomen

Question 113

RACP 2013b Question 85
68 yo lady, presented with lethargy and anorexia. She underwent a partial gastrectomy 3 years ago for bleeding gastric ulcer. Her blood results showed: WBC 3.5, Hb 90, Plt 60. Blood film: oval erythrocytes, macrocytic erythrocytes, hypersegmented neutrophils, low platelets. BMB: cytoblastic picture.
What the most likely cause of her anaemia?
A Iron deficiency anaemia
B Anaemia of chronic disease
C AIHA
D Sideroblast anaemia
E Spur cell haemolysis
F Vitamin-B12 deficiency
F Thalassaemia
G Myelodysplasia

Question 114

RACP 2013b
Question 86
38 year old woman with chronic liver disease due to alcohol. On examination has splenomegaly and signs of CLD. Blood film shows macrocytosis and acanthocytes. Also has hyperbilirubinaemia (although number not given for bilirubin). Hb low (about 80), WCC normal, plts low (about 50) and haptoglobin 5 (so high, although I can’t remember units). What is the diagnosis?

A Iron deficiency anaemia
B Anaemia of chronic disease
C AIHA
D Sideroblast anaemia
E Spur cell haemolysis
F Vitamin-B12 deficiency
F Thalassaemia
G Myelodysplasia

Question 115

RACP 2013b Question 98
Barrett oesophagus is characterised by which of the following histopathology?

A. Columnar cell dysplasia
B. Specialised intestinal metaplasia
C. Eosinophilic oesophagitis
D. Crypt abscesses
E. Squamous cell metaplasia

Question 116

RACP 2012a QUESTION 4
A person has 10 loose bowel motions per day. He does not have a history of
recent travel. Fecal microscopy revealed leukocytes and red cells. What is the
most likely cause?
A. Campylobacter jejuni
B. Giardia lambdia
C. Clostridium difficile
D. Enterotoxigenic E. coli
E. Rotavirus

Question 117

RACP 2012a QUESTION 21
Lactulose is frequently used in the management of hepatic encephalopathy.
What is the main therapeutic effect of lactulose?
A. Increased CNS stimulation
B. Increased blood glucose level
C. Laxative effect
D. Increase peristalsis
E. Decrease faecal pH

Question 118

RACP 2012a QUESTION 29
What is the best marker for recent change in nutrition status?
A. Albumin
B. Prealbumin
C. Ferritin
D. B12
E. Folate

Question 119

RACP 2012 a QUESTION 32
Bevacizumab used in colon cancer with chemotherapy what is mechanism of
action?

A. VEGF inhibitor
B. EGFR ihibitor
C. Her 2 inhibitor
D. Neurokinin 1 receptor antagonist
E. Platelet derived growth factor inhibitor

Question 120

RACP 2012a QUESTION 51
Which of the following is the best predictor of a flare of inflammatory bowel
disease during pregnancy?
A. Disease activity at conception
B. Number of hospital admissions
C. Length of bowel affected
D. On more than three medications for IBD
E. Disease duration

Question 121

RACP 2012a QUESTION 64
A pathogenic strain of Clostridium difficile produces a binary toxin. Clostridium
difficile which produces the binary toxin is more likely to:
A. Respond only to moxifloxacin
B. Infect the elderly
C. Produce severe abdominal pain
D. Produce toxic megacolon
E. Produce iron deficiency anaemia

Question 122

RACP 2012b QUESTION 4
A 70 year old man with a past history of an ileal resection secondary to ischemic gut
presents with two year history of watery diarrhea. Stool culture is negative and
endoscopy is normal. What is the next best step in management of his diarrhoea?
A. Cholestyramine
B. Codeine phosphate
C. Loperamide
D. Probiotic
E. Salazapyrin

Question 123

RACP 2012b QUESTION 10
A 55 year old male with a past history of successful anterior resection for node
positive localised colonic adenocarcinoma presents for follow up 2 years later. He
remains independent and is otherwise well.
A recent CT scan has found a single 3cm lesion in the left lobe of the liver on CT
scan. A FDG-PET scan does not find any other lesions.
Repeat gastroscopy and colonoscopy is unremarkable and there is no evidence of
metastatic disease elsewhere.
What is the most appropriate treatment?
A. surgical resection of liver lesion
B. palliative chemotherapy
C. supportive care
D. arterial chemoembolization
E. radiotherapy

Question 124

RACP 2012b QUESTION 11
A 45 yr old man has colon cancer, and also has 3 adenomas on colonoscopy. No
family history. Histology shows mismatch repair genes MLH1, MSH2, MSH6 in the
tumour, and also in the surrounding normal tissue. What is the likely diagnosis?
A. Autosomal recessive adenomatous polyposis
B. HNPCC
C. FAP
D. Juvenile polyposis
E. sporadic colon cancer

Question 125

RACP 2012b QUESTION 19
A 28 year old woman presents with a 2 year history of intermittent abdominal pain
and diarrhea. She smokes 20 cigarettes per day. A small bowel series (picture
below) shows a long stricture in the terminal ileum.

In addition to prednisone, what is the best initial management?
A. Infliximab
B. Cyclosporin
C. Smoking cessation
D. Surgery
E. Antibiotics

Question 126

RACP 2012b QUESTION 44
A 45 year old patient is admitted to ICU with systemic inflammatory response
syndrome, secondary to Pancreatitis associated with gallstones. Which form of
nutrition is best?
A. Intravenous fluids
B. PEG feeding
C. Gastrostomy
D. Total parenteral nutrition
E. NG/NJ tube feeding

Question 127

RACP 2012b QUESTION 74
68 year old male admitted with a 3 year history of weight loss and dysphagia.
Manometry showed absent oesophageal peristalsis and elevated resting lower
oesophageal pressures.
Most likely diagnosis is
A. Achalasia
B. GORD
C. Eosinhophilic Oesophagitis
D. Oesophageal Cancer
E. Schatzki Ring

Question 128

RACP 2012b QUESTION 76
An asymptomatic 25 year old lady has a sibling with haemochromatosis and is tested
and found to be homozygous for the C282Y mutation. Ferritin and serum iron are
normal, transferrin saturation is mildly elevated at 70%.
What is the most appropriate next management step:
A. Baseline ECHO
B. Follow up in 1 year with repeat iron studies
C. Low iron diet
D. Venesection
E. Liver biopsy

Question 129

RACP 2012b QUESTION 91
A 54 year old woman presents with a history of increasing lethargy and pruritus.
Clinical examination is normal. Her investigations are shown below.
What is the diagnosis?
A. Autoimmune hepatitis
B. Systemic Lupus Erythematosis
C. Primary Biliary Cirrhosis
D. Drug induced hepatitis
E. Primary Sclerosing Cholangitis

Question 130

RACP 2012b QUESTION 96
An 87 year old lady presented with abdominal pain. She has a history of atrial
fibrillation and hypertension. On examination, she was afebrile with generally tender abdomen but no focal areas of tenderness. Her electrolytes and an arterial blood gas are shown:
What is the most likely diagnosis?
A. Caecal volvulus
B. Septic Peritonitis
C. Mesenteric ischaemia
D. Constipation
E. Small bowel obstruction

Question 131

RACP 2011a Question 11
When is fatty liver of p regnancy most likely to present?

A. First Trimester
B. Second Trimester
C. Within 3 days post-partum
D. Within 3 weeks post-partum
E. Third Trimester

Question 132

RACP 2011a Question 23
The mechanism of action of lactulose in treatment of constipation is:

A. Bulking agent
B. Lubricant
C. Osmotic agent
D. Stool softener
E. Stimulant

Question 133

RACP 2011a Question 30
A 35yr old man presents with an acute onset of di arrhea, passing more
than 10 stools a day. Microscopic examination shows leukocytes and
erythrocytes. He has had no history of recent travel.
What is the most likely cause?

A. Campylobacter jejuni
B. Clostridium perfringens
C. Enterotoxigenic E. Coli
D. Rotavirus
E.Giardia lamblia

Question 134

RACP 2011a Question 50

In older people, the absorption of which electrolyte is decreased with
proton-pump inhibitor (PPI) use?

A. Bicarbonate
B. Calcium
C. Magnesium
D. Potassium
E. Sodium

Question 135

RACP 2011a Question 52
Ingestion of 100g of which of the following would cause the greatest
caloric intake

A. Carbohydrate
B. Protein
C. 60% alcohol
D. Polyunsaturated fat
E. Soft drink

Question 136

RACP 2011a
Question 56
Liver damage in alpha 1 antitrypsin deficiency is mediated by:

A. Lack of alpha 1 antitrypsin
B. Liver Fibrosis
C. Protease activity
D. Oxidative stress
E. Protein accumulation in the hepatocytes

Question 137

RACP 2011a Question 60
In Refeeding syndrome, which is the most clinically significant electrolyte abnormality?

A. Hypocalcaemia
B. Hyponatremia
C. Hypokalaemia
D. Hypophosphatemia
E. Hypomagnesaemia

Question 138

RACP 2011a Question 67
Hyperbilirubinaemia In Gilbert’s disease is due to a defect of:
A. Hepatic recycling
B. Bilirubin excretion
C. Intravascular haemolysis
D. Bilirubin glucuronidation
E. Haem production

Question 139

RACP 2011a 36, in the ICU for treatment of cholangitis related sepsis, received cephalosporin and gentamicin which levels were measured 2 n d d ail y and were within norm al ranges, developed acute kidney injury with his creatinine doubling f rom 70 to 150 m mol/L . He has past 2.4 L of urine in the past 24 hrs. His urinalysis showed hyaline casts. The most likely cause of his renal impairment is:
A. Aminoglycoside toxicity
B. Glomerulonephritis
C. Hepatorenal syndrome
D. Acute tubular necrosis
E. Acute interstitial nephritis

Question 140

RACP 2011
Question 34
A 28 year old female has a 2 year history of abdominal p ain an d diarrhoea. She
smokes 20 cigarettes a da y. A small bowel series shows a long stricture in the
terminal ileum .

In addition to prednisone, what is the best initial treatment?
A. Cyclosporine
B. Infliximab
C. Probiotics
D. Sulfasalazine
E. Smoking cessation

Question 141

RACP 2011b Question 40
A 47M presented with wheezing, diarrhea, abdominal pain, skin flushing and a urinary 5 - Hydroxyindolacetic acid (5 -HIAA) assay = 120 m g/ml (range 2-5). An abdominal CT scan is shown below.

What is the most likely location of the primary tumour
A. Colon
B. Oesophagus
C. Rectum
D. Stomach
E. Small intestine

Question 142

RACP 2011b Question 74

A 35 year old female admitted for repair of a fractured femur. Transfused 2
units blood post-operatively for blood loss. Develops cellulitis managed with flucloxacillin. Discharged uneventfully.
10 days later she represents with lethargy and SOB. Not jaundiced. Hb 70. blood film shows polychromasia and schistocytes.
What is the most likely cause of her anaemia?
A. Delayed haemolytic transfusion reaction
B. Flucloxacillin induced anaemia
C. Sepsis
D. Iron deficiency
E. Post-operative blood loss

Question 143

RACP 2011b Q 78
An elderly man undergoes urgent laparotomy for bowel obstruction a which point he is found to have stenosing primary bowel cancer. He undergoes colectomy with primary anastomosis. The main reason for doing a follow up colonoscopy afterwards is to:
A. Exclude synchronous cancer
B. Assess for colonic polyps
C. Assess for tum our at the anastomotic site
D. Assess for terminal ileitis
E. Assess for celiac disease

Question 144

RACP 2011b Q99

99) A 54 year old m an with Type 2 diabetes mellitus, complicated by proliferative diabetic retinopathy and nephropathy, now presents with early satiety and malodorous breath. What is the best test for diagnosing diabetic gastroparesis?
a) Gastroscopy
b) Barium swallow
c) Gastric emptying study
d) Abdominal computed tomography
e) Capsule Endoscopy

Question 145

RACP 2010a Question 2
Increased secretion of which substance below will increase oral intake ?
A. Ghrelin
B. Adiponectin
C. peptide YY
D. Leptin
E. GLP-1

Question 146

RACP 2010a Question 5
43y alcoholic man presents with anaemia. Blood shows many spur cells and moderate
thrmobocytopenia. Whati si the most likely cause of his anaemia.
A. Acute blood loss
B. Cirrhosis
C. Fe deficiency
D. Folate deficiency
E. B12 deficiency

Question 147

RACP 2010a Question 6
What is the lifetime risk of developing colorectal cancer in a person with genetically confirmed FAP who does not have a prophylactic colectomy.
A. 10%
B. 20%
C. 60%
D. 75%
E. 95%

Question 148

RACP 2010a Question 13
A patient presents with recent onset of 10 loose bowel movements per day. Stool microscopy shows leukocytes and erythrocytes. The patient has not travelled overseas. Which of the following is the most likely pathogen?
A. Campylobacter jejuni.
B. Clostridium perfringens.
C. Enterotoxigenic E. coli.
D. Giardia lamblia.
E. Rotovirus.

Question 149

RACP 2010a Question 20
Consumption of 100gram of the following has the highest caloric intact?
A. 60% ethanol
B. animal protein
C. polyunsaturated fat
D. carbohydrate
E. soft drink

Question 150

RACP 2010a Question 29
The main site of folic acid absorption is :

A. proximal jejunum
B. duodenum
C. distal jejunum
D. terminal ileum
E. stomach

Question 151

RACP 2010a Question 33
What is the mechanism of cirrhosis in alpha-1 antitrypsin deficiency?
A. Abscence of alpha 1 antitrypsin expression
B. Excess protease activity
C. Hepatic fibrosis
D. Oxidative stress
E. Protein accumulation in hepatocytes

Question 152

RACP 2010a Question 43
What is the main risk factor for Clostridium difficile infection?
A. Advanced age
B. Colonoscopy
C. Hospitalisation
D. Immunosuppression
E. PPI use

Question 153

RACP 2010a Question 48
A 45 year old man is about to commence chemotherapy for lymphoma. Which of the following profiles carries the highest risk for reactivation of hepatitis?

Question 154

RACP 2010b Question 4
A 24yo male has abdominal pain 2 weeks after travelling through SE Asia. Blood film shows eosinophilia. (Blood film shown plus description). What is the most likely organism:
A. P. falciparum
B. PCP
C. strongyloidiasis
D. Salmonella typhi
E. E.coli

Question 155

RACP 2010b Question 6
A 25yo male presents with symptoms suggestive of coeliac disease. Early investigations are
performed:-
IgA ± within normal range
Transglutaminase Ab ± within normal range
Which has the highest negative predictive valve for coeliac disease?
A. Transglutaminase Ig A Antibody
B. Duodenal Biopsy
C. HLA DQ2/8
D. Anti-glidan antibodies
E. Anti-endomysial IgA antibody

Question 156

RACP 2010b Question 7
A 79 year old man presents with abdominal pain. He is found to have retroperitoneal
lymphadenopathy. WCC is 15 with 70% lymphocytes. There are several atypical lymphocytes.
What is the most appropriate diagnostic test?
A. Bone marrow Biopsy
B. Serum Cytogenetic analysis
C. PET scan
D. Retroperitoneal lymph node biopsy
E. PSA

Question 157

RACP 2010b Question 9
In a patient with peptic ulcer disease, what is optimal advice regarding timing of PPI?
A. Any time of day
B. As needed for symptoms
C. Before each meal of day
D. With ranitidine
E. With food

Question 158

RACP 2010b Question 12
A patient with IgA deficiency is going for a liver transplant. Which if the following events is most likely to result in severe adverse reaction:

A. Antibiotic administration
B. Blood transfusion
C. Hepatobiliary anastomotic stricture (?)
D. Immunosuppression
E. Post-operative ventilation

Question 159

RACP 2010b Question 23
A backpacker returned from Thailand two months ago. He is still has crampy abdominal pain, loose stools and urgency. Which of the following is the most likely cause of his symptoms?
A. Campylobacter
B. E. coli
C. Lactose intolerance
D. Post-infectious irritable bowel syndrome
E. Tropical sprue

Question 160

RACP 2010b Question 26
65 y/o presenting with 3/12 proximal muscle weakeness. Her CK is 30,000.
What is the most likely cause of this picture ?
A. Hypothyroid
B. Inflammatory Bowel Disease
C. Celiac Disease
D. Malignancy
E. Sarcoidosis

Question 161

RACP 2010b Question 37
A 40 year old female with new diagnosis of ulcerative colitis presents for routine bloods.
Bilirubin 35
ALP 555
GGT 458
ALT 48
Albumin 40
Ultrasound : nil extrahepatic duct dilatation. nil gallstones
The next best investigation to establish the cause of the abnormal LFTs :
A. MRCP
B. ERCP
C. liver biopsy
D. anti-neutrophil cytoplasmic antibody
E. anti-mitochondrial antibody

Question 162

RACP 2010b (Repeated from 2009)
A 72 year old man had a gastric resection for a mid-gastric adenocarcinoma one year ago. He now presents with symptomatic anaemia. The peripheral blood film shows macrocytosis, fragmented red
blood cells and moderate thrombocytopaenia (blood film shown). What is the most likely cause for this
man’s anaemia?

A. Iron deficiency
B. B12 deficiency
C. Anaemia of chronic disease
D. Acute blood loss
E. Metastatic disease

Question 163

RACP 2010b Question 50
Alcholic male presents with jaundice and abdominal pain.
Maddrey score 36
Bilirubin 60
ALT 250
AST 310
Bili 60
Prothrombin time (elevated)
He is diagnosed with alcoholic hepatitis, what should he be treated with?
A. NAC
B. Nutritional support
C. Infliximab
D. Prednislone
E. Beta blocker.

Question 164

RACP 2010b Question 58
An 87 year old woman with advanced dementia is fully dependent from a nursing home. She is bedbound, doubly incontinent and does not recognize family members. She has new onset dysphagia and is aspirating fluids. She coughs up clear fluids and spits out thickened fluids. She is nil by mouth
awaiting assessment but appears distressed at not being able to eat or drink. Which is the most appropriate management for her?
A. PEG feeding
B. NGT feeding
C. Free access to diet and fluids
D. Thickened fluids only
E. NBM with subcut fluids

Question 165

RACP 2010b Question 73
A 68 yo male had a large bowel resection due to a stenosing bowel cancer. A hemicolectomy with primary anastomosis was performed which revealed no evidence of spread. Following surgery, what
is the reason for follow-up colonscopy?
A. Check for anastomotic integrity
B. check for colonic polyps
C. check for synchronous cancer
D. check for anastomotic cancer
E. check for terminal ileitis

Question 166

RACP 2010b Question 91
A 74 yo man presents with spontaneous bruising and muscle haematoma. He has a palpable liver of 12cm span, and enlarged spleen. He has no personal or family history of bleeding problems. His Full
blood count is shown below
- Hb =122
- WCC=10.1 (or 7.2)
- Plts=57 (or 88)

Which of the following is the most likely diagnosis?
A. Hepatic cirrhosis
B. MDS
C. Primary Myelofibrosis
D. SLE
E. Iron deficiency

Question 167

RACP 2010b Question 97
89 year old nursing home resident is bed bound and dependent for all ADLs. Poor oral intake. Found to be incontinent of liquid faeces. AXR is performed. How would you manage this patient?
A. fiber supplements
B. glycerine suppository
C. phosphate-containing enema
D. loperamide
E. oral docusate
F. Sodium phosphate laxative

Question 168

RACP 2009a Question 22

For which clinical scenario would H.pylori eradication have the greatest clinical benefit?

a) Non-ulcer dyspepsia

b) Barrett’s oesophagus

c) Gastric MALT lymphoma

d) Reflux oesophagitis

e) Intestinal metaplasia

Question 169

RACP 2009a Question 28

What are the following findings most suggestive of
Hepatitis B surface Antigen Negative
Hepatitis B surface Antibody Positive
Hepatitis B e Antigen Negative
Hepatitis B e Antibody Positive

a) Acute hepatitis B infection
b) Previous immunization
c) Past hepatitis B infection
d) Chronic hepatitis B infection

e) Pre-core mutant infection

Question 170

RACP 2009a Question 33

A man presents with new onset ascites. During a TIPS procedure the hepatic pressures were measured: the Portal vein was 32 mmHg, and the Hepatic vein was 12 mmHg.

What is the most likely cause of the ascities?

a) Right Heart Failure
b) Portal vein thrombosis
c) Hepatic vein thrombosis
d) Malignant ascites
e) cirrhosis

Question 171

RACP 2009a Question 41

Which is the best for sustained weight loss at 5 years
a) Laparoscopic gastric banding
b) Very low calorie diet
c) Diet and exercise
d) orlistat
e) Sibutramine

Question 172

RACP 2009a QUESTION 16

A 34 week pregnant woman presents with right upper quadrant pain and nausea. Her blood results are as follow:
Bilirubin 25
PT 14 secs
ALT 150
Hb 90
Plts 75

Transabdominal ultrasound reveals gallbladder sludge
What is the next best management?

A. ERCP with sphincterotomy
B. Antibiotics and elective cholecystectomy
C. Urgent delivery
D. Plasma Exchange
E. Magnesium Sulphate

Question 173

RACP 2009a QUESTION 26

A 60 year old man with diabetes complains of intermittent regurgitation of food eaten a few hours prior. There is no loss of weight. His wife complains of him having halitosis. He occasionally has dysphagia of solid food which he localises to his throat. Which of the following is the most likely diagnosis?

A. Eosinophilic oesophagitis
B. Achalasia
C. Gastroesophageal reflux
D. Pharyngeal pouch
E. Schatzki ring

Question 174

RACP 2009a QUESTION 29

A patient bleeding from drain post partial hepatectomy for solitary liver met from colon ca. He had the following tests [exact numbers]
PT 18↑
APTT 46↑
INR 1.5↑
Fibrinogen 0.6 ↓ (1.5 – 3.5)
D-dimer 0.75 ↑
Platelet 92

Which of the following would decrease his chance of bleeding?
A. Cryoprecipitate
B. FFP
C. Platelet
D. Recombinant Factor VIIa
E. Aprotinin

Question 175

RACP 2009a QUESTION 37

A 45 year old male heavy alcohol drinker who has recently been drinking heavily for the past week, presents tremulous, with muscle wasting, spider naevi and a tender right upper quadrant. Aside from increased prothrombin time, what else is the best predictor of short term mortality?

A. Bilirubin
B. Creatinine
C. GGT
D. ALT
E. Arterial ammonia

Question 176

RACP 2009a QUESTION 45

A donut indulger comes to you one month after laparoscopic gastric banding surgery with lethargy having lost 7kg. His liver function tests before and one month after surgery are as follows:

What is the best explanation for his abnormal liver function tests?

A. Biliary obstruction
B. NASH exacerbation
C. Anaesthetic‐induced hepatitis
D. Malnutrition
E. Hepatitis B

Question 177

RACP 2009b QUESTION 75

A 32 year old lady presents with a 2 year history of bloating and diarrhoea up to 4 times a day, usually in the morning, associated with urgency. There is no history of nocturnal diarrhoea or loss of weight. Her full blood examination, coeliac serology and CRP are normal. She has experienced no change in symptoms with a lactose‐free diet. What is the next most appropriate investigation?

A. Gastroscopy, small bowel biopsy, and colonoscopy
B. Hydrogen breath test
C. Loperamide
D. Diet high in fibre eg. Metamucil
E. Colonoscopy

Question 178

RACP 2009b QUESTION 99

In a patient with IgA deficiency undergoing liver transplantation, which of the following
postoperative interventions will maximally contribute to perioperative complications?

???Wording of question

A. Blood transfusions
B. Immunosuppresion
C. Postoperative ventilation
D. Hepatobiliary anastomosis
E. Antibiotic selection

Question 179

RACP 2008a QUESTION 2

Which of the following is the most appropriate initial intervention that will result in sustained

improvement in liver histology in an obese patient with non-alcoholic steato-hepatitis?

A. Vitamin E.

B. Metformin.

C. Weight loss.

D. Rosiglitazone.

E. Smoking cessation.

Question 180

RACP 2008a QUESTION 15

Which of the following electrolyte disturbances is most suggestive of refeeding syndrome?

A. Hypokalaemia.

B. Hyponatraemia.

C. Hypocalcaemia.

D. Hypophosphataemia.

E. Hypomagnasaemia.

Question 181

RACP 2008a QUESTION 44

Following partial gastrectomy, a patient complains of recurrent light-headedness, sweating and

palpitations two hours after eating. These symptoms are most likely due to:

A. hypoglycaemia.

B. hypovolaemia.

C. vagal stimulation.

D. serotonin (5-HT) release.

E. adrenergic stimulation

Question 182

RACP 2008a QUESTION 55

A 65-year-old man with cirrhosis has significant (grade 2 of 3) oesophageal varices detected on

screening endoscopy. Which of the following is the most appropriate initial management?

A. Transjugular intrahepatic portosystemic shunt (TIPS).

B. Non-selective beta-blocker.

C. Isosorbide mononitrate.

D. Lienorenal shunt.

E. Endoscopic variceal ligation.

Question 183

RACP 2008a QUESTION 67

What is the best interpretation of the following serological results?

Hepatitis B surface antigen Not detected
Hepatitis B surface antibody Detected
Hepatitis B core antibody Detected
Hepatitis B e antigen Not detected
Hepatitis B e antibody Detected

A. Previous Hepatitis B vaccination.
B. Past Hepatitis B infection.
C. Chronic Hepatitis B infection.
D. Acute Hepatitis B infection.
E. Pre-core mutant infection.

Question 184

RACP 2008b QUESTION 27

For which of the following presentations of inflammatory bowel disease is infliximab of most benefit?

A. Ulcerative colitis refractory to treatment with azathioprine.

B. Crohn’s disease with perianal fistulae.

C. Pouchitis refractory to antibiotic treatment.

D. Fulminant ulcerative colitis.

E. Small bowel Crohn’s disease with previous stricturoplasty

Question 185

RACP 2008b QUESTION 38

Which of the following factors is the strongest contraindication to the use of interferon in the treatment of viral hepatitis?

A. Disease acquisition during childhood.
B. Child-Pugh category C status.
C. Serum alanine transaminase levels <2 times normal.
D. Hepatitis e antigen negative infection.
E. Immunocompromised status.

Question 186

RACP 2008b QUESTION 56

A 52-year-old man with no personal or family history of colon cancer, colonic polyps, or inflammatory bowel disease underwent a colonoscopy for rectal bleeding that showed haemorrhoids and a 1.5 cm pedunculated polyp at the hepatic flexure that was removed by means of a snare with cautery. The polyp was a tubulovillous adenoma without high-grade dysplasia. What advice should be conveyed about risks to close relatives?

A. He should encourage his first-degree relatives to discuss their family history and screening with their clinicians.
B. He should encourage his first and second-degree relatives to discuss their family history and screening with their clinicians.
C. First-degree relatives should begin colonoscopic screening at 40 years of age.
D. First and second-degree relatives should begin colonoscopic screening at 50 years of age.
E. There is no increased risk of colorectal cancer among relatives, and they should undergo standard population screens.

Question 187

RACP 2008b QUESTION 57

A 25-year-old presents with acute pancreatitis. There is no significant past medical history and minimal alcohol intake. Ultrasound demonstrates stones in the gall bladder. Which of the following most strongly indicates the need for urgent endoscopic retrograde cholangiopancreatography (ERCP)?

A. Age <30 years.
B. Bilirubin 80 μmol/L [14 – 22 μmol/L].
C. Alanine transaminase (ALT) >310 IU/L [15 – 45 IU/L].
D. Lipase 10 000.
E. Extensive interstitial (oedematous) pancreatitis in computed tomography (CT) scan

Question 188

RACP 2007a QUESTION 8
In which of the following conditions is ursodeoxycholic acid most likely to relieve symptoms?
A. Primary sclerosing cholangitis.
B. Massive choledocholithiasis.
C. Primary biliary cirrhosis.
D. Microlithiasis associated pancreatitis.
E. Cholecystolithiasis in a poor surgical candidate.

Question 189

RACP 2007a QUESTION 25
The risk factor with the greatest impact on development of esophageal cancer is:
A. achalasia.
B. Barrett’s oesophagus.
C. low fibre diet.
D. smoking.
E. reflux.

Question 190

RACP 2007a QUESTION 35
Absorption of which of the following is most likely to be impaired in untreated coeliac disease?
A. Vitamin K.
B. Iron.
C. Vitamin B12.
D. Folate.
E. Calcium.

Question 191

RACP 2007a QUESTION 51
Which of the following most increases the risk of hepatotoxicity of paracetamol when taken in overdose?
A. Cigarette smoking.
B. Old age.
C. Chronic Alcohol ingestion.
D. Acute Alcohol ingestion.
E. Hepatitis B Virus (HBV) infection.

Question 192

RACP 2007a QUESTION 60
The primary factor leading to the accumulation of ascites in patients with chronic liver disease is?
A. Excessive abdominal lymph formation.
B. Splanchnic vasodilatation.
C. Hypoalbuminaemia.
D. Increased aldosterone secretion.
E. Expansion of plasma volume.

Question 193

RACP 2007b QUESTION 4
Which of the following factors is the strongest contraindication to the use of interferon in the treatment of viral hepatitis:
A. disease acquisition during childhood.
B. Child-Pugh category C status.
C. serum alanine transaminase levels <2 times normal.
D. hepatitis e antigen negative infection.
E. immunocompromised status.

Question 194

RACP 2007b QUESTION 17
A 75-year-old presents with progressive dysphagia for solids and liquids over two years. There has been no episodes of bolus impaction. There has been a two kilogram weight loss over six months. Oesophageal manometry demonstrates increased teritiary wave activity and decreased amplitude of
contractions. The most likely diagnosis is:
A. ulcerative reflux oesophagitis.
B. presbyoesophagus.
C. achalasia.
D. scleroderma.
E. diffuse oesophageal spasm .

Question 195

RACP 2007b QUESTION 32
For which of the following presentations of inflammatory bowel disease is infliximab of most benefit?
A. Ulcerative colitis refractory to treatment with azathiaprine.
B. Crohn’s disease with perianal fistulae.
C. Pouchitis refractory to antibiotic treatment.
D. Fulminant ulcerative colitis.
E. Small bowel Crohn’s disease with previous stricturoplasty.

Question 196

RACP 2007b QUESTION 47
A 26-year-old female has been found to be homozygous for the HFE gene C282Y polymorphism, when screened for haemochromatosis. Her serum ferritin is 18 micrograms/L [15-200 micrograms/L]
and her transferrin saturation is 82% [< 45%]. Her haemoglobin is 120 g/L [120-160 g/L]
Which of the following is the most appropriate next step in her management?
A. Venesection.
B. Observation.
C. Liver biopsy.
D. Imaging of liver for iron loading.
E. Desferrioxamine.

Question 197

RACP 2007b QUESTION 49
An 65-year-old man is on chronic haemodialysis. He complains of crampy lower abdominal pain and passes blood per rectum three times over two hours. Colonoscopy demonstrates normal rectal
mucosa and inflammation from the proximal sigmoid to transverse colon. The most likely cause of the inflammation is:
A. salmonella infection.
B. ischaemic colitis.
C. clostridium difficile colitis.
D. diverticulitis.
E. Crohn’s colitis.

Question 198

RACP 2007b QUESTION 52
A 20-year-old female presents with a one month history of malaise, nausea, abdominal pain, itch and
polyarthralgia. She gives no history of recent use of prescribed or illicit drugs. Examination reveals
jaundice, multiple bruises, and tender hepatomegaly. Laboratory results are consistent with an acute
hepatocellular injury, with a polyclonal increase in IgG (immunoglobulin G) of 32g/L (6.1-15.5).
Serological tests for hepatitis A, B, and C viruses are negative. Histopathological findings on liver biopsy are of a periportal mixed mononuclear cell infiltrate of plasma cells, lymphocytes and eosinophils consistent with an autoimmune hepatitis.
Which of the following autoantibodies, if present, is most predictive of a poor clinical and biochemical response to therapy?
A. Anti-nuclear antibody.
B. Anti-smooth muscle antibody (F-actin–specific).
C. Anti-mitochondrial antibody.
D. Anti-liver-kidney microsomal antibody.
E. Atypical perinuclear anti-neutrophil cytoplasmic antibody.

Question 199

RACP 2007b QUESTION 54
A 55-year-old woman presents with vague abdominal pain. Her CT scan is shown below.
A biopsy of the lesion shows spindle shaped cells. The most likely diagnosis is:
A. adenocarcinoma of esophagus.
B. gastrointestinal stromal tumour.
C. linitis plastica.
D. adrenal tumour.
E. renal cell tumour (hypernephroma).

Question 200

RACP 2007b QUESTION 67
A 60-year-old male with no significant past or family history presents for anti-hypertensive medication. With regard to his risk of colon cancer, which of the following is the most appropriate strategy?
A. Dietary advice.
B. CT colography.
C. Annual digital rectal examination.
D. Annual faecal occult blood test.
E. Five yearly colonoscopy.

Question 201

RACP 2007b QUESTION 74
A 28-year-old male has the following biochemical findings 24 hours after suffering a thoracic gun shot wound resulting in hypovolemic shock, requiring massive blood transfusion.
AST 3800 U/L [5-55 U/L]
Alkaline Phosphatase 69 U/L [0-130 U/L]
ALT 6400 U/L [5-55 U/L]
Gamma GT 90 U/L [0-60 U/L]
Bilirubin 20 micromole/L [0-18 micromole/L]
LDH 1800 U/L [<220 U/L]
Creatinine 180 micromole/L [70-110 micromol/L]

The most likely explanation for these findings is:
A. halothane hepatitis.
B. hepatic vein transection.
C. transfusion reaction.
D. hepatic congestion.
E. ischaemic hepatitis.

Question 202

RACP 2006a QUESTION 22

Liberation of dietary cobalamin from R-proteins would be most likely to be adversely affected by:

A. ileal resection.

B. pancreatic insufficiency.

C. coeliac disease.

D. Crohn’s disease.

E. Helicobacter pylori chronic gastritis.

Question 203

RACP 2006a QUESTION 38

Which of the following is most predictive of variceal haemorrhage in a patient with oesophageal varices?

A. Portal vein pressure.

B. Child-Pugh score.

C. Variceal size.

D. Prolonged prothrombin time.

E. Thrombocytopenia.

Question 204

RACP 2006a QUESTION 43

A 36-year-old woman has a very strong family history of premature coronary disease. Physical examination is normal. Fasting lipid profile reveals:
total cholesterol 9.5 mmol/L [2.5-5.2]
high-density lipoprotein (HDL) cholesterol 1.5 mmol/L [0.9-1.8]
triglycerides 2.00 mmol/L [0.10-1.85]

Which abnormality is most likely to be present?

A. apoB 3500 mutation.
B. Cholesteryl ester transfer protein (CETP) deficiency.
C. Hypoalphalipoproteinaemia.
D. Low-density lipoprotein (LDL) receptor defect.
E. Lecithin:cholesterol acetyltransferase (LCAT) deficiency.

Question 205

RACP 2006a QUESTION 53

The primary factor leading to the accumulation of ascites in patients with chronic liver disease is?

A. Excessive abdominal lymph formation.
B. Splanchnic vasodilatation.
C. Hypoalbuminaemia.
D. Increased aldosterone secretion.
E. Expansion of plasma volume.

Question 206

RACP 2006a QUESTION 58

In the general community, which of the following is the major pathogenic factor for reflux oesophagitis?

A. Excessive acid secretion.
B. Excessive transient lower oesophageal sphincter relaxations.
C. Presence of a hiatus hernia.
D. Impaired oesophageal motility.
E. Impaired gastric emptying.

Question 207

RACP 2006a QUESTION 67

Which of the following is the primary mechanism of body iron regulation?

A. Shedding of duodenal enterocytes.
B. Regulation of enterocyte surface expression of transferrin receptor (TfR1).
C. Regulation of enterocyte ferritin content.
D. Renal haemosiderin excretion.
E. Alteration of Kuppfer cell iron metabolism gene expression.

Question 208

RACP 2006b QUESTION 2

A 62-year-old woman with rheumatoid arthritis for eight years presents for review. Her arthritis is well controlled with 15mg of methotrexate weekly, folic acid supplements and ketoprofen sustained release 200mg daily, all of which she has been on for the past five years. She is overweight with a body mass index of 35kg/m2 [18-26] and has mild, diet-treated type 2 diabetes mellitus. She is on no other medications. You review her routine blood tests which are normal apart from her liver function tests which have been progressively worsening over the past six months.

The most recent test is shown below.
protein 88 g/L [63-82]
albumin 41 g/L [35-50]
bilirubin 8 μmol/L [<10]
alanine transaminase (ALT) 150 U/L [<52]
aspartate transaminase (AST) 120 U/L [<36]
alkaline phosphatase (ALP) 120 U/L [<126]
gamma glutamyltranspeptidase (GGT) 150 U/L [<43]
The most likely explanation for this woman’s liver function test abnormalities is:

A. methotrexate induced hepatitis.
B. ketoprofen-induced hepatitis.
C. non-alcoholic steatohepatitis.
D. auto-immune hepatitis.
E. viral hepatitis.

Question 209

RACP 2006b
QUESTION 18

A patient has the following abnormal findings:
sodium 130 mmol/L [134-145]
potassium 2.9 mmol/L [3.5-5.0]
phosphate 0.22 mmol/L [0.6-1.3]
magnesium 0.6 mmol/L [0.72-0.92]
creatinine 120 μmol/L [70-110]
ionised calcium 1.1 mmol/L [1.14 - 1.27]
glucose 5.1 mmol/L [4.1- 6.1]

Which of the following is the most likely cause?
A. Tumour lysis syndrome.
B. Diabetic ketoacidosis.
C. Hyperparathyroidism.
D. Refeeding syndrome.
E. Vitamin D deficiency.

Question 210

RACP 2006b QUESTION 29

A 50-year-old male has chronic liver disease secondary to Hepatitis B infection. Previous endoscopy has revealed large oesophageal varices. Blood results are:
Albumin 32 g/L [38-55]
Prothrombin Time 14 seconds [8-12]
Platelet count 70 x 109/L [150-450]
On routine review, his alpha fetoprotein is 300 ng/mL [0-15]. His abdominal computed tomography (CT) scan is shown below.

The optimal treatment for this condition is:

A. chemoembolisation.
B. liver transplantation.
C. cryotherapy.
D. local resection.
E. radiofrequency ablation.

Question 211

RACP 2006b A 65-year-old man with a past history of diverticular disease presents with one week of fever and right upper quadrant pain. He has never travelled overseas. His CT scan reveals a large fluid-filled lesion. In addition to drainage of the abscess, what is the most appropriate initial empiric antibiotic treatment?

A. Ampicillin, gentamicin and metronidazole.
B. Cefazolin and metronidazole.
C. Vancomycin and metronidazole.
D. Meropenem.
E. Cefoxitin and gentamicin

Question 212

RACP 2006b QUESTION 39

A 52-year-old female is sent home ten days after a left hemicolectomy. Her husband brings her back to hospital 48 hours later with jaundice and confusion. She is anuric. She has ingested 14 grams of paracetamol since discharge from hospital.

Which of the following findings indicates the worst prognosis without transplantation?

A. pH 7.28 [7.36-7.44].
B. Creatinine 220 μmol/L [50-90].
C. Bilirubin 53 μmol/L [0-18].
D. Glasgow coma score 8 [15].
E. Prothrombin time (PT) 160 secs [8-12].

Question 213

RACP 2006b QUESTION 60

A patient is referred for investigation of diarrhoea and weight loss. The following results are obtained:
haemoglobin 100 g/L [130-180]
mean corpuscular volume (MCV) 72 fL [82-98]
anti-gliadin IgG 43 units [0-25]
anti-gliadin IgA 0 units [0-25]
IgA-endomysial antibody <5 [<5]
Which of the following is the next most appropriate test?

A. Serum IgA level.
B. Haemoglobin electrophoresis.
C. 3-day faecal fat.
D. Tissue transglutaminase antibodies.
E. Faecal microscopy and culture.

Question 214

RACP 2006b QUESTION 81

Which of the following is the most appropriate indication for treatment with ursodeoxycholic acid?

A. Primary sclerosing cholangitis.

B. Massive choledocholithiasis.

C. Primary biliary cirrhosis.

D. Microlithiasis associated pancreatitis.

E. Cholecystolithiasis in a poor surgical candidate.

Question 215

RACP 2006b QUESTION 87

A previously well 64-year-old man presents with symptoms of gastro-oesophageal reflux disease. He is on no current medications. Gastroscopy demonstrates Barrett’s oesophagus with erosive oesophagitis above the squamo-columnar junction. Random biopsies are reported as demonstrating dysplastic epithelium with features of active inflammation.

The most appropriate next step in management is:

A. endoscopic ultrasound.

B. CT (computed tomography) chest/abdomen.

C. repeat biopsies after two months of treatment with proton pump inhibitors.

D. surgical resection.

E. surveillance endoscopy in one year.

Question 216

RACP 2006b
QUESTION 97

An otherwise well 55-year-old female undergoes upper endoscopy for investigation of mild reflux symptoms. An endoscopic image of the lower oesophagus is shown above. Biopsies demonstrate intestinal metaplasia with high grade dysplasia and no inflammation.

The most appropriate management is:

A. repeat endoscopy in six months.

B. surgical resection.

C. photodynamic therapy.

D. high dose proton-pump inhibitor (PPI) therapy.

E. thermal ablative therapy.

Question 217

RACP 2005a QUESTION 2

Which one of the following is the predominant stimulus to gastric acid secretion in a healthy individual?

A. Acetylcholine.

B. Gastrin.

C. Histamine.

D. Calcium.

E. Somatostatin.

Question 218

RACP 2005 Q14
A 60-year-old male presents with worsening dysphagia for solid and liquid food. Manometry is shown above (reference normal on left, patient tracing on right). The most likely diagnosis is:

A. hiatus hernia.

B. gastroesophageal reflux.

C. achalasia.

D. distal oesophageal malignancy.

E. presbyoesophagus.

Question 219

RACP 2005a A 22-year-old male presents with his fourth episode of pancreatitis. A computed tomography (CT) scan of the pancreas is shown above. He has two first degree relatives with chronic pancreatitis. There is no other significant family history.

The most likely explanation for his episodes is:

A. cystic fibrosis.

B. alcoholic pancreatitis.

C. hyperparathyroidism.

D. hereditary pancreatitis.

E. haemochromatosis.

Question 220

RACP 2005a QUESTION 32

Which of the following findings is most specific for a diagnosis of pernicious anaemia?

A. A low serum vitamin B12 level.

B. An elevated fasting homocysteine level.

C. An elevated serum gastrin level.

D. A positive gastric parietal cell antibody.

E. A positive intrinsic factor antibody.

Question 221

RACP 2005a QUESTION 40

Which of the following is most likely to cause predominantly zone 1 (periportal) rather than zone 3 (centrilobular) liver pathology?

A. Alcohol.

B. Paracetamol.

C. Morbid obesity.

D. Budd-Chiari syndrome.

E. Primary biliary cirrhosis

Question 222

RACP 2005a QUESTION 58

Liberation of dietary cobalamin from R-proteins would be most likely to be adversely affected by:

A. ileal resection.

B. pancreatic insufficiency.

C. coeliac disease.

D. Crohn’s disease.

E. Helicobacter pylori chronic gastritis.

Question 223

RACP 2005b QUESTION 7

Prior to which of the following procedures is antibiotic prophylaxis most appropriate?

A. Colonoscopy with polypectomy.

B. Colonoscopy in a patient with a knee prosthesis.

C. Percutaneous endoscopic gastrostomy placement.

D. Endoscopic retrograde cholangiopancreatography (ERCP).

E. Band ligation of oesophageal varices.

Question 224

RACP 2005b
QUESTION 29

A 55-year-old woman presents with a 10-year history of rheumatoid arthritis and is on longstanding, stable treatment with methotrexate 10 mg weekly, folic acid 10 mg weekly, diclofenac 50 mg three times daily and prednis(ol)one 7.5 mg daily. She also has hypertension controlled with amlodipine 5 mg daily and mild type 2 (non-insulin-dependent) diabetes mellitus treated with diet and metformin 500 mg three times daily. She denies drinking alcohol.

On examination, she is overweight (body mass index (BMI) 28 kg/m2 [18-25]), with rheumatoid nodules, rheumatoid hand deformity and synovitis in the wrists and metatarsophalangeal (MTP) joints. Her blood pressure is 150/85 mmHg. There are no other abnormal signs.

Blood tests (which have been stable over 6 months) reveal:

A liver biopsy is planned.

Which of the following is most likely to be found on liver biopsy?

A. Methotrexate hepatotoxicity.
B. Amyloidosis.
C. Non-alcoholic fatty liver disease.
D. Chronic active hepatitis.
E. Cirrhosis.

Question 225

RACP 2005b QUESTION 44

In a 23-year-old female with Crohn’s disease who becomes pregnant, which of the following medications is most likely to result in an adverse foetal outcome?

A. Prednis(ol)one.

B. Azathioprine.

C. Methotrexate.

D. Sulfasalazine.

E. Mesalazine.

Question 226

RACP 2005b QUESTION 60

A 45-year-old woman presents with a three-year history of recurrent rash, characterised as palpable purpura over both legs. Some of these lesions have ulcerated.
Laboratory results include:
Serum:creatinine 0.10 mmol/L [0.06-0.11]
alanine transaminase (ALT) 51 U/L [15-50]
aspartate transaminase (AST) 64 U/L [15-45]
hepatitis C antibody positive
cryoglobulins positive with 8% cryoprecipitate
Urinalysis is normal.
Which of the following is the most appropriate management?

A. Plasmapheresis and corticosteroids.
B. Corticosteroids and pegylated interferon α.
C. Pegylated interferon α and ribavirin.
D. Cyclophosphamide and corticosteroids.
E. Cyclophosphamide and ribavirin

Question 227

RACP 2005b QUESTION 66

A 45-year-old male with known chronic hepatitis B virus (HBV) infection and multiple flares over five years presents with mild jaundice and lethargy. There is no history of intravenous drug use.
Blood tests reveal the following:
aspartate transaminase (AST) 350 U/L [0-40]
alanine transaminase (ALT) 400 U/L [0-40]
bilirubin 55 μmol/L [0-20]
gamma glutamyltranspeptidase (GGT) 350 U/L [0-45]
alkaline phosphatase (ALP) 450 U/L [30-115]
hepatitis B surface antigen (HBsAg) +
hepatitis B e antigen (HBeAg) -
Which of the following is the most likely explanation for this presentation?

A. Development of hepatoma.
B. Choledocholithiasis.
C. Emergence of an HBV pre-core mutant.
D. Delta super-infection.
E. Emergence of a YMDD mutant.

Question 228

RACP 2005b QUESTION 86

A 45-year-old alcoholic presents with his first oesophageal variceal bleed. His acute bleeding is controlled with endoscopic band ligation. Which one of the following is the most appropriate management strategy to prevent recurrent bleeding?

A. Refer for liver transplantation.

B. Propranolol.

C. Isosorbide mononitrate.

D. Transjugular intrahepatic portosystemic shunt (TIPS).

E. Repeated endoscopies and band ligation.

Question 229

RACP 2005b QUESTION 92

A patient is referred for investigation of diarrhoea and weight loss. The following results are obtained:
haemoglobin 100 g/L [130-180]
mean corpuscular volume (MCV) 72 fL [82-98]
anti-gliadin IgG 43 units [0-25]
anti-gliadin IgA 0 units [0-25]
IgA-endomysial antibody <5 [<5]

Which of the following is the next most appropriate test?

A. Serum IgA level.
B. Haemoglobin electrophoresis.
C. 3-day faecal fat.
D. Tissue transglutaminase antibodies.
E. Faecal microscopy and culture.

Question 230

RACP 2004a QUESTION 15

In patients with untreated post-transfusion hepatitis C, the lifetime risk of progression to cirrhosis best approximates:

A. 1%.

B. 5%.

C. 20%.

D. 50%.

E. 80%.

Question 231

RACP 2004a QUESTION 26

In the acute management of oesophageal variceal bleeding, which of the following is least likely to control bleeding?

A. Intravenous omeprazole.
B. Intravenous octreotide.
C. Endoscopic band ligation.
D. Endoscopic injection therapy.
E. Intravenous vasopressin.

Question 232

RACP 2004a QUESTION 34

Cirrhosis of the liver in genetic alpha-1-antitrypsin deficiency is most likely to be the result of which of the following?

A. Loss of inhibition of serum elastase.
B. Concomitant infection with hepatitis C.
C. Intracellular accumulation of alpha-1-antitrypsin.
D. Associated alcohol-induced fibrosis.
E. Hypoxia secondary to emphysema.

Question 233

RACP 2004a QUESTION 50

Which of the following best explains the lipid-modifying effect of fibric acids (such as gemfibrozil)?

A. Increasing low density lipoprotein (LDL) receptor expression.
B. Stimulating lipoprotein lipase activity.
C. Interfering with bile acid reabsorption in the small intestine.
D. Inhibiting hepatic cholesterol synthesis.
E. Inhibiting LDL peroxidation.

Question 234

RACP 2004a QUESTION 57

In a patient with a distal gastrectomy, which of the following deficiencies is most likely?

A. Vitamin B12.

B. Folate.

C. Iron.

D. Calcium.

E. Magnesium.

Question 235

RACP 2004b QUESTION 8

Which of the following is the most appropriate medication to maintain remission in ileo-colonic Crohn’s disease?

A. Nicotine.

B. Azathioprine.

C. Mesalazine.

D. Budesonide.

E. Cyclosporin.

Question 236

RACP 2004b QUESTION 75

Which one of the following features is most suggestive of autosomal dominant familial hypercholesterolaemia rather than other causes of hypercholesterolaemia?

A. Tendon xanthomas.

B. Corneal opacities.

C. Lipaemia retinalis.

D. Eruptive xanthomas.

E. Recurrent pancreatitis.

Question 237

RACP 2003a QUESTION 6

The presence of which one of the following histological findings in a biopsy of the distal oesophagus is most important for a diagnosis of Barrett’s oesophagus?

A. Specialised intestinal metaplasia.

B. Chronic inflammation.

C. Dysplasia.

D. Helicobacter infection in the mucosa.

E. Eosinophils in the submucosa.

Question 238

RACP 2003a QUESTION 38

The most common cause for asymptomatic, mildly elevated serum transaminases in Western society is:

A. hepatitis B.

B. hepatitis C.

C. non-alcoholic fatty liver disease.

D. drug-induced reactions.

E. haemochromatosis.

Question 239

RACP 2003a QUESTION 62

Which one of the following colonic polyps has the highest potential for malignant transformation?

A. Hyperplastic.

B. Tubular.

C. Villous.

D. Hamartomatous.

E. Peutz-Jegher.

Question 240

RACP 2003b PAPER 2

QUESTION 7

Which one of the following is the most common complication of endoscopic biliary sphincterotomy?

A. Haemorrhage.

B. Pancreatitis.

C. Cholangitis.

D. Perforation.

E. Diarrhoea.

Question 241

RACP 2003b Q50
A 50-year-old man with alcohol-induced cirrhosis and portal hypertension presents with haematemesis. He is found to have grade IV oesophageal varices. Bleeding is controlled by an infusion of octreotide and endoscopic band ligation.

On discharge, which one of the following is least likely to be of benefit with respect to recurrent variceal bleeding?

A. Interval endoscopic band ligation.

B. Interval endoscopic sclerotherapy.

C. Oral beta-blocker therapy.

D. Oral nitrate therapy.

E. Oral proton pump inhibitor therapy.

Question 242

RACP 2003b QUESTION 64

A 75-year-old woman presents with a three-week history of episodic severe epigastric pain and vomiting. The pain lasts for about three hours and radiates to the right upper quadrant and back. Apart from episodic nausea, she is well between attacks of pain. Past medical history includes a cholecystectomy nine years ago, peptic ulcer disease secondary to non-steroidal anti-inflammatory drugs three years ago and type 2 (non-insulin-dependent) diabetes mellitus diagnosed four years ago.

The most likely diagnosis is:

A. choledocholithiasis.

B. biliary dyskinesia.

C. perforated peptic ulcer.

D. reflux oesophagitis.

E. pancreatitis.

Question 243

RACP 2002a QUESTION 5

In patients with cirrhosis and oesophageal varices, the strongest predictor of variceal bleeding is:

A. prothrombin time.

B. platelet count.

C. Childs-Pugh class.

D. portal venous pressure.

E. systemic blood pressure

Question 244

RACP 2002a QUESTION 35

Which one of the following has the highest sensitivity for the detection of gallbladder stones?

A. Ultrasonography.

B. Computed tomography (CT) scanning.

C. Magnetic resonance imaging (MRI).

D. Plain abdominal X-ray.

E. Hepatic immunodiacetic acid (HIDA) biliary scintigraphy.

Question 245

RACP 2002a QUESTION 46

Which one of the following has the strongest association with Helicobacter pylori infection?

A. Barrett’s oesophagus.

B. Mucosal-associated lymphoid tissue (MALT) lymphoma.

C. Non-ulcer dyspepsia.

D. Gastric adenocarcinoma.

E. Pernicious anaemia.

Question 246

RACP 2002a QUESTION 61

The most common acute complication of percutaneous endoscopic gastrostomy (PEG) insertion is:

A. gastric perforation.

B. colonic perforation.

C. peritonitis.

D. bleeding at insertion site.

E. wound infection.

Question 247

RACP 2002b QUESTION 4

A 45-year-old Samoan man presents with epigastric pain and vomiting. He has been diagnosed with type 2 (non-insulin dependent) diabetes mellitus four years earlier and takes oral hypoglycaemic agents. He is otherwise well. At endoscopy, he is found to have a pyloric channel ulcer. Gastric biopsies reveal Helicobacter pylori gastritis. He is treated with a course of eradication therapy and successful eradication is confirmed by a negative urea breath test. Two months later, he presents with vomiting and abdominal fullness. A plain abdominal X-ray is shown below.
The most likely diagnosis is:

A. ulcer perforation.
B. small bowel obstruction.
C. gastric outlet obstruction.
D. diabetic gastroparesis.
E. gastric volvulus.

Question 248

RACP 2002b QUESTION 19

A 37-year-old man is referred for assessment of a low platelet count. He has no symptoms and no past significant illnesses. He is noted on physical examination to have an enlarged spleen (5 cm below the costal margin). There is no lymphadenopathy and no signs of chronic liver disease. The liver span is normal. The remainder of the physical examination is normal. Full blood examination is normal apart from a platelet count of 78 x 109/L [150-450]. Serum electrolytes, urea, creatinine and liver function tests are also normal.

On further questioning, he recalls being beaten at the age of 17 and being hospitalised for several days. He also recalls requiring a nasogastric tube because of ‘pancreatic injury’.

Two non-sequential slices of an abdominal computed tomography (CT) scan are shown below.
The most likely explanation for these findings is:

A. pancreatic pseudocyst.
B. Budd-Chiari syndrome.
C. splenic vein thrombosis.
D. chronic myeloid leukaemia.
E. systemic lupus erythematosus.

Question 249

RACP 2002b QUESTION 29

A 54-year-old man with colonic Crohn’s disease is in remission following an eight-week course of prednis(ol)one.

Which one of the following medications is most likely to maintain his remission?

A. Prednis(ol)one.

B. Sulfasalazine.

C. Azathioprine.

D. Metronidazole.

E. Methotrexate.

Question 250

RACP 2002b QUESTION 90

A 25-year-old man presents with one episode of haematemesis. He describes feeling nauseous and then having one large volume vomitus with fresh blood. He denies any dizziness or syncope. He denies any past history of peptic ulcer disease. He has no significant past medical or surgical problems. He has a five-pack- year history of smoking and consumes 140 g of alcohol/week.

Physical examination reveals a pulse rate of 90/minute and blood pressure of 130/90 mmHg, with no postural drop. The abdomen is slightly tender in the epigastric region with no other abdominal abnormality. Rectal examination reveals soft brown faeces. The remainder of the physical examination is normal.

Based on this information, the most likely cause for his upper gastrointestinal bleeding is:

A. Mallory-Weiss tear.

B. oesophageal varices.

C. gastric ulcer.

D. duodenal ulcer.

E. acute Helicobacter gastritis.

Question 251

RACP 2002b QUESTION 59

A 24-year-old man develops acute severe tonsillitis with high fever (39.8oC). He is treated with erythromycin. The next day he is noticed to be icteric. Abdominal examination is unremarkable.

The following blood tests are obtained:
The most likely explanation for his jaundice is:

A. haemolysis.

B. Epstein-Barr virus.

C. Gilbert’s syndrome.

D. Wilson’s disease.

E. erythromycin.

Question 252

RACP 2002b QUESTION 59

A 24-year-old man develops acute severe tonsillitis with high fever (39.8oC). He is treated with erythromycin. The next day he is noticed to be icteric. Abdominal examination is unremarkable.

The following blood tests are obtained:
The most likely explanation for his jaundice is:

A. haemolysis.

B. Epstein-Barr virus.

C. Gilbert’s syndrome.

D. Wilson’s disease.

E. erythromycin.

Question 253

RACP 2002b QUESTION 46

A 45-year-old Caucasian man is referred because of abnormal liver function tests. He complains of the recent onset of lethargy. Examination reveals a 15 cm smooth edged liver and some spider naevi.

Blood investigations show:
The next most appropriate blood test in the investigation of this patient is:

A. hepatitis serology.

B. autoimmune serology.

C. testing for the haemochromatosis gene (HFE).

D. alpha-1-antitrypsin phenotyping.

E. haemolysis screen.

Question 254

RACP 2001a Question 5

At 72 hours following a significant paracetamol overdose, which one of the following tests will allow the best prediction of death or need for liver transplantation?

A. Serum alanine transaminase (ALT).

B. Serum bilirubin.

C. Prothrombin time-international normalised ratio (PT-INR).

D. Serum gamma glutamyltranspeptidase (GGT).

E. Blood ammonia.

Question 255

RACP 2001a
Question 20

Which one of the following is associated with the highest risk of NSAID (non-steroidal anti-inflammatory drug)- induced gastric ulceration?

A. Concomitant use of steroids.

B. Infection with Helicobacter pylori.

C. Higher therapeutic dose of NSAID.

D. Advanced age.

E. Concomitant use of anticoagulants.

Question 256

RACP 2001a Question 22

In treating constipation, which one of the following agents administered over an extended period of time is most likely to lose its effectiveness?

A. Docusate sodium (Coloxyl).

B. Lactulose.

C. Senna.

D. Psyllium husk powder (Metamucil).

E. Epsom salts.

Question 257

RACP 2001a
Question 41

A patient undergoes a Schilling test because of vitamin B12 deficiency. The following results are obtained:

The most likely pathology is:

A. small bowel bacterial overgrowth.

B. pernicious anaemia.

C. partial (Billroth II) gastrectomy.

D. terminal ileal Crohn’s disease.

E. short bowel syndrome.

Question 258

RACP 2001a Question 52

The manometric feature most characteristic of achalasia is:

A. lack of peristalsis in the oesophageal body.

B. high resting tone of the lower oesophageal sphincter.

C. failure of lower oesophageal sphincter relaxation with swallowing.

D. poor propagation of oesophageal contraction waves.

E. diffuse spasm in the oesophageal body.

Question 259

RACP 2001b Question 3

A 40-year-old man is seen for follow-up at the outpatients’ department. Eight weeks prior, he had presented with melaena and was found to have a duodenal ulcer and Helicobacter pylori gastritis. He was treated with a combination pack containing omeprazole, amoxycillin and metronidazole for two weeks and took all the prescribed tablets according to the instructions.

A urea breath test performed six weeks following the end of the eradication regimen was positive.

The most likely explanation for the failure of the eradication of Helicobacter pylori in this patient is:

A. metronidazole resistance.

B. amoxycillin resistance.

C. the short duration of therapy.

D. the low sensitivity and specificity of the urea breath test following eradication therapy.

E. an insufficient period between the end of the eradication therapy and the urea breath test

Question 260

RACP 2001b Question 5

In which one of the following disorders is the highest proportion of patients with anti-mitochondrial antibodies found?

A. Drug-induced cholestasis.

B. Extrahepatic biliary obstruction.

C. Primary biliary cirrhosis.

D. Cryptogenic cirrhosis.

E. Autoimmune active chronic hepatitis

Question 261

RACP 2001b Question 12

A 40-year-old man had profuse colonic polyposis diagnosed 15 years ago. A clinical diagnosis of familial adenomatous polyposis (FAP) had been made. He had a total colectomy. There is no family history of polyposis or colorectal cancer.

Mutation studies fail to identify a pathogenic mutation in the adenomatous polyposis coli (APC) gene in a blood sample.

The normal DNA result is best explained by:

A. the correct clinical diagnosis being juvenile polyposis.

B. the mutation occurring in a non-coding region of the APC gene.

C. gonadal mosaicism of the APC gene mutation.

D. the causative mutation being in another gene.

E. the APC gene mutation occurring only in cells derived from adenomatous polyps

Question 262

RACP 2001b Question 21

A 36-year-old woman presents with a 12-month history of lassitude, intermittent diarrhoea (described as watery, occurring up to six times a day), colicky abdominal pain, bloating and involuntary weight loss of 12 kg.

Blood tests reveal normal electrolytes, urea, creatinine and liver function tests. Her full blood count reveals a mild anaemia (haemoglobin 110 g/L [120-160]), but other indices are normal. Further blood tests show that she is iron and folate deficient.

Upper and lower gastrointestinal endoscopies are performed and the mucosa appears normal macroscopically. Shown below are sections of small bowel mucosa taken from the duodenum (A), distal to the major papilla, and from the terminal ileum (B).

The most likely diagnosis is:

A. Crohn’s disease.

B. coeliac disease.

C. irritable bowel syndrome.

D. giardiasis.

E. yersiniosis.

Question 263

RACP 2001b Question 31

A critically ill 50-year-old patient in the intensive care unit develops abdominal distension. A supine abdominal X-ray is obtained and is shown below.
The most likely diagnosis is:

A. obstructing carcinoma at the splenic flexure.

B. colonic pseudo-obstruction.

C. small bowel paralytic ileus.

D. faecal loading.

E. sigmoid volvulus.

Question 264

RACP 2001b Question 43

A 50-year-old woman is referred for investigation of longstanding bloating and watery diarrhoea. Her history includes treated vitamin B12 deficiency. She denies laxative abuse. Her blood pressure is 110/65 mmHg with a 10 mmHg postural fall. Examination of her heart, chest and abdomen reveals no abnormality.

Serum potassium is 3.1 mmol/L [3.5-5.0]. Serum sodium and creatinine are normal. Full blood examination, erythrocyte sedimentation rate (ESR), thyroid function tests and stool cultures are also normal. Urinary sodium is 2 mmol/L and urinary potassium is 50 mmol/L.

The appearance shown below is seen throughout the colon.
The most appropriate next investigation is:

A. upper gastrointestinal endoscopy and duodenal biopsy.

B. 24-hour urinary 5-hydroxyindoleacetic acid (5-HIAA) excretion.

C. small bowel enema.

D. 14C-xylose absorption test.

E. stool and urine testing for laxatives.

Question 265

RACP 2001b Question 55

A 54-year-old man with colonic Crohn’s disease is in remission following an eight-week course of prednis(ol)one.

Which one of the following medications is most likely to maintain his remission?

A. Prednis(ol)one.

B. Sulphasalazine.

C. Azathioprine.

D. Metronidazole.

E. Methotrexate.

Question 266

RACP 2001b
Question 70

Which one of the following is most likely to slow progression of primary biliary cirrhosis?

A. Prednis(ol)one.

B. Colchicine.

C. Methotrexate.

D. Cyclosporin.

E. Ursodeoxycholic acid.

Question 267

RACP 2000a
Question 7

Which one of the following is the most efficacious in the prevention of gastro-duodenal ulceration from non- steroidal anti-inflammatory drugs?

A. Misoprostol.

B. Enprostol.

C. Omeprazole.

D. Sucralfate.

E. Ranitidine.

Question 268

RACP 2000a
Question 30

Which one of the following is the most important pathogenic factor in gastro-oesophageal reflux disease?

A. A sliding hiatus hernia.

B. Smoking more than 20 cigarettes/day.

C. An increased frequency of transient lower oesophageal sphincter relaxation.

D. Impaired oesophageal peristalsis.

E. A low resting lower oesophageal sphincter pressure.

Question 269

RACP 2000b
Question 11

A 28-year-old man was found apnoeic and pulseless. There were a syringe and needle nearby and he had well defined “track marks” (venous puncture marks) on his arms. He was successfully resuscitated at the scene and brought to the Accident and Emergency Department. On arrival, he was breathing spontaneously and was normotensive. Following routine investigations, he was admitted for observation.

The next day you are called because of the results of the liver function tests below. The patient is clinically unchanged.
The most likely cause for these liver function tests is:

A. acute hepatitis C.

B. post-CPR (cardiopulmonary resuscitation) liver trauma.

C. acute hepatitis A.

D. drug-induced hepatitis.

E. ischaemic hepatitis.

Question 270

RACP 2000b Question 26

A 52-year-old man with known chronic liver disease, due to alcohol, is admitted to hospital because of increasing ascites, peripheral oedema and confusion. He has been abstinent from alcohol for over two years. His condition has been stable prior to this deterioration which has developed over the previous four weeks.

On examination, he is afebrile. His vital signs are normal. He has a flapping tremor, with moderate ascites and peripheral oedema to the knees. He is drowsy with disorientation. The liver span is decreased (10 cm by percussion) and the spleen is palpable 2 cm below the costal margin. No malignant cells are detected in ascitic fluid following ascitic fluid drainage. The fluid is a transudate.
A representative slice of an abdominal computed tomography (CT) scan is shown below.

The most likely cause for his deterioration is:

A. hepatocellular carcinoma.

B. multiple liver metastases.

C. gallstone disease.

D. portal vein thrombosis.

E. liver abscess.

Question 271

RACP 2000b Question 33

A 54-year-old diabetic woman with chronic renal impairment presents with peritonitis secondary to a perforated diverticulum. Blood cultures grew Enterobacter species. The organism tests sensitive to ceftriaxone. After laparotomy, lavage and commencement of intravenous ceftriaxone and metronidazole, the patient makes no improvement. A computed tomography (CT) scan of the abdomen is performed and reveals no collection. Blood culture repeated three days later again grows the same Enterobacter species.

Which one of the following is the most appropriate next step?

A. Continuation of current therapy.

B. Laparotomy.

C. Cessation of ceftriaxone, continuation of metronidazole and addition of ampicillin and gentamicin.

D. Cessation of current antibiotics and commencement of meropenem.

E. Addition of vancomycin.

Question 272

RACP 2000b Question 39

A 50-year-old woman undergoes an upper abdominal ultrasound because of long standing intermittent epigastric pain. She has had no weight loss or fever. A representative slice of her ultrasound is shown below. Her liver function tests are normal. An endoscopy performed soon after shows a chronic duodenal ulcer with Helicobacter pylori gastritis.

Following successful H. pylori eradication therapy, her pain resolves. An abdominal computed tomography (CT) scan is performed in view of the ultrasound appearance; a representative slice is also shown below. The most likely diagnosis is:

A. liver metastases.

B. liver haemangiomata.

C. benign liver cysts.

D. liver abscesses.

E. hydatid disease.

Question 273

RACP 2000b Question 43

A 35-year-old man presents to your office four months after resection of 50 cm of terminal ileum for Crohn’s disease. He has been well, but complains of excessive diarrhoea, especially in the morning. The motion has been watery, but without blood or mucus.

A recent colonoscopy failed to show any evidence of colitis or enteritis and the anastomosis appeared healthy. He is currently on no medications. Physical examination reveals a well-healed scar, with no tenderness in the abdomen and normal bowel sounds.

Stool cultures are negative.

The most appropriate treatment is:

A. prednis(ol)one.

B. sulfasalazine.

C. azathioprine.

D. cholestyramine.

E. metronidazole

Question 274

RACP 2000b Question 54

Which one of the following has the greatest positive impact on outcome in patients with acutely bleeding peptic ulcers?

A. Nil by mouth for 24 hours.

B. Endoscopic injection therapy.

C. Admission to an intensive care unit.

D. Intravenous ranitidine.

E. Intravenous octreotide.

Question 275

RACP 2000b Question 64

Which one of the following is most likely to slow progression of primary biliary cirrhosis?

A. Prednis(ol)one.

B. Colchicine.

C. Methotrexate.

D. Cyclosporin.

E. Ursodeoxycholic acid.

Question 276

RACP 2000b Question 82

A 24-year-old woman was investigated for right upper quadrant pain. The computed tomography (CT) scan of the upper abdomen is shown (below) before and following injection of contrast.Which one of the following is the next most appropriate investigation?

A. Abdominal ultrasonography.

B. Endoscopic retrograde cholangiopancreatography.

C. CT-guided biopsy.

D. Pooled labelled red blood cell nuclear scan.

E. Repeat abdominal CT scan in six months.

Question 277

RACP 2000b Question 91

A 43-year-old man with a long history of ileal Crohn’s disease presents with rigors, a temperature of 39.8°C, lower abdominal pain and marked right iliac fossa tenderness. He is taking prednis(ol)one 10 mg/day and sulfasalazine 1 g twice/day. Blood cultures are obtained. An urgent computed tomography (CT) scan of the abdomen is shown below. Which one of the following is the most appropriate next step in this patient’s management?

A. Intravenous hydrocortisone.

B. Intravenous antibiotics.

C. Azathioprine.

D. Intravenous hydrocortisone and intravenous antibiotics.

E. Laparotomy.

Question 278

RACP 2000b Question 96

A 63-year-old man presents to his general practitioner with a four-month history of crampy lower abdominal pain, increasing constipation and bright red rectal bleeding. There is mild left iliac fossa tenderness. He undergoes barium enema examination which is shown below. Which one of the following is the most appropriate next step in the management of this patient?

A. Abdominal ultrasonography.

B. Abdominal computed tomography (CT).

C. Colonoscopy.

D. Institution of a high fibre diet and therapy with antispasmodic agents.

E. Sigmoid colectomy.

Question 279

RACP 2000b Question 100

A 52-year-old patient presents with indigestion. Upper endoscopy reveals extensive gastritis and a biopsy shows both mucosal-associated lymphoid tissue (MALT) lymphoma and Helicobacter pylori infection. Physical examination, computed tomography (CT) scan of the chest, abdomen and pelvis, gallium scan and bone marrow examination are all normal.

The most appropriate initial therapy is:

A. combination cytotoxic chemotherapy.

B. Helicobacter pylori eradication therapy.

C. single agent chemotherapy.

D. gastric irradiation.

E. gastrectomy.

Question 280

RACP 1999a Question 13

A 35-year-old man presents with rectal bleeding. He describes the blood as being mixed with the stool. He is otherwise well. His brother was diagnosed with bowel cancer at the age of 38.

At colonoscopy he was found to have two exophytic tumours, one at the hepatic flexure, the other in the distal transverse colon. The remainder of the colon was normal. Biopsies of both areas showed adenocarcinoma.

The most likely genetic disorder in this family is:

A. familial adenomatous polyposis coli (FAP).

B. hereditary non-polyposis colorectal cancer (HNPCC). *

C. Gardner’s syndrome.

D. Peutz-Jeghers syndrome.

E. a p53 gene mutation.

Question 281

RACP 1999a Question 29

The most specific non-invasive test for the diagnosis of coeliac disease is:

A. IgA anti-endomysial antibody. * 90-95% spec and sensitivity

B. IgG anti-endomysial antibody.

C. IgG anti-gliadin antibody.

D. IgA anti-gliadin antibody.

E. IgG anti-parietal cell antibody

Question 282

RACP 19999a Question 40

The factor most commonly responsible for gastro-oesophageal reflux is:

A. transient relaxations of the lower oesophageal sphincter. *

B. reduced resting lower oesophageal sphincter tone.

C. the presence of a hiatus hernia.

D. increased gastric acid production.

E. impaired oesophageal clearance of acid.

Question 283

RACP 19999a Question 63

Which one of the following is the most efficacious in the prevention of gastro-duodenal ulceration from non- steroidal anti-inflammatory drugs (NSAIDs)?

A. Misoprostol.

B. Enprostol.

C. Omeprazole. *

D. Sucralfate.

E. Ranitidine.

Question 283

RACP 19999a Question 63

Which one of the following is the most efficacious in the prevention of gastro-duodenal ulceration from non- steroidal anti-inflammatory drugs (NSAIDs)?

A. Misoprostol.

B. Enprostol.

C. Omeprazole. *

D. Sucralfate.

E. Ranitidine.

Question 284

RACP 1999a Question 42

A 52-year-old man is brought to the Accident and Emergency Department with a six-hour history of haematemesis and melaena. He has experienced postural dizziness, but no loss of consciousness. His medical history includes

a peptic ulcer diagnosed by barium meal, gout and hypertension. He takes atenolol and indocid. He consumes 60 g of alcohol a day. He is a non-smoker.

On arrival, he has a pulse rate of 85/minute and a blood pressure of 110/70 mmHg supine. There is a postural drop of 30 mmHg. Physical examination is otherwise normal and there are no clinical features of chronic liver disease.

Following resuscitation, an endoscopy is performed. A deep ulcer is seen in the gastric antrum with an overlying fresh blood clot. Old blood is noted in the stomach, but no active bleeding.

The next most appropriate step in the management of this patient is:

A. close observation and resuscitation as required.

B. intravenous H2 antagonist.

C. endoscopic injection therapy. *

D. intravenous octreotide.

E. emergency surgery.

Question 285

RACP 1999a Question 65

A 35-year-old man with long standing ulcerative colitis has quiescent disease. He is on a maintenance regimen of salazopyrine 1 g bd and azathioprine 100 mg/day. At a routine follow up visit, he reports feeling well, with two formed stools a day and no blood or mucus. The physical examination is normal.

You perform some blood tests and the following results are available the next day:His liver function tests were normal two years ago. An abdominal ultrasound shows a normal sized liver with non-

dilated bile ducts. The gall bladder is normal with no calculi.

The most likely cause for these results is:

A. gall stone disease.

B. salazopyrine.

C. sclerosing cholangitis. *

D. azathioprine.

E. opportunistic infection.

Question 286

RACP 1999a Question 81

A 28-year-old man was found apnoeic and pulseless. There were a syringe and needle nearby and he had well defined “track marks” (venous puncture marks) on his arms. He was successfully resuscitated at the scene and brought to the Accident and Emergency Department. On arrival, he was breathing spontaneously and was normotensive. Following routine investigations, he was admitted for observation.

The next day you are called because of the results of the liver function tests below. The patient is clinically unchanged. The most likely cause for these liver function tests is:

A. acute hepatitis C.

B. post-CPR (cardiopulmonary resuscitation) liver trauma.

C. acute hepatitis A.

D. drug-induced hepatitis.

E. ischaemic hepatitis. *

Question 287

RACP 1999a Question 85

A 69-year-old man has a long history of dyspepsia and a previous peptic ulcer. After a recent severe flare of epigastric pain, he is referred for endoscopy which reveals an active duodenal ulcer. Antral biopsies show Helicobacter pylori infection. He receives 14 days treatment with “triple therapy” (bismuth, tetracycline and metronidazole).

The result of a 14C-urea breath test conducted six weeks after completion of therapy is illustrated (see following page).Which one of the following is the best interpretation of the test result?

A. Re-infection with H. pylori.

B. Failure of triple therapy to eradicate the infection. *

C. Test performed too soon after therapy.

D. Test is inaccurate in patients older than 65 years.

E. False positive due to oral infection.

Question 288

RACP 1999a Question 95

A 46-year-old man has had pancolonic ulcerative colitis since age 23. He has had colonoscopies every two years for the last six years. He has been asymptomatic for three years, and has been prescribed sulphasalazine 1 g twice daily which he often forgets to take.

The photo shown was the appearance of the sigmoid colon. Biopsies show chronic active mucosal inflammation with low grade epithelial dysplasia.

The most appropriate management is:

A. regular sulphasalazine in increased dose.

B. regular sulphasalazine and prednis(ol)one.

C. endoscopic polypectomy.

D. sigmoid colectomy.

E. total colectomy.

Question 289

RACP 1999b Question 89

A 55-year-old lady consults her gastroenterologist because of recent onset of intermittent dysphagia for solids. She has a history of gastro-oesophageal reflux proven by endoscopy, for which she is on proton pump inhibitor therapy. Her health is otherwise good and her reflux symptoms have been well controlled. She has not lost any weight. She is a smoker, but rarely consumes alcohol. The physical examination is unremarkable.

The next most appropriate course of action is:

A. a barium swallow.

B. 24-hour pH monitoring.

C. oesophageal manometry.

D. a repeat endoscopy. *

E. double the dose of proton pump inhibitor.