Question: 1 of 83

A 78-year-old man was seen in the casualty

department.
He had been referred by his general practitioner
with abdominal pain which had come and gone
intermittently over a period of several weeks. During
the pain, he felt nauseated and had occasionally
vomited. He reported that he had not opened his
bowels for several days and he could not recall if he
had passed flatus recently.
Over the past three months his weight had decreased by
two stones and his appetite had diminished. He had also
noticed some loosening of his bowel motions but he had
not passed any blood or mucus in his stool.

Three years previously he had undergone an anterior

resection for colonic cancer. His recovery had been
hampered by an abscess and wound infection. This had
necessitated a second laparotomy. However after
discharge he had recovered well.

On examination he looked pale and thin. He was afebrile.

His pulse was 80 beats per minute and regular with blood
pressure of 115/75 mmHg. Heart sounds were normal and
the chest was clear on auscultation. His abdomen was
distended but was soft; bowel sounds were present and
active. Rectal examination was unremarkable.

Further investigations revealed:

Haemoglobin 9.2 g/dL (13-18)

MCV 77 fL (80-96)
White cell count 5 x109/L (4-11 x109)
Platelets 190 x109/L (150-400 x109)
Serum sodium 139 mmol/L (137-144)
Serum potassium 4.1 mmol/L (3.5-4.9)
Serum urea 2.4 mmol/L (2.5-7.5)
Serum creatinine 101 mol/L (60-110)

Arterial blood gas analysis showed:

pH 7.4 (7.36-7.44)
PCO2 5 kPa (4.7-6.0)
PO2 11 kPa (11.3-12.6)
Base Excess -1 mmol/L (+/-2)
HCO3 26 mmol/L (20-28)

What is the most likely cause of his symptoms?

(Please select 1 option)

Bowel obstruction secondary to adhesions

Constipation
Ischaemic bowel
Pseudo obstruction
Subacute obstruction due to recurrence of
carcinoma

(Please select 1 option)

Bowel obstruction secondary to adhesions

Constipation
Ischaemic bowel
 Pseudo obstruction
Subacute obstruction due to recurrence of
carcinoma Correct

The past history of cancer and his recent weight loss,

anorexia, altered bowel habit and anaemia puts
recurrence near the top.

The normal gases makes ischaemic gut unlikely, the

history does not sound like intestinal angina although this
must be thought of in smokers/ vasculopaths.

Pseudo obstruction usually occurs in ill patients but it often

occurs in the setting of abnormal urea and electrolytes.

Adhesions would give similar symptoms but the malignant

sounding symptoms push the answer towards recurrence.

Question: 2 of 83

A 52-year-old man with newly diagnosed diabetes is

referred to the diabetes clinic. He gave a two month
history of polyuria and polydipsia and his urine tested
positive for glucose in the GP surgery after returning from
holiday in Portugal. He has no past history of note and
was not taking any regular medication, although he had
requested a trial of sildenafil from his GP for recent onset
of erectile dysfunction. On examination he appears tanned
and well. A liver edge is palpable 2cm below the right
costal margin and his testes are found to be small.
Investigations reveal:

Haemoglobin 15.1 g/dL (13.0-18.0)

White blood cells 7.2 x109/L (4-11 x109)
Platelets 341 x109/L (150-400 x109)
Serum iron 50 µmol/L (12-30)
Transferrin saturation 85% (<50%)
Urinalysis: Glucose +

Which investigation is most likely to assist in making a

diagnosis?
(Please select 1 option)

Genetic analysis for C282Y and H63D mutations

Red cell transketolase
Serum ferritin
Total iron binding capacity (TIBC)
Ultrasound scan of the abdomen

(Please select 1 option)

Genetic analysis for C282Y and H63D

mutations Correct
Red cell transketolase
 Serum ferritin
Total iron binding capacity (TIBC)
Ultrasound scan of the abdomen

The patient has haemochromatosis. The skin appears

tanned, he is impotent (hypogonadal), and has diabetes.
There is an elevated level of iron and transferring
saturation is high.

Haemochromatosis is an autosomal recessive condition.

Two mutations of the HFE gene (C282Y and H63D)
account for over 90% of cases in Europeans. The disease
is also associated with HLA-A3 and HLA-B14.

Question: 3 of 83

A 42-year-old widow presents with a one week history of

progressive confusion and unsteady gait. She works as a
barmaid and lives in poor social circumstances.
On examination she is malnourished and disorientated.
She has nystagmus and is unable to abduct either eye.
The pupils are sluggish and unequal. Ankle jerks are
absent but upper limb reflexes are present.

Shortly after her admission you are called to the ward as

she has become very drowsy and has collapsed on the
floor.
Investigations on admission were as follows:

Haemoglobin 11.4 g/dL (11.5-16.5)

MCV 99 fL (80-96)
White blood count 5.6 x109/L (4-11 x109)
Platelets 230 x109/L (150-400 x109)
Serum sodium 129 mmol/L (137-144)
Serum potassium 3.2 mmol/L (3.5-4.9)
Serum bilirubin 27 µmol/L (1-22)
Serum gamma GT 440 U/L (4-35)
Serum alkaline phosphatase 180U/L (45-105)
Serum AST 90 U/L (1-31)
Serum ALT 45 U/L (5-35)
Serum albumin 33 g/L (37-49)
Prothrombin time 12 secs (11.5-15.5)

What was is the most likely cause of her presentation and

drowsiness?
(Please select 1 option)

Hyponatraemia
Brain stem CVA
Central pontine myelinolysis
 Liver failure
Wernicke’s encephalopathy

(Please select 1 option)

Hyponatraemia
Brain stem CVA
Central pontine myelinolysis
Liver failure
Wernicke’s encephalopathy Correct
This lady presents with the classic triad of WE
(encephalopathy, gait ataxia and occulomotor
dysfunction). Lower limb neuropathy is also a feature of
WE. Her occupation, poor nutrition, social situation, and
blood results all suggest underlying alcoholism. The
hyponatraemia is mild and unlikely to cause symptoms
and CPM (related to the rapid correction of Na+) is
unlikely. A brainstem CVA is unlikely due to the gradual
onset over 2 weeks. Liver function appears well preserved
(normal PT and reasonable Albumin).

Question: 4 of 83

An 85-year-old lady is admitted from a residential home

with an eight hour history of confusion and diarrhoea. No
additional history is available from the patient.

A carer from the home, who has accompanied the patient

to hospital says that the patient is usually alert and self-
caring, though the general practitioner has been called to
see her twice recently because she has complained of
dysuria and foul-smelling diarrhoea.

On examination, the patient is afebrile. She has a

distended tender abdomen with no bowel sounds. You ask
a surgical colleague to review her. She is subsequently
taken to the operating theatre for an explorative
laparotomy. A section of bowel is excised (shown).

What is the diagnosis?

(Please select 1 option)

Angiodysplasia
Ischaemic colitis
Multiple colonic adenomata
Pneumatosis coli
Pseudomembranous colitis

(Please select 1 option)

Angiodysplasia
Ischaemic colitis
Multiple colonic adenomata
Pneumatosis coli
Pseudomembranous colitis Correct
The picture shows a thick pseudomembrane adherent to
the colonic mucosa.

Diarrhoea due to Clostridium difficile has a characteristic

foul smell and is usually managed conservatively with oral
metronidazole / vancomycin.

If associated with pseudomembranous colitis the mortality

risk is greatly increased.

Question: 5 of 83

A 40-year-old gentleman, known to have advanced

cryptogenic liver cirrhosis, presents with acute onset
confusion. His wife claims that over the last few days his
abdomen has become increasingly distended, however
she is more concerned about him being disoriented to
time and place. The patient was previously controlled on
100mg of Spironolactone daily together with 2mgs of
Bumetanide dly and 10mls of lactulose bd.

On examination the patient is deeply jaundiced with

widespread spider naevi. There is tense ascitis with
eversion of the umbilicus together with distended
abdominal veins. Asterixis is also noted. He is confused to
time and place and is afebrile.
Investigations show:

Haemoglobin 10.3 g/dL (13.0-18.0)

Platelets 48 x109/L (150-400 x109)
MCV 102 fL (80-96)
White cell count 10 x109/L (4-11 x109)
INR 2.8 (<1.4)
Serum sodium 128 mmol/L (137-144)
Serum potassium 3.0 mmol/L (3.5-4.9)
Serum urea 4.1 mmol/L (2.5-7.5)
Serum creatinine 90 µmol/L (60-110)
Serum albumin 28 g/L (37-49)
Serum bilirubin 95 µmol/L (1-22)
Serum GGT 59 U/L (<50)
Serum ALT 60 U/L (5-35)

Which of the following will constitute the best initial

management?
(Please select 1 option)

Start oral neomycin

Start IV cefotaxime
Give 4 units of platelets
 Paracentesis
Increase dose of spironolactone

(Please select 1 option)

Start oral neomycin

Start IV cefotaxime
Give 4 units of platelets
Paracentesis This is the correct
answer
 Increase dose of spironolactone

This patient is suffering from decompensation of

previously stable liver failure. He is encephalopathic. Of
the options given, a diagnostic tap will diagnose SBP if
present or exclude it if not – this is a very common cause
.of deterioration in such patients

Question: 6 of 83

A 55-year-old man with a history of asthma presents for

upper GI endoscopy to investigate chest pain, reflux
symptoms, and mild dysphagia for solids. The picture
below is from the mid oesophagus.
What is the diagnosis?
(Please select 1 option)

Achalasia
Barrett's oesophagus with ulceration
Hiatus Hernia
Oesophageal candidiasis
Oesophageal carcinoma

(Please select 1 option)

Achalasia
Barrett's oesophagus with ulceration
Correct
Hiatus Hernia
 Oesophageal candidiasis
Oesophageal carcinoma

The photograph shows a long segment of Barrett's

epithelium which has replaced the normal squamous
epithelium (normal mucosa seen in the bottom right corner
of the photo). There is an ulcerated circumfrencial stricture
and a linear ulcer scar extending up the oesophagus in
the 5 O'clock position. He requires biopsies to exclude
.dysplasia / malignancy and acid suppression with a PPI

Question: 7 of 83

A 15-year-old girl is referred to the outpatient clinic with a

two-year hiostory of progressive weight loss (8kg). She
has a balanced diet and her appetite is good according to
her mother. There is a history of intermittent abdominal
cramps, but no abdominal pain, diarrhoea or rectal blood
loss. Examination is unremarkable.

Investigations

Haemoglobin 10.5 g/dL (12-16)

MCV 85 fL (80-96)
WBC 7.2 x109/L (4-11 x109)
Platelets 399 x109/L (150-400 x109)

An endoscopic examination is performed and a biopsy

obtained (shown below).

What is the diagnosis?

(Please select 1 option)

Amyloidosis
Bulimia nervosa
Coeliac disease
Crohn's disease
Ulcerative colitis

(Please select 1 option)

Amyloidosis
Bulimia nervosa Correct
Coeliac disease
 Crohn's disease
Ulcerative colitis

The patient has bulimia nervosa and is abusing laxatives.

Melanosis coli is found in patients who use and abuse
anthraquinone laxatives. Melanosis coli is a histological
diagnosis made from rectal biopsy material which shows
numerous macrophages filled with brown pigment within
the lamina propria. This phenomenon is seen in over 70%
of persons who use anthraquinone laxatives (e.g. cascara
sagrada, senna, and frangula) within several months of
use. The condition is benign and reversible on stopping
the laxatives. The macroscopic appearance varies from
deep black pigmentation to reticulated brown
discolouration. Melanosis coli may involve the entire large
intestine, but can be segmental. The discolouration is
caused by deposits of lipofuscin rather than true melanin
deposition. Anthraquinone cathartics induce apoptosis of
epithelial cells of the large intestine. The apoptotic bodies
are taken up by epithelial macrophages and they are
.converted to lipofuscin

Question: 8 of 83

A 30-year-old Bank worker was seen in the outpatient

clinic. He described six months of diarrhoea. He described
the stools as bloody, with at least ten motions per day and
often at night. There was no recent travel history. He
reported being very stressed at work due to financial
targets. He did not eat regular meals and often eat
convenience foods.
His sister had suffered with a bowel complaint which
improved after excluding bread from her diet.
On examination he looked tired and pale. Temperature 37.9°C; Blood pressure 139/67
mmHg; Pulse 90 beats per minute. Abdominal examination was normal apart from
bloody stool on the glove after per rectal examination.

Haemoglobin 10.7 g/dL (13-18)

White Blood Cell 13.2 x109/L (4-11 x109)
Platelets 160 x109/L (150-400 x109)
Serum sodium 143 mmol/L (137-144)
Serum potassium 4.0 mmol/L (3.5-4.9)
Serum urea 4.0 mmol/L (2.5-7.5)
Serum creatinine 100 µmol/L (60-110)
Plasma glucose 5.1 mmol/L (3.0-6.0)
Serum Albumin 35 g/L (37-49)
Serum AST 22 U/L (1-31)
Serum Alkaline 100 U/L (45-105)
Phosphatase
Serum C Reactive Protein 110 mg/L (<10)

What investigation would be most likely to yield the

diagnosis?
(Please select 1 option)

Anti Tissue Transglutaminase Antibodies

Colonoscopy
Hydrogen Breath Test
 Small bowel biopsy
Stool Culture

(Please select 1 option)

Anti Tissue Transglutaminase Antibodies

Colonoscopy Correct
Hydrogen Breath Test
 Small bowel biopsy
Stool Culture

This history is very suggestive of Inflammatory Bowel

Disease. The Anaemia, low Albumin, CRP together with a
history of bloody diarrhea, frequency and nocturnal;
symptoms are classical. The bloody diarrhea and
frequency point to large bowel pathology, indeed when
investigating diarrhea the colon is usually the place to
start. The stool culture is vital but the diagnostic test of
choice is colonoscopy and colonic biopsy.
IBS is diagnosed by the Rome criteria however the
symptoms and blood results do not support IBS. The
sisters history is not helpful as many people with IBS
exclude various foods and derive benefit without a firm
diagnosis. Hydrogen breath test is for bacterial overgrowth
and is not likely to help.

Question: 9 of 83

A 45-year-old man was admitted with worsening ascites.

He was diagnosed with decompensated alcoholic liver
disease.
He was subsequently treated with spironolcatone 100mg
od and furosemide 40mg od, and he was administered an
intravenous albumin infusion.

Over the next 10 days in hospital he developed oliguria

and his serum creatinine rose from 130 µmol/L to 380
µmol/L (60-110). The diuretics were stopped but his serum
creatinine did not improve. Urine dipstick examination
revealed no proteinuria or haematuria.

Ultrasound of the kidneys was normal. Examination of the

ascitic fluid did not reveal any evidence of microbial
infection. His blood pressure was maintained at 118/70.

Which drug, given intravenously is likely to improve his

renal function?
(Please select 1 option)

Dobutamine
Dopamine
Octreotide
Prostacycline
Terlipressin

(Please select 1 option)

Dobutamine
Dopamine
Octreotide
Prostacycline
 Terlipressin Correct
The diagnosis here is hepatorenal syndrome, and more
specifically hepatorenal syndrome type 2. Hepatorenal
syndrome type 2 is characterized by a moderate and
stable reduction in renal function,hypotension and diuretic
resistance. In the treatment of hepatorenal syndrome
attention has turned to agonists of vasopressin V1
receptors such as Terlipressin. This causes splanchnic
vascoconstriction, which may reverse the early splanchnic
vasodilatation seen in hepatorenal syndrome. Small
studies have demonstrated the utility of terlipressin in
patients with hepatorenal syndrome. Small studies with
Dopamine have shown no renal benefit in such patients.
No evidence exists for the use of dobutamine or octreotide
in these circumstances.

Question: 10 of 83

A 40-year-old male with ulcerative colitis of 10 years

duration presented with feeling unwell. He has complained
of right upper quadrant pain and has recently noticed he
has started to itch. His stools are pale coloured. He is on
sulphasalazine and has had only two previous minor
relapses.

On examination he has five spider naevi on the upper

trunk. A liver edge is palpable 5 cm below the right costal
margin. The tip of the spleen is also palpable but there are
no signs of ascites.
Investigations show:

Platelets 110 x109/L (150-400

x109)
Prothrombin time 20 secs (11.5-15.5)
Serum bilirubin 55 µmol/L (1-22)
Serum aspartate 101 U/L (1-31)
aminotransferase
Serum alanine 38 U/L (5-35)
aminotransferase
Serum alkaline phosphatase 482 U/L (45-105)
Hepatitis B surface antigen Negative

Which investigation is most likely to confirm the diagnosis?

(Please select 1 option)

Anti-mitochondrial antibodies
ERCP
Liver biopsy
Liver ultrasound
Withdrawal of sulphasalazine

(Please select 1 option)

Anti-mitochondrial antibodies
ERCP Correct
Liver biopsy
Liver ultrasound
Withdrawal of sulphasalazine
This man has primary sclerosing cholangitis (PSC), a
diagnosis made on endoscopic retrograde
cholangiopancreatography (ERCP) (intra- and/or extra-
hepatic bile duct stricturing).

Liver ultrasound is likely to show a cirrhotic-looking liver

but not confirm a cause.

Liver biopsy will confirm biliary cirrhosis but does not

provide information on whether there is a dominant extra-
hepatic stricture which may be amenable to endoscopic
intervention.

Anti-mitochondrial antibodies (AMAs) are associated with

primary biliary cirrhosis (PBC) not PSC.

Withdrawal of his medication will be of no benefit as this

chap has established liver disease due to PSC rather than
drug related cholestasis.

Question: 11 of 83

A 23-year-old woman gave a 4 year history of intermittent

diarrhoea and constipation. This had become more
problematical since return from a back-packing trip around
Thailand eight months ago. Her past medical history was
otherwise unremarkable. Her family history revealed only
that her mother was suffering from hyperthyroidism.

On examination she had a body mass index of 18.5 kg/m2

but without any other specific abnormality.
Investigations revealed:

Haemoglobin 10.3 g/dL (11.5-16.5)

MCV 72.4 fL (80-96)
White Cell Count 6.7 x109/L (4-11 x109)
Platelets 192 x109/L (150-400 x109)
ESR (Westergren) 5 mm/hr (0-20)
Serum sodium 139 mmol/L (137-144)
Serum potassium 4.2 mmol/L (3.5-4.9)
Serum urea 6.4 mmol/L (2.5-7.5)
Serum creatinine 75 µmol/L (60-110)
Corrected calcium 1.92 mmol/L (2.2-2.6)
Serum Free T4 14.5 pmol/L (10-22)
Serum TSH 0.8 mU/L (0.4-5.0)

What is the likely diagnosis?

(Please select 1 option)

Coeliac disease
Collagenous colitis
Crohns disease
Tropical sprue
Sick euthyroid

(Please select 1 option)

Coeliac disease Correct

Collagenous colitis
Crohns disease
Tropical sprue
 Sick euthyroid

The most likely explanation for this patient's 4 year history

plus hypocalcaemia and iron deificiency anaemia with
normal inflammatory markers is Coeliac disease. In
particular, the family history of autoimmunity would also
favour this diagnosis. A macrocytic anaemia would be
more in keeping with tropical sprue and the history that
precedes the trip to Thailand would argue against this.

Question: 12 of 83

A 61-year-old old lady was referred to clinic by her GP

with a six month history of fatigue. There was no history of
weight loss or change in bowel habit, no cough or sputum
production.
She denied having any fevers or sweats. Her only other
complaint was of occasional pains in her joints secondary
to rheumatoid arthritis, which had been diagnosed three
years previously.

She worked as an assistant in a bookshop and lived with

her husband. She had three children, all of whom were
well. There was no family history of note. She was a
lifelong non-smoker and seldom drank alcohol.

On examination she appeared well. She was afebrile.

Xanthelasma were noted around both eyes. A few faint
scratch marks were visible on the skin of her arms. She
attributed this to an 'allergy' to a new washing powder.

Her pulse was 70/min with blood pressure 110/65 mmHg.

Heart sounds were normal with no murmurs or added
sounds. Her chest was clear. The abdomen was soft and
non-tender. The spleen was palpable 3 centimetres below
the left costal margin. The liver and kidneys were not
palpable. Neurological examination was normal.

What is the most likely diagnosis?

(Please select 1 option)

Chronic lymphocytic leukaemia (CLL)

Familial hypercholesterolaemia
 Hodgkin's lymphoma
Primary biliary cirrhosis
Pseudoxanthoma elasticum

(Please select 1 option)

Chronic lymphocytic leukaemia (CLL)

Familial hypercholesterolaemia
 Hodgkin's lymphoma
Primary biliary cirrhosis Correct
Pseudoxanthoma elasticum

Over 90% of cases of primary biliary cirrhosis (PBC) occur

in women aged 35 to 70.

The presentation is usually insidious. Pruritus, non-

specific fatigue, or both are the initial symptoms in more
than 50% of patients and can precede other symptoms by
months or years.

About 50% of patients present with an enlarged, firm, non-

tender liver; 25%, with splenomegaly; about 15%, with
skin xanthomas; and 10%, with hyperpigmentation.

Jaundice is present in 20% of patients and tends to

develop in others with time.

Clubbing, metabolic bone disease (that is, osteoporosis),

peripheral neuropathy, renal tubular acidosis, and
steatorrhea (from the cholestasis and pancreatic secretory
failure) are possible. Later, all the features and
complications of cirrhosis can develop.

PBC is commonly associated with autoimmune disorders

(for example, RA, scleroderma, sicca complex,
autoimmune thyroiditis).

CLL is usually associated with symmetrical

lymphadenopathy; splenomegaly is detectable in about
50% of cases.

Localised lymphadenopathy (usually above the

diaphragm) is the commonest presentation of Hodgkin's
disease; hepatosplenomegaly is usually associated with
NHL.
While familial hypercholesterolaemia might explain the
xanthelasma in this case, it does not adequately explain
the other symptoms of fatigue and pruritis or the presence
of splenomegaly.

Question: 13 of 83
A 32-year-old gentleman was seen in the outpatient clinic
with a six week history of diarrhea. He admitted to opening
his bowels up-to eight times per day and at least twice at
night. He described the diarrhea as bloody and also had
an ache in the left iliac fossa.

He recalled several similar episodes over the past ten

years which were self limiting but he had never sought
medical advice.

His general practitioner had started Loperamide.

On examinations he looked generally well but had yellow sclera with mild tenderness
in the left iliac fossa, sigmoidoscopy revealed an inflamed mucosa.

Haemoglobin 10.2 g/dL (13-18)

White cells 9.0 x109/L (4-11 x109)
Platelets 300 x109/L (150-400
x109)
MCV 90 fL (80-96)
Albumin 35g/L (37-49)
Bilirubin 80 μmol/L (1-22)
Aspartate transaminase 50 U/L (5-35)
Alkaline phosphatase 590 U/L (45-105)
Gamma gluteryltransferase 800U/L (<50)
C reactive protein 35 mg/L (<10)
Anti neutrophil cytoplasmic Detected
antibody:

What is the cause of the liver dysfunction?

(Please select 1 option)

Autoimmune Hepatitis
Cholelithiasis
Drug induced cholestasis
 Non specific markers of inflammation
Primary Sclerosing Cholangitis

(Please select 1 option)

Autoimmune Hepatitis
Cholelithiasis
Drug induced cholestasis
 Non specific markers of inflammation
Primary Sclerosing Cholangitis Correct

The features of episodic bloody diarrhoea and the clinical

findings point to a diagnosis of Ulcerative Colitis. ALK
Phos and GGT can often act as non specific markers of
inflammation, the raised bilirubin points to a more
cholestatic process and drugs often cause this but is not
common with loperamide, the combination of UC and
cholestasis really should point to PSC the ANCA helps a
little ( this is not a specific marker). Cholilithiasis is a
.possibility but rare in young men

Question: 14 of 83

A 40-year-old male is admitted with fever and acute

abdominal pain. Over the last 3 days he has developed
increasing abdominal swelling and a low grade fever. On
examination he has right upper quadrant pain with 2 fingr
breadth hepatomegaly and he has shifting dullness. His
radiology is illustrated.

What is the diagnosis

(Please select 1 option)

Amoebic abscess
Focal fatty sparring
Hepatocellular carcinoma
Pancreatitis
Portal vein thrombosis

Please select 1 option)

Amoebic abscess
Focal fatty sparring
Hepatocellular carcinoma
Pancreatitis
Portal vein thrombosis This is the correct
answer
The diagnosis is portal vein thrombosis, which can be
secondary to pancreatitis as seems likely in this man's
case. The portal vein is expanded and contains thrombus
(the non enhancing vessel). There are associated wedge
defects within the liver consistent with either perfusion
defects or infarcts.

Question: 15 of 83

A 40-year-old male with ulcerative colitis (UC) of 10 years

duration presented with feeling unwell. He has complained
of right upper quadrant pain and has recently noticed he
has started to itch. His stools are pale coloured. He is on
sulphasalazine and has had only 2 previous minor
relapses.
On examination he has 5-spider naevi on the upper trunk.
In his abdomen he has a 5-cm hepatomegaly and a
tipable spleen, but no ascites.
Investigations show:

Platelets 110 x109/L (150-400

x109)
Prothrombin time 20 secs (11.5-15.5)
Serum bilirubin 55 µmol/L (1-22)
Serum aspartate 101 U/L (1-31)
aminotransferase
Serum alanine 38 U/L (5-35)
aminotransferase
Serum alkaline phosphatase 482 U/L (45-105)
Hepatitis B surface antigen Negative

What is the most likely diagnosis?

(Please select 1 option)

Colonic carcinoma
Drug cholestasis
Cholangiocarcinoma
Primary biliary cirrhosis
Primary sclerosing cholangitis
(Please select 1 option)

Colonic carcinoma
Drug cholestasis
Cholangiocarcinoma
Primary biliary cirrhosis
Primary sclerosing cholangitis Correct
This man has cirrhosis with portal hypertension,
cholestasis and liver synthetic failure. Primary sclerosing
cholangitis (PSC) has a strong association with ulcerative
colitis and is the most likely diagnosis. There is an
increased risk of cholangiocarcinoma with PSC, and it is
possible that his deterioration may be due to the
development of cholangiocarcinoma. Drug cholestasis
would not explain the stigmata of chronic liver disease
(spiders, splenomegaly), neither would colonic carcinoma.
Primary biliary cirrhosis is not associated with UC and is
uncommon in men.