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MyPasTest: MRCS A Online - Jan Exam 201524. Surgical Specialities; General Surgery; Abdomen (62Qs)
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01. A 17-year-old male is being investigated for tremor and dysarthria. His GP has performed blood tests
which show very deranged LFT’s. On examination, he is noted to have a tremor, impaired memory and
slit-lamp examination reveals Kayser-Fleischer rings. What is the most likely diagnosis? Select one
answer only.
Alcoholic cirrhosis« YOUR ANSWER
Alpha-1 antitrypsin deficiency Page
Autoimmune hepatitis 1436
Hepatitis B
Wilson’s disease« CORRECT ANSWER.
Wilson’s disease is an autosomal recessive disorder that results in the toxic accumulation of copper in
the liver and CNS (in particular the basal ganglia). Children often present with liver disease, and adults
with CNS features. Kayser-Fleischer rings are copper deposits in the iris (Descemet’s membrane) that are
pathognomic but not invariable and may require a slit-lamp to be seen.
02. Theme: Gastrointestinal (GI) investigations
A Colonoscopy
B Selective mesenteric angiography
C Colloid red cell scan
D Oesophagogastroduodenoscopy
E Computerised tomography
F Magnetic resonance imaging (MRI) scan.
Select the most appropriate first investigation for the assessment of the patients below. Each option may
be used once, more than once or not at all.
Scenario 1
A 60-year-old man presenting with massive rectal bleeding. He has passed 800 ml of clotted blood with no
evidence of melaena. There is no history of ingestion of non-steroidal anti-inflammatory drugs (NSAIDs) or
change in bowel habit. Following aggressive resuscitation he now has a blood pressure (BP) of 120/65 mmHg,
and a pulse of 86 beats/min. Rigid sigmoidoscopy is normal.
A - Colonoscopy« YOUR ANSWER
D - Oesophagogastroduodenoscopy« CORRECT ANSWER.
In cases of massive bleeding per rectum, one should exclude an upper GI tract haemorrhage first.
Scenario 2
A 65-year-old woman presenting with a tender non-pulsatile mass in the left iliac fossa. It is associated with a
swinging pyrexia. There is mild abdominal distension but no change in bowel habit.
B - Selective mesenteric angiography« YOUR ANSWER
E - Computerised tomography« CORRECT ANSWER.
Computerised tomography is the gold-standard investigation for diverticular abscess.
Scenario 3
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Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail: drsikhan@gmail.com
, MyPasTest: MRCS A Online - Jan Exam 2015
24. Surgical Specialities; General Surgery; Abdomen (62Qs)
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A 35-year-old man with long-standing Crohn’s disease presenting with complex anal fistulae. Previous
fistulograms have been unhelpful.
C - Colloid red cell scan« YOUR ANSWER
F - Magnetic resonance imaging (MRI) scan« CORRECT ANSWER.
MRI is now considered an excellent imaging modality for investigation of complex anal fistulae.
Page
03. Theme: Polyps 1437
A Inflammatory polyps
B Metaplastic polyps
C Peutz–Jeghers polyps
D Tubular adenomatous polyps
E Villous adenomatous polyps.
For each of the descriptions below, select the most appropriate polyp from the above list. Each option
may be used once, more than once, or not at all.
Scenario 1
Are usually a consequence of a severe episode of ulcerative colitis
A - Inflammatory polyps« CORRECT ANSWER.
Scenario 2
Are hamartomas
B - Metaplastic polyps« YOUR ANSWER
C - Peutz–Jeghers polyps« CORRECT ANSWER.
Scenario 3
May cause hypokalaemia
C - Peutz–Jeghers polyps« YOUR ANSWER
E - Villous adenomatous polyps« CORRECT ANSWER.
Scenario 4
Have the greatest malignant potential of all colonic polyps
D - Tubular adenomatous polyps« YOUR ANSWER
E - Villous adenomatous polyps« CORRECT ANSWER.
Scenario 5
Are the commonest type of polyp seen in familial adenomatous polyposis
E - Villous adenomatous polyps« YOUR ANSWER
D - Tubular adenomatous polyps« CORRECT ANSWER.
Villous adenomas of the rectum frequently present with the passage of bright-red blood and mucus per
rectum. If villous adenomas are large, mucus secretion is significant and hypokalaemia may occur.
Villous adenomas have the greatest malignant potential of all colorectal polyps. Peutz–Jeghers polyps
have no malignant potential themselves, but are associated with an increased risk of other malignant gut
polyps. Metaplastic polyps are also known as hyperplastic polyps. They are symptomless, occurring
throughout the large bowel and are the most common type of polyp found in the rectum. They are thought
not to undergo dysplastic or neoplastic change. Inflammatory polyps have no malignant potential.
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Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail: drsikhan@gmail.com
, MyPasTest: MRCS A Online - Jan Exam 2015
24. Surgical Specialities; General Surgery; Abdomen (62Qs)
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04. Theme: Abdominal pain investigations - diagnostic
A Upper GI endoscopy
B Serum amylase
C Erect chest X-ray (CXR)
D Supine abdominal X-ray (AXR)
E Angiography (mesenteric)
F Computed tomography (CT) Page
G Barium enema 1438
H Barium meal - small bowel follow-through
I Abdominal ultrasound.
For each of the patients described below, select the most appropriate investigation from the list of
options above. Each option may be used once, more than once or not at all. You may believe that more
than one diagnosis is possible but you should choose the ONE most likely (diagnosis) diagnostic
investigation.
Scenario 1
An 80-year-old man presents to the emergency department with severe central abdominal pain. He has recently
had a myocardial infarction (MI) and he is in atrial fibrillation. The abdomen is distended and tender. Rectal
examination reveals an empty rectum.
A - Upper GI endoscopy« YOUR ANSWER
E - Angiography (mesenteric)« CORRECT ANSWER.
The most appropriate investigation for this clinical scenario would be a mesenteric angiogram as the
most likely diagnosis is a mesenteric artery embolus (probably due to atrial fibrillation).
Scenario 2
A 21-year-old lady presents to the surgical outpatient clinic with a 2-year history of abdominal discomfort and
weight loss. She used to get central abdominal pain which, in the past few weeks, has moved to the right iliac
fossa. She says that she opens her bowels 4-5 times a day and has noticed occasional blood and mucus in her
stools.
B - Serum amylase« YOUR ANSWER
H - Barium meal - small bowel follow-through« CORRECT ANSWER.
The history of a young woman with long-standing lower abdominal pain which is localising to the right
iliac fossa, increased frequency of motions and stools mixed with blood and/or mucus is suggestive of
Crohn's disease.A barium meal with small bowel follow through would be the most appropriate
investigation in this patient.
Scenario 3
A 49-year-old presents with severe epigastric pain and vomiting. On examination, her pulse is 120/min, blood
pressure is 124/82 mmHg and her respiratory rate is 20/min (shallow respiration). Bowel sounds are absent. She
suffers from rheumatoid arthritis for which she takes regular gold injections, oral steroids and diclofenac. Her dose
of oral steroids was increased a week ago to treat exacerbation of chronic obstructive airways disease. Plain erect
chest radiography suggests the presence of air under the diaphragm.
C - Erect chest X-ray (CXR)« YOUR ANSWER
F - Computed tomography (CT)« CORRECT ANSWER
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail: drsikhan@gmail.com
, MyPasTest: MRCS A Online - Jan Exam 2015
24. Surgical Specialities; General Surgery; Abdomen (62Qs)
----------------------------------------------------------------------------------------------------------------------------------
The patient in this clinical scenario has probably got a perforated peptic/duodenal ulcer due to the intake
of oral steroids and non-steriodal drugs. After pneumoperitoneum is suggested on erect CXR, contrast
CT of the abdomen and pelvis will be useful in confirming the site of perforation (provided the patient is
stable) to facilitate pre-operative planning.
Scenario 4
A 90-year-old lady is brought to the emergency department with a 7-h history of copious fresh red rectal bleeding. Page
She is tachycardic and hypotensive. Of note is a longstanding history of rheumatoid arthritis for which the patient 1439
has been on NSAIDs. Initial blood tests indicate disproportionately raised serum urea.
D - Supine abdominal X-ray (AXR)« YOUR ANSWER
A - Upper GI endoscopy« CORRECT ANSWER.
The presenting history and initial investigations allude to an upper GI bleed likely from a peptic ulcer. One
must remember that torrential upper GI bleeds may present as fresh rectal bleeding instead of melaena
(i.e. due to rapid gut transit). In such cases, the initial investigation of choice, after adequate
resuscitation, is upper GI endoscopy to identify and treat any potential bleeding points.
Scenario 5
A 75-year-old lady in the orthopaedic ward who is taking oral steroids for COAD, and diclofenac for pain
complains of sudden-onset acute epigastric pain. She is tachypnoeic and tachycardic. Any movement
exacerbates her abdominal pain. Erect CXR suggests the presence of air under the diaphragm and she is
adequately resuscitated with intravenous fluids.
E - Angiography (mesenteric)« YOUR ANSWER
F - Computed tomography (CT)« CORRECT ANSWER.
As in the third case scenario, this patient has most likely got a perforated duodenal ulcer and CT of the
abdomen and pelvis will aid preoperative planning, provided the patient is stable.
Scenario 6
A 70-year-old lady with mental health problems presents to the emergency department with peri-umbilical pain,
gross abdominal distension, and absolute constipation.
F - Computed tomography (CT)« YOUR ANSWER
D - Supine abdominal X-ray (AXR)« CORRECT ANSWER.
The most likely diagnosis in this patient would be a sigmoid volvulus and a supine AXR is the
investigation of choice. This would reveal an 'omega loop'.
05. A 22-year-old female presents to her GP with a history of vague abdominal pain and bloating. On
further questioning she reports weight loss and passing offensive stools which are difficult to flush away.
As part of her investigations a jejunal biopsy is performed. This shows crypt hyperplasia and subtotal
villous atrophy. What is the most likely diagnosis? Select one answer only.
Bacterial overgrowth« YOUR ANSWER
Coeliac disease« CORRECT ANSWER
Crohns disease
Ulcerative colitis
Tropical malabsorption.
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Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail: drsikhan@gmail.com
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