Mock examination

1.A 50-year-old man with ileocaecal Crohn’s disease (CD) in long-term remission had been taking azathioprine monotherapy 200 mg once a day for the last seven years.

Which pattern of drug-induced liver injury is this most likely to have caused?

A. Drug-induced autoimmune hepatitis (AIH)

B. Fibrosis

C. Granulomatous hepatitis

D. Nodular regenerative hyperplasia (NRH)

E. Steatosis

2.A 59-year-old man underwent small bowel resection for mesenteric infarction. He was seen in clinic and complained of persistent thirst. He had 130 cm small bowel to an end jejunostomy with a stoma output of 1,300 ml per day.

What is the best management advice for this patient?

A. Ensure he has long-term parenteral support

B. Increase oral water intake to at least 1,000 ml per day

C. Restrict hypotonic fluid intake to less than 500 ml per day and commence a mix of 20 g glucose, 3.5 g salt, and 2.5 g sodium bicarbonate in 1 litre water

D. Restrict hypotonic fluid intake to less than 500 ml per day and commence Dioralyte™ 5 sachets in 1 litre water

E. Restrict hypotonic fluid intake to less than 500 ml per day but add no additional fluid

3.A 56-year-old man presented with painless jaundice. CT liver and magnetic resonance cholangiopancreatography (MRCP) demonstrated a hilar biliary stricture with subsequent endoscopic retrograde cholangiopancreatography (ERCP) and brushings confirming cholangiocarcinoma.

Which radiological finding is an absolute contraindication to surgical resection?

A. Bilateral involvement of the main left and right hepatic ducts

B. Involvement of the common hepatic duct

C. Locoregional lymphadenopathy

D. Tumour abutting hepatic artery

E. Underlying primary sclerosing cholangitis (PSC)

4.A 29-year-old dancer presented with persistent abdominal pain, nausea, and constipation. She denied taking opiates or anticholinergics but did smoke cannabis once per month. On examination, her body mass index (BMI) was 17.4 kg/m². She was not diabetic but there was a history of dizziness on standing.

Investigations:

Gastroscopy	Normal
Ileocolonoscopy	Normal
MR enterography	Normal
Tilt table test	Consistent with postural orthostatic tachycardia syndrome
Beighton score	6/9 suggestive of hypermobility

What is the most likely cause of her abdominal symptoms?

A. Anorexia nervosa

B. Cannabis excess

C. Diabetic gastroparesis

D. Dysmotility associated with hypermobile-type Ehlers-Danlos syndrome (hEDS)

E. Mitochondrial neurogastrointestinal encephalomyopathy

5.A 34-year-old man presented with symptoms suggestive of delayed gastric emptying.

With regard to the physiology of gastric emptying, which of the following cells are responsible for controlling the slow-wave phase in the distal stomach?

A. Chief cells

B. Enterochromaffin cells

C. Interstitial cells of Cajal

D. Mucous neck cells

E. Parietal cells

6.A 19-year-old woman with a history of anorexia nervosa was brought to hospital by her flatmates. She had been withdrawn for several months, eating little and losing weight. Her current weight was 33 kg. She had been running twice daily until the week before, when she had become weaker and had not left her flat since. Physical examination and investigations were performed.

Which finding would indicate that the patient should be deemed high risk in the context of refeeding and rehydration?

A. Alanine aminotransferase (ALT) 56 U/L

B. Blood glucose 4.1 mmol/L

C. Creatinine 109 μmol/L

D. Heart rate (HR) 44 beats per minute (bpm)

E. QT interval 430 ms

7.The management of a 60-year-old man with a new diagnosis of head of pancreas adenocarcinoma was discussed by the multi-disciplinary team.

Which of the following CT findings makes the tumour most likely to be unresectable?

A. Tumour contact with aorta without deformity or stenosis

B. Tumour contact with the common hepatic artery

C. Tumour ≥4 cm

D. Tumour contact with one third of the coeliac axis without deformity or stenosis

E. Tumour contact with one third of the superior mesenteric vein not exceeding the inferior border of duodenum

8.A 64-year-old man was admitted with melaena. He had a background of angina and had two drug-eluting coronary stents inserted 10 months previously. His medications comprised aspirin, clopidogrel, bisoprolol, ramipril, and atorvastatin. He had recently been using naproxen for lower back pain.

Investigations:

Gastroscopy Duodenal ulcer on the anterior wall of the duodenal bulb (Forrest classification IIc)

How should you manage his antiplatelet therapy following the endoscopy?

A. Restart aspirin after three days, stop clopidogrel

B. Restart aspirin immediately, essential to discuss with cardiology regarding clopidogrel

C. Restart both aspirin and clopidogrel immediately

D. Restart clopidogrel after three days, stop aspirin

E. Stop both aspirin and clopidogrel

9.A 56-year-old man presented with pruritus ani.

Which of the following statements is true?

A. Candida infections are a cause of less than 5% of cases

B. Capsaicin has good evidence for alleviating the condition through effects on histamine release

C. Most cases are due to a single identifiable cause

D. Pinworm is a common cause of the condition in children

E. The use of soap to clean the perianal area should be encouraged

10.

Regarding gastric acid secretion, which of the following statements is true?

A. Enterochromaffin cells are found in abundance in the gastric antrum

B. Enterochromaffin cells release histamine when stimulated by gastrin or acetylcholine

C. Gastrin is released from G cells in the body

D. In the presence of intrinsic factor, pepsinogen is converted to the active enzyme, pepsin, in the stomach lumen

E. Parietal cells secrete hydrochloric acid only

11.A 63-year-old lorry driver was referred with a four-month history of bloody diarrhoea 4–6 times per day. He had mild left-sided abdominal pain. There was no history of fevers or weight loss. He denied recent foreign travel. His past medical history included ischaemic heart disease and hypertension.

Investigations:

Haemoglobin	129 g/L
Platelet count	475 × 10⁹/L
Serum albumin	31 g/L
Serum C-reactive protein (CRP)	25 mg/L
Flexible sigmoidoscopy	Confluent colitis to point of insertion (50 cm) consistent with ulcerative colitis (UC)

With respect to inflammatory bowel disease (IBD) in the elderly, which statement is most accurate?

A. Elderly-onset UC is more common in women

B. Elderly UC patients have a higher risk of being hospitalized, especially with their first flare

C. In elderly CD patients, ileal involvement is more common than colonic involvement

D. Isolated proctitis is most common and left-sided disease is less common in the elderly UC population

E. Older age is not an independent risk factor for adverse events to medications

12.A 68-year-old woman was referred with chronic diarrhoea. Her background included hypothyroidism and hypertension for which she took levothyroxine and ramipril. A colonoscopy was indicated but she recalled having had a colonoscopy eight years before and did not tolerate the bowel preparation well.

With respect to bowel preparation, which statement is most accurate?

A. All bowel preparations are associated with dehydration and electrolyte imbalances

B. Extended bowel preparation is recommended in patients with constipation

C. High-volume polyethylene glycol (PEG) is not safe in the setting of renal impairment

D. Lower adenoma detection rates correlate with inadequate bowel preparation

E. Split-dose low-volume PEG is superior to split-dose low-volume PEG preparations

13.A 45-year-old woman with Child-Pugh C alcohol-related cirrhosis was admitted with a fractured tibia following a fall. She was currently drinking two bottles of wine a day. After 18 hours, she developed severe alcohol withdrawal syndrome (AWS)

Which of the following would be the best treatment option?

A. Intramuscular haloperidol

B. Intravenous diazepam

C. Intravenous lorazepam

D. Oral baclofen

E. Oral chlordiazepoxide

14.A 45-year-old man with a history of alcohol excess presented with epigastric pain, vomiting, systemic inflammatory response syndrome, and acute kidney injury.

Investigations:

Serum amylase	1,200 U/L
Abdominal ultrasound	Normal

Five weeks after presentation, a computed tomography (CT) scan was performed because of ongoing abdominal pain and fevers.

CT abdomen	10 cm encapsulated homogenous fluid collection around the head of the pancreas
White cell count	15 × 10⁹/L
Serum C-reactive protein (CRP)	145 mg/L
Serum amylase	205 U/L

What is the most likely diagnosis?

A. Acute necrotic collection (ANC)

B. Acute peripancreatic fluid collection

C. Interstitial oedematous pancreatitis (IOP)

D. Pancreatic pseudocyst

E. Walled-off necrosis (WON)

15.A 35-year-old woman was referred to clinic with deranged liver function tests. She reported lifelong abstinence from alcohol, which was corroborated by her husband. She had a background of hypertension and type 2 diabetes. She was taking ramipril, metformin, and had completed a course of trimethoprim 2 weeks before for a urinary tract infection.

Investigations:

Serum bilirubin	10 µmol/L
Serum alanine transferase (ALT)	87 U/L
Serum alkaline phosphatase (ALP)	100 U/L
Serum albumin	42 g/L
Serum ferritin	545 µg/L
Anti-smooth muscle antibody	positive
Liver histology	(Fig. 11.1)

Fig. 11.1 Liver histology specimen. See also Plate 18

Image courtesy of Dr Eve Fryer, OUH NHS Foundation Trust, Oxford

What is the most likely diagnosis?

A. AIH

B. Drug-induced liver injury

C. Haemochromatosis

D. Non-alcoholic steatohepatitis

E. Wilson’s disease

16.A 43-year-old-man is reviewed in clinic with nine months of upper abdominal pain. He has a history of smoking 20 cigarettes a day for the past 15 years.

Investigations:

MRCP Marked parenchymal atrophy of the pancreas. Irregular and beaded main pancreatic duct with 6 mm calculi in the mid-pancreatic duct with moderate proximal dilatation

What would be the next best management for his pain?

A. ERCP and pancreatic duct stenting

B. ERCP and stone extraction

C. Extracorporeal shock wave lithotripsy

D. Pancreatectomy

E. Pancreatic enzyme supplementation

17.A 20-year-old man presented to the gastroenterology outpatient clinic. He was an only child whose father was diagnosed with hereditary non-polyposis CRC at the age of 40 years and died of CRC. No other family history was available. The patient was asymptomatic.

What is the next most appropriate step in his management?

A. Colonoscopy and gastroscopy

B. Colonoscopy from age 25 years

C. Colonoscopy with dye spray

D. Five-yearly colonoscopy from age 50 to 75 years

E. Genetic testing

18.

Which statement regarding primary sclerosing cholangitis/inflammatory bowel disease (PSC/IBD) is true?

A. CRC incidence in primary sclerosing cholangitis/ulcerative colitis (PSC/UC) is fourfold greater than in UC alone

B. IBD is detected at colonoscopy in 50% of patients with PSC

C. Mesalazine is considered an ineffective first-line therapy in PSC/UC

D. PSC is associated with an increased incidence of small bowel CD

E. Screening for CRC should begin 8–10 years after PSC/IBD diagnosis.

19.A 19-year-old student was referred to clinic with persistent non-bloody diarrhoea, abdominal cramps, and bloating. She returned from her gap year a month earlier.

Investigations:

Faecal microscopy and culture	Negative
Faecal polymerase chain reaction (PCR)	Positive for Giardia lamblia

Which statement best describes the Giardia lamblia trophozoite cycle?

A. Trophozoite colonization is limited to the upper small bowel

B. Trophozoites adhere to the mucosal surface, causing cytokine release and consequent fluid and electrolyte loss

C. Trophozoites invade tissues and gain entry to the lymphatic system, facilitating systemic spread

D. Trophozoites invade the epithelium and alter gut hormone balance, resulting in fluid and electrolyte loss

E. Upon entry into the duodenum, intestinal bacteria break down the encapsulating cyst, releasing the trophozoite

20.A 42-year-old presented with non-specific abdominal discomfort and proceeded to endoscopy.

Investigations:

Gastroscopy	There was a 1 cm, pale yellow, sessile polypoid lesion located at 36 cm from the incisors. The lesion was firm but passable with the endoscope and appeared submucosal. The appearances of the upper GI tract were otherwise normal
Endoscopic ultrasound (EUS)	At 36 cm there is a smooth-edged, hypoechoic, homogenous appearing lesion arising from the submucosa
Histology of polyp	Polygonal cells with granular eosinophilic cytoplasm

What is the most likely diagnosis?

A. Adenocarcinoma

B. Fibrovascular polyp

C. Granular cell tumour

D. Leiomyoma

E. Lipoma

21.A 35-year old woman with extensive UC was admitted to hospital with 16 bloody, loose stools per day.

Investigations:

Flexible sigmoidoscopy

Continuous inflammation to 35 cm with deep ulceration, complete obliteration of vascular pattern and free liquid blood in the lumen

What is the Ulcerative Colitis Endoscopic Index of Severity (UCEIS) score?

22.An 87-year-old man with progressive dysphagia was referred urgently for endoscopy. The endoscope was introduced into the oesophagus with some difficulty, and the view shown in (Fig. 11.2) was seen at 31 cm.

Fig. 11.2 Endoscopic image of oesophagus. See also Plate 19

Which of the following is most appropriate?

A. Covered stent placement

B. Endoscopic clipping

C. Endoscopic gluing

D. Nasogastric tube placement for feeding

E. Urgent thoracotomy

23. 0Variants in which gene are the most common cause of hereditary pancreatitis?

A. Calcium-sensing receptor (CASR)

B. Cystic fibrosis transmembrane conductance regulator (CFTR)

C. Chymotrypsin C (CTRC)

D. Serine protease 1 (PRSS1)

E. Serine protease inhibitor Kazal-type (SPINK)

24.A 45-year-old man was diagnosed with ulcerative pancolitis and concurrent PSC one year ago. He returned for his first annual follow-up appointment. He was asymptomatic.

Investigations:

Serum bilirubin	15 µmol/L
Serum alkaline phosphatase (ALP)	125 U/L
Serum alanine aminotransferase (ALT)	25 U/L
Serum albumin	37 g/L
Serum CA 19-9	20 U/ml
Colonoscopy	Quiescent UC
Abdominal ultrasound	8 mm polyp posterior wall of the gallbladder

What is the best next step in this patient’s management?

A. Cholecystectomy

B. EUS

C. MRCP

D. Repeat ultrasound in six months

E. Repeat ultrasound in one year

25.A 36-year-old ex-offender was referred to the gastroenterology clinic with nausea, vomiting, abdominal pain, and early satiety. He reported 6 kg unintentional weight loss recently. He gave a history of previous substance misuse.

Which recreational drug is associated with delayed gastric emptying?

26.A 48-year-old man with PSC was reviewed in clinic. He had some fatigue but otherwise felt well. He had concomitant UC, which was in clinical remission. His medications were ursodeoxycholic acid (UDCA) 500 mg twice a day and mesalazine 2 g once a day.

Investigations:

Serum bilirubin	16 µmol/L
Serum alkaline phosphatase (ALP)	195 U/L
Serum alanine transferase (ALT)	285 U/L
Serum albumin	39 g/L
Full blood count	Normal
INR	1.0
Antinuclear antibody	Positive
Antinuclear cytoplasmic antibody	Positive
Anti-mitochondrial antibody	Negative
Anti-smooth muscle antibody	Negative
IgA	1.8 g/L
IgG	19 g/L
IgM	1.5 g/L

What investigation would you order next?

A. Anti-sp100 and anti-gp210

B. Liver biopsy

C. Liver elastography

D. MRCP

E. No further investigations required

27.A 46-year-old female with a history of CD attended clinic. She underwent an ileocaecal resection four years ago and was on no maintenance therapy. She continued to smoke 15 cigarettes/day. She underwent a colonoscopy for symptoms of loose stool.

Investigation:

Colonoscopy

Insertion to neo-terminal ileum. Ileocolic anastomosis patent. Colon normal. Diffuse aphthous ileitis with diffusely inflamed mucosa. No evidence of stenosis or large ulcers.

What is her Rutgeerts score?

28.A 37-year-old male presented with a five-week history of fevers, non-productive cough, bloody diarrhoea, and myalgia. Four weeks ago, he returned to the UK from travelling in rural India where he had been in contact with fresh water lakes. On close questioning, he had developed an itchy rash at the start of his symptoms, which had resolved within 3–4 days.

Investigations:

Haemoglobin	130 g/L
White cell count	7.0 × 10⁹/L
Platelet count	180 × 10⁹/L
Eosinophil count	0.6 × 10⁹/L
Serum C-reactive protein (CRP)	30 mg/L
Serum alanine transferase (ALT)	34 U/L
Serum alkaline phosphatase (ALP)	110 U/L
Serum bilirubin	10 µmol/L
Faecal microscopy and culture	Negative including ova, cysts, and parasites
Chest radiograph	Ill-defined nodular pulmonary infiltrates

Which is the next most appropriate diagnostic test?

A. Kato-Katz thick smear technique

B. Rectal biopsy

C. Repeat stool microscopy

D. Serology

E. Urine microscopy

29.A 65-year-old woman with alcohol-related cirrhosis is seen with her husband in the hepatology clinic. She has been abstinent from alcohol for two years. Her husband is concerned that she is not her usual self. She appears oriented to time and place.

Which of the following is correct in the diagnosis of hepatic encephalopathy (HE)?

A. A rise in blood ammonia level is diagnostic of HE

B. Brain imaging is essential for diagnosis

C. Electroencephalography (EEG) examination is only useful in grade IV HE

D. The Stroop test can be used to help make a diagnosis of HE

E. There is no indication for screening for minimal HE

30.A 37-year-old man with UC had required multiple courses of oral corticosteroids over the past two years. Bowel symptoms recurred whenever prednisolone was reduced below 15 mg daily. Azathioprine was therefore recommended.

Investigation:

Thiopurine methyltransferase

16 U/L

Which of the following statements about thiopurine methyltransferase (TPMT) levels is most accurate?

A. Normal TPMT levels predict clinical response to thiopurines

B. TPMT activity is absent in 1% of the population

C. TPMT activity is normal in 50% of the population

D. TPMT levels accurately predict the risk of leucopenia

E. Variants in TPMT account for up to 25% of thiopurine-induced leucopenia

31. A 65-year-old man with Child-Pugh C (10) alcohol-related cirrhosis presents with Grade 3 ascites. Routine blood tests and a diagnostic paracentesis are performed.

Investigations:

Serum bilirubin	58 µmol/L
Serum creatinine	105 µmol/L
Serum sodium	129 mmol/L
Ascites white cell count	410 cells/µL
Ascites neutrophil count	220 cells/µL
Ascites albumin	5 g/L
Ascites total protein	9 g/L

The patient has been referred for consideration of liver transplantation (LT) or transjugular intrahepatic portosystemic shunt (TIPSS) and in the interim repeated large volume paracentesis is performed.

Which of the above would be an indication for long-term antibiotic prophylaxis?

A. Ascites protein concentration

B. Ascites total white cell count

C. Prospective LT

D. Prospective TIPSS

E. Repeated large volume paracentesis

32.A 56-year-old man presented with a three-month history of intermittent vomiting and weight loss. He had no past medical history, drank 10 units of alcohol a week, and was a non-smoker.

Investigations:

Gastroscopy	4 cm antral tumour
Histology	Adenocarcinoma

With regard to the initial staging of gastric cancer, which is the most useful modality as an adjunct to CT scanning?

A. Barium meal

B. Endoscopic mucosal resection (EMR)

C. Endoscopic ultrasound

D. Laparoscopy

E. Magnetic resonance imaging (MRI)

33.A 28-year-old Iranian farmer, who had recently immigrated to the UK, was referred to clinic with persistent diarrhoea. He also complained of hair loss, taste disturbance, and a superficial scaling erythematous patchy rash that was most prominent in intertriginous areas and periorally. There was no cognitive impairment.

Which is the most likely nutrient deficiency?

34.A 68-year-old woman attended for a gastroscopy having been referred by her GP with anaemia, 4 kg weight loss, and abdominal discomfort. No melaena had been witnessed, although she reported occasional dark stools.

Investigations:

Haemoglobin	122 g/L
White cell count	4.6 × 10⁹/L
Mean corpuscular volume	76 fL
Platelet count	209 × 10⁹/L
Serum ferritin	6 µg/L
Serum folate	2.6 µg/L
Serum vitamin B12	178 ng/L
Serum C-reactive protein (CRP)	16 mg/L

The endoscopic images demonstrated the findings shown in (Fig. 11.3).

Fig. 11.3 Endoscopic image of stomach. See also Plate 20

Which of the following is the most appropriate next step?

A. Antrectomy

B. Argon plasma coagulation

C. Iron supplementation

D. Propranolol

E. Transjugular intrahepatic portosystemic stent shunt (TIPSS)

35.A 47-year-old woman presented to the emergency department with recurrent episodes of right upper quadrant pain. She underwent an elective laparoscopic cholecystectomy six months before for similar ‘attacks’ despite no evidence of biliary calculi found on imaging. Her serum liver enzymes and amylase have always been within the normal limit with each episode.

Investigations:

Gallbladder histology	Chronic cholecystitis with no gallstones
MRCP	Common bile duct (CBD) diameter 4.9 mm, main pancreatic duct diameter 1.2 mm, no features of chronic pancreatitis
EUS	CBD 4.5 mm, no evidence of biliary microlithiasis or sludge

What is the next most appropriate management strategy?

A. Endoscopic intra-sphincteric botulinum toxin injection

B. ERCP with biliary sphincterotomy

C. ERCP with manometry

D. ERCP with pancreatic sphincterotomy

E. Trial of calcium-channel blocker

36.A 56-year-old woman presented with progressive dysphagia to solids but not liquids. She took omeprazole 20 mg twice daily for heartburn.

Investigations:

Gastroscopy

Impassable stricture at 34 cm which appeared endoscopically benign

Which of the following is true with regards to dilatation of benign-appearing peptic strictures?

A. Balloon dilatation is more effective than wire-guided bougie dilatation

B. Barium swallow must be performed for all oesophageal strictures

C. Biopsies should be taken before proceeding to dilatation

D. Oesophageal perforation occurs in 4% of procedures

E. The use of post-dilatation H2 receptor antagonists reduces rates of stricture recurrence

37.A 78-year-old woman was reviewed in outpatients for dysphagia. She described intermittent difficulties swallowing for several years associated with occasional regurgitation and a sensation of ‘bubbling’ at the back of her throat. She had a persistent cough and friends had commented that her breath smelt foul. She had a hospital admission with pneumonia a year ago but had fully recovered. Her only medication was amlodipine 5 mg once a day for hypertension.

Investigation:

Barium swallow

(Fig. 11.4)

Fig. 11.4 Barium swallow

Image courtesy of Dr Horace D’Costa, Consultant Radiologist, Oxford University Hospitals NHS Foundation Trust

Given the diagnosis, which of the following would provide definitive management?

A. Cognitive behavioural therapy

B. Cricopharyngeal myotomy and pouch excision

C. Endoscopic balloon dilatation

D. Endoscopic diverticulectomy

E. Long-term antibiotics

38.An 18-year-old woman with a three-month history of abdominal discomfort and unintentional weight loss presented with right-sided abdominal pain and vomiting. Her blood pressure was 110/70 mmHg and pulse 110 beats per minute.

Investigations:

Haemoglobin	104 g/L
White cell count	13.1 × 10⁹/L
Platelet count	430 × 10⁹/L
Serum C-reactive protein (CRP)	112 mg/L
CT abdomen and pelvis	12-cm length of terminal ileal stricturing with an adjacent intra-abdominal collection. There are proximal loops of dilated small bowel. Three closely spaced mid-ileal strictures, each about 3 cm, are demonstrated proximal to the dilated loops. Appearances are compatible with active CD.

What is the most likely surgical procedure?

A. Defunctioning loop ileostomy proximal to the mid-ileal strictures

B. Defunctioning loop ileostomy proximal to the terminal ileal stricture

C. Ileocaecal resection

D. Ileocaecal resection and en bloc mid-ileal stricture resection

E. Ileocaecal resection and three mid-ileal stricturoplasties

39.A 54-year-old businessman was referred from the rheumatology clinic with a two-year history of migratory arthralgia of the large joints. He had developed episodic non-bloody diarrhoea and crampy abdominal pain. He had lost weight. On examination, a pericardial rub was audible and there was small volume ascites.

Investigations:

Rheumatoid factor	Negative
IgA tissue transglutaminase antibody	Negative
Thyroid stimulating hormone (TSH)	Normal
Faecal microscopy and culture	Negative
Faecal ova, cysts, and parasites	Negative
HIV	Negative
Gastroscopy	Normal
Duodenal histology	Mild duodenal villous blunting
Colonoscopy	Normal
Colonic histology	Normal
MR enterography	No evidence of small bowel inflammation

What is the diagnostic test?

A. Carcinoembryonic antigen

B. Faecal calprotectin

C. HLA-DQ2 and DQ8

D. Periodic acid-Schiff (PAS) staining of duodenal biopsies

E. Serology for Treponema pallidum

40.A 48-year-old woman with primary biliary cholangitis (PBC) attended annual clinic follow-up suffering from severe fatigue.

Investigations:

Platelet count	170 × 10⁹/L
Liver stiffness measurement (LSM)	10.8 kPa
Serum alkaline phosphatase (ALP)	180 U/L
Serum bilirubin	45 µmol/L
Liver ultrasound	Coarse irregular heterogenous liver, no focal lesion, normal portal vein flow, no ascites, spleen size 12 cm

Which of the following is true about PBC?

A. Fatigue is an indication for LT

B. Recurrent PBC following LT often leads to graft loss

C. Severity of symptoms does not correlate with stage of disease

D. This patient should undergo endoscopy for variceal screening

E. Women are at increased risk of hepatocellular carcinoma compared with men

41.A 40-year-old woman was reviewed on the ward 24 hours after LT for alcohol-related cirrhosis. The organ donor was positive and the recipient was negative for cytomegalovirus (CMV) (D+/R−).

What is the most appropriate management regarding CMV infection post-transplantation?

A. Foscarnet prophylaxis for three months

B. Intravenous ganciclovir for two weeks

C. No prophylaxis and send CMV polymerase chain reaction (PCR) only if clinical suspicion of CMV disease

D. Valganciclovir prophylaxis for three months

E. Weekly CMV PCR during hospitalization and start valganciclovir if persisting viraemia

42.A 43-year-old female was admitted from the mental health unit having reportedly swallowed a foreign object. She denied any symptoms but refused to say what she had ingested.

Which of the following objects may be safely considered for conservative management?

A. 15 mm button battery

B. 15 mm magnet

C. 15 mm × 60 mm nail file

D. 20 mm coin

E. 25 mm metal toothpick

43.A 34-year-old man with complex ileocolonic CD developed a secondary loss of response to infliximab. He had evidence of active disease at recent ileocolonoscopy. His background included psoriasis for which he was under the dermatologists.

Which novel therapy is most appropriate to introduce?