Free UKMLA gastrointestinal and liver questions with explanations

A. Glasgow-Blatchford score

The Glasgow-Blatchford score is the pre-endoscopy risk tool for acute upper gastrointestinal bleeding; it uses urea, haemoglobin, blood pressure, pulse, melaena, syncope and hepatic or cardiac disease, and a score of 0 identifies patients at very low risk who can be considered for early discharge and outpatient endoscopy. The full Rockall score requires endoscopic findings, so it is applied after endoscopy to predict rebleeding and death. AIMS65 predicts mortality but is not the tool UK guidance recommends for discharge decisions. The Forrest classification grades ulcer stigmata at endoscopy.

D. Endoscopic haemostasis with clips or adrenaline injection plus a second modality

Most Mallory-Weiss tears stop bleeding spontaneously, but a tear that is actively bleeding at endoscopy is treated at the same procedure with endoscopic therapy, using mechanical clips, adrenaline injection combined with a second modality, or thermal coagulation. Terlipressin is for variceal haemorrhage and has no role in a mucosal tear. High-dose proton pump inhibitor infusion is used after endoscopic treatment of a peptic ulcer with high-risk stigmata; on its own it does not stop active arterial oozing from a tear. Embolisation or surgery is reserved for bleeding that endoscopy cannot control.

C. Ascending cholangitis

Fever with rigors, jaundice, and confusion in a patient with biliary obstruction indicates ascending cholangitis; confusion is one of the two extra features that, added to Charcot triad (fever, jaundice, right upper quadrant pain), form Reynolds pentad of severe cholangitis, the other being hypotension. Obstruction from the pancreatic head mass causes bile stasis and bacterial ascent, requiring urgent IV antibiotics and biliary decompression by ERCP.

C. Intravenous cefotaxime

Ascitic neutrophil count ≥250 cells/mm³ in a cirrhotic patient confirms spontaneous bacterial peritonitis (SBP), and empirical IV cefotaxime (or another third-generation cephalosporin) is first-line as it covers the enteric Gram-negative organisms (E. coli, Klebsiella) and streptococci responsible for most cases. IV albumin (1.5 g/kg day 1, 1 g/kg day 3) should be co-administered to reduce hepatorenal syndrome and mortality.

D. Laparoscopic cholecystectomy

Laparoscopic cholecystectomy is the definitive treatment for symptomatic gallstones in pregnancy and is recommended for recurrent biliary colic to prevent progression to cholecystitis, cholangitis or gallstone pancreatitis, which carry significant fetal loss rates. The second trimester is the optimal operative window as organogenesis is complete and the gravid uterus does not yet obstruct laparoscopic access; laparoscopy is safe throughout pregnancy when clinically indicated.

D. Percutaneous cholecystostomy

Percutaneous cholecystostomy is the correct choice: it provides source control by draining the infected gallbladder via an image-guided catheter inserted under local anaesthesia and sedation, avoiding the physiological stress of general anaesthesia. It is reserved for patients who are genuinely unfit for general anaesthesia and cholecystectomy, as here, when acute cholecystitis fails conservative therapy; fitter high-risk patients do better with early laparoscopic cholecystectomy.

C. Pioglitazone

Pioglitazone improves insulin sensitivity in adipose tissue and liver and is the glucose-lowering drug with the strongest trial evidence for resolving steatohepatitis, so it is a recognised option for adults with steatohepatitis and advanced fibrosis under specialist care. It causes weight gain, fluid retention and an increased fracture risk, and is contraindicated in heart failure and in anyone with a history of bladder cancer, which is why those were checked. Sulfonylureas, DPP-4 inhibitors, basal insulin and acarbose all lower glucose without any demonstrated benefit on liver inflammation or fibrosis. Weight loss remains the foundation of treatment alongside any drug.

A. Pyoderma gangrenosum

Pyoderma gangrenosum is a neutrophilic dermatosis classically associated with IBD, rheumatoid arthritis and haematological malignancy, presenting as a rapidly expanding painful ulcer with a violaceous undermined border. Treatment is potent topical or intralesional corticosteroids for localised disease and systemic immunosuppression (oral steroids, ciclosporin or biologics) for severe disease; surgical debridement causes pathergy and is contraindicated.

D. Full-thickness rectal prolapse

A circumferential protrusion of several centimetres with concentric rings of mucosa is a full-thickness (complete) rectal prolapse, in which the whole rectal wall intussuscepts through the anus. It is most common in older women with weak pelvic floors and a long history of straining, and mucus, bleeding and faecal incontinence from the stretched sphincter are typical. Prolapsed haemorrhoids are the nearest alternative but form separate lobulated cushions with radial grooves between them rather than concentric rings, and a mucosal prolapse involves mucosa alone, producing radial folds and rarely more than 2 to 3 cm of tissue. A polyp or a polypoid carcinoma prolapses as a discrete mass on a stalk rather than a symmetrical cylinder of bowel.

D. Mu-opioid receptor activation

Opioids cause constipation primarily through activation of mu-opioid receptors on enteric neurones of the myenteric and submucosal plexuses, which inhibits acetylcholine release, reduces propulsive peristalsis, increases non-propulsive segmental contractions, and raises anal sphincter tone. Co-prescription of a stimulant laxative (such as senna) from initiation is recommended because tolerance to this adverse effect does not develop.