FRCPath OSPE Questions

30th May 2014

 Q1
A. Patient presents with steatorrhoea.
1. What is the differential diagnosis and what investigations
would you advise?
2. What is the gold standard pancreatic function test and how
is it performed?
B. Patient presents with diarrhoea and asthma-type symptoms.
1. What is the differential diagnosis and what investigation
would you advise?
2. What foods can interfere with the analysis of this test?
3. What is the platelet marker that has been shown to be of
value in the diagnosis of this condition?
 Q2
You are duty biochemist. What comments would you append to the following results? What
further tests would you request?

A. Amylase > 1500 IU/L on a GP patient complaining of abdo pain. What comment would you
make about the accompanying GFC graph?

B. Small Bowel Permeability and Absorption Test

% Lactulose excreted 0.136% < 0.9

% D Xylose excreted 16.90% 20.0 - 55.0
% L-Rhamnose excreted 5.10 % 6.7 - 21.0
Lactulose/Rhamnose ratio 0.027 < 0.05 Volume (0-5hr) 308mls

C. Small Bowel Permeability and Absorption Test

% Lactulose excreted 5.4% < 0.9
% D Xylose excreted 24.50% 20.0 - 55.0
% L-Rhamnose excreted 6.90 % 6.7 - 21.0
Lactulose/Rhamnose ratio 0.78 < 0.05 Volume (0-5hr) 152mls
Q2 A. GFC chromatogram
 Q3
A. What are the indications for the SeHCAT test,
how is it performed and how is it interpreted?

B. What is the youngest age a sweat test can be

performed on an infant? What is the preferred
biochemical measurement? How is it
interpreted?
 Q1 answers
A1. ? Pancreatic exocrine insufficiency – chronic pancreatitis – faecal elastase-1.
?Coeliac – serum anti-tissue transglutaminase antibody.
? Laxative abuse – screen?

A2. Secretin stimulation test:

• A collection tube is placed in the duodenum under fluoroscopic guidance.
• Overnight fast.
• Basal samples of fluid are collected from the tube.
• Synthetic cholecystokinin (CCK, formerly pancreozymin) and secretin administered
i.v.
• Duodenal fluid is continuously collected in 15 min aliquots for 1 h.
• A bicarbonate concentration < 80 mEq/L in all of the 4 aliquots represents exocrine
insufficiency.
• Lipase concentration in duodenal fluid increases nearly 3-fold from baseline after
CCK stimulation in healthy volunteers but is markedly reduced in patients with
chronic pancreatic disease.
 Q1 answers
B1. ?Carcinoid – suggest 24h (or random) urine
for 5HIAA.
B2. Chocolate, bananas, walnuts, pecans,
pineapple, kiwi fruit, avocados, tomatoes,
(cough medicines, alcohol, aspirin).
B3. Platelet serotonin.
 Q2 answers
A. Amylase > 3URL is suggestive of acute pancreatitis. Phone the GP or
out of hours service. Suggest check serum lipase and urine amylase.
GFC shows the presence of a high Mw amylase (to the left of the
albumin peak) suggestive of macroamylase. The amylase peak to the
right is normal Mw amylase. PEG precipitation would provide an
estimate of the true level of amylase in this patient.

B. SBPT suggestive of reduced absorptive surface of the gut ?Coeliac.

Request IgA anti-tissue transglutaminase antibody (TTG) and possibly
IgA anti-endomysial antibody (EMA).

C. SBPT suggestive of altered cell architecture.?Crohns. Suggest faecal

calprotectin, if positive suggest referral for colonoscopy.
 LACTULOSE PEG 400
L-RHAMNOSE
D-glucose D-xylose 51CREDTA

ATP

ADP
 Q3 answers
A. ?bile salt malabsorption (chronic diarrhoea).
- Oral administration of synthetic radioactive bile
acid 75selenohomocholyltaurine (75SeHCAT) and
perform whole body gamma counting to estimate
the basal activity 1 h after the dose. The gamma
count is measured again after 7 days.
- In normal patients >15% of the administered
dose is retained after 7 days.
B.
- 7 days (if term infant).
- Sweat chloride. If conductivity is measured
sweat chloride should also be measured.

• A sweat chloride concentration of > 60

mmol/L supports the diagnosis of CF.
• Chloride concentration of 40–60 mmol/L is
suggestive but not diagnostic of CF.
• A sweat chloride of < 40 mmol/L is normal and
there is a low probability of CF.