MCQ bank · 11 questions · free
Haematology, transfusion & spleen MCQs with answers
11 single-best-answer questions on HIT, TTP, anticoagulant reversal, transfusion and splenectomy. Try each one, then open the answer to see the explanation, why the other options are wrong, and the guideline or trial behind it.
Seven days after starting heparin, a postoperative patient’s platelet count has fallen from 260 to 90 and she has a new DVT. What is the management?
- Start warfarin alone immediately
- Switch to LMWH
- Suspect heparin-induced thrombocytopenia: stop all heparin (including flushes), test for HIT antibodies, and start a non-heparin anticoagulant (such as argatroban, fondaparinux or a DOAC)
- Continue heparin and transfuse platelets
- Stop anticoagulation completely
Show the answer and explanation
Answer: C. Suspect heparin-induced thrombocytopenia: stop all heparin (including flushes), test for HIT antibodies, and start a non-heparin anticoagulant (such as argatroban, fondaparinux or a DOAC). HIT is an immune reaction causing a fall in platelets 5–10 days after heparin and, paradoxically, thrombosis. The 4T score estimates probability. Low-molecular-weight heparin cross-reacts. Warfarin alone can cause venous limb gangrene early on, and platelet transfusion is avoided.
Why not the others? HIT causes clots, not bleeding.
References
A 28-year-old has bruising, confusion, fever, a platelet count of 12, anaemia with schistocytes on the blood film, and a raised LDH. What is the urgent treatment?
- Suspected thrombotic thrombocytopenic purpura: urgent plasma exchange (with steroids and caplacizumab), after sending ADAMTS13 activity
- Heparin
- Observation
- Platelet transfusion first
- Splenectomy
Show the answer and explanation
Answer: A. Suspected thrombotic thrombocytopenic purpura: urgent plasma exchange (with steroids and caplacizumab), after sending ADAMTS13 activity. TTP is caused by severe deficiency of ADAMTS13, leading to microthrombi. Untreated, it is usually fatal. Plasma exchange replaces the enzyme and removes antibodies. Platelet transfusion may worsen thrombosis and is avoided unless there is life-threatening bleeding.
Why not the others? Microangiopathic haemolysis with low platelets must prompt urgent haematology input.
References
A 35-year-old with chronic immune thrombocytopenia has persistent low platelets and bleeding despite steroids and second-line drugs. Splenectomy is planned. Which statement is correct?
- Vaccines are not needed after splenectomy
- Only open surgery is possible
- Splenectomy is never used in ITP
- Laparoscopic splenectomy is effective in many patients; give vaccinations at least 2 weeks before elective surgery and look for accessory spleens
- Platelets must be normal before any surgery
Show the answer and explanation
Answer: D. Laparoscopic splenectomy is effective in many patients; give vaccinations at least 2 weeks before elective surgery and look for accessory spleens. Splenectomy produces durable responses in about two-thirds of patients with ITP. Elective patients are vaccinated beforehand. Missed accessory spleens are a cause of relapse. Platelet transfusion is given only if needed after the splenic artery is clamped.
Why not the others? Thrombopoietin receptor agonists and rituximab are alternatives to surgery.
References
A 12-year-old with hereditary spherocytosis has transfusion-dependent anaemia and symptomatic gallstones. What surgery is appropriate?
- Liver resection
- No surgery until adulthood
- Cholecystectomy alone and continue transfusions
- Bone marrow transplant
- Splenectomy (often partial or total, laparoscopic) combined with cholecystectomy, after vaccination
Show the answer and explanation
Answer: E. Splenectomy (often partial or total, laparoscopic) combined with cholecystectomy, after vaccination. In hereditary spherocytosis, the spleen destroys the abnormal red cells. Splenectomy reduces haemolysis in moderate to severe disease, and pigment gallstones from haemolysis are removed at the same operation. Delaying splenectomy until after about age 6 reduces overwhelming infection risk.
Why not the others? Leaving the spleen in place lets haemolysis and stone formation continue.
References
A patient with type 1 von Willebrand disease needs an elective cholecystectomy. What is the plan?
- Cancel all surgery permanently
- Plan with haematology: desmopressin (if a trial shows response) or von Willebrand factor concentrate around surgery, with tranexamic acid
- No preparation; proceed as normal
- Vitamin K
- Platelet transfusion only
Show the answer and explanation
Answer: B. Plan with haematology: desmopressin (if a trial shows response) or von Willebrand factor concentrate around surgery, with tranexamic acid. Von Willebrand disease is the commonest inherited bleeding disorder. Desmopressin releases stored VWF in type 1 disease. Factor concentrate is used for non-responders, other types or major surgery. Tranexamic acid helps, especially in mucosal bleeding.
Why not the others? Desmopressin can cause hyponatraemia, so fluid intake is restricted after doses.
References
A patient on warfarin with an INR of 5 has a large intracranial bleed. What is the immediate reversal?
- Oral vitamin K only
- Protamine
- Stop warfarin and wait for INR to fall
- Four-factor prothrombin complex concentrate plus intravenous vitamin K (5–10 mg)
- Fresh frozen plasma alone as first choice
Show the answer and explanation
Answer: D. Four-factor prothrombin complex concentrate plus intravenous vitamin K (5–10 mg). PCC reverses warfarin within minutes, much faster than plasma, with less volume. Intravenous vitamin K sustains the reversal as PCC wears off. Time to reversal is critical in intracranial haemorrhage.
Why not the others? Protamine reverses heparin, not warfarin.
References
A patient on dabigatran needs an emergency laparotomy for a perforated viscus. Which reversal agent is specific for dabigatran?
- Desmopressin
- Andexanet alfa
- Protamine
- Vitamin K
- Idarucizumab
Show the answer and explanation
Answer: E. Idarucizumab. Idarucizumab is a monoclonal antibody fragment that binds dabigatran and reverses it within minutes. Andexanet alfa reverses factor Xa inhibitors (apixaban, rivaroxaban). Dabigatran is also removed by dialysis.
Why not the others? Kidney function strongly affects dabigatran levels.
References
During an elective open AAA repair with expected large blood loss, which technique reduces the need for donor blood?
- Liberal transfusion to Hb 120
- Haemodilution with 10 litres of saline
- Avoiding tranexamic acid
- Routine fresh frozen plasma
- Intraoperative cell salvage
Show the answer and explanation
Answer: E. Intraoperative cell salvage. Cell salvage collects, washes and returns the patient’s own blood, reducing allogeneic transfusion in operations with expected blood loss over about 500 mL. It is part of patient blood management, along with treating anaemia beforehand and tranexamic acid.
Why not the others? Its use in cancer surgery or contaminated fields needs specific consideration (for example leucocyte filters).
References
How can transfusion be guided in a bleeding trauma patient in a well-equipped centre?
- Viscoelastic testing (TEG or ROTEM) to target specific coagulation defects, such as low fibrinogen
- Only by the platelet count taken the next day
- Fixed transfusion without any monitoring
- Clotting tests are not useful
- Only by haemoglobin
Show the answer and explanation
Answer: A. Viscoelastic testing (TEG or ROTEM) to target specific coagulation defects, such as low fibrinogen. Viscoelastic tests give rapid information about clot formation and strength, allowing targeted use of fibrinogen, plasma, platelets and antifibrinolytics. Fibrinogen is often the first factor to fall in major bleeding.
Why not the others? Standard laboratory clotting tests take longer and correlate poorly with bleeding.
References
A patient with sickle cell anaemia (HbSS) is scheduled for an elective laparoscopic cholecystectomy. What does the TAPS trial support?
- Preoperative transfusion to a haemoglobin of about 100 g/L to reduce perioperative complications such as acute chest syndrome
- Avoid oxygen during surgery
- Restrict fluids for 24 hours
- No preparation is needed
- Exchange transfusion for every minor operation
Show the answer and explanation
Answer: A. Preoperative transfusion to a haemoglobin of about 100 g/L to reduce perioperative complications such as acute chest syndrome. The TAPS trial showed that simple preoperative transfusion reduced perioperative complications, mainly acute chest syndrome, in HbSS patients having medium-risk surgery. Oxygen, warmth, hydration and good analgesia also prevent sickling crises.
Why not the others? Hypoxia, dehydration and cold trigger sickling.
References
CT in a 30-year-old woman who is planning a pregnancy shows a 1.5-cm splenic artery aneurysm. Why is treatment recommended despite its small size?
- Small aneurysms never rupture
- Splenectomy is mandatory
- Treatment is only for aneurysms over 5 cm in all patients
- Pregnancy reduces rupture risk
- Splenic artery aneurysms have a high risk of rupture in pregnancy, with high maternal and fetal mortality, so treatment (usually endovascular) is advised in women of childbearing age
Show the answer and explanation
Answer: E. Splenic artery aneurysms have a high risk of rupture in pregnancy, with high maternal and fetal mortality, so treatment (usually endovascular) is advised in women of childbearing age. Splenic artery aneurysm is the commonest visceral aneurysm. Most small aneurysms are observed, but treatment is recommended in women of childbearing age, symptomatic patients and pseudoaneurysms, because rupture in pregnancy is often catastrophic.
Why not the others? Endovascular embolisation or stenting is usually first-line.
References