Pancreas-pag Asa.docx

1. A 40-year old fat female who denies history of alcohol abuse was admitted because of severe abdominal pain radiating to the back. Laboratory results show an increase in the serum amylase and lipase. Which is the most probable diagnosis a. GERD b. Acute pancreatitis c. Chronic cholecystitis d. Acute appendicitis 2. Which of the following are initiated by injuries that lead to auto digestion of pancreas by its own enzyme? a. acute pancreatitis b. chronic pancreatitis c. all of the above d. none of the above Ans: C 3. Which cells secrete Trypsin inhibitors, including serine protease Kazal Type 1 (SPINK 1), which further limit intrapancreatic trypsin activity? a. Ductal cells b. Mucus cells c. Acinar cells d. A and C e. B and C Ans. D 4. Most digestive enzymes are synthesized as inactive proenzymes (zymogens), which are packaged within what? a. Acinar granules b. Mucus granules c. Secretory granules d. Ductal granules Ans: C 5. Most pro enzymes are activated by _______, which itself is activated by duodenal enteropeptidase (enterokinase) in the small bowel. a. Amylase b. Lipase c. Trypsin d. Serine protease Ans: C 6. Which of the following are initiated by injuries that lead to auto digestion of pancreas by its own enzyme? a. acute pancreatitis b. chronic pancreatitis c. all of the above

d. none of the above Ans: C 7. An autopsy study of pancreatitis is performed. In some cases, there is evidence for death from acute pancreatitis in which there are changes of chronic pancreatitis. Microscopic examination shows acute inflammation, chronic inflammation with fibrosis and acinar atrophy, and inspissated protein plugs in small, obstructed pancreatic ducts. Some of the protein plugs show calcification. What is the most likely risk factor for pancreatitis in these cases? a. Alcohol abuse b. Biliary tract lithiasis c. Cystic fibrosis d. Drug toxicity e. Trauma f. Viral infection Ans: (A) Ratio: Although the exact mechanism for development of pancreatitis with alcoholism is unknown, the production of a protein-rich pancreatic secretion that forms inspissated plugs that cause ductal obstruction is observed in many cases. Patients with a history of alcohol abuse may have bouts of chronic pancreatitis that go unnoticed, only to have a superimposed case of clinically apparent acute pancreatitis. Alcohol, drugs, traumatic injury, and viral agents may have a direct injurious effect on pancreatic exocrine acinar cells. Large duct obstruction is a feature of pancreatitis caused by gallstones, typically a stone that lodges in the region of the ampulla of Vater. Cystic fibrosis decreases bicarbonate excretion and promotes protein plugging of ducts, but the appearance is more of a chronic pancreatitis, and other features of cystic fibrosis may be lacking in these patients 8. Patient Benjamin, 24, a known alcoholic in Barangay 4-A, San Pedro St., Davao City, came in with a chief complaint of abdominal pain which is constant and intense, felt in the upper back and left shoulder. What enzyme is responsible for converting prekallikrein to its activated form? a. Lipase b. Amylase c. Trypsin d. Pepsin Ans: C 9. A 52-year-old man has had severe abdominal pain for the past 2 days. Physical examination shows boardlike rigidity of the abdominal muscles, making further examination difficult. There is no observable abdominal distention. The disease process shows acute hemorrhagic pancreatitis with foci of chalky white fat necrosis. Which of the following is the mechanism most likely to produce this appearance? a. CFTR gene mutation b. Coxsackievirus B infection c. Dysregulation of trypsinogen inactivation

d. Marked hypertriglyceridemia e. Vasculitis with acute ischemia f. Blunt force trauma to the abdomen Ans: D 10. A 38-year-old woman with a long history of gallbladder disease has a sudden onset of severe midabdominal pain. On physical examination, she has marked abdominal tenderness, particularly in the upper abdomen, and bowel sounds are reduced. She is given intravenous fluids and nasogastric suction and recovers gradually. Which of the following serum laboratory tests is most useful for diagnosis of her disease process? a. Alanine aminotransferase b. Ammonia c. Bicarbonate d. Bilirubin e. Glucose f. Amylase Ans: F 11. A leaky microvasculature develops interstitial edema because of “danger” signals from adipocyte death that locally stimulate periacinar myofibroblasts and leukocytes to release pro-inflammatory cytokines and other inflammatory mediators. Which parasites usually cause this condition? a. Ascaris lumbricoides b. Clonorchis sinensis c. Paragonimus westermani d. A and B e. All of the above Ans: D 12. A 35-year-old man has a 1-year history of bouts of dull abdominal pain. Over the next 5 years he also develops steatorrhea and mild glucose intolerance. He does not develop jaundice. An abdominal CT scan shows specks of calcification in the midabdomen, particularly near the duodenum. One of his sisters has a similar clinical picture, but both parents are unaffected. Loss of inhibition of which of the following is the most likely cause for the disease seen in these persons? a. Amylase b. Complement c. Lipase d. Transforming growth factor beta (TGF-β) e. Trypsin Ans: E 13. Which of the following is not true about laboratory findings in acute pancreatitis? a. Serum amylase is specific for acute pancreatitis

b. c. d. e.

Lipase levels are clinically useful. Hypocalcemia Hyperglycemia Decreased fecal elastase is specific for pancreatic exocrine dysfunction.

Ans: A 14. How does calcium affects the regulation of trypsin activation? a. If calcium levels are low, trypsin tends to cleave and inactivate itself. b. If calcium levels are high, autoinhibition is abrogated. c. If calcium levels are high, activation of trypsinogen by trypsin is favored. d. Both A and B e. Both A and C f. ALL OF THE ABOVE ans: f. All of the above Page. 886 15. Which of the following has a role in regulatory trypsin regulation? a. Magnesium b. Calcium c. Iron d. Sodium Ans: B. CALCIUM. Ratio: When Ca2+ levels are low, trypsin tends to cleave and inactivate itself but when Ca2+ levels are high, autoinhibition is abrogated, and activation of trypsinogen to trypsin is favored. pp. 886 16. Which of the following choices contribute to the destruction of pancreatic tissue and acute inflammatory reaction? a. Trypsin activates phospholipase then degrade fat cells b. Trypsin activates proelastase then degrade elastic fibers of blood vessels c. Trypsin plays a role in activating clotting and complement system d. All of the above Ans: D. All are true. Ratio: The resulting inflammation and small vessel thromboses damage acinar cells, further amplifying intrapancreatic activation of digestive enzymes. Pg 884-885 17. The following are recognized triggers of acute pancreatitis. a. Hyperparathyroidism b. Mumps c. Both d. Neither Ans: C. Both Pg 886

Ratio: metabolic disorders like metabolic disorders (such as hyperparathyroidism) and Infections (ei. Mumps) are proven or suspected triggers of acute pancreatitis. 18. A gene whose function is to degrade trypsin thus protecting the pancrease from trypin-related injury. a. CTRC b. PRSS1 c. CPA1 d. CFTR Ans: A. CTRC Ratio: Table 19-2 pg 886 19. A gene whose function relates with zymogen activation. a. CPA1 b. CFTR c. PRSS1 d. CASR Ans: A. CPA1 Ratio: Table 19-2 pg 886 20. Basic alterations in acute pancreatitis, except: a. Microvascular leakage and edema b. Fat necrosis c. Acute inflammation d. Thrombosis e. Interstitial haemorrhage Ans: D. Thrombosis Ratio: Basic alterations are: microvascular leakage, fat necrosis, acute inflammation, destruction of pancrewtic parenchyma, and destruction of blood vessels and interstitial haemorrhage 21. Patient A who is a 29 year old man experienced intense abdominal pain sought medical attention and was given the partial diagnosis of acute pancreatitis. Upon microscopic investigation, the pancreas showed which characteristics that would verify the diagnosis of the physician? a. Fat necrosis b. Microvascular leakage c. Both answers are correct d. None is correct Ans: C Rationale: page 887; orange box: morphology Basic alterations are: microvascular leakage, fat necrosis, acute inflammation, destruction of pancrewtic parenchyma, and destruction of blood vessels and interstitial haemorrhage

22. Patient AE, a male prostitute from Catalunan Grande, was confined at the hospital for acute pancreatitis. What is the key management for his condition? a. Sexual abstinence b. Avoid strenuous activities c. Total restriction of oral intake d. Avoid the use of recreation drugs Ans: C. Rationale: page 887; clinical features 23. Aristotle Enojambre, a 39-year old chronic alcoholic was brought to the emergency room presenting with 12 hours of severe abdominal pain and fever. The pain radiates to the back and is associated with an urge to vomit. Physical examination reveals tenderness in the epigastrium as well as tenderness in the right upper quadrant. A quick laboratory test immediately revealed which analytes to be greatly elevated in this patient. a. Bilirubin b. Amylase c. Lipase d. Calcium Answer: B. Amylase. Ratio: Laboratory findings in acute pancreatitis include marked elevation of serum amylase levels during the first 24 hours, followed by a rising serum lipase level by 72 to 96 hours after the beginning of the attack. Page 887 24. It is a form of chronic pancreatitis that is associated with the presence of IgG4-secreting plasma cells in the pancreas a. Interstitial Pancreatitis b. Autoimmune Pancreatitis c. Hereditary Pancreatitis d. Necrotizing Pancreatitis Answer: B (Rationale: pp. 888) 25. What characteristics are observed in alcoholic chronic pancreatitis? a. Ductal dilatation b. Ductal constriction c. Ductal concretions d. Both A and C e. Both B and C Answer: D (Rationale: pp. 888-889)

26. A 63-year-old man who had worsening congestive heart failure with cardiac dysrhythmias for the past year of his life died of pneumonia. At autopsy, his pancreas is grossly small and densely fibrotic. Microscopic examination shows extensive atrophy of the acini with residual chronic inflammation, fibrosis, and inspissated protein plugs in small, obstructed pancreatic ducts. Some of the protein plugs show calcification. The islets of Langerhans appear normal. The heart weighs 500 g, and all four chambers are dilated. Which of the following conditions is most likely to account for his findings? a. αl-Antitrypsin deficiency b. Blunt trauma to the abdomen c. Cholelithiasis d. Chronic alcoholism e. Cystic fibrosis f. Hypercholesterolemia Answer: D (Rationale: pp. 888-889) Rationale: This patient has chronic pancreatitis. Alcohol promotes intracellular proenzyme activation that leads to acinar cell injury. Although the exact mechanism for development of pancreatitis with alcoholism is unknown, the production of a protein-rich pancreatic secretion that forms inspissated plugs that cause ductal obstruction is observed in many cases. Ductal obstruction predisposes to acinar injury, and the ongoing or repeated injury leads to chronic pancreatitis. Patients with a history of alcohol abuse may have bouts of chronic pancreatitis that go unnoticed, only to have a superimposed case of clinically apparent acute pancreatitis. Alcohol, drugs, traumatic injury, and viral agents may have a direct injurious effect on pancreatic exocrine acinar cells. A dilated cardiomyopathy also can occur in chronic alcoholism, as in this case. A deficiency of α1-antitrypsin can produce liver disease with chronic hepatitis or cirrhosis, or both. Blunt abdominal trauma can produce hemorrhage, sometimes with a component of acute pancreatitis. Cystic fibrosis decreases bicarbonate excretion and promotes protein plugging of ducts, but the appearance is more of a subclinical chronic pancreatitis, with fat and fat-soluble vitamin malabsorption, and depending upon the CFTR mutation, other features of cystic fibrosis may be lacking in these patients. Hypercholesterolemia (typically at least 1000 mg/dL or more) can cause acute pancreatitis, as can cholelithiasis. 27. Pancreatic stellate cells belong to what type of cell? a. Fibroblast b. Myofibroblast c. Monocyte/Macrophage d. None of the Above Answer: B (Rationale: ppp. 888) 28. The following characterized chronic pancreatitis, except a. Variable dilation of pancreatic ducts b. Fibrosis

c. Epithelial metaplasia and granulation tissue d. Atrophy and dropout of acini Answer: C (Rationale: pp. 888) 29. A 46-year old woman has severe abdominal pain for 2 days. On PE, she has marked epigastric pain, and bowel sounds are reduced. Laboratory studies show an elevated serum lipase. With supportive care, her acute condition subsides within 7 days. Which of the ff complications is most likely to occur in this patient? a. Gastric Ulceration b. Pseudocyst formation c. Ketoacidosis d. Hyperosmolar coma ANSWER: B. PSEUDOCYST FORMATION 30. Which of the following type of cystic neoplasms is/are entirely benign? a. Intraductal papillary mucinous b. Mucinous Cystic c. Serous cystic d. Solid-Pseudopapillary Ans: C Ratio: p.890. Serous Cystic neoplasms are entirely benign, whereas others such as intraductal papillary mucinous neoplasm and mucinous cystic neoplasms are precancerous. Solidpseudopapillary neoplasms are large, well circumscribed malignant type of neoplasm. 31. A type of pancreatic cysts that can be a precursor to invasive carcinomas, located in the body and tail with a radiographic feature of one or few cysts; thick or irregular walls. a. Serous cystadenoma b. Papillary cystic neoplasm c. Mucinous cystadenoma d. Pseudocyst Ans: C 32. An 11-year-old boy has experienced multiple bouts of severe abdominal pain for the past 6 years, but no other medical problems. His father and grandfather have been similarly affected. On examination during the last episode, bowel sounds were absent, and he exhibited marked diffuse abdominal pain with abdominal wall rigidity. A radiograph of the abdomen showed dilated loops of bowel with air-fluid levels. Laboratory studies showed serum amylase of 3320 U/L. This boy is most likely to have an inherited mutation involving which of the following genes? a. CFTR b. SMAD4 c. K-RAS

d. PRSS1 e. SPINK1 ANSWER: (D) Ratio: This boy has evidence for recurrent pancreatitis, marked by severe abdominal pain, paralytic ileus, and hyperamylasemia. An onset of pancreatitis in children suggests a genetic basis, and the history of an involved parent and grandparent suggests an autosomal dominant mode of transmission. The PRSS1 gene encodes for cationic trypsinogen, which, when mutated, leads to resistance of trypsin to inactivation. The SPINK1 gene encodes for a trypsin inhibitor, and mutation can lead to pancreatitis, but the inheritance is autosomal recessive. A mutation in the CFTR gene can lead to cystic fibrosis, but there should be pulmonary problems by age 11, and bouts of pancreatitis are usually not severe. K- RAS (an oncogene) andSMAD4 (a tumor-suppressor gene) are involved with development of pancreatic adenocarcinoma 33. Which of the following is the most frequently altered oncogene in pancreatic cancer? a. KRAS b. CDKN2A c. SMAD4 d. TP53 Ans: A 34. These are large, well circumscribed malignant neoplasm that have solid cystic components filled with hemorrhagic debris. a. Solid-pseudopapillary neoplasm b. mucinous cystic neoplasm c. serous cystic neoplasm d. IPMNs Ans: A 35. A 68-year-old man notes dull but constant abdominal pain accompanied by nausea with vomiting for the past 8 months. On physical examination he has tenderness to palpation of the upper abdomen. Abdominal CT imaging shows a 2-cm circumscribed mass in the body of the pancreas. Pancreatectomy is performed and microscopic examination of this mass shows tall, columnar, mucinous epithelial cells lining papillary excrescences within the main pancreatic duct. There is minimal atypia and no invasion. What is the most likely future course for this man? a. Additional gastrointestinal neoplasms b. Local recurrence c. Development of extraabdominal malignancies d. Complete remission e. Pseudocyst formation Ans. D Ratio: He has an intraductal papillary mucinous neoplasm (IPMN) of the pancreas. If they are discovered early and when small, they can be noninvasive and curable with surgery, and without

recurrence. Over time, they may progress to contain more severe dysplasia and give rise to adenocarcinoma. They are not likely to be part of a syndrome with development of additional neoplasms. If the pancreas is resected, there is nothing left to form a pseudocyst. 36. The presence of poorly to moderately differentiated glandular malignancy in the pancreas disposed in a desmoplastic stroma merits a diagnosis of: a. serous Adenocarcinoma b. Mucinous cystic neoplasm c. Pncreatic Adenocarcinoma d. Solid pseudopapillary tumor Ans: C 37. The following are molecular alterations in invasive pancreatic Adenocarcinoma except: a. TP53 b. CFTR c. KRAS d. CDKN2A Ans: B 38. What is the leading preventable of pancreatic cancer? a. cigarette smoking b. High fat diet c. Chronic alcoholism d. H. pylori Ans: A 39. Which of the following is mostly associated with obstructive jaundice? a. Carcinoma of the head of the pancreas b. Carcinoma of the tail of the pancreas c. Carcinoma of the body of the pancreas d. All of the above Ans: A 40. Which among the carcinomas are virtually benign? a. Pancreatic pseudocyst b. Pancreatic mucinous cystic neoplasm c. Intraductal papillary mucinous neoplasm d. Serous cystic neoplasm Ans: D

41. Which of the following statement is true? a. Carcinoma arising from the blood and lymphatic channels of the pancreas are usually asymptomatic and follow a slow course of progression b. Carcinoma arising from the blood and lymphatic channels of the pancreas remains asymptomatic because they don’t affect the biliary tract c. Carcinoma arising from the blood and lymphatic channels of the pancreas are usually not a neuroendocrine type of cancer cells hence do not show serum markers. d. Carcinoma arising from the blood and lymphatic channels of the pancreas are of the benign type. Ans: B 42. A clinical study of patients with acute abdomen is performed. Those patients with elevated serum lipase are identified. A decrease in which of the following analytes is most likely to predict a worse prognosis? a. Albumin b. Bilirubin c. Calcium d. Fibrinogen e. Haptoglobin Answer: C 43. Acute pancreatitis is marked by release of enzymes that produce chalky areas of fat necrosis, with precipitation of calcium that lowers serum calcium. The worse the inflammation, the lower the calcium level. Hypoalbuminemia is more likely to occur as a complication of chronic pancreatitis with malabsorption. Hyperbilirubinemia can occur in cases of gallstone-induced pancreatitis, but the level of bilirubin does not give an indication of the severity of pancreatitis. Fibrinogen is an acute phase reactant that increases with inflammation, but does not correlate well with location or extent of inflammation. The serum haptoglobin decreases with hemolysis. According to Courvoisier’s law, a pancreatic cancer located in the head of the pancreas would characteristically produce… a. Migratory thrombophlebitis b. Obstructive jaundice and a dilated gallbladder c. Obstructive jaundice and a nonpalpable gallbladder d. Steatorrhea and a nontender gallbladder e. Steatorrhea and a tender gallbladder Answer: B Ratio: Pp. 894, Robbins. Morphology. 3rd part 44. Most carcinomas of the head of the pancreas obstruct the distal common bile duct. Consequence is marked dilatation of the biliary tree. Pancreatoblastoma is a rare neoplasm characterized by the ff.: a. Primarily occur in adult 30-50 years old b. Histologic appearance consist of squamous islands admixed with acinar cells c. A benign neoplasm

d. none of the above Answer: B Ratio: Pp. 895. Robbins. 45. A 16-year-old boy incurs a gunshot wound to the abdomen in a drive-by shooting. At exploratory laparotomy, the surgeon finds a perforated portion of jejunum. She resects this portion and palpates a mass in the jejunal submucosa. Sectioning of this lesion reveals that it is a 1.5-cm diameter circumscribed, solid, tan mass. The mass is sent for frozen section. What is the pathologist most likely to see under her microscope? a. Adenocarcinoma b. Adrenal medulla c. Gastric mucosa d. Non-Hodgkin lymphoma e. Pancreatic acini Answer: E Ratio:This incidental finding is consistent with ectopic pancreas, which can be found in the bowel in 2% of individuals. It may be found within a Meckel diverticulum, although in this case no diverticulum was found, and such a diverticulum is found in the ileum as a vitelline duct remnant. Adenocarcinoma is unlikely in a boy in his teens, and adenocarcinoma of the small intestine is rare. Adrenal cortical rests may be found in the pelvis, but usually not bowel. Ectopic gastric mucosa is most often found within a Meckel diverticulum. Non-Hodgkin lymphomas of the bowel produce larger masses and are usually seen in older individuals. 46. The pancreas usually arises from the? a. Fusion of the dorsal and ventral outpouchings of the foregut b. Dorsal outpouching of the foregut c. Ventral outpouching of the foregut d. None of the above Answer: A Ratio: pp 883 47. It is the most common congenital anomaly of the pancreas and has an incidence of? a. 2-9% b. 5-10% c. 3-10% d. 4-8% Answer: C Ratio: pp 883 48. Pancreatic divisum predisposes a person to? a. Acute Pancreatitis b. Full-Blown pancreatitis c. Chronic Pancreatitis d. All of the above

Answer: C Ratio: pp 883 49. In an annular pancreas which structures does it encircles? a. First part of the duodenum b. Second part of the duodenum c. Third part of the duodenum d. Jejunum Answer: B Ratio: pp 883 50. Are the most common sites of ectopic pancreas a. Stomach and duodenum b. Jejunum and Meckel diverticula c. Stomach and Ileum d. Duodenum and jejunum Answer: A Ratio: pp 883-884 51. Some cases of agenesia of the pancreas results from the germline mutation of which gene? a. PD3 b. PDX3 c. PD1 d. PDX1 Answer: D Ration: Pp 884

52. It is characterized by fibrosis,loss of parenchyma, loss of exocrine and endocrine functioning of the pancreas and has a high risk of developing? a. Pseudocyst b. Cyst c. Pancreatic CA d. Pancreatoblastoma Answer: A Ratio: pp 889 53. What type of neoplasms are those that commonly arise from the tail of the pancreas in women? a. IPMN b. Mucinous Cystic Neoplasms c. Serous Cystic Neoplasms d. Solid-Pseudopapillary neoplasms Answer: B Ratio: Pp 890-891 54. It is a precursor to invasive carcinoma

a. Mucinous Cystic Neoplasms b. Serous Cystic Neoplasms c. Both d. Neither Answer: A Ratio: Pp 890-891 55. Calcium has a key role in regulating trypsin activity. It does this when? a. High Calcium = Low Trypsin Synthesis b. High Calcium = High Trypsin Synthesis c. High Calcium = Decrease secretion of digestive enzymes d. High Calcium = Trypsin cleaves itself and activates itself Answer: B Ratio: Pp 886