Practice questions, exocrine pancreas/gallbladder
Practice
questions, exocrine pancreas/gallbladder
© Jun Wang, MD, PhD
1. Use this
case and this image for the next four questions. A 41-year-old woman
presents with worsening dull epigastric pain, nausea and vomiting for 2 days.
The pain is not related to activity, but start radiating to back in the last 4
hours. Her past medical history include chronic cholecystitis, hyperlipidemia,
chronic gastritis and reflux esophagitis. She denies alcohol or tobacco use.
Her vital signs are normal. Physical examination reveals slight sclera icterus,
central epigastric tenderness and decreased bowel sound. No rebound or guarding
is noted. Murphy sign is negative. Initial laboratory tests are within normal
range except a white blood cell count of 17 x 109/L (normal 4.5 –
10.5 x 109/L). EKG and abdominal plain X-ray exam is unremarkable.
What blood test is likely to confirm the diagnosis?
A. Bilirubin
B. CA19-9
C. Culture
D. Lipase
E. Troponin
2. A 41-year-old woman presents with worsening dull
epigastric pain, nausea and vomiting for 2 days. The pain is not related to
activity, but start radiating to back in the last 4 hours. Her past medical
history include chronic cholecystitis, hyperlipidemia, chronic gastritis and
reflux esophagitis. She denies alcohol or tobacco use. Her vital signs are
normal. Physical examination reveals slight sclera icterus, central epigastric
tenderness and decreased bowel sound. No rebound or guarding is noted. Murphy
sign is negative. Initial laboratory tests are within normal range except a
white blood cell count of 17 x 109/L (normal 4.5 – 10.5 x 109/L).
EKG and abdominal plain X-ray exam is unremarkable.
Additional tests reveal a lipase of 210 U/L (normal
0-160 U/L) and an amylase of 80 U/L (normal 25-85 U/L). What test is likely to
confirm the diagnosis?
A. Abdominal CT
B. Barium swallow
C. D-dimer
D. Mesentery angiography
E. Upper endoscopy
3. A 41-year-old woman presents with worsening dull
epigastric pain, nausea and vomiting for 2 days. The pain is not related to activity,
but start radiating to back in the last 4 hours. Her past medical history
include chronic cholecystitis, hyperlipidemia, chronic gastritis and reflux
esophagitis. She denies alcohol or tobacco use. Her vital signs are normal.
Physical examination reveals slight sclera icterus, central epigastric
tenderness and decreased bowel sound. No rebound or guarding is noted. Murphy
sign is negative. Initial laboratory tests are within normal range except a
white blood cell count of 17 x 109/L (normal 4.5 – 10.5 x 109/L).
EKG and abdominal plain X-ray exam is unremarkable. Additional tests reveal a
lipase of 210 U/L (normal 0-160 U/L) and an amylase of 80 U/L (normal 25-85
U/L). An image of abdominal CT is shown. What is the diagnosis?
(Image: By Hellerhoff, CC BY-SA 3.0,
https://commons.wikimedia.org/w/index.php?curid=27846842)
A. Acute pancreatitis
B. Chronic pancreatitis
C. Mucinous cystic neoplasm
D. Pancreatic adenocarcinoma
E. Serous cystadenoma
4. A 41-year-old woman presents with worsening dull epigastric
pain, nausea and vomiting for 2 days. The pain is not related to activity, but
start radiating to back in the last 4 hours. Her past medical history include
chronic cholecystitis, hyperlipidemia, chronic gastritis and reflux
esophagitis. She denies alcohol or tobacco use. Her vital signs are normal.
Physical examination reveals slight sclera icterus, central epigastric
tenderness and decreased bowel sound. No rebound or guarding is noted. Murphy
sign is negative. Initial laboratory tests are within normal range except a
white blood cell count of 17 x 109/L (normal 4.5 – 10.5 x 109/L).
EKG and abdominal plain X-ray exam is unremarkable. Additional tests reveal a
lipase of 210 U/L (normal 0-160 U/L) and an amylase of 80 U/L (normal 25-85
U/L). An image of abdominal CT is shown. What is most likely associated with
her condition?
(Image: By Hellerhoff, CC BY-SA 3.0,
https://commons.wikimedia.org/w/index.php?curid=27846842)
A. Alcohol usage
B. Helicobacter infection
C. Hyperlipidemia
D. Scorpion bite
E. Trypsinogen mutation
5. Use this
case for the next two questions. A 45-year-old man was found dead in his
apartment by his roommate. An empty alcohol bottle is found beside him. He has
a history of heavy alcohol use, but no other history is known. No trauma is
noted on his skin. All orifices are clean without blood. Internal examination
reveals a hard liver that is smaller than normal, and many hemorrhagic changes
are seen in various organs, including pancreas, stomach and kidneys.
Microscopically the liver has band of fibrotic tissue separating nodules of
hepatocytes, the pancreas has hemorrhagic and necrosis. Focal hemorrhage is
seen in stomach and small intestine and lungs. His gallbladder is unremarkable.
What is the most likely direct cause of death?
A. Acute pancreatitis
B. Alcohol intoxication
C. Hepatocellular carcinoma
D. Sepsis
E. Thrombotic thrombocytopenic purpura
6. A 45-year-old man was found dead in his apartment
by his roommate. An empty alcohol bottle is found beside him. He has a history
of heavy alcohol use, but no other history is known. No trauma is noted on his
skin. All orifices are clean without blood. Internal examination reveals a hard
liver that is smaller than normal, and many hemorrhagic changes are seen in
various organs, including pancreas, stomach and kidneys. Microscopically the
liver has band of fibrotic tissue separating nodules of hepatocytes, the
pancreas has hemorrhagic and necrosis. Focal hemorrhage is seen in stomach and
small intestine and lungs. His gallbladder is unremarkable. What is the most
important cause of these findings?
A. Activation of trypsinogen
B. ADAMTS13 mutation
C. Bacterial toxin
D. Liver failure
E. Obstruction of bile duct by stones
7. A 50-year-old woman presents with severe persistent
dull epigastric pain, nausea and vomiting for one day. She denies other
symptoms. She has a history of obesity, chronic cholecystitis and
cholelithiasis, reflux esophagitis and peptic ulcer. She does not smoke
cigarette or drink alcohol. Physical examination reveals epigastric tenderness
without rebound or guarding. No organomegaly is noted. Laboratory tests reveal
a white cell count of 15 x 109/L (normal 4.5 – 10.5 x 109/L),
lipase of 710 U/L (normal 0-160 U/L) and an amylase of 510 U/L (normal 25-85
U/L). Other lab tests results are within normal range. What is the next step of
management?
A. Abdominal CT
B. Blood culture and sensitivity test
C. Fluid replacement
D. Gastroscopy
E. Mesentery angiography
8. A 55-year-old man presents with vague epigastric
dull pain for a week. The pain is intermittent and is not associated wiht meals or
activity. He does not have nausea, vomiting, fever, chill, or diarrhea. He was
hospitalized 6 months ago for acute pancreatitis. He has a history of 6 cans of
beer per day for 30 years but quitted after his hospitalization. He has a 35
pack-year history of cigarette smoking. His family history is unremarkable.
Physical examination and routine laboratory tests are within normal range.
Abdominal CT exam reveals a 5 cm cystic mass at the central portion of his
pancreas. Core biopsy of the mass reveal predominately fibrous tissue without
epithelial lining. Scattered normal appearing acini and islets are seen. What
is the diagnosis?
A. Autoimmune pancreatitis
B. Congenital cyst
C. Mucinous cystic neoplasm
D. Pseudocyst
E. Serous cystadenoma
9. Use this
case for the next two questions. A 45-year-old man presents with
intermittent nausea, diarrhea with greasy foul smelling stools and epigastric
dull pain for 3 years. He had three episodes of acute pancreatitis at age 30,
33, and 40. His past medical history include reflux esophagitis, peptic ulcer
and chronic cholecystitis. He has a 30 pack-year history of cigarette smoking
and used to drink 6 cans of beer each day since age 22 until his episode of
pancreatitis. His family history is unremarkable. Physical examination reveals
no significant abnormalities except central upper abdomen tenderness.
Laboratory tests reveals a serum glucose of 225 mg/dL (normal 70-125 mg/dL),
lipase of 120 U/L (normal 0-160 U/L), and an amylase of 95 U/L (normal 25-85
U/L). IgG4, rheumatoid factor, ANA, and anti-smooth muscle antibody titer are
all within normal ranges. Quantitative fecal fat test reveals 12 g/day (normal
< 7g/day) fecal lipid. Abdominal CT reveals ductal dilation and foci of
calcification in pancreas. No discrete mass is noted. Other organs are
unremarkable. What is the diagnosis?
A. Acute pancreatitis
B. Autoimmune pancreatitis
C. Chronic pancreatitis
D. Pancreatic adenocarcinoma
E. Pseudocyst
10. A 45-year-old man presents with intermittent
nausea, diarrhea with greasy foul smelling stools and epigastric dull pain for
3 years. He had three episodes of acute pancreatitis at age 30, 33, and 40. His
past medical history include reflux esophagitis, peptic ulcer and chronic
cholecystitis. He has a 30 pack-year history of cigarette smoking and used to
drink 6 cans of beer each day since age 22 until his episode of pancreatitis.
His family history is unremarkable. Physical examination reveals no significant
abnormalities except central upper abdomen tenderness. Laboratory tests reveals
a serum glucose of 225 mg/dL (normal 70-125 mg/dL), lipase of 120 U/L (normal
0-160 U/L), and an amylase of 95 U/L (normal 25-85 U/L). IgG4, rheumatoid
factor, ANA, and anti-smooth muscle antibody titer are all within normal
ranges. Quantitative fecal fat test reveals 12 g/day (normal < 7g/day) fecal
lipid. Abdominal CT reveals ductal dilation and foci of calcification in
pancreas. No discrete mass is noted. Other organs are unremarkable. What is
likely to be seen if a biopsy of the pancreas is performed?
A. Cysts with fibrotic wall without epithelial lining
B. Diffuse lymphoplasmacytic infiltration with IgG4 positive
plasma cells
C. Irregular glands lined by atypical cells in a
fibrotic background
D. Microabscesses and ductal ulceration
E. Stroma fibrosis with acinar and islet atrophy
11. Use this
case for the next two questions. A 62-year-old man presents intermittent
nausea and worsening abdominal pain and jaundice for 3 weeks. The pain is
triggered by meals. He does not have other symptoms. He has chronic sclerosing
sialadenitis at age 52. He does not drink alcohol nor smoke cigarette. Physical
examination reveals diffuse abdominal tenderness and mild distention without
rebound or guarding. His sclera is icteric. Laboratory tests reveal an AST of
120 U/L (normal 10-40 U/L), ALT 87 U/L (normal 7-56 U/L), direct bilirubin of
1.1 mg/dl (normal < 0.2 mg/dl) and total bilirubin of 2.5 mg/dl (normal <
1.1 mg/dl). Other laboratory tests including CBC and renal functions are within
normal range. Image studies reveal mild dilatation of intrahepatic biliary
ducts. A 2.5 cm vague mass is seen at the pancreas head. Biopsy of the mass
reveals markedly lymphoplasmacytic infiltration with focal fibrosis. Per
immunohistochemistry, these are mixed population of CD3 positive cells and CD20
positive cells with either kappa or lambda expression. There are scattered
glandular structures. No cytological atypia is noted. What is most likely the
diagnosis?
A. Acute pancreatitis
B. Autoimmune pancreatitis
C. Chronic pancreatitis
D. Diffuse large B-cell lymphoma
E. Pancreatic adenocarcinoma
12. A 62-year-old man presents intermittent nausea and
worsening abdominal pain and jaundice for 3 weeks. The pain is triggered by
meals. He does not have other symptoms. He has chronic sclerosing sialadenitis
at age 52. He does not drink alcohol nor smoke cigarette. Physical examination
reveals diffuse abdominal tenderness and mild distention without rebound or
guarding. His sclera is icteric. Laboratory tests reveal an AST of 120 U/L
(normal 10-40 U/L), ALT 87 U/L (normal 7-56 U/L), direct bilirubin of 1.1 mg/dl
(normal < 0.2 mg/dl) and total bilirubin of 2.5 mg/dl (normal < 1.1
mg/dl). Other laboratory tests including CBC and renal functions are within
normal range. Image studies reveal mild dilatation of intrahepatic biliary
ducts. A 2.5 cm vague mass is seen at the pancreas head. Biopsy of the mass
reveals markedly lymphoplasmacytic infiltration with focal fibrosis. Per
immunohistochemistry, these are mixed population of CD3 positive cells and CD20
positive cells with either kappa or lambda expression. There are scattered
glandular structures. No cytological atypia is noted. What serum marker is
likely to be elevated?
A. CA19-9
B. CD20
C. CEA
D. IgG4
E. IgM
13. Use this
case for the next two questions. A 21-year-old man presents with nausea,
vomiting and severe persistent epigastric pain radiating to his back for 6
hours. His past medical including type 1 diabetes and acute pancreatitis since age 11 and 14, respectively. His past history is otherwise
unremarkable. He has a few paternal family members with pancreatitis, pancreas
cancers and diabetes. He does not smoke cigarette nor drink alcohol. Physical examination reveals epigastric tenderness, mild
abdomen distention, reduced bowel sound, but no rebound or guarding. Laboratory
tests reveal a white cell count of 18 x 109/L (normal 4.5 – 10.5 x
109/L), serum glucose of 250 mg/dL (normal 70-125 mg/dL) and lipase
of 560 U/L (normal 0-160 U/L). Serum IgG4, rheumatoid factor, ANA, and
anti-smooth muscle antibody titer are all within normal ranges. Image studies reveal enlarged pancreas without
discrete mass. What is most
likely causing these presentations?
A. Accelerated fat metabolism
B. Alcohol usage
C. Bile duct obstruction
D. PRSS1 mutation
E. Viral infection
14. A 21-year-old man presents with nausea, vomiting
and severe persistent epigastric pain radiating to his back for 6 hours. He
does not His past medical including type 1 diabetes and recurrent pancreatitis
since age 11 and 14, respectively. His past history is otherwise unremarkable.
He has a few paternal family members with pancreatitis, pancreas cancers and
diabetes. He does not smoke cigarette nor drink alcohol. Physical examination reveals epigastric tenderness, mild abdomen
distention, reduced bowel sound, but no rebound or guarding. Laboratory tests
reveal a white cell count of 18 x 109/L (normal 4.5 – 10.5 x 109/L),
serum glucose of 250 mg/dL (normal 70-125 mg/dL) and lipase of 560 U/L (normal
0-160 U/L). Serum IgG4, rheumatoid factor, ANA, and anti-smooth muscle antibody
titer are all within normal ranges. Image studies reveal enlarged pancreas without
discrete mass. What is most likely the diagnosis?
A. Autoimmune pancreatitis
B. Chronic pancreatitis
C. Diabetic ketoacidosis
D. Hereditary pancreatitis
E. Pancreatic cancer
15. Use this image
for this question. A 71-year-old woman presents with vague epigastric discomfort
for 3 months. She has a history of acute pancreatitis 20 years ago and ovarian
serous cystadenocarcinoma a year ago, that was treated with surgery and
chemotherapy. Other medical history include obesity, diabetes and reflux
esophagitis. Physical examination and laboratory tests reveal no significant
abnormalities. Abdominal CT reveals a 4.5 cm mass at the tail of her pancreas.
No other abnormalities are noted. An image of the biopsy is shown. What is the
diagnosis?
(Image: KGH assumed (based on copyright claims). [CC BY-SA
3.0 (http://creativecommons.org/licenses/by-sa/3.0/)])
A. Acinar cell carcinoma
B. Metastatic ovarian serous cystadenocarcinoma
C. Mucinous cystic neoplasm
D. Pancreatic pseudocyst
E. Serous cystadenoma
16. Use this image
and this case for the next two questions. A 49-year-old woman presents with
vague epigastric discomfort for 3 months. She has a history of endometriosis
and obesity. Physical examination and laboratory tests reveal no significant
abnormalities. Abdominal CT reveals a 3.5 cm mass at the body of her pancreas.
No other abnormalities are noted. An image of the biopsy is shown. Per
immunohistochemistry studies, the stromal cells underneath epithelium are
positive for estrogen receptor. What is the diagnosis?
(Image: Humpath [CC BY-SA 3.0
(https://creativecommons.org/licenses/by-sa/3.0)])
A. Endometriosis
B. Intraductal papillary mucinous neoplasm
C. Mucinous cystic neoplasm
D. Pancreatic congenital cyst
E. Serous cystadenoma
17. A 49-year-old woman presents with vague epigastric
discomfort for 3 months. She has a history of endometriosis and obesity.
Physical examination and laboratory tests reveal no significant abnormalities.
Abdominal CT reveals a 3.5 cm mass at the body of her pancreas. No other
abnormalities are noted. An image of the biopsy is shown. Per
immunohistochemistry studies, the stromal cells underneath epithelium are
positive for estrogen receptor.
The mass is resected. An image of a focus of it is
shown. What is the diagnosis?
(Image: KGH [CC BY-SA 3.0
(https://creativecommons.org/licenses/by-sa/3.0)])
A. Adenocarcinoma
B. Chronic pancreatitis
C. Intraductal papillary mucinous neoplasm
D. Mucinous cystic neoplasm
E. Serous cystadenoma
18. A 67-year-old man presents with mild to moderate
epigastric pain, jaundice and a 10 pound weight loss during the last 3 months.
His past medical history including hypertension, hyperlipidemia, and chronic cholecystitis.
Physical examination reveal vague epigastric tenderness and sclera icterus.
Laboratory test results are within normal range except elevated bilirubin
levels. Abdominal CT exam reveals a 2.5 cm mass at the head of his pancreas.
Dilated pancreatic ducts are noted. A biopsy of the mass reveals cystic lesion lined
by columnar cells with pale cytoplasm, forming finger-like projects toward the lumen.
No cytological atypia nor necrosis is noted. What is most likely the diagnosis?
A. Adenocarcinoma
B. Intraductal papillary mucinous neoplasm
C. Mucinous cystic neoplasm
D. Serous cystadenoma
E. Solid-pseudopapillary neoplasm
19. Use this image
and this case for the next two questions. A 34-year-old woman presents with
intermittent epigastric pain and nausea for 3 days. Her past medical history, physical
examination and laboratory tests are unremarkable. Sonographic exam reveal a
5.5 cm mass at the tail of her pancreas. An image of the biopsy is shown. What
genetic abnormality is likely to be associated with this lesion?
(Image: Nephron [CC BY-SA 3.0
(https://creativecommons.org/licenses/by-sa/3.0)])
A. Beta-catenin
B. PRSS1
C. SMAD4
D. STK11
E. VHL
20. A 34-year-old woman presents with intermittent epigastric
pain and nausea for 3 days. Her past medical history, physical examination and laboratory
tests are unremarkable. Sonographic exam reveal a 5.5 cm mass at the tail of
her pancreas. An image of the biopsy is shown. What is the diagnosis?
(Image: Nephron [CC BY-SA 3.0
(https://creativecommons.org/licenses/by-sa/3.0)])
A. Acinar cell carcinoma
B. Adenocarcinoma
C. Mucinous cystic neoplasm
D. Serous cystadenoma
E. Solid-pseudopapillary neoplasm
21. Use this image
and this case for the next two questions. A 76-year-old man presents with fatigue
and a 30 pound weight loss for the last 6 months. He denies other symptoms. His
past medical history include hypertension, obesity and type 2 diabetes. He has
a 55 pack-year history of cigarette smoking and drinks 2 glasses of wine each
day since age 30. Physical examination reveals slight sclera icterus. No other
abnormality is noted. Laboratory tests reveal a total bilirubin of 7 mg/dl
(normal 0.1-1.2 mg/dl), direct bilirubin 4.2 mg/dl (normal < 0.3 mg/dl), AST
of 55 IU/L (normal 5-31 IU/IU/L), ALT of 68 IU/L (normal 5-35 IU/L).
Sonographic examination reveals a 4.5 cm mass at the head of his pancreas. An
image of the biopsy is shown. What serum marker is likely to be elevated?
(Image KGH [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0/)])
A. AFP
B. Amylase
C. CA19-9
D. IgG4
E. Lipase
22. A 76-year-old man presents with fatigue and a 30
pound weight loss for the last 6 months. He denies other symptoms. His past
medical history include hypertension, obesity and type 2 diabetes. He has a 55 pack-year
history of cigarette smoking and drinks 2 glasses of wine each day since age
30. Physical examination reveals slight sclera icterus. No other abnormality is
noted. Laboratory tests reveal a total bilirubin of 7 mg/dl (normal 0.1-1.2
mg/dl), direct bilirubin 4.2 mg/dl (normal < 0.3 mg/dl), AST of 55 IU/L
(normal 5-31 IU/IU/L), ALT of 68 IU/L (normal 5-35 IU/L). Sonographic
examination reveals a 4.5 cm mass at the head of his pancreas. An image of the biopsy
is shown. What is the diagnosis?
(Image KGH [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0/)])
A. Acinar cell carcinoma
B. Adenocarcinoma
C. Mucinous cystic neoplasm
D. Serous cystadenoma
E. Solid-pseudopapillary neoplasm
23. Use this image
for this question. A 76-year-old man presents with epigastric pain and a 20-pound
weight loss for 2 months. His past medical history is unremarkable. Physical examination
reveals slightly distended abdomen with vague left upper quadrant tenderness. No
lymphadenopathy is noted. Routine laboratory tests results are within normal
ranges. Image studies reveal a 3 cm mass at the body of pancreas. An image of the
biopsy is shown. Per immunohistochemistry studies, these cells are positive for
trypsin, lipase and amylase, but negative for mucin and chromogranin. What is
the diagnosis?
(Image: Nephron [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)])
A. Acinar cell carcinoma
B. Adenocarcinoma
C. Islet cell tumor
D. Serous cystadenoma
E. Solid-pseudopapillary neoplasm
24. Use this image
and this case for the next two questions. A 45-year-old woman presents with
intermittent right upper abdomen pain for 2 years. She has a history of reflux
esophagitis, peptic ulcer and obesity. Physical examination reveals an
overweight woman with distended abdomen and vague tenderness at right upper
quadrant. Murphy sign is positive. Sonographic examination reveals slightly
enlarged gallbladder with thickened wall. A few stones are seen. Cholecystectomy
is performed and an image of the microscopic findings is shown. What is the
diagnosis?
(Image: Nephron [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)])
A. Acute cholecystitis
B. Adenocarcinoma
C. Chronic cholecystitis
D. Gangrenous cholecystitis
25. A 45-year-old woman presents with intermittent right
upper abdomen pain for 2 years. She has a history of reflux esophagitis, peptic
ulcer and obesity. Physical examination reveals an overweight woman with
distended abdomen and vague tenderness at right upper quadrant. Murphy sign is
positive. Sonographic examination reveals slightly enlarged gallbladder with
thickened wall. A few stones are seen. Cholecystectomy is performed and an image
of the microscopic findings is shown. This patient has an increased risk for
what disorder?
(Image: Nephron [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)])
A. Acute pancreatitis
B. Autoimmune pancreatitis
C. Chronic hepatitis
D. Pancreatic adenocarcinoma
E. Pancreatic mucinous cystic neoplasm
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