JCU MB4 Term 2 Week 4 (Gall Bladder and Pancreas)

1

38yo female, obese, colicky abdominal pain, gross specimen of gall bladder shown. What type of stones are present?

Gall bladder pure cholesterol


  Pure cholesterol

  Mixed cholesterol

  Pigment

  Calcium

  Triple phosphate

2

38yo female, obese, colicky abdominal pain, gross specimen of gall bladder shown. What type of stones are present?

Gall bladder mixed stones


  Pure cholesterol

  Mixed cholesterol

  Pigment

  Calcium

  Triple phosphate

3

A 45yo mildly obese woman, 1-week history of upper abdominal pain, fever, shaking chills and occasional vomiting. Physical examination shows severe right upper quadrant tenderness. Laboratory studies include serum bilirubin of 1.0 mg/dL, AST of 25 U/L, ALT of 35 U/L, alkaline phosphatase of 220 U/L (high), WBC of 14,000/┬ÁL and amylase of 95 U/L (normal). An ultrasound examination of the abdomen reveals a normal-appearing liver and bile duct and thickening of the wall of gallbladder. Most likely diagnosis?


  Acute cholecystitis

  Acute pancreatitis

  Carcinoma pancreas

  Carcinoma gall bladder

  Primary biliary cirrhosis


ALP likely elevated due to cholestasis

4

40yo black woman, indigestion, abdominal pain, gross specimen of gall bladder shown. What is the most likely associated disease?

Gall bladder pigment stones


  Chronic pancreatitis

  Diabetes mellitis

  Familial hypercholesterolaemia

  Hyperparathyroidism

  Sickle cell disease

5

69yo male, massive GI bleeding, jaundice, section of gross liver specimen shown. What is the likely pathogenesis?

Liver metastatic carcinoma


  Cholangiocarcinoma

  Hepatocellular carcinoma

  Metastatic carcinoma

  Liver abscesses

  Tubercuolosis


To distinguish between metastatic carcinoma and cholangiocarcinoma (both of which may result in multiple nodules), the history must be considered. Most cancers that metastasis to the liver are gastrointestinal; the GI bleeding is more consistent with this than cholangiocarcinoma.

6

38yo female, obese, abdominal colicky pain, gall bladder microscopy shown. What is the diagnosis?

Gall bladder cholecystitis


  Cholecystitis

  Cholesterosis

  Adenocarcinoma

  Choletlithiasis

  Primary biliary cirrhosis


Glandular tissue extending into the muscular layer is typical of chronic cholecystitis.

7

38yo female, abdominal colicky pain, gross specimen of gall bladder shown. What is the most likely metabolic abnormality?

Gall bladder pure cholesterol


  Decreased bilirubin conjugation

  Decreased serum albumin

  Increase bilirubin uptake

  Increased hepatic calcium secretion

  Increased hepatic cholesterol secretion

8

62yo female, abdominal pain and jaundice. Biopsy of gall bladder shown. What is the diagnosis?

Gall bladder adenocarcinoma


  Cholecystitis

  Cholesterosis

  Adenocarcinoma

  Aschoff-Rokitansky sinuses

  Primary biliary cirrhosis

9

38yo female, jaundice, gross specimen of gall bladdder shown. What is the pathogenesis?

Gall bladder pigment stones


  Excess bilirubin

  Low cholesterol

  Low bile salts

  Infection

  Cholestasis

10

34yo male, alcoholic, mild icterus and malaise for 6 months. Liver biopsy shown. What is the diagnosis?

Fatty liver


  Acute alcoholic hepatitis

  Chronic persistent hepatitis

  Hepatitis C infection

  Fatty liver

  Alcoholic cirrhosis

11

42yo male, alcoholic, recurrent fatigue. Liver biopsy shown. What is the diagnosis?

Liver chronic hepatitis


  Acute hepatitis

  Leukaemic infiltrate

  Chronic hepatitis

  Fulminant hepatitis

  Cirrhosis


Periportal inflammation can be seen, which is characteristic of chronic hepatitis. Acute hepatitis more typically shows parenchymal inflammation.

12

26yo female, medical student, day before pathology exam presents with mild scleral icterus. Physcial examination normal. Liver function tests: Protein total 7.9, albumin 4.8 g/L, AST 35 U/L, ALT 16 U/L, ALP 36 U/L, total bilirubin 4.9, direct 0.7 mg/dL. Icterus resolves week later after exams. What is the most likely diagnosis?


  Alcoholic hepatitis

  Primary biliary cirrhosis

  Gilbert syndrome

  Acute HAV infection

  Acetaminophen poisoning


All LFT's are normal but rise in unconjugated bilirubin. Frequent occurence in stressful situations in people with Gilbert syndrome.

13

Viral serology interpretation. HBsAg positive, HBcAg positive, anti-HBcAg IgM negative, anti-HBsAg Ig negative, HBeAg positive.


  Acute viral hepatitis

  Immunised against hepatitis B

  Chronic hepatitis B

  Healthy carrier

  Fulminant hepatitis B


HBe indicates currently replicating virus, indicating that this is not a 'carrier'.

14

1yo male, bilious vomiting. Mid duodenal narrowing. What is the diagnosis?


  Annular pancreas

  Duodenal polyp

  Pncreatic adenoma

  Pancreas divisum

  Congenital pyloric stenosis


Typically present in the first year, not pyloric stenosis because this would present much earlier.

15

65yo male, "positive Courvoisier's sign". What does this mean?


  Painful jaundice with purpuric spots

  Jaundice with high coloured urine

  Painful jaundice with itching

  Palpable gall bladder with jaundice

  Jaundice with abdominal pigmentation

16

65yo male, weight loss, pedal oedema. Pancreatic biopsy shown. Identify B.

Pancreatic carcinoma micro


  Malignant glands

  Pancreatic islets

  Fibrous tissue

  Inflammatory cells

  Benign glands


A - fibrous tissue

B - Malignant glands

C - Inflammatory cells

17

52yo female, multiple red-brown, tender subcutaneous nodules with 15kg wt loss since 3 months. Microscopy of nodules show inflammation, fat necrosis, no malignant cells. What is the diagnosis?

Migrating thrombophlebitis


  Acute pancreatitis

  Chronic pancreatitis

  Adenocarcinoma

  Pancreatic pseudocyst

  MEN1 syndrome


Migrating thrombophelbitis is shown.

18

65yo male, weight loss, pedal oedema. Pancreatic biopsy is shown. Identify B.

Pancreas biopsy dilated ducts


  Malignant glands

  Pacreatic islets

  Fibrous tissue

  Inflammatory cells

  Dilated ducts


Chronic pancreatitis - weight loss due to malabsorption.

19

38yo female episodic fainting, sweating, hunger and weight gain. Scan shows 1.5cm circumscribed round mass in pancreas. What is the diagnosis?

Pancreas round mass


  Adenocarcinoma

  Gastrinoma

  Glucagonoma

  Insulinoma

  Carcinoid tumour


Symptoms may be explained by hypoglycaemia. Insulin is an anabolic hormone, so hypersecretion is likely to result in weight gain.

20

65yo male, acromegaly, epigastric pain, malaena, hypercalcaemia, hyperlipidaemia, hyperacidity. What is the diganosis?


  Glucagonoma

  Insulinoma

  MEN1 syndrome

  Pancreatic carcinoid

  MEN2 syndrome


Acromegaly likely due pituitary tumour, hypercalcaemia can be attributed to a parathyroid hormone. Other symptoms due to functional pancreatic adenomas - the 3 P's of MEN1.

21

52yo female, severe multiple peptic ulcers in both deodenum and jejunum not responding to treatment. Pancreas shows 1.2cm rounded tumour. What is the diagnosis?

Multiple peptic ulcers


  Helicbacter pylori and peptic ulcer

  Insulinoma

  MEN2 syndrome

  Pancreatic carcinoid

  Gastrinoma


Typical of Zollinger-Ellison syndrome.

22

Which of the following is an uncommon risk factor for acute pancreatitis?


  Alcohol abuse

  Gall stones

  Hyperlipidaemia

  Genetic

  Hyperparathyroidism


Cystic fibrosis is one such example.

23

Mary, 58yo female, 6 month history of epigastric pain, weight loss, foul smelling diarrhoea. Lab results: amylase 56 U/L (30-110), lipase 460 U/L (30-300), Ca2+ 1.92 (2.1 - 2.55). What is the most likely diagnosis?


  Acute appendicitis

  Chronic cholecystitis

  Acute pancreatitis

  Chronic pancreatitis

  Ulcerative colitis

24

Which of the following findings is most likely to be encountered in the patient from question 24 (58yo female with 6mo history of epigastric pain, weight loss, foul smelling diarrhoea with elevated serum lipase).


  Alcoholic hepatitis

  Malaena

  Pernicious anaemia

  Steatorrhoea

  Hypoglycaemia

25

The patient from question 24 presents again after 3 years. Physical examination shows jaundice. A CT scan of the abdomen shows a large fluid-filled cyst in the lesser sac. What is the most likely diagnosis?


  Adenocarcinoma

  Carcinoid tumour

  True pancreatic cyst

  Abscess in pancreas

  Pancreatic pseudocyst

26

34yo male, alcoholic homosexual - icterus and fever for 6 months. Liver biopsy shown. What is the diagnosis?

Liver biopsy chronic hepatitis


  Acute hepatitis

  Chronic hepatitis

  Cirrhosis progressing to carcinoma

  Fulminant hepatitis

  Hepatitis progressing to cirrhosis

27

34yo male, icterus and fever. Livery biopsy shown. What is the diagnosis?

Liver biopsy acute hepatitis


  Acute hepatitis

  Chronic hepatitis

  Bridging necrosis

  Fulminant hepatitis

  Cirrhosis

28

56yo chronic alcoholic, 2 days of fever, abdomen distended, tender. Abdominal tap yielded cloudy yellow fluid with 98% neutrophils. Blood culture shows E. coli. Patient dies 3 days later. Gross specimen of liver shown. What is the most likely diagnosis?

Liver cirrohsis


  Alpha-1 antitrypsin deficiency

  HEV infection

  Hereditary haemochromatosis

  Primary sclerosing cholangitis

  Alcoholic cirrhosis

29

58yo male, alcoholic, distended abdomen and icterus. Liver biopsy shown. What is the diagnosis?


  Chronic active hepatitis

  Chronic persistent hepatitis

  Hepatocellular carcinoma

  Cirrhosis

  Chronic alcoholic hepatitis

30

Viral serology interpretation: HBsAg negative, anti-HBcAg Ig negative, anti-HBcAg IgM negative, anti-HBsAg Ig positive.


  Acute viral hepatitis

  Immunised against hepatitis B

  Past hepatitis B

  Hepatitis B carrier stage

  Fulminant hepatitis B

31

69yo female, chronic bronchitis. Died following chronic cardiac failure. Gross liver specimen shown. What is the likely diagnosis?

Nutmeg liver


  Alcohol hepatitis

  Dubin-Johnson syndrome

  Alcohol cirrhosis

  Nutmeg liver

  Metastatic deposits

32

Viral serology interpretation: HBsAg negative, anti-HBsAg Ig positive, anti-HBcAg Ig positive, anti-HBcAg IgM negative.


  Acute viral hepatitis B

  Immunised against hepatitis B

  Past hepatitis B

  Hepatitis B carrier stage

  Carrier state of hepatitis B

33

59yo male, alcoholic, presents with fatigue and anorexia. Normal liver function tests. Liver specimen. What is the likely diagnosis?

Fatty liver


  Dubin-Johnson syndrome

  Alcohol cirrhosis

  Alcoholic hepatitis

  Fatty liver

  Nutmeg liver

34

Shown is a histopathology specimen from lung biopsy of 61yo male chronic smoker. What is the most likely type of carcinoma?

Lung squamous cell carcinoma


  Small cell carcinoma

  Adenocarcinoma

  Metastatic deposits

  Squamous carcinoma

  Lung abscesses

35

The gross image of lung specimen from a 59yo male heavy smoker presented with high fever and shortness of breath. What is the likely type of pneumonia?

Bronchopneumonia


  Lobar pneumonia

  Interstitial pneumonia

  Bronchopneumonia

  Fungal pneumonia

  Carcinomatous pneumonia

36

46yo male on treatment for lymphoma presents with pallor, shortness of breath and mild jaundice. Image shows his blood film appearance. What is the most likely type of anaemia?

Haemolysis


  Anaemia of chronic disease

  Megaloblastic anaemia

  Haemolytic anaemia

  Aplastic anaemia

  Iron deficiency anaemia

37

12yo girl presents with two week history of fever and joint pain. The image shows her heart specimen. What feature of the disease is shown by the arrow?

Fibrinous pericarditis


  MI with pericarditis

  Bacterial endocarditis

  Pancarditis

  Endocarditis

  Pericarditis


Fibrinous pericarditis as a result of acute rheumatic fever (not RHD, which is chronic).

38

78yo female presents with prolonged weakness, fatigue and anaemia. She has a palpable spleen and a few enlarged cervical lymph nodes. Image shows her blood film. What is the most likely diagnosis?

CLL


  Acute myeloid leukaemia

  Acute lymphatic leukaemia

  Chronic myeloid leukaemia

  Chronic lymphatic leukaemia

  Non-Hodgkin's lymphoma


Film shows mature lymphocytes.