LE5

Question 1

1. The arterial supply to the common bile duct is derived from which of the following?
   a. Left hepatic artery
   b. Right hepatic artery
   c. Gastroduodenal artery
   d. Right hepatic and gastroduodenal arteries

Answer 1

d. Right hepatic and gastroduodenal arteries
Rationale: The common bile duct receives its blood supply primarily from the right hepatic artery (superior portion) and the gastroduodenal artery (inferior portion). These anastomose along the duct, ensuring a dual supply.

Question 2

2. Relaxation of the sphincter of Oddi in response to a meal is largely under the control of which hormone?
   a. Gastrin
   b. Cholecystokinin (CCK)
   c. Motilin
   d. Secretin

Answer 2

b. Cholecystokinin (CCK)
Rationale: CCK is released from the duodenum in response to fats and proteins, stimulating gallbladder contraction and relaxation of the sphincter of Oddi, allowing bile flow into the duodenum.

Question 3

3. What percentage of the bile acid pool is reabsorbed in the ileum through the enterohepatic circulation?
   a. 25%
   b. 50%
   c. 75%
   d. 95%

Answer 3

d. 95%
Rationale: Bile acids are extensively reabsorbed in the ileum via active transport (Na⁺-dependent bile acid transporter), with only 5% excreted in feces—a key step in the enterohepatic circulation.

Question 4

4. Acute cholecystitis is best described as:
   a. A primary infectious process with secondary inflammation
   b. A sterile primary inflammatory process
   c. A primary inflammatory process with occasional bacterial contamination
   d. A primary autoimmune process

Answer 4

c. A primary inflammatory process with occasional bacterial contamination
Rationale: Acute cholecystitis is caused by cystic duct obstruction (usually from gallstones), leading to bile stasis, mucosal injury, and inflammation. Secondary bacterial infection may occur but is not the initiating event.

Question 5

5. The most common type of gallbladder cancer is:
   a. Oat cell carcinoma
   b. Adenocarcinoma
   c. Adenosquamous carcinoma
   d. Squamous cell carcinoma

Answer 5

b. Adenocarcinoma
Rationale: Adenocarcinoma accounts for 85–90% of gallbladder cancers, arising from chronic inflammation (e.g., gallstones, chronic cholecystitis). It has a poor prognosis due to late diagnosis.

Question 6

6. The best initial test for a suspected postoperative bile leak is:
   a. Percutaneous transhepatic cholangiography (PTC)
   b. Endoscopic retrograde cholangiopancreatography (ERCP)
   c. Magnetic resonance imaging (MRI)
   d. Ultrasound (US)

Answer 6

b. Endoscopic retrograde cholangiopancreatography (ERCP)
Rationale: ERCP is the best initial test for a suspected postoperative bile leak, as it provides both diagnostic imaging (contrast study of the bile ducts) and therapeutic options (stenting, sphincterotomy).

Question 7

7. In the early postoperative period, what is the most common presentation of a patient with a biliary injury?
   a. Fever
   b. Abdominal pain
   c. Steatorrhea
   d. Elevated transaminases

Answer 7

b. Abdominal pain
Rationale: Biliary injury postoperatively often presents with abdominal pain, bile leakage, or jaundice. Fever can develop if infection occurs, but pain is typically the earliest symptom.

Question 8

22. A patient presents with biliary colic. On ultrasound, multiple stones are noted in the gallbladder, and the common bile duct measures 9 mm in diameter, but no stone is visualized in the common bile duct. What is the most reasonable next step?
    a. Repeat ultrasound in 24-48 hours
    b. Magnetic resonance cholangiopancreatography (MRCP) with contrast
    c. Percutaneous cholangiography
    d. Laparoscopic cholecystectomy with intraoperative cholangiography

Answer 8

d. Laparoscopic cholecystectomy with intraoperative cholangiography

Question 9

23. The gallbladder can store only a small fraction of the bile produced by the liver. What is the primary mechanism that prevents the gallbladder from becoming distended and developing high pressure?
    a. Bile continuously secretes into the duodenum once gallbladder pressure increases
    b. Gallbladder contraction in response to eating empties the large volume of bile
    c. The gallbladder concentrates the bile to reduce its volume
    d. The liver decreases bile production when gallbladder pressure increases

Answer 9

c. The gallbladder concentrates the bile to reduce its volume

Question 10

24. After a cholecystectomy, the surgeon opens the gallbladder specimen and observes a milky content. What is the most likely cause?
    a. Secretion of pancreatic juice into the common bile duct
    b. Reabsorption of bile pigments by the gallbladder mucosa
    c. Reduced bile pigment production in the liver
    d. Absence of bilirubin glucuronidase

Answer 10

b. Reabsorption of bile pigments by the gallbladder mucosa

Question 11

25. A 45-year-old female presents with fever, jaundice, and right upper quadrant pain. What is the most likely initial diagnosis?
    a. Acute cholecystitis
    b. Acute hepatitis
    c. Acute pancreatitis
    d. Ascending cholangitis

Answer 11

d. Ascending cholangitis
Rationale: Charcot’s triad (fever, jaundice, RUQ pain) is highly suggestive of ascending cholangitis, a life-threatening biliary infection often caused by obstruction (e.g., CBD stones), leading to bacterial overgrowth and systemic infection.

Question 12

46. A patient presents with fever, jaundice, and right upper quadrant pain. What is the most likely initial diagnosis?
    a. Ascending cholangitis
    b. Hepatitis
    c. Pancreatitis
    d. Acute cholecystitis

Answer 12

a. Ascending cholangitis
Rationale: Charcot’s triad (fever, jaundice, RUQ pain) is classic for ascending cholangitis, a biliary tract infection due to obstruction (often from choledocholithiasis).

Question 13

47. What is the half-life of cholecystokinin (CCK)?
    a. 2-3 minutes
    b. 20-30 minutes
    c. 1-3 hours
    d. 12-24 hours

Answer 13

a. 2-3 minutes
Rationale: Cholecystokinin (CCK) has a short half-life (2-3 minutes), ensuring rapid regulation of gallbladder contraction and bile secretion in response to meals.

Question 14

48. A 53-year-old patient is admitted with 24 hours of pain from acute cholecystitis. He is placed on NPO, IV antibiotics, and given analgesia. When should he undergo a cholecystectomy?
    a. Urgently
    b. In 1-3 days
    c. In 7-10 days
    d. In 6-8 weeks

Answer 14

b. In 1-3 days
Rationale: Early laparoscopic cholecystectomy (within 72 hours) is preferred for acute cholecystitis to reduce complications and shorten hospital stay. Delayed surgery increases the risk of recurrent attacks.

Question 15

49. Choledochal stones are primarily composed of:
    a. Cholesterol stones
    b. Black pigment stones
    c. Brown pigment stones
    d. Mulberry stones

Answer 15

c. Brown pigment stones
Rationale: Choledochal (bile duct) stones are usually brown pigment stones, formed due to biliary stasis and infection, with calcium bilirubinate and bacterial debris as key components.

Question 16

50. Which of the following is a major component of gallstones?
    a. Biliverdin
    b. Hemoglobin
    c. Lecithin
    d. Myoglobin

Answer 16

c. Lecithin
Rationale: Lecithin (phosphatidylcholine) is a major component of gallstones, along with cholesterol and bile salts. A deficiency in lecithin can promote gallstone formation.

Question 17

51. The primary stimulus for gallbladder contraction is:
    a. Somatostatin
    b. Cholecystokinin (CCK)
    c. Vasoactive intestinal polypeptide
    d. Enkephalin

Answer 17

b. Cholecystokinin (CCK)
Rationale: CCK is the primary hormone that stimulates gallbladder contraction, triggered by the presence of fats and proteins in the duodenum.

Question 18

52. A patient presents with biliary colic. Ultrasound shows small stones in the gallbladder, and the common bile duct measures 9 mm in diameter. No stone is visualized in the common bile duct. What is the most reasonable next step?
    a. MRCP with contrast
    b. Laparoscopic cholecystectomy and intraoperative cholangiography
    c. Percutaneous cholangiography
    d. Repeat ultrasound in 24-48 hours

Answer 18

b. Laparoscopic cholecystectomy and intraoperative cholangiography

Question 19

53. The gallbladder differs histologically from the rest of the gastrointestinal tract by:
    a. Absence of serosa
    b. Lack of muscularis mucosae and submucosa
    c. Presence of villi
    d. Presence of crypts

Answer 19

b. Lack of muscularis mucosae and submucosa
Rationale: Unlike the rest of the gastrointestinal tract, the gallbladder lacks a muscularis mucosae and submucosa, which makes it more prone to perforation in inflammation.

Question 20

54. Which of the following is an indication for cholecystectomy in an asymptomatic patient with an incidental finding of gallstones?
    a. Porcelain gallbladder
    b. Single gallstone larger than 1 cm
    c. Presence of sludge in the gallbladder
    d. Thickened gallbladder wall without symptoms

Answer 20

a. Porcelain gallbladder
Rationale: Porcelain gallbladder (intramural calcification) is a strong risk factor for gallbladder cancer, warranting prophylactic cholecystectomy.

Question 21

55. Which theory explains how gallstones can cause pancreatitis?
    a. Common channel theory
    b. Bile reflux theory
    c. Ischemic ductal injury theory
    d. Autoimmune activation theory

Answer 21

a. Common channel theory
Rationale: The common channel theory explains gallstone-induced pancreatitis, where an impacted stone at the ampulla of Vater causes reflux of bile into the pancreatic duct, leading to pancreatic inflammation.

Question 22

66. Which of the following is TRUE regarding splenic abscess?
    a. It is a common condition with a high incidence.
    b. It usually arises from a systemic infection.
    c. Clinical manifestations appear early and are easily diagnosed.
    d. Splenectomy is rarely required for treatment.

Answer 22

66. b. It usually arises from a systemic infection.
    🔹 Rationale: Splenic abscesses are rare but often result from hematogenous spread of infection (e.g., endocarditis, septicemia). Risk factors include immunosuppression, IV drug use, and trauma.

Question 23

67. Which of the following is NOT a common indication for splenectomy?
    a. Myeloproliferative disorders
    b. Disorders of red blood cells
    c. Acute viral infections
    d. Disorders of platelets

Answer 23

c. Acute viral infections.
🔹 Rationale: Splenectomy is not indicated for acute viral infections, as most resolve spontaneously. Common indications include:

Myeloproliferative disorders (e.g., myelofibrosis, CML)
RBC disorders (e.g., hereditary spherocytosis, sickle cell disease)
Platelet disorders (e.g., ITP, TTP)

Question 24

68. What is the primary function of Tuftsin?
    a. Stimulates phagocytic function
    b. Activates the coagulation cascade
    c. Enhances red blood cell production
    d. Acts as an enzyme in digestion

Answer 24

a. Stimulates phagocytic function.
🔹 Rationale: Tuftsin is a tetrapeptide produced in the spleen that enhances phagocytosis by neutrophils and macrophages, aiding immune defense.

Question 25

69. Properdin plays a key role in which of the following biological processes?
    a. Blood clotting
    b. Alternative pathway of complement activation
    c. Hemoglobin synthesis
    d. Glycogen metabolism

Answer 25

b. Alternative pathway of complement activation.
🔹 Rationale: Properdin stabilizes the C3 convertase in the alternative complement pathway, enhancing immune response against pathogens.

Question 26

70. Which of the following structures lies directly anterior to the portal vein?
    a. Head of the pancreas
    b. Neck of the pancreas
    c. Tail of the pancreas
    d. Superior mesenteric artery

Answer 26

b. Neck of the pancreas.
🔹 Rationale: The portal vein is formed by the confluence of the superior mesenteric vein (SMV) and splenic vein, located directly posterior to the neck of the pancreas.

Question 27

71. The splenic index is used to express spleen size in milliliters (mL). Which of the following formulas is used to calculate the splenic index?
    a. Volume (cc) = length (cm) × width (cm) × height (cm) × 0.52
    b. Volume (cc) = length (cm) × width (cm) × height (cm) × 0.75
    c. Volume (cc) = length (cm) × width (cm) × height (cm) × 0.30
    d. Volume (cc) = length (cm) × width (cm) × height (cm) × 1.25

Answer 27

a. Volume (cc) = length (cm) × width (cm) × height (cm) × 0.52.
🔹 Rationale: This formula is used to estimate splenic size in milliliters and assess splenomegaly.

Question 28

72. Which of the following diagnostic imaging modalities offers the highest resolution when examining the spleen?
    a. Whole abdominal ultrasound
    b. Whole abdominal CT scan with IV contrast
    c. Plain abdominal X-ray
    d. MRI without contrast

Answer 28

b. Whole abdominal CT scan with IV contrast.
🔹 Rationale: CT with IV contrast provides the highest resolution for spleen imaging, allowing detailed assessment of vascularity, infarcts, abscesses, and tumors.

Question 29

87. Which of the following is an indication for surgery in chronic pancreatitis?
    a. Intractable pain unresponsive to medical management
    b. Biliary or duodenal obstruction
    c. Suspected malignancy
    d. Pancreatic pseudocyst with complications
    e. All of the above

Answer 29

e. All of the above
🔹 Rationale: Surgery is indicated in chronic pancreatitis when complications arise, including:

Intractable pain unresponsive to medical management (most common indication).
Biliary or duodenal obstruction due to pancreatic fibrosis.
Suspected malignancy requiring biopsy or resection.
Complicated pancreatic pseudocyst (infection, rupture, hemorrhage).

Question 30

88. Which of the following is a cause of pain in acute pancreatitis?
    a. Pancreatic edema and distension of the capsule
    b. Peripancreatic fat necrosis and inflammation
    c. Involvement of the celiac plexus
    d. Increased intrapancreatic pressure due to ductal obstruction
    e. All of the above

Answer 30

e. All of the above
🔹 Rationale: Pain in acute pancreatitis is multifactorial:

Pancreatic edema and distension of the capsule → Causes stretching of pain-sensitive receptors.
Peripancreatic fat necrosis and inflammation → Leads to cytokine release and nociceptor activation.
Involvement of the celiac plexus → Direct neural irritation.
Increased intrapancreatic pressure due to ductal obstruction → Causes ductal hypertension and ischemia.

Question 31

89. Grey Turner’s sign is characterized by which of the following?
    a. Bluish discoloration around the umbilicus due to retroperitoneal hemorrhage
    b. Ecchymosis in the flank due to retroperitoneal hemorrhage
    c. Yellowish discoloration of the sclera due to obstructive jaundice
    d. Severe right upper quadrant pain with radiation to the back

Answer 31

b. Ecchymosis in the flank due to retroperitoneal hemorrhage
🔹 Rationale: Grey Turner’s sign is flank ecchymosis due to retroperitoneal hemorrhage in severe necrotizing pancreatitis.

Cullen’s sign (bluish discoloration around the umbilicus) is also seen in hemorrhagic pancreatitis.

Question 32

90. Which of the following is an indication for surgery in acute pancreatitis?
    a. Infected pancreatic necrosis
    b. Large or symptomatic pancreatic pseudocyst
    c. Biliary pancreatitis with recurrent episodes despite cholecystectomy
    d. Persistent abdominal compartment syndrome
    e. All of the above

Answer 32

e. All of the above
🔹 Rationale: Surgery is reserved for complications in acute pancreatitis, including:

Infected pancreatic necrosis → Requires debridement (open or minimally invasive).
Large or symptomatic pancreatic pseudocyst → If >6 cm, causing pain, infection, or rupture, drainage is needed.
Biliary pancreatitis with recurrent episodes despite cholecystectomy → Suggests persistent CBD stones or strictures, requiring ERCP or surgery.
Persistent abdominal compartment syndrome → Decompression surgery is indicated if intra-abdominal hypertension worsens organ function.

Question 33

91. Pancreatic ductal carcinoma most commonly arises from which part of the pancreas?
    a. Head
    b. Neck
    c. Body
    d. Tail

Answer 33

a. Head
🔹 Rationale: Pancreatic ductal adenocarcinoma most commonly arises in the head of the pancreas (~70% of cases).

Tumors in the pancreatic head often cause obstructive jaundice (due to CBD compression) and are diagnosed earlier than body/tail tumors.

Question 34

1. Who performed the first successful cholecystectomy in 1882?
   a. Carl Langenbuch
   b. Billroth I
   c. Billroth II
   d. Whipple

Answer 34

a. Carl Langenbuch
🔹 Rationale: Carl Langenbuch performed the first successful cholecystectomy in 1882 in Germany, recognizing that gallbladder removal was necessary to treat gallstones.

Question 35

2. Which of the following is the most common location for pain during an attack of biliary colic?
   a. Left periumbilical area
   b. Right shoulder
   c. Epigastrium
   d. Scapula

Answer 35

c. Epigastrium
🔹 Rationale: Biliary colic pain is most commonly felt in the epigastrium or right upper quadrant (RUQ), with possible radiation to the right shoulder or scapula due to diaphragmatic irritation (referred pain via the phrenic nerve).

Question 36

3. What percentage of the population has a common bile duct and pancreatic duct that merge to enter the duodenum as a single duct?
   a. 20%
   b. 30%
   c. 50%
   d. 70%

Answer 36

d. 70%
🔹 Rationale: In about 70% of individuals, the common bile duct (CBD) and pancreatic duct merge at the ampulla of Vater before entering the duodenum. The remaining 30% have separate openings.

Question 37

4. The cystic artery most commonly arises from the right hepatic artery (80–90%). The second most common anatomical configuration, occurring in 10% of people, is:
   a. Two cystic arteries, both arising from the right hepatic artery
   b. Two cystic arteries, one arising from the right hepatic artery and one from the left hepatic artery
   c. One cystic artery, arising from an aberrant right hepatic artery
   d. One cystic artery, arising from the gastroduodenal artery

Answer 37

c. One cystic artery, arising from an aberrant right hepatic artery
🔹 Rationale: While 80–90% of cystic arteries originate from the right hepatic artery, the second most common variation (10%) is from an aberrant right hepatic artery (which may arise from the superior mesenteric artery instead of the proper hepatic artery).

Question 38

5. The gallbladder is able to store only a small fraction of the bile produced by the liver. What is the primary mechanism that prevents the gallbladder from becoming distended and developing high pressure?
   a. Bile continuously secretes into the duodenum once gallbladder pressure increases
   b. Gallbladder contraction in response to eating empties the large volume of bile
   c. The gallbladder concentrates the bile to reduce its volume
   d. The liver decreases bile production when gallbladder pressure increases

Answer 38

c. The gallbladder concentrates the bile to reduce its volume
🔹 Rationale: The gallbladder actively reabsorbs water and electrolytes, concentrating bile up to 10 times to store more bile in a smaller volume without increasing pressure.

Question 39

6. The primary stimulus for gallbladder contraction is:
   a. Vasoactive intestinal polypeptide
   b. Somatostatin
   c. Cholecystokinin
   d. Enkephalin

Answer 39

c. Cholecystokinin (CCK)
🔹 Rationale: CCK is the primary stimulus for gallbladder contraction, released from the duodenum in response to fats and proteins, triggering bile ejection into the intestine.

Question 40

7. What is the half-life of cholecystokinin (CCK)?
   a. 2-3 minutes
   b. 20-30 minutes
   c. 1-3 hours
   d. 12-24 hours

Answer 40

a. 2-3 minutes
🔹 Rationale: CCK has a short half-life (2-3 minutes), allowing rapid and transient gallbladder contraction in response to meals.

Question 41

11. Strawberry gallbladder refers to which of the following pathological findings?
    a. Bile stasis and sludge formation
    b. Triglyceride and cholesterol ester deposition in the gallbladder wall
    c. Gallbladder wall calcification
    d. Bacterial infiltration of the gallbladder epithelium

Answer 41

b. Triglyceride and cholesterol ester deposition in the gallbladder wall
🔹 Rationale: Strawberry gallbladder refers to cholesterolosis, where triglyceride and cholesterol esters accumulate in macrophages within the gallbladder mucosa, creating a yellow speckled appearance on a red background.

Question 42

12. What is the normal gallbladder volume in milliliters (mL)?
    a. 10-20 mL
    b. 20-30 mL
    c. 30-50 mL
    d. 50-100 mL

Answer 42

c. 30-50 mL
🔹 Rationale: The normal gallbladder volume is 30-50 mL, though it can distend up to 300 mL in cases of chronic obstruction or hydrops.

Question 43

13. A surgical specimen of the gallbladder shows Rokitansky-Aschoff sinuses. What is the most probable diagnosis?
    a. Sclerosing cholangitis
    b. Ascending cholangitis
    c. Acute cholecystitis
    d. Chronic cholecystitis

Answer 43

d. Chronic cholecystitis
🔹 Rationale: Rokitansky-Aschoff sinuses (RAS) are outpouchings of mucosa into the muscularis layer, commonly seen in chronic cholecystitis due to long-standing gallstone disease.

Question 44

14. The gallbladder differs histologically from the rest of the gastrointestinal tract because it:
    a. Lacks muscularis mucosae and submucosa
    b. Has a double-layered epithelium
    c. Contains numerous crypts and glands
    d. Has a well-defined serosal layer

Answer 44

a. Lacks muscularis mucosae and submucosa
🔹 Rationale: The gallbladder lacks a muscularis mucosae and submucosa, making it more vulnerable to perforation and inflammation-related complications.

Question 45

15. A 24-year-old pregnant woman in her 20th week of pregnancy experiences a single episode of biliary colic. What is the most appropriate initial management?
    a. Observation with follow-up after delivery for recurrent episodes
    b. Dietary modifications
    c. Elective laparoscopic cholecystectomy during the second trimester
    d. Elective open cholecystectomy during the second trimester

Answer 45

b. Dietary modifications

Question 46

16. A 53-year-old male is admitted with 24 hours of pain from acute cholecystitis. He was placed on NPO, IV antibiotics, and given analgesia. When should he undergo cholecystectomy?
    a. Urgently
    b. In 1 to 3 days
    c. In 7 to 10 days
    d. In 6 to 8 weeks

Answer 46

b. In 1 to 3 days
🔹 Rationale: Early laparoscopic cholecystectomy within 72 hours is preferred for acute cholecystitis, as it reduces complications and recurrence compared to delayed surgery.

Question 47

17. What is the half-life of cholecystokinin (CCK)?
    a. 2-3 minutes
    b. 20-30 minutes
    c. 1-3 hours
    d. 12-24 hours

Answer 47

a. 2-3 minutes
🔹 Rationale: CCK has a short half-life (2-3 minutes), allowing rapid gallbladder contraction in response to food intake.

Question 48

18. What is the sensitivity of ultrasound in detecting gallbladder stones?
    a. 60-70%
    b. 75-85%
    c. 90-95%
    d. 99%

Answer 48

c. 90-95%
🔹 Rationale: Ultrasound has a sensitivity of 90-95% for detecting gallstones, making it the first-line imaging modality for gallbladder pathology.

Question 49

1. True statements regarding pancreas anatomy, EXCEPT:
   a. The right renal artery and vena cava lie posterior to the head of the pancreas.
   b. The neck of the pancreas lies directly anterior to the portal vein.
   c. The body of the pancreas lies anterior to the splenic artery and vein.
   d. The superior mesenteric vein is joined by the inferior mesenteric vein commonly at the inferior border of the neck of the pancreas.
   e. None of the above.

Answer 49

D. SMV is joined by IMV commonly at the inferior border of the neck of the pancreas
Rationale: The head of the pancreas is posterior to the vena cava, right renal artery, and both renal veins. The neck of the pancreas lies anterior to the portal vein, but the inferior mesenteric vein (IMV) joins the splenic vein before it meets the superior mesenteric vein (SMV) to form the portal vein.

Question 50

2. True statements regarding pancreatic histology and physiology:
   a. Only 2% of the gland comprises endocrine secretion.
   b. Acinar cells are responsible for about 85% of pancreatic secretion.
   c. At least 20% of the normal pancreas is required to prevent insufficiency.
   d. All of the above.
   e. None of the above.

Answer 50

D. All of the above
Rationale: The endocrine pancreas comprises only 2% of the gland, while acinar cells contribute to 85% of pancreatic secretion. At least 20% of normal pancreatic tissue is needed to prevent insufficiency.

Question 51

3. A 72-year-old male presents with painless jaundice without a palpable abdominal mass. What is the most likely location of biliary obstruction?
   a. Duodenal or ampullary tumor
   b. Pancreatic head carcinoma
   c. Carcinoma of the distal common bile duct (CBD)
   d. All of the above
   e. Cholelithiasis

Answer 51

c. Carcinoma of the distal common bile duct (CBD)

Question 52

4. A 38-year-old female complained of severe colicky right upper quadrant pain 2 days prior to consultation, which later became constant epigastric pain radiating to the midback. On admission, serum amylase was 5000 IU/L, alkaline phosphatase was 400 IU/L, and ALT was 200 IU/L. Ultrasound showed multiple echogenic foci in the gallbladder. What is the most likely etiology?
   a. Alcohol-induced pancreatitis
   b. Biliary pancreatitis
   c. Acute acalculous cholecystitis
   d. Peptic ulcer disease

Answer 52

B. Biliary pancreatitis
Rationale: Gallstones seen on ultrasound in a patient with high serum amylase suggest gallstone-induced biliary pancreatitis.

Question 53

5. A 73-year-old woman is evaluated for obstructive jaundice due to common bile duct injury 7 months after laparoscopic cholecystectomy. Her alkaline phosphatase level is elevated. In obstructive jaundice, what is alkaline phosphatase likely to do?
   a. Its level increases before that of bilirubin.
   b. Its level is unlikely to be increased in pancreatic malignancy.
   c. Its elevation indicates bone metastasis.
   d. Its elevation excludes hepatic metastasis.
   e. Its level falls after that of bilirubin following surgical intervention.

Answer 53

a. Its level increases before that of bilirubin.
Rationale: Alkaline phosphatase rises before bilirubin in obstructive jaundice and remains elevated longer post-surgery.

Question 54

6. Activation of pancreatic trypsinogen normally involves which of the following?
   a. Pancreatic amylase
   b. pH greater than 7
   c. Lysosomal hydrolase
   d. Pancreatic enterokinase
   e. Duodenal enterokinase

Answer 54

e. Duodenal enterokinase

Rationale: Enterokinase in the duodenum converts trypsinogen to trypsin, which then activates other pancreatic enzymes.

Question 55

7. A 30-year-old male is admitted with frequent episodes of hypoglycemia and is found to have a localized 2-cm mass in the body of the pancreas. Which of the following is NOT typical of insulinoma?
   a. Fasting hypoglycemia
   b. Glucose levels below 50 mg/dL
   c. Relief of symptoms with glucose administration
   d. Managed by subtotal pancreatectomy
   e. Palpitations, diaphoresis, and confusion are common symptoms

Answer 55

c. Relief of symptoms with glucose administration

Rationale: Insulinomas cause fasting hypoglycemia with serum glucose <50 mg/dL, which is relieved by glucose or frequent eating.

Question 56

8. Which pancreatic islet cell type produces a hormonal peptide that stimulates glycogenolysis and gluconeogenesis?
   a. Alpha cell
   b. Beta cell
   c. Delta cell
   d. E cell
   e. PP cell

Answer 56

a. Alpha cell
Rationale: Alpha cells produce glucagon, which increases blood glucose by promoting glycogenolysis and gluconeogenesis.

Question 57

9. True statements regarding acinar cell events in acute pancreatitis, EXCEPT:
   a. Common channel obstruction of the pancreatic duct with bile reflux
   b. Insult to acinar cells leads to colocalization of lysosomal and zymogen contents
   c. Trypsinogen is activated to trypsin by cathepsin B
   d. Release of cytokines occurs as a result of NF-kappa B activation

Answer 57

a. Common channel obstruction of the pancreatic duct with bile reflux
While bile reflux can contribute to pancreatitis, the primary mechanism involves acinar cell injury, activation of digestive enzymes, and inflammatory response. The other statements accurately describe cellular mechanisms of pancreatitis.

Question 58

10. What is the most commonly mutated gene in pancreatic cancer?
    a. p53
    b. K-ras
    c. p16
    d. DPC4
    e. BRCA2

Answer 58

b. K-ras
The K-ras gene mutation is the most common genetic alteration in pancreatic cancer, found in over 90% of cases.

Question 59

11. True statement regarding a replaced right hepatic artery:
    a. Commonly occurs in about 70% of individuals
    b. Right hepatic artery arises from the superior mesenteric artery (SMA)
    c. Right hepatic artery originates from the hepatic artery proper
    d. Due to its high incidence, preoperative CT scans are very important
    e. None of the above

Answer 59

b. Right hepatic artery arises from the superior mesenteric artery (SMA)
A replaced right hepatic artery arises from the SMA instead of the common hepatic artery. This variant occurs in about 15-20% of individuals.

Question 60

12. The anterior wall of a pancreatic pseudocyst most commonly develops in which of the following areas?
    a. Posterior aspect of the stomach
    b. Floor of the lesser sac
    c. Transverse mesocolon
    d. Pancreatic neck
    e. None of the above

Answer 60

b. Floor of the lesser sac
Pancreatic pseudocysts typically form in the lesser sac, which is located between the stomach and pancreas.

Question 61

13. What is the most effective prevention strategy against overwhelming post-splenectomy sepsis (OPSI)?
    a. Antibiotic prophylaxis
    b. Isolation
    c. Preoperative vaccination
    d. Postoperative vaccination

Answer 61

c. Preoperative vaccination
Preoperative vaccination against encapsulated organisms (Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae) is the best strategy to prevent OPSI.

Question 62

14. What is the most common etiology of splenic cysts worldwide?
    a. Parasitic infection
    b. Bacterial infection
    c. Trauma
    d. Congenital anomaly

Answer 62

a. Parasitic infection
The most common cause of splenic cysts worldwide is parasitic infection, particularly Echinococcus (hydatid disease).

Question 63

15. True statements regarding causes of acute pancreatitis, EXCEPT:
    a. Endoscopic retrograde cholangiopancreatography (ERCP)
    b. Hyperlipidemia
    c. Associated with furosemide and propofol
    d. Diabetes mellitus

Answer 63

d. Diabetes mellitus
While diabetes can be a consequence of pancreatitis, it is not a direct cause. The other options (ERCP, hyperlipidemia, and certain drugs like furosemide/propofol) are known triggers of acute pancreatitis.

Question 64

16. True statements regarding pancreatic beta cells, EXCEPT:
    a. Beta cells make up about 70% of the total islet cell mass
    b. Beta cells are evenly distributed throughout the pancreas
    c. Beta cells secrete multiple hormones
    d. Beta cells are mostly in the pancreatic body and tail

Answer 64

b. Beta cells are evenly distributed throughout the pancreas
Beta cells are predominantly located in the body and tail of the pancreas, not evenly distributed.

Question 65

A 66-year-old man with obstructive jaundice is found on ERCP to have a mass in the periampullary area. Which of the following is an unlikely cause?
A. Tumor of distal CBD
B. Duodenal cancer
C. Duodenal ulcer
D. Ampullary cancer
E. Pancreatic head cancer

Answer 65

C. Duodenal ulcer

Question 66

18. Which of the following is an unlikely indication for splenectomy?
    a. Polycythemia vera
    b. Hereditary spherocytosis
    c. Abscess of the spleen
    d. Blunt trauma

Answer 66

a. Polycythemia vera
Splenectomy is not typically indicated for polycythemia vera, as it is managed with phlebotomy and medications.
Splenectomy is indicated for:
Hereditary spherocytosis (to prevent hemolysis)
Splenic abscess (due to high mortality risk)
Blunt trauma (if massive splenic rupture occurs)

Question 67

19. Penetrating, severe, and boring type of pain radiating to the back in acute pancreatitis is most likely due to which of the following?
    a. The pancreas is located in the right upper quadrant close to the gallbladder
    b. The pancreas is situated deep in the center of the abdomen
    c. The pancreas weighs about 200 grams
    d. All of the above

Answer 67

b. The pancreas is situated deep in the center of the abdomen
The retroperitoneal location of the pancreas means inflammation can irritate the celiac plexus, leading to deep, boring pain radiating to the back.

Question 68

20. A 48-year-old woman presents with severe recurrent peptic ulcers located in the proximal jejunum. Five years ago, she underwent a parathyroidectomy for hypercalcemia. Her brother was diagnosed with Zollinger-Ellison syndrome. High levels of gastrin confirm the diagnosis. Which of the following is NOT a border of the Passaro triangle?
    a. Head of the pancreas
    b. Neck and body of the pancreas
    c. Second and third portions of the duodenum
    d. Junction of the cystic and common bile duct

Answer 68

A. Head of the pancreas
Explanation:
Passaro’s triangle, also called the gastrinoma triangle, is an anatomical area where most gastrinomas are found in Zollinger-Ellison syndrome. It is defined by three borders:

Junction of the cystic and common bile duct (superior border)
Second and third portions of the duodenum (inferior border)
Junction of the neck and body of the pancreas (medial border)

Question 69

21. What is the most common location of an accessory spleen?
    a. Gastrocolic ligament
    b. Pancreatic tail
    c. Greater omentum
    d. Splenocolic ligament
    e. Splenic hilum

Answer 69

e. Splenic hilum
Accessory spleens are most commonly found near the splenic hilum (around 80% of cases). Other possible locations include the pancreatic tail, greater omentum, or ligaments around the spleen.

Question 70

22. What hormone inhibits pancreatic exocrine secretion and the action of all pancreatic and gut peptides?
    a. Bombesin
    b. Glucagon
    c. Somatostatin
    d. Insulin
    e. Pancreatic polypeptide

Answer 70

c. Somatostatin
Somatostatin inhibits the secretion of pancreatic enzymes and hormones, including glucagon, insulin, and other gut peptides. It is also used clinically in the treatment of neuroendocrine tumors and pancreatic fistulas.

Question 71

23. The mechanism of alcohol-induced acute pancreatitis is thought to involve all of the following EXCEPT:
    a. Spasm of the sphincter of Oddi with a secretory burst of acinar cells
    b. Predisposes acinar cells to autodigestive injury and cell death
    c. Leads to synthesis of proinflammatory mediators and cytokines
    d. Mutation of PRSS1 and SPINK1 protein

Answer 71

d. Mutation of PRSS1 and SPINK1 protein
PRSS1 (cationic trypsinogen mutation) and SPINK1 (serine protease inhibitor) mutations are associated with hereditary pancreatitis, not alcohol-induced pancreatitis.
Alcohol-induced pancreatitis mechanisms include:
Spasm of the sphincter of Oddi
Increased secretion of pancreatic enzymes
Inflammatory cytokine activation leading to autodigestion

Question 72

24. A 68-year-old male with recent-onset diabetes develops vague abdominal pain radiating to the back. On physical examination, he has had a weight loss of 10 kg over the past three months. What is the most appropriate diagnostic test?
    a. Total bilirubin, direct and indirect (B1B2)
    b. Abdominal X-ray (upright and supine)
    c. Abdominal ultrasound
    d. Multidetector CT scan of the abdomen

Answer 72

d. Multidetector CT scan of the abdomen
Pancreatic cancer should be suspected in an elderly patient with new-onset diabetes, weight loss, and abdominal pain. Multidetector CT (MDCT) is the gold standard for detecting pancreatic masses.

Question 73

25. A 25-year-old female presents with episodes of bizarre behavior, memory lapses, and unconsciousness. She has also experienced episodes of extreme hunger, sweating, and tachycardia. During one of these episodes, her blood sugar was tested and found to be 40 mg/dL. Which finding would suggest a diagnosis of insulinoma?
    a. Demonstration of insulin antibodies in the blood
    b. Abnormal glucagon levels
    c. CT scan of the pancreas
    d. Hypoglycemia during a symptomatic episode with relief of symptoms by intravenous glucose
    e. Decreased circulating C-peptide in the blood

Answer 73

d. Hypoglycemia during a symptomatic episode with relief of symptoms by intravenous glucose
This fulfills Whipple’s triad, which confirms insulinoma:
Symptoms of hypoglycemia
Low blood glucose (<50 mg/dL)
Relief of symptoms with glucose administration
CT scan of the pancreas may help localize the tumor but is not diagnostic by itself.

Question 74

26. A 62-year-old man is admitted with vague abdominal pain, weight loss, and jaundice. His direct bilirubin level is 5.6 mg/dL, and his total bilirubin is 8 mg/dL. What is the most likely cause of his jaundice?
    a. Acute cholecystitis
    b. Carcinoma of the pancreas
    c. Liver cirrhosis
    d. Pancreatic pseudocyst
    e. Hemolytic anemia

Answer 74

b. Carcinoma of the pancreas
Painless jaundice, weight loss, and elevated direct bilirubin strongly suggest pancreatic head cancer, which obstructs the common bile duct (CBD).

Question 75

27. Which of the following is an unfavorable prognostic factor in acute pancreatitis?
    a. WBC count of 12,500 per cubic mm, glucose 130 mg/dL
    b. Abdominal tenderness
    c. Hematocrit of 12%
    d. Normal creatinine

Answer 75

c. Hematocrit of 12%
Severe pancreatitis can cause hemoconcentration (>44%) early or severe anemia (<30%) later, both of which indicate poor prognosis.
Other markers of severe pancreatitis:
WBC >16,000
Glucose >200 mg/dL
Creatinine >1.8 mg/dL

Question 76

28. The high rate of overwhelming post-splenectomy infection (OPSI) in thalassemia patients is thought to be due to an immune deficiency. Which of the following strategies has been shown to effectively reduce mortality?
    a. Partial splenectomy
    b. Prophylactic antibiotics
    c. Delaying splenectomy until after 2 years of age
    d. Maintenance of >9 mg/dL hemoglobin

Answer 76

A. Partial splenectomy
🩸 Rationale:
Partial splenectomy has been studied as a strategy to reduce the risk of Overwhelming Post-Splenectomy Infection (OPSI) in thalassemia patients.
The spleen plays an essential role in immune function, particularly in filtering encapsulated bacteria like Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae.
Completely removing the spleen increases infection risk, while partial splenectomy preserves some splenic function, reducing mortality and severe infections.
🛑 Why Not the Other Options?
❌ B. Prophylactic antibiotics – While antibiotics are useful after splenectomy, they are not as effective as preserving splenic function through partial splenectomy.
❌ C. Delaying splenectomy until after 2 years of age – Current guidelines recommend delaying splenectomy until at least 4 years of age, making this an incorrect timeframe.
❌ D. Maintenance of >9 mg/dL hemoglobin – Maintaining hemoglobin levels is beneficial for overall health but does not directly reduce the risk of OPSI.

Question 77

29. True statements regarding the exocrine pancreas, EXCEPT:
    a. Acinar cell secretion is alkaline and odorless
    b. Amylase, lipase, and proteases are secreted as proenzymes
    c. Amylase, lipase, and proteases are secreted in active form
    d. All of the above
    e. None of the above

Answer 77

A. Acinar cell secretion is alkaline and odorless
📌 Explanation:
Pancreatic juice is composed of acinar cell and duct cell secretions and is:
✔ Alkaline (pH ~8.0) to help neutralize gastric acid.
✔ Colorless and odorless.
✔ Isosmotic (same osmolarity as plasma).

Acinar cells secrete digestive enzymes:

Amylase (active form) → Breaks down starch and glycogen.
Proteases (e.g., trypsinogen, chymotrypsinogen, procarboxypeptidase) (inactive form) → Activated in the duodenum.
Lipases (inactive form) → Requires activation by bile salts.

Question 78

30. The highest mortality can be anticipated when pancreatitis occurs after which of the following?
    a. Beer ingestion
    b. Heavy fatty meal
    c. ERCP
    d. Parotitis

Answer 78

c. ERCP
🔹 Post-ERCP pancreatitis can be severe and lead to necrotizing pancreatitis, causing multi-organ failure.
🔹 Alcohol and high-fat meals can trigger pancreatitis, but mortality is lower.

Question 79

31. A 67-year-old man with a chronic history of biliary sludge and recurrent abdominal pain is admitted due to severe abdominal pain. His amylase level is 2000 IU/L, and examination reveals epigastric tenderness. What is the best test to determine the likely cause of the pain?
    a. Endoscopic retrograde cholangiopancreatography (ERCP)
    b. Upper GI endoscopy
    c. Abdominal CT scan with pancreatic protocol
    d. Hepatobiliary tree ultrasound

Answer 79

C. Abdominal CT scan with pancreatic protocol
📌 Explanation:
The patient presents with severe epigastric pain, a history of biliary sludge, and an elevated amylase level (2000 IU/L), strongly suggesting acute pancreatitis.
The best test to determine the cause and assess complications is a contrast-enhanced CT scan with a pancreatic protocol.

Question 80

32. Which of the following does NOT stimulate pancreatic bicarbonate secretion?
    a. Secretin
    b. Cholecystokinin (CCK)
    c. Gastrin and acetylcholine
    d. All of the above
    e. None of the above

Answer 80

d. All of the above

Question 81

33. Which of the following is the least likely differential diagnosis for acute pancreatitis?
    a. Perforated peptic ulcer
    b. Acute cholecystitis
    c. Diverticulitis
    d. Dyspepsia
    e. Incarcerated inguinal hernia

Answer 81

d. Dyspepsia
🔹 Perforated ulcers, cholecystitis, diverticulitis, and hernias can mimic pancreatitis.
🔹 Dyspepsia (indigestion) is usually mild and not associated with severe inflammation.

Question 82

34. A 58-year-old man with a 30-year history of alcoholism and pancreatitis is admitted with an elevated bilirubin level of 5 mg/dL, pale stools, and an amylase level of 600 U. Obstructive jaundice in chronic pancreatitis usually results from which of the following?
    a. Sclerosing cholangitis
    b. Common bile duct (CBD) compression caused by inflammation
    c. Biliary dyskinesia
    d. Cirrhosis

Answer 82

b. Common bile duct (CBD) compression caused by inflammation
🔹 Chronic inflammation and fibrosis can compress the CBD, causing obstructive jaundice.
🔹 Sclerosing cholangitis is rare in pancreatitis but common in primary biliary diseases.

Question 83

35. A 67-year-old woman is evaluated for obstructive jaundice. Cholangiographic findings indicate cancer of the lower end of the common bile duct. Which of the following clinical examination findings is most likely?
    a. Shrunken gallbladder
    b. Enlarged gallbladder
    c. Enlarged pancreas
    d. Shrunken pancreas
    e. Palpable tumor

Answer 83

b. Enlarged gallbladder
🔹 Courvoisier’s sign: Non-tender, palpable gallbladder suggests malignant biliary obstruction.
🔹 The gallbladder enlarges due to backflow, unlike gallstones, where it shrinks.

Question 84

36. A 41-year-old woman with multiple endocrine neoplasia (MEN) syndrome has a family history of adenomas in the parathyroid, pancreas, and/or pituitary glands. She has severe diarrhea associated with low gastric acid secretion and a normal gastrin level. Which serum assay would be best to evaluate the possible cause of her diarrhea?
    a. Somatostatin
    b. Vasoactive intestinal peptide (VIP)
    c. Cholecystokinin (CCK)
    d. Pituitary hormone assay
    e. Glucagon

Answer 84

b. Vasoactive intestinal peptide (VIP)
🔹 VIPoma causes severe watery diarrhea (WDHA syndrome) with low acid secretion.
🔹 MEN-1 (multiple endocrine neoplasia) commonly involves the parathyroid, pancreas, and pituitary.

Question 85

37. A 22-year-old college student recovers from a severe episode of pancreatitis. About 14 days later, he still experiences mild epigastric discomfort, bloating, and loss of appetite. Ultrasound reveals a cystic mass around the stomach. What should be the next step in management?
    a. Percutaneous drainage of the cyst
    b. Laparotomy and internal drainage of the cyst
    c. Nutritional support and pain control
    d. Pancreatectomy

Answer 85

c. Nutritional support and pain control
🔹 Pancreatic pseudocysts often resolve spontaneously within 4-6 weeks.
🔹 Drainage is indicated only if the cyst is large (>6 cm), infected, or symptomatic.

Question 86

38. True statements regarding acute pancreatitis:
    a. It is a common and challenging disease that can develop local and systemic complications
    b. It is the 9th most common non-cancer cause of gastrointestinal deaths
    c. Smoking is an independent risk factor
    d. All of the above
    e. None of the above

Answer 86

d. All of the above
🔹 Pancreatitis is a common and life-threatening disease with both local (necrosis) and systemic (multi-organ failure) complications.
🔹 Smoking is a significant independent risk factor for chronic pancreatitis and pancreatic cancer.

Question 87

39. Which of the following is an indication for surgical treatment of splenic aneurysms?
    a. Pregnancy
    b. Neutropenia
    c. Thrombocytopenia
    d. 1.5 cm size

Answer 87

A. Pregnancy
🔹 Splenic artery aneurysms (SAA) are the most common visceral artery aneurysms and are more likely to rupture during pregnancy, with a high mortality rate (~75%) if rupture occurs.
🔹 Indications for surgical treatment:

Pregnancy or childbearing-age women.
Aneurysms >2 cm in size (not just 1.5 cm).
Rapid enlargement or symptomatic cases.
🔹 Neutropenia and thrombocytopenia are not indications.

Question 88

40. A 67-year-old woman presents with vague abdominal pain, and an MRI with MRCP reveals a 3.5 cm pancreatic cyst with a thickened enhancing cyst wall and non-enhancing mural nodules in the body of the pancreas. Which statement is correct regarding the management of pancreatic cysts?
    a. No further work-up needed, just do surveillance
    b. Advise endoscopic ultrasound
    c. Immediate surgical resection

Answer 88

B. Advise endoscopic ultrasound (EUS)
🔹 Pancreatic cysts with thickened enhancing walls and mural nodules raise suspicion for mucinous cystic neoplasms (MCN) or intraductal papillary mucinous neoplasm (IPMN), which can be malignant.
🔹 EUS with fine needle aspiration (FNA) is required for further evaluation.
🔹 Surgical resection is indicated only if malignancy is confirmed.

Question 89

41. A patient is diagnosed with thrombotic thrombocytopenic purpura (TTP). In addition to purpura and thrombocytopenia, studies will most likely show which of the following?
    a. Normal arterioles on biopsy of the spleen
    b. Absence of infarction on biopsy of the spleen
    c. Leukopenia
    d. Elevated urea and creatinine levels
    e. Suppression of reticulocytes

Answer 89

d. Elevated urea and creatinine levels
🔹 TTP is a thrombotic microangiopathy characterized by:

Microangiopathic hemolytic anemia (MAHA) → Fragmented RBCs (schistocytes).
Thrombocytopenia (low platelets).
Renal failure → Elevated urea and creatinine due to ischemic damage.
🔹 Suppression of reticulocytes is incorrect because TTP involves hemolysis, which triggers increased reticulocyte production.

Question 90

42. The human spleen plays a key immunologic role in defense against which of the following organisms?
    a. Staphylococcus aureus
    b. Escherichia coli
    c. Klebsiella pneumoniae
    d. Streptococcus pneumoniae
    e. Clostridium tetani

Answer 90

d. Streptococcus pneumoniae
🔹 The spleen is critical for clearing encapsulated bacteria, including:

Streptococcus pneumoniae
Haemophilus influenzae
Neisseria meningitidis
🔹 These organisms have polysaccharide capsules, which require opsonization for effective immune clearance.

Question 91

43. What is the most important role of pancreatic polypeptide?
    a. Regulation of hepatic insulin receptor gene expression
    b. Inhibition of choleresis (bile secretion)
    c. Inhibition of exocrine pancreatic secretion
    d. Inhibition of gallbladder contraction

Answer 91

A. Regulation of hepatic insulin receptor gene expression
📌 Explanation:
Pancreatic polypeptide (PP) plays a role in glucose metabolism by regulating hepatic insulin receptor gene expression.
A deficiency of PP leads to reduced hepatic insulin receptor availability, resulting in hepatic insulin resistance.
This effect is seen in patients with chronic pancreatitis, proximal pancreatectomy, and cystic fibrosis.

Question 92

44. All of the following are functions of the spleen EXCEPT:
    a. Clearance of damaged or aged red blood cells
    b. Initiation of adaptive immune response through filtration of lymph
    c. Extramedullary site for hematopoiesis and iron recycling
    d. Clearance of encapsulated bacteria from the bloodstream

Answer 92

b. Initiation of adaptive immune response through filtration of lymph
🔹 The spleen does NOT directly filter lymph; this is the role of lymph nodes.
🔹 The spleen clears damaged RBCs, recycles iron, and removes encapsulated bacteria from circulation.

Question 93

45. A 45-year-old patient with chronic pancreatitis is suffering from malnutrition and weight loss due to inadequate pancreatic exocrine secretions. Which statement is true regarding pancreatic secretions?
    a. Secretin releases fluid rich in enzymes
    b. Secretin releases fluid rich mainly in electrolytes and bicarbonate
    c. Cholecystokinin releases fluid predominantly rich in electrolytes and bicarbonate
    d. All pancreatic enzymes are secreted in an inactive form
    e. The pancreas produces proteolytic enzymes only

Answer 93

d. All pancreatic enzymes are secreted in an inactive form
🔹 Pancreatic enzymes are secreted as inactive precursors (zymogens) to prevent autodigestion:

Trypsinogen → Trypsin (activated in the duodenum).
Chymotrypsinogen → Chymotrypsin.
Procarboxypeptidase → Carboxypeptidase.
🔹 Only amylase is secreted in its active form.

Question 94

46. Which of the following statements is true regarding ghrelin?
    a. Orexigenic, appetite-stimulating
    b. Stimulates growth hormone-releasing hormone (GHRH)
    c. Blocks insulin effects on the liver
    d. All of the above
    e. None of the above

Answer 94

D. All of the above
📌 Explanation:
Ghrelin is a peptide hormone secreted primarily by the stomach and to a lesser extent by the pancreas. It plays multiple roles in metabolism, appetite regulation, and endocrine signaling.

✔ A. Orexigenic, appetite-stimulating

Ghrelin is known as the “hunger hormone.”
It increases appetite and food intake by acting on the hypothalamus (arcuate nucleus).
Levels of ghrelin rise before meals and fall after eating.
✔ B. Stimulates growth hormone-releasing hormone (GHRH)

Ghrelin stimulates GHRH release from the hypothalamus, leading to an increase in growth hormone (GH) secretion from the pituitary gland.
This is an important function in growth regulation and metabolism.
✔ C. Blocks insulin effects on the liver

Ghrelin reduces insulin sensitivity and promotes glucose production (gluconeogenesis) in the liver.
It plays a role in energy homeostasis and metabolic regulation.

Question 95

47. Which of the following statements is true regarding insulin?
    a. Secretion is not influenced by levels of arginine, lysine, leucine, and free fatty acids
    b. Stimulates endogenous glucose production
    c. Stimulates protein synthesis
    d. All of the above
    e. None of the above

Answer 95

C. Stimulates protein synthesis
🔹 Insulin promotes protein synthesis by increasing amino acid uptake in muscle and liver.
🔹 Incorrect choices:

(A) Insulin secretion is influenced by amino acids (arginine, lysine, leucine) and free fatty acids.
(B) Insulin inhibits endogenous glucose production by suppressing gluconeogenesis.
(D) & (E) are incorrect because statement C is true.

Question 96

48. Which of the following inhibits insulin release?
    a. Pancreastatin
    b. Somatostatin
    c. Amylin
    d. All of the above
    e. None of the above

Answer 96

D. All of the above
🔹 Insulin release is inhibited by:

Pancreastatin (inhibits pancreatic endocrine function).
Somatostatin (directly suppresses insulin and glucagon secretion).
Amylin (inhibits postprandial glucagon release and slows gastric emptying).

Question 97

49. A 39-year-old man who has consumed more than three bottles of gin weekly for the past 15 years is admitted with upper abdominal pain radiating to the back, nausea, and vomiting. Serum amylase and lipase are elevated, and a diagnosis of pancreatitis is made. Which of the following factors would be most concerning in determining his prognosis?
    a. Calcium level < 6 mg/dL
    b. Age less than 40 years
    c. Blood glucose of 190 mg/dL
    d. Creatinine of 0.8 mg/dL

Answer 97

A. Calcium level < 6 mg/dL
🔹 Hypocalcemia is a poor prognostic factor and may indicate severe pancreatitis with fat necrosis (calcium binds to free fatty acids).
🔹 Other factors:

(B) Age < 40 is not a poor prognostic factor; older age (>55) is.
(C) Hyperglycemia (>200 mg/dL) is concerning but not as critical as hypocalcemia.
(D) Creatinine of 0.8 mg/dL is normal and not a poor prognostic factor.

Question 98

50. A 70-year-old man was diagnosed with polycythemia vera with associated back pain and myeloid metaplasia. This condition is characterized by which of the following?
    a. Decrease in connective tissue of the spleen
    b. Decrease in the blood elements of the spleen
    c. Aplastic anemia
    d. Deterioration after splenectomy
    e. A favorable response to alkylating agents

Answer 98

e. A favorable response to alkylating agents

Question 99

51. Splenectomy is most effective as a treatment for which of the following conditions?
    a. Cold-antibody autoimmune hemolytic anemia
    b. Wandering spleen
    c. Hodgkin’s disease
    d. G6PD deficiency

Answer 99

B. Wandering spleen
🔹 Wandering spleen is a rare condition where the spleen lacks proper ligamentous attachment, leading to torsion and infarction. Splenectomy is curative.
🔹 Incorrect choices:

(A) Cold-antibody AIHA is treated with immunosuppression, not splenectomy.
(C) Hodgkin’s disease is treated with chemotherapy, not splenectomy.
(D) G6PD deficiency is managed by avoiding oxidative triggers, not splenectomy.

Question 100

52. Splenectomy is often indicated in the management of which of the following conditions?
    a. Hereditary neurofibromatosis
    b. Aplastic anemia
    c. Pheochromocytoma
    d. Hairy cell leukemia

Answer 100

D. Hairy cell leukemia
🔹 Hairy cell leukemia leads to massive splenomegaly, and splenectomy improves cytopenia and symptoms.
🔹 Incorrect choices:

(A) Hereditary neurofibromatosis is a genetic disorder and does not require splenectomy.
(B) Aplastic anemia is treated with bone marrow transplant and immunosuppressants.
(C) Pheochromocytoma is treated with adrenalectomy, not splenectomy.

Question 101

53. What type of diabetes mellitus (DM) patient usually presents with high levels of insulin and pancreatic polypeptide with rare occurrences of hypoglycemia and ketoacidosis?
    a. Type 4 DM
    b. Pancreatogenic DM
    c. Non-insulin-dependent DM
    d. Insulin-dependent DM

Answer 101

c. Non-insulin-dependent DM

Question 102

54. A 42-year-old woman has a history of intermittent abdominal pain and indigestion for six months. Her bilirubin and amylase levels were initially elevated but later returned to near-normal values. Ultrasound reveals multiple gallbladder polyps. Her symptoms abate by the 5th day of admission. What is the best course of management?
    a. Start a low-fat diet
    b. Increase the fat content of her diet
    c. Undergo immediate cholecystectomy
    d. Be discharged and undergo elective cholecystectomy after three months

Answer 102

c. Undergo immediate cholecystectomy

Question 103

55. Which statement is true regarding nutritional support in the management of acute pancreatitis?
    a. Rest the pancreas
    b. Prescribe parenteral nutrition
    c. Initiate enteral nutrition early
    d. Elemental and immune-enhancing formula preferred
    e. All of the above

Answer 103

C. Initiate enteral nutrition early
🔹 Early enteral nutrition (via nasojejunal or nasogastric tube) is preferred over parenteral nutrition because it:

Maintains gut integrity and prevents bacterial translocation.
Reduces infection risk and complications.
🔹 Incorrect choices:
(A) Resting the pancreas (keeping the patient NPO) is outdated.
(B) Parenteral nutrition is only used when enteral feeding is not possible.
(D) Elemental and immune-enhancing formulas are not preferred in all cases.
(E) “All of the above” is incorrect because A and B are incorrect.

Question 104

56. Surgical intervention is usually NOT recommended in patients with pancreatitis under which condition?
    a. Obstructive jaundice
    b. Pseudocyst
    c. Abscess
    d. Acute edematous pancreatitis
    e. Choledocholithiasis

Answer 104

D. Acute edematous pancreatitis
🔹 Mild acute (edematous) pancreatitis is self-limiting and resolves with supportive care (fluids, pain control, enteral nutrition).
🔹 Surgery is indicated for:

Obstructive jaundice (A) → Surgery if caused by tumors or strictures.
Pseudocysts (B) & Abscesses (C) → Drainage needed if symptomatic/infected.
Choledocholithiasis (E) → ERCP is first-line, but cholecystectomy may follow.

Question 105

57. A 48-year-old woman presents with severe recurrent peptic ulcer disease located in the proximal jejunum. Five years ago, she underwent parathyroidectomy for hypercalcemia. Her brother was previously diagnosed with Zollinger-Ellison syndrome. She develops severe peptic ulcer disease that recurs despite gastric resection and vagotomy. Now, she presents with melena from a peptic ulcer located in the third part of the duodenum. Which diagnostic modality is best for localizing the gastrin-producing tumor?
    a. CT scan of the abdomen
    b. Ultrasound of the abdomen
    c. Somatostatin receptor scintigraphy (SRS)
    d. MRI of the abdomen
    e. Barium meal and follow-through

Answer 105

C. Somatostatin receptor scintigraphy (SRS)
🔹 SRS (Octreotide scan) is the most sensitive test for localizing gastrinomas.
🔹 Why not other options?

(A) CT scan → Less sensitive for small gastrinomas.
(B) Ultrasound → Not useful for detecting pancreatic neuroendocrine tumors.
(D) MRI → Sometimes used but less sensitive than SRS.
(E) Barium meal → Detects ulcers but not the tumor.

Question 106

58. Failure to express a normal trypsinogen inhibitor is associated with familial pancreatitis. Which of the following is involved?
    a. Pancreatic secretory trypsin inhibitor (PSTI)
    b. Serine protease inhibitor Kazal type 1 (SPINK1)
    c. Premature intrapancreatic activation of trypsinogen (PRSS1)
    d. All of the above
    e. None of the above

Answer 106

D. All of the above
🔹 Familial pancreatitis is linked to genetic mutations affecting trypsin activation and inhibition:

(A) PSTI (Pancreatic Secretory Trypsin Inhibitor) → Prevents premature trypsin activation.
(B) SPINK1 (Serine Protease Inhibitor Kazal Type 1) → Loss-of-function mutations lead to pancreatitis.
(C) PRSS1 (Cationic Trypsinogen Mutation) → Causes premature activation of trypsin.

Question 107

59. In which of the following conditions is splenectomy NOT recommended?
    a. Hodgkin’s lymphoma
    b. Splenic artery aneurysm
    c. Thrombotic thrombocytopenic purpura (TTP)
    d. Splenic abscess

Answer 107

A. Hodgkin’s lymphoma
🔹 Hodgkin’s lymphoma is treated with chemotherapy/radiation, NOT splenectomy.
🔹 Splenectomy is indicated for:

Splenic artery aneurysm (B) → Rupture risk.
TTP (C) → If refractory to plasma exchange.
Splenic abscess (D) → High mortality if untreated.

Question 108

60. What is the preferred management of infected pancreatic necrosis as a complication of acute pancreatitis?
    a. CT-guided percutaneous or endoscopic drainage
    b. Video-assisted retroperitoneal debridement and/or endoscopic transluminal debridement
    c. All of the above
    d. Laparotomy is the management of choice

Answer 108

b. Video-assisted retroperitoneal debridement and/or endoscopic transluminal debridement

Question 109

61. A patient is suspected to have pancreatitis due to gallstones. What is the most appropriate recommendation once abdominal pain resolves?
    a. Immediate cholecystectomy
    b. Cholecystectomy within 72 hours during the same hospitalization
    c. Immediate ERCP
    d. Discharge the patient
    e. Give a proton pump inhibitor

Answer 109

B. Cholecystectomy within 72 hours during the same hospitalization
🔹 Early cholecystectomy prevents recurrent gallstone-related pancreatitis.
🔹 Incorrect choices:

(A) Immediate cholecystectomy → Not necessary if patient is stable.
(C) Immediate ERCP → Only needed if there is persistent biliary obstruction.
(D) Discharge without cholecystectomy → High risk of recurrence!
(E) PPI does not treat gallstone pancreatitis.

Question 110

62. Which of the following patients is at the highest risk for overwhelming post-splenectomy infection (OPSI)?
    a. A 5-year-old girl who underwent splenectomy due to bleeding after a vehicular crash
    b. A 30-year-old male who underwent splenectomy due to iatrogenic splenic injury during a left hemicolectomy
    c. A 4-year-old boy who underwent splenectomy for hereditary spherocytosis
    d. A 25-year-old female who underwent splenectomy for immune thrombocytopenic purpura (ITP)

Answer 110

C. A 4-year-old boy who underwent splenectomy for hereditary spherocytosis
🔹 Children under 5 years old are at the highest risk for OPSI due to their immature immune system.
🔹 Patients with hereditary spherocytosis, sickle cell disease, or congenital asplenia are at higher lifelong risk because of their reliance on splenic function for bacterial clearance.
🔹 Incorrect choices:

(A) A 5-year-old trauma patient → High risk but slightly lower than a child with congenital hematologic disorders.
(B) & (D) (Adults post-splenectomy) → Still at risk but lower than young children.

Question 111

63. True statements regarding stimulation of somatostatin release, EXCEPT:
    a. Acetylcholine from cholinergic neurons stimulates release
    b. Acidification of gastric and duodenal mucosa stimulates release
    c. Presence of intraluminal fat after a meal
    d. Octreotide

Answer 111

A. Acetylcholine from cholinergic neurons stimulates release
🔹 Somatostatin release is INHIBITED by acetylcholine and vagal stimulation.
🔹 Somatostatin is stimulated by:

(B) Acidification of gastric and duodenal mucosa (low pH).
(C) Presence of intraluminal fat after a meal.
(D) Octreotide (somatostatin analog).

Question 112

64. The recommended principles of management for moderate acute pancreatitis, EXCEPT:
    a. Maintain normal blood pressure and urine output
    b. Start antibiotics early
    c. Initiate early enteral nutrition
    d. Polymeric formula preferred over immune-enhancing or elemental formula

Answer 112

B. Start antibiotics early
🔹 Antibiotics are NOT routinely recommended in pancreatitis unless there is infected necrosis.
🔹 Standard management includes:

(A) Maintaining normal blood pressure and urine output (fluid resuscitation).
(C) Early enteral nutrition to prevent bacterial translocation.
(D) Polymeric formula is preferred for feeding.

Question 113

65. Hyperfunctioning of the spleen will lead to the development of which condition?
    a. Splenomegaly
    b. Hypersplenism
    c. Both A and B
    d. None of the above

Answer 113

c. Both A and B

Question 114

66. Which hormone has the ability to block insulin effects on the liver and inhibit beta-cell response to incretin hormones and glucose?
    a. Glucagon
    b. Pancreatic polypeptide
    c. Pancreastatin
    d. Ghrelin

Answer 114

d. Ghrelin

Question 115

67. True regarding the blood supply of the pancreas, EXCEPT:
    a. Gastroduodenal artery arises from the right gastric artery
    b. Gastroduodenal artery arises from the common hepatic artery
    c. Superior pancreaticoduodenal artery arises from the gastroduodenal artery
    d. Inferior pancreaticoduodenal artery arises from the inferior mesenteric artery
    e. None of the above

Answer 115

d. Inferior pancreaticoduodenal artery arises from the inferior mesenteric artery

Question 116

68. True regarding pancreatic secretion:
    a. Parasympathetic nervous system stimulates endocrine secretion
    b. Parasympathetic nervous system stimulates exocrine secretion
    c. Sympathetic nervous system inhibits exocrine secretion
    d. All of the above
    e. None of the above

Answer 116

D. All of the above
🔹 Pancreatic secretion is regulated by both the autonomic nervous system and hormonal signals:

(A) Parasympathetic system (vagus nerve) stimulates endocrine secretion (insulin & glucagon).
(B) Parasympathetic system stimulates exocrine secretion (digestive enzymes & bicarbonate).
(C) Sympathetic stimulation inhibits pancreatic exocrine secretion.

Question 117

69. True regarding a replaced right hepatic artery:
    a. Occurs in 15% of patients
    b. Injury during dissection of the porta hepatis leads to hepatic necrosis
    c. Multidetector thin-cut CT images help prevent injury
    d. All of the above
    e. None of the above

Answer 117

D. All of the above
🔹 Replaced right hepatic artery occurs in ~15% of patients, arising from the superior mesenteric artery (SMA).
🔹 Injury during porta hepatis dissection can lead to hepatic necrosis.
🔹 Multidetector thin-cut CT scans help prevent accidental injury during surgery.

Question 118

70. True statements regarding pancreas divisum:
    a. Failure of fusion of ventral and dorsal pancreatic ducts occurs in 10% of cases
    b. Best seen on ERCP and MRCP
    c. May result in pancreatitis
    d. All of the above
    e. None of the above

Answer 118

D. All of the above
🔹 Pancreas divisum results from incomplete fusion of the dorsal and ventral pancreatic ducts, occurring in ~10% of cases.
🔹 Best diagnosed via ERCP or MRCP.
🔹 Can cause recurrent pancreatitis due to inadequate pancreatic drainage.

Question 119

He performed the first successful cholecystectomy in 1882.
A. Billroth I
B. Whipple
C. Billroth II
D. Carl Langenbuch

Answer 119

D. Carl Langenbuch

Question 120

He introduced laparoscopic cholecystectomy in 1987.
A. Philippe Mouret
B. De Lumley
C. Wilder Muther
D. Wickham

Answer 120

A. Philippe Mouret

Question 121

The structure found at the triangle of Calot is the
A. Common hepatic duct
B. Cystic duct
C. Cystic artery
D. Common bile duct

Answer 121

C. Cystic artery

Question 122

After cholecystectomy, the surgeon opened the gallbladder specimen and noted its milky content. This is due to
A. Secretion of pancreatic juice into the common bile duct
B. Bile reabsorption of bile pigments by the gallbladder mucosa
C. Reduced bile pigments in the liver
D. Absence of bilirubin glucuronidase

Answer 122

B. Bile reabsorption of bile pigments by the gallbladder mucosa

Question 123

A 45-year-old female came in due to fever, jaundice, and right upper quadrant pain. The most likely initial diagnosis would be
A. Acute cholecystitis
B. Acute hepatitis
C. Acute pancreatitis
D. Ascending cholangitis

Answer 123

D. Ascending cholangitis

Question 124

The common bile duct and pancreatic duct merge to enter the duodenum as a single duct in what percentage of the population?
A. 20%
B. 30%
C. 50%
D. 70%

Answer 124

D. 70%

Question 125

The cystic artery most commonly arises from the right hepatic artery (80-90%). The second most anatomic configuration of the cystic artery, which occurs in 10% of people, is
A. Two cystic arteries, both arising from the right hepatic artery
B. Two cystic arteries and one arising from the right hepatic artery and one arising from the left hepatic artery
C. One cystic artery, arising from an aberrant right hepatic artery
D. One cystic artery, arising from the gastroduodenal artery

Answer 125

C. One cystic artery, arising from an aberrant right hepatic artery

Question 126

The gallbladder is able to store only a small fraction of the bile produced by the liver. The primary mechanism used to keep the gallbladder from becoming distended (and developing high pressure) by this volume of bile is
A. The bile continuously secretes into the duodenum once the pressure in the gallbladder increases.
B. There is enough contraction of the gallbladder in response to eating, to empty the large volume of bile.
C. The gallbladder concentrates the large volume of bile.
D. The liver decreases the bile production when the pressure in gallbladder increases.

Answer 126

C. The gallbladder concentrates the large volume of bile.

Question 127

The primary stimulus of gallbladder contraction is
A. Vasoactive intestinal polypeptide
B. Somatostatin
C. Cholecystokinin
D. Enkephalin

Answer 127

C. Cholecystokinin

Question 128

The half-life of CCK (cholecystokinin) is
A. 2-3 minutes
B. 20-30 minutes
C. 2-3 hours
D. 20-30 hours

Answer 128

A. 2-3 minutes

Question 129

The sensitivity of ultrasound in detecting gallbladder stones is
A. > than 99%
B. 90-95%
C. 85-90%
D. 80-85%

Answer 129

B. 90-95%

Question 130

A 35-year-old female has an incidental finding of cholelithiasis on plain radiograph obtained following a minor car accident. Her risk of developing symptoms from these gallstones in the next 20 years is
A. 7%
B. 18%
C. 33%
D. 52%

Answer 130

C. 33%

Question 131

Which of the following is an indication for cholecystectomy in an asymptomatic patient with an incidental finding of gallstones?
A. Any history of abdominal pain
B. Family history of complications of cholelithiasis
C. Porcelain gallbladder
D. Frequent travel out of the country

Answer 131

C. Porcelain gallbladder

Question 132

Which of the following is one of the components of gallstones?
A. Biliverdin
B. Hemoglobin
C. Lecithin
D. Short chain fatty acids

Answer 132

C. Lecithin

Question 133

Which of the following is the most common location for pain during an attack of biliary colic?
A. Left periumbilical
B. Right shoulder
C. Epigastrium
D. Scapula

Answer 133

C. Epigastrium

Question 134

A 24-year-old female in the 20th week of pregnancy experiences a single episode of biliary colic. The most appropriate initial management is
A. Observation with plans to follow her up after delivery for recurrent episodes
B. Dietary changes
C. Elective laparoscopic cholecystectomy during 2nd trimester
D. Elective open cholecystectomy during the 2nd trimester

Answer 134

B. Dietary changes

Question 135

A 53-year-old male is admitted with 24 hours of pain from acute cholecystitis. He was placed on NPO, IV antibiotics started, and analgesia given. He should undergo cholecystectomy
A. Urgently
B. In 1-3 days
C. In 7-10 days
D. 6-8 weeks

Answer 135

B. In 1-3 days

Question 136

Primary choledochal stones are usually
A. Cholesterol stones
B. Black pigment stones
C. Brown pigment stones
D. Mulberry stones

Answer 136

C. Brown pigment stones

Question 137

A patient presents with biliary colic. On ultrasound, there are multiple small stones in the gallbladder and the common bile duct measures 9mm in diameter. No stone is visualized in the common bile duct. Which of the following is the most reasonable next step?
A. Repeat ultrasound in 24-48 hours
B. MRCP with contrast
C. Percutaneous cholangiography
D. Laparoscopic cholecystectomy and intraoperative cholangiography

Answer 137

D. Laparoscopic cholecystectomy and intraoperative cholangiography

Question 138

A 75-year-old man presents with cholangitis, symptomatic cholelithiasis, and choledocholithiasis. The best treatment for him is
A. ERCP followed by cholecystectomy
B. Cholecystectomy, flushing of the common bile duct with subsequent ERCP if necessary
C. Laparoscopic cholecystectomy and common bile duct exploration
D. ERCP and endoscopic sphincterotomy

Answer 138

D. ERCP and endoscopic sphincterotomy

Question 139

The treatment of a type II choledochal cyst is
A. Observation with annual ultrasound
B. ERCP with sphincterotomy
C. Drainage with a Roux-en-Y choledochojejunostomy
D. Resection with a Roux-en-Y hepaticojejunostomy

Answer 139

D. Resection with a Roux-en-Y hepaticojejunostomy

Question 140

In addition to regional lymphadenectomy, appropriate surgical treatment for a T2 carcinoma of the gallbladder is
A. Cholecystectomy only
B. Cholecystectomy with resection of liver segments IVB and V
C. Cholecystectomy with limited right hepatectomy
D. Cholecystectomy with extended right hepatectomy

Answer 140

B. Cholecystectomy with resection of liver segments IVB and V

Question 141

Cholangiocarcinoma most commonly occurs
A. In the intrahepatic ducts
B. In the common hepatic duct at the bifurcation
C. At the junction of the hepatic and common bile ducts
D. In the distal common bile duct

Answer 141

B. In the common hepatic duct at the bifurcation

Question 142

Insulin secretion is stimulated by
A. Lysine
B. Somatostatin
C. Amylase
D. Alpha adrenergic stimulation

Answer 142

A. Lysine

Question 143

Which of the following pancreatic enzymes is secreted in an active form?
A. Amylase
B. Chymotrypsinogen
C. Trypsinogen
D. Pepsin

Answer 143

A. Amylase

Question 144

Sympathetic stimulation of the pancreas results in
A. Stimulation of endocrine and exocrine secretion
B. Inhibition of endocrine and exocrine secretion
C. Stimulation of endocrine and inhibition of exocrine secretion
D. Inhibition of endocrine and stimulation of exocrine secretion

Answer 144

B. Inhibition of endocrine and exocrine secretion

Question 145

The most common gene mutation found in pancreatic cancer is
A. HER2/neu
B. K-ras
C. p53
D. Smad 4

Answer 145

B. K-ras

Question 146

Pancreatic delta cells produce
A. Somatostatin
B. Ghrelin
C. Pancreatic polypeptide (PP)
D. Glucagon

Answer 146

A. Somatostatin

Question 147

Pancreatic acinar cells secrete
A. Lipase
B. Amylase
C. Proteases
D. All of the above

Answer 147

D. All of the above

Question 148

Which of the following is the primary stimulus for secretion of bicarbonate by the pancreas?
A. CCK
B. Gastrin
C. Acetylcholine
D. Secretin

Answer 148

D. Secretin

Question 149

A 4-week-old baby was brought to the ER because of yellowish discoloration of the skin and sclera which was noted to be progressive since birth. The most likely diagnosis is
A. Hemolytic disease of the newborn
B. Puerperal sepsis
C. Biliary atresia
D. Neonatal syphilis

Answer 149

C. Biliary atresia

Question 150

Surgical specimen showed Rokitansky-Aschoff sinuses. The most probable diagnosis is
A. Sclerosing cholangitis
B. Chronic cholecystitis
C. Ascending cholangitis
D. Acute cholecystitis

Answer 150

B. Chronic cholecystitis

Question 151

Bile is
A. 95% excreted in the stool
B. 80% is absorbed in the proximal jejunum
C. Cholesterol and phospholipids are the principal lipids
D. Primary bile salts of deoxycholate and lithocholate acids
E. None of the above

Answer 151

C. Cholesterol and phospholipids are the principal lipids

Question 152

The gallbladder differs histologically from the rest of the GIT by
A. It lacks muscularis mucosae and submucosa
B. Absence of serosa
C. Stratified squamous epithelium
D. None of the above
E. All of the above

Answer 152

A. It lacks muscularis mucosae and submucosa

Question 153

Injury to the gallbladder is best treated
A. Primary repair
B. Primary repair with tube cholecystostomy
C. Cholecystectomy
D. Primary repair with tube choledochostomy

Answer 153

C. Cholecystectomy

Question 154

Mechanism by which gallstones cause pancreatitis
A. Common channel theory
B. Incompetent sphincter of Oddi
C. Colocalization theory
D. All of the above
E. A and B

Answer 154

A. Common channel theory

Question 155

Enzyme responsible for the activation of zymogens
A. Trypsinase
B. Pancreatic lipase
C. Enteropeptidase
D. All of the above
E. A and B

Answer 155

C. Enteropeptidase

Question 156

Pancreas is protected from autodigestion by
A. Zymogen granules
B. Trypsin inhibitors
C. Duodenal activation of proenzymes
D. All of the above
E. A and B

Answer 156

D. All of the above

Question 157

Differential diagnosis for acute pancreatitis
A. Perforated peptic ulcer
B. Gangrenous small bowel obstruction
C. Diverticulitis
D. All of the above
E. A and B

Answer 157

E. A and B

Question 158

In acute pancreatitis, serum amylase is
A. Elevated for 3-5 days
B. Highly specific
C. Elevation correlates with severity
D. All of the above
E. A and B

Answer 158

D. All of the above

Question 159

Splenectomy is most effective as a treatment in which of the following conditions?
A. Cold-antibody
B. Autoimmune
C. Hemolytic anemia
D. Wandering spleen
E. Hodgkin’s disease G6PD deficiency

Answer 159

D. Wandering spleen

Question 160

Which is an indication for surgical treatment for splenic aneurysms?
A. Pregnancy
B. Neutropenia
C. Thrombocytopenia
D. 1.5cm size

Answer 160

A. Pregnancy

Question 161

A patient was diagnosed to have thrombotic thrombocytopenic purpura (TTP). In addition to purpura and thrombocytopenia, studies will show which of the following?
A. Normal arterioles on biopsy of spleen
B. Absence of infarction on biopsy of spleen
C. Leukopenia
D. Elevated urea and creatinine levels
E. Suppression of reticulocyte

Answer 161

D. Elevated urea and creatinine levels

Question 162

A 25-year-old female presents with episodes of bizarre behavior, memory lapse, and unconsciousness. She also demonstrated previous episodes of extreme hunger, sweating, and tachycardia. During one of these episodes, her blood sugar was tested and was found to be 40 mg/dL. Which would suggest a diagnosis of insulinoma?
A. Demonstration of insulin antibodies in blood
B. Abnormal glucagon level
C. CT of the pancreas
D. Hypoglycemia during a symptomatic episode with relief of symptoms by intravenous glucose

Answer 162

D. Hypoglycemia during a symptomatic episode with relief of symptoms by intravenous glucose

Question 163

Factors in Harmless acute pancreatitis score, EXCEPT
A. Normal WBC, glucose, and LDH values
B. Abdominal tenderness
C. Normal hematocrit
D. Creatinine

Answer 163

A. Normal WBC, glucose, and LDH values

Question 164

True statements re: causes of Acute Pancreatitis, EXCEPT
A. ERCP
B. Hyperlipidemia
C. Associated with furosemide and propofol
D. Diabetes mellitus

Answer 164

D. Diabetes mellitus

Question 165

A 48-year-old woman presents with severe recurrent peptic ulcer located in the proximal jejunum. Five years previously she underwent parathyroidectomy for hypercalcemia. Her brother was previously diagnosed as having Zollinger-Ellison syndrome. The patient develops severe peptic ulcer disease that recurs despite gastric resection and vagotomy operation. She now presents with melena from a peptic ulcer located in the third part of the duodenum. To localize the gastrin-producing tumor, she should have which of the following?
A. CT scan of the abdomen
B. Ultrasound of the abdomen
C. Somatostatin receptor scintigraphy (SRS)
D. MRI of the abdomen
E. Barium meal and follow through

Answer 165

C. Somatostatin receptor scintigraphy (SRS)

Question 166

True regarding Pancreatic secretion, EXCEPT
A. Parasympathetic nervous system stimulates endocrine secretion
B. Sympathetic nervous system stimulates exocrine secretion
C. Somatic and afferent sensory fibers are responsible for the intense pain in pancreatic cancer
D. Sympathetic nervous system inhibits secretion

Answer 166

B. Sympathetic nervous system stimulates exocrine secretion

Question 167

Which of the following is the most likely differential diagnosis for acute pancreatitis?
A. Perforated peptic ulcer
B. Cystitis
C. Diverticulitis
D. Pelvic inflammatory disease
E. Incarcerated inguinal hernia

Answer 167

A. Perforated peptic ulcer

Question 168

A 48-year-old woman presents with a severe recurrent peptic ulcer located in the proximal jejunum. Five years previously she underwent parathyroidectomy for hypercalcemia. Her brother was previously diagnosed as having Zollinger-Ellison syndrome. High levels of gastrin confirm the diagnosis of Zollinger-Ellison syndrome. What are the borders of the Passaro triangle to determine the usual location of gastrinoma?
A. Head of the pancreas
B. Neck and body of pancreas
C. Second and third portion of duodenum
D. Junction of cystic and common duct

Answer 168

A. Head of the pancreas

Question 169

Which of the following is an unlikely indication for splenectomy?
A. Polycythemia vera
B. Hereditary spherocytosis
C. Abscess of the spleen
D. Blunt trauma

Answer 169

A. Polycythemia vera

Question 170

A 73-year-old woman is evaluated for obstructive jaundice consequent to an injury to the CBD 7 months previously at laparoscopic cholecystectomy. The alkaline phosphatase is elevated. In obstructive jaundice, what is alkaline phosphatase likely to do?
A. Its level increases before that of bilirubin
B. Its level is unlikely to be increased in pancreatic malignancy
C. Its elevation indicates bone metastasis
D. Its level falls after that of the bilirubin following surgical intervention

Answer 170

A. Its level increases before that of bilirubin

Question 171

True regarding the pancreatic histology and physiology, EXCEPT
A. Only 2% of the gland comprises endocrine secretion
B. Acinar cells responsible for about 85% of pancreatic secretion
C. At least 40% of pancreatic mass is required to prevent insufficiency
D. Complex system of endocrine and exocrine pancreas allows coordinated regulatory feedback system

Answer 171

C. At least 40% of pancreatic mass is required to prevent insufficiency

Question 172

A 30-year-old male is admitted with frequent episodes of hypoglycemia with a localized 2-cm mass in the body of the pancreas. Which of the following is not typical of insulinoma?
A. Fasting hypoglycemia
B. Glucose levels below 50 mg/dL
C. Relief of symptoms with glucose administration managed by subtotal pancreatectomy
D. Palpitation ,diaphoresis ,confusion are common symptoms

Answer 172

C. Relief of symptoms with glucose administration managed by subtotal pancreatectomy

Question 173

Splenectomy is not recommended in patients with?
A. Hodgkin’s lymphoma
B. Splenic artery aneurysm
C. Thrombotic thrombocytopenic purpura
D. Splenic abscess

Answer 173

A. Hodgkin’s lymphoma

Question 174

Which of the following is at highest risk for OPSI (overwhelming post-splenectomy infection)?
A. 5-year-old girl who underwent splenectomy due to bleeding after a vehicular crash
B. 30-year-old male who underwent splenectomy due to iatrogenic splenic injury during a left hemicolectomy
C. 4-year-old boy who underwent splenectomy for hereditary spherocytosis
D. 25-year-old female who underwent splenectomy for ITP

Answer 174

C. 4-year-old boy who underwent splenectomy for hereditary spherocytosis

Question 175

The mechanism of alcohol-induced acute pancreatitis is thought to involve all the following EXCEPT
A. Spasm of sphincter of Oddi with secretory burst of acinar cells
B. Predisposes the cells to autodigestive injury and cell death leading to synthesis of proinflammatory mediators and cytokines
C. Mutation of PRSS1 and SPINK1 protein

Answer 175

C. Mutation of PRSS1 and SPINK1 protein

Question 176

A 67-year-old woman is evaluated for obstructive jaundice. The cholangiographic findings indicate that she has cancer of the lower end of the common bile duct. Clinical examination would most likely reveal which of the following?
A. Enlarged gallbladder
B. Shrunken gallbladder
C. Enlarged pancreas
D. Shrunken pancreas
E. Palpable tumor

Answer 176

A. Enlarged gallbladder

Question 177

True statements regarding pancreatic beta cells, EXCEPT
A. Beta cells make up about 70% of the total islet cell mass
B. Beta cells are evenly distributed throughout the pancreas
C. Beta cells secrete multiple hormones
D. Beta cells are mostly in the pancreatic body and tail

Answer 177

B. Beta cells are evenly distributed throughout the pancreas

Question 178

What hormone inhibits pancreatic exocrine secretion and facilitates hepatic action of insulin?
A. Bombesin
B. Glucagon
C. Somatostatin
D. Pancreatic polypeptide

Answer 178

D. Pancreatic polypeptide

Question 179

True statements regarding the replaced right hepatic artery, EXCEPT
A. Occurs in about 20% or 1 in every five patients
B. Right hepatic artery arises from the superior mesenteric artery
C. Right hepatic artery from the hepatic artery proper
D. Due to high incidence, preoperative CT scans are very important

Answer 179

C. Right hepatic artery from the hepatic artery proper

Question 180

True statements regarding Pancreas Divisum
A. Important to identify anomalies and clarify ductal patterns prior to intervention
B. Poorly visualized on CT scan and best seen only by endoscopic retrograde cholangiopancreatography
C. Congenital anomaly without consequences to patients; the main pancreatic duct is the duct of Wirsung

Answer 180

A. Important to identify anomalies and clarify ductal patterns prior to intervention

Question 181

A 62-year-old man is admitted with vague abdominal pain, weight loss, and jaundice. The direct bilirubin level is 5.6 mg/dL with a total bilirubin of 8 mg/dL. What is the most likely cause of jaundice in this patient?
A. Alcoholic hepatitis
B. Carcinoma of the pancreas
C. Liver cirrhosis
D. Pancreatic pseudocyst
E. Hemolytic anemia

Answer 181

B. Carcinoma of the pancreas

Question 182

Which of the following stimulates insulin release?
A. Pancreastatin
B. Incretins
C. Beta sympathetic fibers
D. Amylin

Answer 182

B. Incretins

Question 183

The human spleen plays a key immunologic role in defense against a number of organisms, particularly
A. Staphylococcus aureus
B. E. coli
C. Klebsiella
D. Streptococcus
E. Clostridium tetani

Answer 183

D. Streptococcus

Question 184

A type of hormone with the ability to block insulin effects on the liver and inhibits beta cell response to incretin hormones and glucose?
A. Glucagon
B. Pancreatic polypeptide
C. Pancreastatin
D. Ghrelin

Answer 184

D. Ghrelin

Question 185

A 42-year-old woman with a history of on and off abdominal pain and indigestion for 6 months. Bilirubin and amylase levels are initially elevated but repeat tests showed top normal values. An ultrasound reveals multiple gallbladder polyps. The symptoms abate on the 5th day after admission. How should she be advised?
A. To start on a low-fat diet
B. To increase the fat content of her diet
C. To undergo immediate cholecystectomy
D. That she will be discharged and should undergo elective cholecystectomy after 3 months

Answer 185

C. To undergo immediate cholecystectomy

Question 186

Splenectomy is often indicated in the management of the following?
A. Hereditary neurofibromatosis
B. Aplastic anemia
C. Pheochromocytoma
D. Hairy cell leukemia

Answer 186

D. Hairy cell leukemia

Question 187

The high rate of Overwhelming post-splenectomy infection (OPSI) in thalassemia patients is thought to be due to an immune deficiency. Which of the following strategies has been shown effective to reduce mortality?
A. Partial splenectomy
B. Prophylactic antibiotics
C. Delaying splenectomy until after 2 years of age
D. Maintenance of >9 mg/dL hemoglobin

Answer 187

A. Partial splenectomy

Question 188

A 39-year-old man who consumed more than 3 bottles of gin weekly over the past 15 years is admitted with upper abdominal pain radiating to the back, nausea, and vomiting. Serum amylase and lipase are elevated, and a diagnosis of pancreatitis is made. In determining his prognosis, which of the following factors would cause the greatest concern?
A. Calcium level < 10 mg/dL
B. Age less than 40 years
C. Blood glucose of 200 mg/dL
D. Creatinine of 2 mg/dL

Answer 188

D. Creatinine of 2 mg/dL

Question 189

Which pancreatic islet cell type produces a hormonal peptide to stimulate glycogenesis, protein synthesis, and glucose uptake?
A. Alpha cell
B. Beta cell
C. Delta cell
D. F cell
E. PP cell

Answer 189

B. Beta cell

Question 190

What is the most common etiology of splenic cysts worldwide?
A. Parasitic infection
B. Bacterial infection
C. Trauma
D. Congenital anomaly

Answer 190

A. Parasitic infection

Question 191

A 58-year-old man with a 30-year history of alcoholism and pancreatitis is admitted to the hospital with an elevated bilirubin level of 5 mg/dL, alcoholic stools, and an amylase level of 600 U. Obstructive jaundice in chronic pancreatitis usually results from which of the following?
A. Sclerosing cholangitis
B. Common bile duct (CBD) compression caused by inflammation
C. Biliary dyskinesia
D. Cirrhosis

Answer 191

B. Common bile duct (CBD) compression caused by inflammation

Question 192

All of the following are functions of the spleen EXCEPT
A. Clearance of damaged or aged RBC
B. Initiation of adaptive immune response from filtration of lymph
C. Extramedullary site for hematopoiesis and iron recycling
D. Clearance of encapsulated bacteria from the bloodstream

Answer 192

B. Initiation of adaptive immune response from filtration of lymph

Question 193

True statements regarding acinar cell events in acute pancreatitis, EXCEPT
A. Common channel obstruction of pancreatic duct with bile reflux
B. Insult to acinar cells leads to colocalized lysosomal and zymogen contents
C. Trypsinogen is activated to trypsin by cathepsin B
D. Release of cytokines as a result of NF-kappa Beta activation

Answer 193

A. Common channel obstruction of pancreatic duct with bile reflux

Question 194

A 45-year-old patient with chronic pancreatitis is suffering from malnutrition and weight loss secondary to inadequate pancreatic exocrine secretions. Which is true regarding pancreatic secretions?
A. Secretin releases fluid rich in enzymes
B. Secretin releases fluid rich mainly in electrolytes and bicarbonate
C. Cholecystokinin releases fluid, predominantly rich in electrolytes and bicarbonate
D. All pancreatic enzymes are secreted in an inactive form
E. The pancreas produces proteolytic enzymes only

Answer 194

D. All pancreatic enzymes are secreted in an inactive form

Question 195

A 72-year-old male was referred for evaluation of painless jaundice without palpable abdominal mass. Where is the most likely location of the tumor?
A. Cancer of the head of the pancreas
B. Ampullary tumor
C. Carcinoma of distal CBD
D. Duodenal carcinoma

Answer 195

C. Carcinoma of distal CBD

Question 196

A 70-year-old man was diagnosed with polycythemia vera with associated back pain and myeloid metaplasia. This condition is characterized by which of the following?
A. Decrease in connective tissue of the spleen
B. Decrease in the blood elements of the spleen
C. Aplastic anemia
D. Deterioration after splenectomy
E. A favorable response to alkylating agents

Answer 196

E. A favorable response to alkylating agents

Question 197

Pancreatic pseudocyst commonly develops in this area
A. Main pancreatic duct
B. Floor of the lesser sac
C. Pancreatic body
D. Pancreatic tail

Answer 197

B. Floor of the lesser sac

Question 198

A 20-year-old college student recovers from a bout of severe pancreatitis. About 14 days after his recovery, he still has mild epigastric discomfort, sensation of bloating, and loss of appetite. Ultrasound showed presence of cystic mass around the stomach. What should be the next step in management?
A. Percutaneous drainage of the cyst
B. Laparotomy and internal drainage of the cyst
C. Pancreatectomy
D. Nutritional support and pain control

Answer 198

D. Nutritional support and pain control

Question 199

What type of DM patient usually presents with high levels of insulin and pancreatic polypeptide with rare occurrence of hypoglycemia and ketoacidosis?
A. Type 4m
B. Type 3c
C. Type 2
D. Type 1

Answer 199

B. Type 3c

Question 200

True regarding the blood supply of Pancreas, EXCEPT
A. Gastroduodenal artery from right gastric artery
B. Gastroduodenal artery from common hepatic artery
C. Superior pancreaticoduodenal artery from gastroduodenal artery
D. Inferior pancreaticoduodenal artery from inferior mesenteric artery

Answer 200

D. Inferior pancreaticoduodenal artery from inferior mesenteric artery

Question 201

True statements regarding Pancreas anatomy EXCEPT
A. Behind the head of the pancreas lie the right renal artery and vena cava
B. Neck of the pancreas lies directly anterior to portal vein
C. Body of the pancreas lies anterior to splenic artery and vein
D. SMV is joined by IMV commonly at the inferior border of neck of pancreas

Answer 201

D. SMV is joined by IMV commonly at the inferior border of neck of pancreas

Question 202

A patient is suspected to have pancreatitis due to gallstone. What management modality is LEAST appropriate?
A. Cholecystectomy within 48 hours
B. Cholecystectomy after 72 hours within same hospitalization
C. Immediate ERCP
D. ERCP after 24 hours
E. Give proton pump inhibitor

Answer 202

C. Immediate ERCP

Question 203

A 67-year-old man with a chronic history of biliary sludge and on and off abdominal pain was admitted due to severe abdominal pain. Amylase level is 2000 IU/L and Examination of the abdomen reveals epigastric tenderness. What is the best test to determine the likely cause of the pain?
A. Endoscopic retrograde cholangiopancreatography
B. Upper GI endoscopy
C. Abdominal CT scan pancreatic protocol
D. Hepatobiliary tree ultrasound

Answer 203

C. Abdominal CT scan pancreatic protocol

Question 204

Normally, activation of pancreatic trypsinogen involves which of the following?
A. Pancreatic amylase
B. pH greater than 7
C. Lysosomal hydrolase
D. Pancreatic enterokinase
E. Duodenal enterokinase

Answer 204

E. Duodenal enterokinase

Question 205

The recommended principles of management for moderate acute pancreatitis, EXCEPT
A. Maintain normal blood pressure and urine output
B. Adequate pain control with morphine
C. Initiate early enteral nutrition
D. Polymeric formula preferred over immune-enhancing or elemental formula

Answer 205

B. Adequate pain control with morphine

Question 206

Hyperfunctioning spleen will lead to development of what condition?
A. Splenomegaly
B. Hypersplenism
C. Both A and B
D. None of the above

Answer 206

C. Both A and B

Question 207

The most common location of accessory spleen
A. Gastrocolic ligament
B. Pancreatic tail
C. Greater omentum
D. Splenocolic ligament
E. Splenic hilum

Answer 207

E. Splenic hilum

Question 208

True statements regarding stimulation of somatostatin release, EXCEPT
A. Acetylcholine from cholinergic neurons stimulates release
B. Acidification of gastric and duodenal mucosa stimulates release
C. Presence of intraluminal fat after a meal stimulates release
D. Octreotide stimulates release

Answer 208

A. Acetylcholine from cholinergic neurons stimulates release

Question 209

What is the most commonly mutated gene in pancreatic cancer?
A. p53
B. K-ras
C. p16 DPC4
D. BRCA2

Answer 209

B. K-ras

Question 210

A 68-year-old male with recent onset diabetes developed vague abdominal pain radiating to the back. On PE, he has lost 10 kg in the past 3 months. What test will you request?
A. Total Bilirubin, B1B2
B. Abdominal X-ray upright and supine
C. Abdominal Ultrasound
D. Multidetector CT scan of the abdomen

Answer 210

D. Multidetector CT scan of the abdomen

Question 211

A 56-year-old female complained of severe colicky RUQ pain 2 days prior to consult which later became constant epigastric pain with radiation to the mid-back on the day of admission. Serum amylase level 5000 IU/L, alkaline phosphatase is 400 IU/L with ALT 200 IU/L. Ultrasound showed no echogenic focus in the gallbladder. What is the most likely etiologic agent?
A. Alcohol-induced pancreatitis
B. Gallstone-induced pancreatitis
C. Acute acalculous cholecystitis
D. Peptic ulcer disease

Answer 211

B. Gallstone-induced pancreatitis

Question 212

A 40-year-old woman with vague abdominal pain and weight loss was diagnosed with a 3 cm pancreatic mass located at the body. Biopsy showed lymphoma and on metastatic workup showed no other evidence of abnormal masses. Which of the following management is most appropriate?
A. Pancreaticojejunostomy (Puestow)
B. Whipple’s procedure
C. Chemotherapy
D. Subtotal pancreatectomy
E. Total pancreatectomy with insulin replacement

Answer 212

C. Chemotherapy

Question 213

The highest mortality can be anticipated when pancreatitis occurs after which of the following?
A. Beer ingestion
B. Heavy fatty meal
C. ERCP
D. Parotitis

Answer 213

C. ERCP

Question 214

What is the most effective prevention strategy against OPSI post splenectomy?
A. Antibiotic prophylaxis
B. Isolation
C. Preoperative vaccination
D. Postoperative vaccination

Answer 214

C. Preoperative vaccination

Question 215

A 66-year-old man with obstructive jaundice is found on ERCP to have a mass in the periampullary area. Which of the following is an unlikely cause?
A. Tumor of distal CBD
B. Duodenal cancer
C. Duodenal ulcer
D. Ampullary cancer
E. Pancreatic head cancer

Answer 215

C. Duodenal ulcer

Rationale:
A periampullary mass refers to a tumor located near the ampulla of Vater, where the common bile duct (CBD), pancreatic duct, and duodenum meet. Such masses can obstruct bile flow, leading to obstructive jaundice.

Question 216

Surgical intervention is usually not recommended to treat complications in patients with pancreatitis presenting with what?
A. Obstructive jaundice
B. Pseudocyst
C. Abscess
D. Acute edematous pancreatitis
E. Choledocholithiasis

Answer 216

D. Acute edematous pancreatitis

Question 217

A 41-year-old woman is known to have multiple endocrine neoplasia syndrome. She has multiple family members who have had adenoma tumors removed from the parathyroid, pancreas, and/or pituitary glands. She has severe diarrhea associated with low gastric acid secretion and a normal gastrin level. Which of the following serum assays would be best to evaluate the possible cause of the diarrhea?
A. Gastrin
B. Vasoactive intestinal peptide (VIP)
C. Cholecystokinin
D. Serotonin
E. Norepinephrine

Answer 217

B. Vasoactive intestinal peptide (VIP)

Question 218

A 67-year-old woman complained of vague abdominal pain and MRI scan with MRCP reveals a 3.5 cm pancreatic cyst with thickened enhancing cyst wall and non-enhancing mural nodules at the body of the pancreas. Which statement is correct regarding the management of pancreatic cysts?
A. No further workup needed, just do surveillance
B. Advise endoscopic ultrasound
C. Immediate surgical resection
D. Repeat CT scan with contrast

Answer 218

C. Immediate surgical resection