ANSWERS WITH RATIONALE

64) a
Septic complications occurring after the first 10 to 14
days of the disease are the most frequent cause of
death in patients with pancreatic necrosis. When
necrotic areas become infected by enteric germs, the
prognosis of a patient deteriorates. Mortality rates in
infected necrosis are reported to be between 15 and
25%. The rate of infected pancreatic necrosis
correlates closely with the amount of necrotic
parenchyma in the retroperitoneum and therefore
patients with subtotal to total necrosis of the gland
have the highest risk of experiencing a fatal course. In
contrast, sterile pancreatic necrosis has a better
prognosis with lower mortality rates (between 5 and
10%). As a consequence, the discrimination between
sterile pancreatic necrosis and infected pancreatic
necrosis is one of the main staging principles of the
current treatment guidelines. Antibiotics especially
Imipenams have a role in preventing infections.
65) c
Solitary cysts of the pancreas are rare. In contrast,
multiple pancreatic cysts, lined with cuboidal
epithelium, are more common. They are frequently
associated with polycystic disease of the liver and/or
kidney, and they can be seen in up to half of patients
with von Hippel-Lindau syndrome. Pancreatic cysts
only rarely become symptomatic and, in general, no
treatment is indicated.
66) d
In Pancraetic cancers the following genetic
abnormailities are seen Activation of growth-promoting
oncogenes like kras Mutations that result in the
inactivation of tumor suppressor genes (p53, p16,
SMAD, DCC. DPC, MMR genes) Excessive
expression of growth factors and/or their receptors
(EGFR,HER2, HER3, HER4)
Pancreatic cancer has been observed to be increased
in families with hereditary nonpolyposis colon cancer
(HNPCC), those with familial breast cancer (associated
with the BRCA2 mutation), those with Peutz-Jeghers
syndrome, those with ataxia-telangiectasia, and those
with the familial atypical multiple mole melanoma
(FAMMM) syndrome.
67. a
Ductal adenocarcinoma and its variants account for
80% to 90% of all pancreatic neoplasms and for an
even greater fraction of the malignant tumors. Roughly
70% of ductal cancers arise in the pancreatic head or
uncinate process.
68. d
It can be located in any or all parts of the pancreas,
although involvement of the head appears to be its
most common form. IPMT patients can experience
pancreatitis when mucus, secreted by the tumor,
transiently obstructs the orifice of the pancreatic duct.
The diagnosis of IPMT can be made with near

certainty if mucus is seen extruding through a large,

fish-mouth orifice.
IPMT is believed to follow an adenoma-carcinoma
sequence, and it can be classified according to the
Pan-IN classification scheme ( that categorizes tumors
as having minimal or no dysplasia (PanIN-1), moderate
dysplasia (PanIN-2), or severe dysplasia/carcinoma in
situ (PanIN-3) The natural history of tumors with only
mild or no dysplasia is not known, but those with
severe dysplasia and/or carcinoma in situ are likely to
become locally invasive and metastasize if left
unresected.
69. c. Gallstones. Gallstones are the most common
cause of acute pancreatitis, accounting for 45% of all
cases. This patients history of gallstones, as well as
her elevated serum bilirubin, alkaline phosphatase,
and transaminase levels and markedly elevated serum
amylase and lipase levels strongly suggest biliary and
pancreatic duct obstruction due to gallstone. Although
patient had a cholecystectomy, this surgery does not
rule out gallstone as cause of pancreatitis, patient can
still form stone or could have retained a stone even
after surgery.
70. e. Ultrasonography of RUQ. When ther is strong
suspicion of gallstone induced pancreatitis, ultrasound
is the imaging modality of choice as it is extremely
sensitive in detecting gallstone and a dilated common
bile duct.
71. a. Pancreas usually weigh 75-100 gm.
72.b. 80% occur in the head of gland
73. a. observation. Pseudocyst develop in approx. 10%
of patients who experience pancreatitis. Cysts can
cause pain, become infected , leak, compress adjacent
organs, bleed and even erode into mediatinum.
Because of the patients lack of symptoms, small cyst
size and relatively recent previous episode of acute
pancreatitis, observations is the most appropriate next
step in managing his pancreatitis.
74. b. administration of non-enteric coated pancreatic
enzyme replacement tablets with meals and snacks
with concurrent dosing with a histamine2 blocker. Nonenteric coated pancreatic enzyme replacement with
concurrent dosing with a histamine2 blocker dosing will
deliver active enzymes to the proximal small bowel and
help reduce the malabsorption and steatorrhea that
this patient is experiencing.