PANCREAS

Q1- A 66-yr-old man presents with worsening jaundice, intermittent abdominal pain
and weight loss. He is jaundiced, cachectic and has a non-tender mass in the right
upper quadrant. Which of the following investigations is most likely to establish the
Dx?
A. CT scan of the abdomen
B. Liver biopsy
C. Sweat test
D. Alpha-fetoprotein level
E. Serum gastrin level

Q2- A 55-yr-old man is admitted with acute epigastric pain, nausea and vomiting. He
has Hx of hypertension and takes 2.5 mg bendroflumethiazide daily. He has
tenderness, guarding and rigidity of the abdomen. Which one of the following
investigations is least likely to help in making a Dx?
A. Serum amylase
B. Contrast-enhanced CT scan of the abdomen
C. Ultrasound of the abdomen
D. Barium swallow
E. Plain abdominal X-ray

Q3- A 62-yr-old woman complains of abdominal pain, nausea, and anorexia and
weight loss of four months duration. The pain is dull, boring and radiates through to
her back. Examination shows mild epigastric tenderness but there are no palpable
masses. GT and ALP are both above the upper limit of normal. What is the most
likely Dx?
A. ZollingerEllison syndrome
B. Gastric carcinoma
C. Carcinoma of the pancreas
D. Peptic ulcer disease
E. Cholangiocarcinoma

Q4- A 77-yr-old man presented with facial flushing, diarrhoea, and weight loss and
leg oedema. He reported a gradual worsening in his breathing. O/E he has a bilateral
wheeze and a 13 palpable liver. Ultrasound showed multiple lesions within the liver.
What test is most likely to reveal the cause of his symptoms?

A. Colonoscopy
B. CT scan of the abdomen
C. Fasting serum gastrin
D. Urinary catecholamines
E. Urinary 5-hydroxyindoleacetic acid

Q5- A 44-yr-old man, with a long Hx of alcohol abuse, was admitted with abdominal
pain, weight loss of 10 kg in the previous six months and diarrhoea. Investigations
showed a speckled 14 pancreatic calcification on plain abdominal X-ray and an
albumin level of 23 g/l. What is the diagnostic test most likely to establish the
underlying cause of his symptoms?

A. CT scan of the pancreas

B. Faecal elastase
C. Lactulose hydrogen breath test
D. Oral glucose tolerance test
E. Serum folate
Q6- A 65-yr-old woman was admitted with acute severe abdominal pain, vomiting
and a fever. Investigations showed an amylase level of 1250 U/l and a corrected
calcium concentration of 1.78 mmol/l. Which one of the following suggests a poor
prognosis?

A. Amylase 1250 IU/l

B. Glucose 9.1 mmol/l
C. pa(O2) 8.7 kPa
D. pH 7.30
E. WCC 18 109 /l

Q7- A 46-yr-old woman was referred with profuse watery diarrhoea and dehydration.
Investigations showed an average daily stool weight of 4,353 g/24 h and a serum VIP
level of > 400 pg/ml (< 20 pg/ml). What is the most likely mechanism of her
diarrhoea?

A. Infective due to small-bowel overgrowth

B. Inflammatory due to intercurrent malignancy
C. Malabsorptive due to pancreatic insufficiency
D. Osmotic secondary to high oral water intake
E. Secretory due to enterocyte stimulation

Q8- A 76-yr-old man is admitted with jaundice and weight loss. He has no Hx of
abdominal pain or fevers. What is the most likely Dx?

A. Chronic pancreatitis
B. Choledochoduodenal fistula
C. Gallstone obstruction
D. Mirizzis syndrome
E. Pancreatic adenocarcinoma

Q9- A 65-yr-old vegetarian woman who prides herself on eating a healthy diet of fruit
and vegetables presents to the clinic complaining of facial flushing and diarrhoea. The
flushing episodes may last from a few minutes to a few hours and the diarrhoea is
often accompanied by a feeling of peristaltic rushing. Her GP is worried she may have
an enlarged liver and sends off for a 24-h urinary 5-HIAA test to rule out carcinoid
syndrome. The 5-HIAA result comes back above the normal range. What would you
do next?

A. Proceed to a CT scan of the abdomen

B. Scan with radiolabelled octreotide
C. Arrange an echocardiogram to rule out right-sided cardiac disease
D. Try subcutaneous somatostatin for symptom relief
E. Repeat the test after dietary restriction

Q10- A 57-yr-old publican is referred by his GP with chronic left-sided/central upper

abdominal pain. He admits to enjoying three or four pints of beer during an evening in
the pub. Over the past 18 months he has lost about 12.5 kg (2 stone) in weight, and his
wife says he prefers alcohol to food. He has intermittent diarrhoea, which he reports
as being oily and difficult to flush away on occasions. Examination reveals a slim
man with some tenderness to deep palpation in the epigastrium. Blood testing reveals
a mild normochromic normocytic anaemia and a raised ALT level to twice the upper
limit of normal. Amylase and antigliadin antibodies are normal. Upper abdominal
ultrasound is performed and there is diffuse pancreatic calcification but nothing else
of note. Which Dx fits best with this clinical picture?

A. Acute pancreatitis
B. Chronic pancreatitis
C. Coeliac disease
D. Pancreatic carcinoma
E. Recurrent cholecystitis

Q11- A 79-yr-old woman has been seen twice by her GP during the past 8 months
complaining of dull abdominal pain radiating through to her back. The GP diagnosed
wear and tear on the spine and prescribed analgesics. The pain is partially relieved
by sitting forward. Her daughter, who says she has not been eating for weeks, has
brought her to casualty. 66 Examination reveals a cachectic woman, she has a
normochromic normocytic anaemia and LFT reveal mildly elevated transaminases
and a grossly elevated bilirubin and ALP. Ultrasound scan reveals bile duct
obstruction with suspicion of a mass in the epigastrum. Which Dx fits best with this
clinical picture?

A. Pancreatic carcinoma
B. Hepatocellular carcinoma
C. Cholecystitis
D. GI lymphoma with bile duct obstruction
E. Gastric carcinoma with local spread

Q12- A 58-yr-old company director has a 6-month Hx of central abdominal pain

accompanied by 5 kg of weight loss. On direct questioning he admitted to smoking 20
cigarettes a day for 30 yrs and 'social drinking'. Investigations reveal Hb 13.4 g/dl,
WBC 7.8 109 /l, CRP 9 mg/l, amylase 78 U/l, albumin 39g/l, normal ultrasound and
upper GI endoscopy. ERCP shows calcification on the control film and irregularity of
pancreatic sidebranches. Helpful symptomatic benefit would be gained from?

A. Proton pump inhibitor

B. Creon
C. Opiates
D. Dietary supplements
E. Distal pancreatectomy
Q13- A 56-yr-old man presents with abdominal pain, diarrhea and heartburn. He has
lost about 2 kg in weight in the last 3 months. Clinical examination does not reveal
anything further. On investigation: Haemoglobin 12.3 g/dl, WCC 8.5 x 109 /l,
Platelets 198 x 109 /l, and MCV 102 fl. Upper GI endoscopy reveals multiple
gastroduodenal ulcers. What is the most likely Dx?

A. Crohns disease
B. Chronic alcohol abuse
C. Gastric adenocarcinoma
D. Helicobacter pylori-associated peptic ulceration
E. ZollingerEllison syndrome

Q14- You are asked to review a 61-yr-old man who has been admitted on the surgical
take. He presented with epigastric pain, nausea and vomiting, the pain soon spreading
through to his back. It was noted on admission that he is on the waiting list for
cholecystectomy. His serum amylase on admission was 1235 IU/l (25170) and he is
being managed for a Dx of acute pancreatitis. Which of the following additional
features on blood testing would fit best with a Dx of severe pancreatitis?

A. Serum lactose dehydrogenase (LDH) of 400 U/l (10250)

B. Serum albumin 33 g/l (3749)
C. pa(O2) of 6.5 kPa (11.312.6)
D. Serum urea of 14 mmol/l (2.57.5)
E. White blood count (WBC) of 12 109 /l (411)

Q15- A 67-yr-old man has presented to the ER with epigastric and LUQ pain for the
third time in a yr. He has suffered from diarrhoea for around 18 months in total, and
claims that his weight has decreased by 12.7 kg (2 stone). The ambulance team who
visited his accommodation noticed empty whisky bottles by the rubbish bin. Amylase
is within the normal range. What Dx fits best with this clinical picture?

A. Cirrhosis
B. Acute pancreatitis
C. Chronic pancreatitis
D. Peptic ulcer disease
E. Coeliac disease

Q16- Which organ is in direct contact with the anterior surface of the left kidney
without the separation of the visceral peritoneum?

A. Duodenum
B. Jejunum
C. Pancreas
D. Spleen
E. Stomach