pathology of biliary & pancreatic disorders - quiz

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54y man with chornic intermittend right upper quadrant pain now presents with severe abdominal pain. Raised Bilirubin (direct), ALP, Amylase. Image abdominal CT. Diagnosis ?.

1 2 3 4 5

7% 7%

14%

0%

71%

1. Acute Cholecystitis.

2. Chronic Pancreatitis.

3. Acute pancreatitis.

4. Acute Hepatitis.

5. Pancreatic carcinoma.

1. Explain the clinical features? – acute, sudden over chronic. 2. Explain the laboratory data? – Bil, ALP, Amylase (pancreatitis).3. What are possible risk factors? – smoking, alcoholism, diabetes, cholelithiasis.4. What is the pathogenesis? – activation of enzymes, inflammation, fat necrosis.

38y F, Obese, abdominal colicky pain, Gallbladder: ? Type of stones

1 2 3 4 5

75%

19%

0%0%6%

A. Pure cholesterolB. Mixed cholesterol.C. Pigment D. CalciumE. Triple phosphate.

38y F, Obese, abdominal colicky pain, Gallbladder: ? Type of stones

1 2 3 4 5

0%

71%

0%0%

29%

A. Pure cholesterolB. Mixed cholesterol.C. Pigment D. CalciumE. Triple phosphate.

A 45y mildly obese woman, 1-week history of upper abdominal pain, fever, shaking chills, and vomiting. P/E severe right upper quadrant tenderness. Lab: serum bilirubin of 1.0 mg/dL, AST of 25 U/L, ALT of 35 U/L, ALP 220 U/L (high), WBC of 14,000/µL, and amylase of 95 U/L (normal).

Most likely diagnosis?

1 2 3 4 5

87%

0%

13%

0%0%

1. Acute Cholecystitis2. Acute Pancreatitis3. Carcinoma pancreas4. Carcinoma Gall bladder5. Primary biliary cirrhosis.

40y Black woman, indigestion, abdominal pain, Gallbladder: Most likely associated disease?

1 2 3 4 5

17%

0%

72%

6%6%

1. Chronic Pancreatitis2. Diabetes mellitus3. Familial hypercholesterolemia4. Hyperparathyroidism5. Sickle cell disease

69y M, Massive GI bleeding, jaundice. Section of liver ? Pathogenesis

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25%

19%

0%

6%

50%

1. Cholangiocarcinoma2. Hepatocellular carcinoma3. Metastatic carcinoma4. Liver abscesses5. Tuberculosis.

38y F, Obese, intermittent abdominal colicky pain since 2y, Gallbladder: ? Diagnosis

A. B. C. D. E.

14%

43%

0%0%

43%

A. Adenocarcinoma

B. Cholelithiasis

C. Cholecystitis

D. Cholesterosis

E. Primary Biliary Cirrhosis.

A 21 year old man, abdominal pain, rigidity since 3 days. Serum Lipase raised but calcium normal. Image shows appearance of his pancreas. He had 4 similar attacks since 8 years. ? Most likely Etiology.

1 2 3 4 5

38%

8% 8%

38%

8%

1. Explain the clinical features? – acute, sudden recurrent. 2. Explain the laboratory data? – Lipase, Calcium.3. What are possible risk factors? – Genetic AD Trypsin mutation (PRSS1), 4. What is the pathogenesis? – uncontrolled activation of enzyme trypsin,

1. Chronic Acoholism.

2. Chronic Cholecystitis.

3. Type 1 Diabetes.

4. Genetic disorder.

5. Unknown.

69y Female, Chronic bronchitis. Died following chronic pulmonary failure. Liver specimen. Likely diagnosis?

1. Alcoholic Hepatitis

2. Dubin-Johnson Syndrome

3. Liver cirrhosis

4. Passive congestion liver

5. Primary Biliary cirrhosis

A 46 year old man, 8 year history of intermittent abdominal pain now presents with steatorrhoea. Image shows abdominal CT. ? Most likely Diagnosis.

1 2 3 4 5

0% 0%

47%

37%

16%1. Explain the clinical features? – chronic steatorrhoea - pancreas. 2. What are possible risk factors? – alcohol, diabetes, cholelithiasis, 3. What is the pathogenesis? pancreatitis fat storage steatorrhoea fatty liver

1. Fatty liver.

2. Chronic Cholecystitis.

3. Chronic pancreatitis

4. Cholelithiasis & fatty liver.

5. Both 1 & 3

38y F, Obese, abdominal colicky pain, Gallbladder: Most likely metabolic abnormality?

1 2 3 4 5

11%

0%

89%

0%0%

1.Decreased bilirubin conjugation.2.Decreased serum albumin.3.Increased bilirubin uptake4.Increased hepatic calcium secretion.5.Increased hepatic cholesterol secretion.

Complications of Cholelithiasis include all the following EXCEPT:

1 2 3 4 5

13%

0%

60%

7%

20%

A. Secondary Biliary CirrhosisB. Recurrent CholangitisC. Liver AbscessD. Chronic PancreatitisE. Primary Biliary cirrhosis.

62y F, Abd. Pain & jaundice. Gall bladder biopsy ? Diag

1 2 3 4 5

0% 0% 0%7%

93%

A. CholecystitisB. CholesterosisC. AdenocarcinomaD. Aschoff-Rokitansky

sinusesE. Primary Biliary Cirrhosis.

38y F, jaundice. Gall bladder ? Pathogenesis

1 2 3 4 5

35%

0% 0%

65%

0%

A. Excess BilirubinB. Low cholesterolC. Low Bile SaltsD. Infection.E. Cholestasis.

34y M, alcholic, fever, abdominal pain, mild icterus and malaise 6 months. Liver biopsy. ? diagnosis

1 2 3 4 5

20%

0% 0%

73%

7%

1. Alcoholic Hepatitis

2. Chronic Persistent Hepatitis.

3. Hepatitis C infection

4. Fatty Liver

5. Alcoholic Cirrhosis

78y woman, epigrastric pain & 4 kg weight loss since 6m. Bilirubin raised, AST & ALT normal, but ALP 216 u/l (<125). Image shows her abd. CT & Microscopy. Likely diagnosis ?.

1 2 3 4 5

14%

5%

71%

0%

10%

1. Explain the clinical features? – Chronic, weight loss, pain, jaundice – Ca Pan. 2. Explain the laboratory data? – AST/ALT Hepatocytes normal, ALP –bile obstr.3. What are possible risk factors? – smoking, chronic pancreatitis, ca. syndromes.4. What is the pathogenesis? – PanIN -1A, PanIN -1B, K-RAS, PanIN -2, 3, Ca.

1. Cholecystitis.

2. Cholelithiasis.

3. Chronic pancreatitis.

4. Chronic Hepatitis.

5. Pancreatic carcinoma.

26y female, medical student, day before pathology exam presents with mild scleral jaundice. Physical Examination normal, Liver function tests: Protein total-7.9, Albumin 4.8 g/dl, AST-36 U.L, ALT 16 U/L, ALP-36 U/L, Total Bilirubin 4.9, direct 0.7 mg/dl. Jaundice resolves week later after exams. Most likely diagnosis?

1 2 3 4 5

5%0%

29%

5%

62%

1. Alcoholic hepatitis.2. Primary biliary cirrhosis.3. Gilbert Syndrome.4. Acute HAV infection.5. Acetaminophen poisoning.

Viral serology interpretation:

HBsAg Positive, Anti HBc Ab PositiveAnti HBc IGM NegativeAnti HBs Ab Negative

A. Acute Viral Hepatitis

B. Immunised against Hep. B

C. Chronic Hepatitis B

D. Hepatitis B carrier stage

E. Fulminant hepatitis B

52y F, multiple red-brown, tender subcutaneous nodules with 15kg wt. Loss since 3m. Microscopy of nodule inflammation, fat necrosis, no malignant cells. ? Diagnosis.

1 2 3 4 5

0%

25%

35%

20%20%

1. Acute Pancreatitis2. Chronic Pancreatitis3. Adenocarcinoma4. Pancreatic Pseudocyst5. MEN I Syndrome

“The ancestor of every action is a thought.”

--Ralph Waldo Emerson

34y M, alcoholic, homosexual- icterus and fever 6 months. Liver biopsy. ? diagnosis

A. Acute HepatitisB. Chronic active Hepatitis.C. Cirrhosis CarcinomaD. Fulminant HepatitisE. Hepatitis Cirrhosis

34y M, icterus and fever. Liver biopsy. ? diagnosis

1. Acute Hepatitis2. Chronic Persistent Hepatitis.3. Chronic active Hepatitis4. Fulminant Hepatitis5. Cirrhosis

56y chronic alcoholic, 2 days fever, abdomen distended, tender, tap yielded cloudy yellow fluid with 98% neutrophils, Blood culture E.coli. Patient dies 3 days later. Image shows his liver. Most Likely diagnosis?

1 2 3 4 5

0% 0% 0%0%0%

1. A1 antitrypsin deficiency2. HEV infection3. Hereditary hemochromatosis4. Primary sclerosing cholangitis5. Alcoholic cirrhosis

58y M, alcoholic, distended abdomen & icterus. Liver biopsy. ? diagnosis

1 2 3 4 5

0% 0% 0%0%0%

1. Chronic active hepatitis.2. Chronic Persistant hepatitis.3. Hepatocellular carcinoma.4. Cirrhosis5. Chronic alcoholic hepatitis.

Viral serology interpretation:

A. B. C. D. E.

0% 0% 0%0%0%

HBsAg Negative, Anti HBc Ab NegativeAnti HBcAg IGM NegativeAnti HBs Ag Positive

A. Acute Viral Hepatitis

B. Immunised against Hep. B

C. Past Hepatitis B infection.

D. Hepatitis B carrier stage

E. Chronic hepatits B

59y Male, Alcoholic, presents with fatigue, anorexia. Normal liver function tests. Liver specimen. Likely diagnosis?

1 2 3 4 5

0% 0% 0%0%0%

A. Dubin-Johnson SyndromeB. Alcoholic cirrhosisC. Alcoholic HepatitisD. Fatty LiverE. Nutmeg liver

42y male smoker presented with recurrent cough & dyspnoea. Image shows cut section of his lung. What is the most likely diagnosis?

1 2 3 4 5

0% 0% 0%0%0%

1. Emphysematous bullae2. Panlobular emphysema3. Centrilobular emphysema4. Chronic Bronchitis + Emphysema.5. Smokers lung with Silicosis

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

1 2 3 4 5

0% 0% 0%0%0%

1. Anemia of chronic disorder2. Megaloblastic anemia3. Hemolytic anemia4. Aplastic anemia5. Iron deficiency Anemia

42y M, alcoholic, recurrent fatigue. Liver biopsy. ? Diagnosis

1 2 3 4 5

0% 0% 0%0%0%

1. Acute Hepatitis2. Chronic Active hepatitis.3. Chronic Persistant hepatitis.4. Fulminant Hepatitis.5. Cirrhosis.

78year female presents with prolonged weakness, fatigue and anemia. She has palpable spleen & few enlarged cervical Lymphnodes. Image shows her blood film. What is the most likely diagnosis?

1 2 3 4 5

0% 0% 0%0%0%

1. Acute myeloid leukaemia2. Acute lymphatic leukaemia3. Chronic myeloid leukaemia4. Chronic lymphatic leukaemia5. Non-hodgkins lymphoma

Health is the greatest possession. Contentment is the greatest treasure. Confidence is the greatest friend. Non-being (selfless) is the greatest joy

Lao Tzu

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CPC-2.7– GIT–Ca Pan+dep• Pathology - Core Learning Issues:

– Pathology of exocrine Pancreas – Acute & Chronic Pancreatitis & complications.

– Neoplasms – Endocrine-adenoma, exocrine malignancy – Adeno-carcinoma. & complications.

– Paraneoplastic syndromes and common tumour markers. – MEN, Insulinoma, Gastrinoma,

• Basic science - Core Learning Issues: – Structure & Function of Pancreas.– Pancreatic enzymes.– Neoplasia – Carcinogenesis, biology of neoplasms.

Uncommon risk factor for Acute Pancreatitis ?

1 2 3 4 5

0% 0% 0%0%0%

1. Alcohol abuse 2. Gallstones 3. Hyperlipidemia4. Genetic5. Hyperparathyroidism

Histopathology Image is from lung biopsy of a 61 year male chronic smoker. What is the most likely type of carcinoma?

1 2 3 4 5

0% 0% 0%0%0%

1. Small cell carcinoma2. Adenocarcinoma3. Metastatic deposits4. Squamous carcinoma5. Lung abscesses

The gross image of lung specimen from a 59year old male heavy smoker presented with high fever, shortness of breath. Likely type of pneumonia?

1 2 3 4 5

0% 0% 0%0%0%

1. Lobar pneumonia2. Interstitial pneumonia 3. Broncho pneumonia4. Fungal pneumonia5. Carcinomatous pneumonia

42y obese female. Acute abdomen.Elevated serum amylase, Normal Lipase & AST.? Diagnosis

1 2 3 4 5

0% 0% 0%0%0%

A. Acute cholecystitisB. Acute PancreatitisC. Acute alcoholic hepatitisD. Chronic pancreatitisE. Recurrent Pancreatitis

Mary, 58y, 6m h/o epigastric pain, weight loss, foul smelling diarrhoea. Lab Results: Serum Amylase-P – 56 U/L (Range 30-110)Serum Lipase – 460 U/L (Range 30-300)Serum Calcium – 1.92 (Range 2.1-2.55)What is the most likely diagnosis?

1 2 3 4 5

0% 0% 0%0%0%

A. Acute AppendicitisB. Chronic CholecystitisC. Acute PancreatitisD. Chronic PancreatitisE. Ulcerative colitis

Which of the following findings is most likely to be encountered in Mary?

1 2 3 4 5

0% 0% 0%0%0%

1. Alcoholic hepatitis2. Melena3. Pernicious anemia4. Steatorrhea5. Hypoglycemia

Mary presents again after 3 years. Physical examination shows jaundice. A CT scan of the abdomen shows a large fluid-filled cyst in the lesser

sac. What is the most likely diagnosis?

1 2 3 4 5

0% 0% 0%0%0%

1. Adenocarcinoma2. Carcinoid tumor3. True Pancreatic cyst4. Abscess in Pancreas5. Pancreatic Pseudocyst

1y male, bilious vomiting. Mid duodenal narrowing. ? Diagnosis

1 2 3 4 5

0% 0% 0%0%0%

1. Annular pancreas2. Duodenal polyp3. Pancreatic adenoma4. Pancreas divisum5. Congenital Pyloric

stenosis

13y boy. Recurrent pancreatitis attacks. Now presents with weight loss since a year, pedal edema. ? Diagnosis

1 2 3 4 5

0% 0% 0%0%0%

1. Annular pancreas2. Ectopic pancreas3. Pancreatic adenoma4. Pancreas divisum5. Congenital Pyloric

stenosis

Major risk factors for Pancreatic cancer?

1 2 3 4 5

0% 0% 0%0%0%

1. Fatty, female, Forty..

2. Life style & Diet

3. Smoking & Diabetes

4. Hypertension & lack of exercise

5. Gall stones & Diabetes.

65y Male, “positive Courvoisier's sign” ??

1 2 3 4 5

0% 0% 0%0%0%

1. Painful jaundice with purpuric spots.2. Jaundice with high colored urine.3. Painful jaundice with itching.4. Palpable gall bladder with jaundice5. Jaundice with abdominal pigmentation.

65y M, Wt loss, pedal edema, Pancreatic biopsy: Identify B ?

1 2 3 4 5

0% 0% 0%0%0% ? A ? C

1. Malignant glands2. Pancreatic Islets3. Fibrous tissue4. Inflammatory cells5. Benign glands

65y M, Wt loss, pedal edema, Pancreatic biopsy: Identify B ?

1 2 3 4 5

0% 0% 0%0%0% ? A ? C

BA

C

1. Malignant glands

2. Pancreatic Islets

3. Fibrous tissue

4. Inflammatory cells

5. Dilated ducts

38y Female episodic fainting, Sweating, hunger & weight gain. Scan shows 1.5cm circumscribed round mass in pancreas.? Diagnosis

1 2 3 4 5

0% 0% 0%0%0%

1. Adenocarcinoma2. Gastrinoma3. Glucagonoma4. Insulinoma5. Carcinoid tumor

65y man, Acromegaly, epigastric pain, melena, hypercalcemia, hyperlipidemia, hyperacidity.? Diagnosis

1 2 3 4 5

0% 0% 0%0%0%

1. Glucagonoma2. Insulinoma3. MEN I4. Pancreatic Carcinoid5. MEN II

52y F, severe multiple peptic ulcers in both duodenum and jejunum not responding to treatment. Pancreas shows 1.2cm rounded tumor. ? Diagnosis.

1 2 3 4 5

0% 0% 0%0%0%

Peptic ulcers

1. H.pylori & peptic ulcer2. Insulinoma3. MEN II syndrome4. Pancreatic Carcinoid5. Gastrinoma

A man with outward courage dares to die.

A man with inward courage dares to live.

Lao Tzu

Self Assessment is the key…!

Retention of Learning

Time Delay No review Review

7 Days 33% 83%

63 Days 14% 70%

Whether new information is "stored" or "dumped" depends, then, on our Interest, Reciting, Writing &

Reviewing the information.Source: http://www.web-us.com/memory/human_memory.htm

53

Living becomes a glorious experience only when there is tolerance and love. Willingness to compromise with other

people’s ways of living and cooperation in common tasks, these make happy and successful societies.

Divine Discourse, 17th February 1980 - Baba.

Love is Selfless Service.

54

5 A’s & SNAP • Ask: 1. patients with diabetes, hypertension,

hyperlidaemia, obesity or existing vascular disease• Assess: 2.Number of cigarettes or equivalent/day,

Dependance 3.readiness to change/motivation• Advise: 4.provide written information, 5.motivational

interviewing • Assist: 6.NRT ? Bupropion(Zyban) 7.Support• Arrange: 8.referral to QUIT 9.follow up with the GP

SNAP Counseling: Smoking, Nutrition, Alcohol & Physical Activity.

Silence…

55

To the question "Who am I?" the only relevant answer is silence. You need to discard all answers in words, including "I am Nothing" or "I am the Cosmic Self" or "I am the Self" - and just stick to the question "Who am I?". All other answers are just thoughts. Thoughts can never be complete. Only Silence is complete.

Thoughts are not the goal in themselves. Their goal is Silence. When you ask the question "Who am I?" you get no answer, there is silence. That is the real answer. For your soul is solidified silence. This solidified silence is wisdom, is knowledge.

The easy way to silence the thoughts is to arouse the feelings. For, through feelings only peace, joy and love dawn. And they are all your very nature.

- Sri Sri Ravishankar

Viral serology interpretation:

1 2 3 4 5

0% 0% 0%0%0%

HBsAg Negative, Anti HBsAg PositiveAnti HBcAg PositiveAnti HBcAg IGM Negative

A. Acute Viral Hepatitis BB. Immunised against Hep. BC. Past Hepatitis BD. Hepatitis B carrier stageE. Carrier state of Hepatitis B