Section 1



Section 1

Gastroenterology and Endocrine

1) Regarding chronic pancreatitis, which of the following is INCORRECT?

a) chronic obstructive pancreatitis has a lobular distribution of lesions

b) it may lead to the development of diabetes mellitus

c) chronic calcifying pancreatitis is especially common in alcoholics

d) it can be precipitated by opiate use

e) it may have a hereditary component to its aetiology

2) What is the location of most carcinomas of the pancreas?

a) body

b) head

c) diffuse or disseminated

d) neck

e) tail

3) Regarding carcinoma of the pancreas, which of the following is INCORRECT?

a) cigarette smoking significantly increases the risk of development

b) it may be associated with migratory thrombophlebitis

c) it more commonly arises in acinar cell than in ductal epithelial cells

d) the average survival time from diagnosis is 6 months

e) it is more common in blacks than in whites

4) Regarding acute pancreatitis, which of the following is INCORRECT?

a) death occurs in about 5% of cases from shock during the first week

b) it may be idiopathic in up to 50% of cases

c) it involves activation of trypsinogen

d) fat necrosis may involve the omentum and mesentery

e) acute haemorrhagic pancreatitis commonly leads to chronic pancreatitis

5) Regarding pancreatic pseudocysts, which of the following is INCORRECT?

a) they are usually located adjacent to the pancreas, near the tail

b) they have no connection or communication with surrounding ductal systems

c) they can become infected leading to generalised peritonitis

d) they possess an epithelial lining

e) they are usually solitary

6) Which of the following is NOT a feature of type I (IDDM) primary diabetes mellitus:

a) islet cell antibodies

b) early insulitis

c) beta cell depletion

d) HLA-B linked

e) severe insulin deficiency

7) What is the MOST common cause of chronic relapsing pancreatitis?

a) idiopathic

b) pancreas divisum

c) alcoholism

d) hypercalcaemia

e) biliary tract disease

8) Which of the following is NOT a feature of type II (NIDDM) primary diabetes mellitus?

a) no HLA association

b) rare ketoacidosis

c) no insulitis

d) insulin resistance

e) less concordance in twins than with type I (IDDM)

9) Which of the following is NOT characteristic of acute pancreatitis?

a) elevated serum amylase within 24 hours

b) hypercalcaemia

c) elevated serum lipase within 72-96 hours

d) glycosuria

e) metabolic acidosis

10) Which organ/type is MOST severely damaged in diabetes mellitus?

a) kidney

b) retina

c) heart

d) brain

e) peripheral nerve

11) Which of the following is NOT associated with acute pancreatitis?

a) hyperthermia

b) trauma

c) hyperlipoproteinaemia

d) mumps

e) hyperparathyroidism

12) In relation to liver cirrhosis, in most Western countries:

a) hepatic fibrosis is reversible over 12 months if aetiological factors are removed

b) oesophageal varices are seen in 95% of cases in advanced cirrhosis

c) the vascular architecture is maintained

d) hepatic failure occurs only once the cirrhotic liver has decreased in mass

e) viral hepatitis is responsible for 10%

13) Acute pancreatitis:

a) may be caused by Helminth infection

b) causes hypercalcaemia

c) develops in 50% of patients with gallstones

d) leads to inhibition of elastase

e) involves acinar cell injury as a late event

14) The following is NOT associated with oesophageal carcinoma:

a) long standing oesophagitis

b) smoking

c) alcohol abuse

d) vitamin A deficiency

e) blood group O positive

15) Pyloric stenosis:

a) occurs in females more than males

b) occurs in about 1:5000 live births

c) is due to hypertrophy of pyloric muscularis mucosa in infants

d) is not associated with peptic ulcers

e) is usually treated with gastrectomy

16) An usual site for peptic ulceration is:

a) within Barrett’s mucosa

b) within the stomach

c) within the duodenum

d) within the jejunum adjacent to Meckel’s diverticulum

e) upper oesophagus in Zollinger-Ellison syndrome

17) Gastric pH is NOT increased by:

a) ingestion alkalis

b) multi trauma acutely

c) treatment with misoprostol

d) treatment with ranitidine

e) vagotomy

18) Haemorrhoids:

a) affect 1% of general population

b) may be associated with portal hypertension

c) are due to venacaval obstruction in pregnancy

d) are not painful when thrombosed

e) are thought to be due to faecal incontinence

19) Regarding acute appendicitis:

a) mortality from perforation is 2%

b) it is triggered by faecolith in 100% of cases

c) is easily clinically differentiated from appendiceal mucocoele

d) a clinical false positive diagnosis rate of 20% is far too high

e) liver abscess is not a complication

20) Acute pancreatitis:

a) is caused by alcohol more commonly in women than in men

b) occurs in 20% of patients with gallstones

c) is due to mumps virus infections in 20% of patients

d) is seen as a direct complication of SLE

e) is caused by sulphonamides but not loop diuretics

21) Crohn’s disease may be differentiated from ulcerative colitis by:

a) association with ankylosing spondylitis

b) an association with uveitis

c) an associated pericholangitis

d) the presence of chronic mucosal damage and fibrosis

e) the presence of granulomas

22) Conn’s Syndrome (hyperaldosteronism) is characterised by all of the following EXCEPT:

a) sodium and water retention

b) hypertension

c) generalised oedema

d) hypokalaemia

e) alkalosis

23) Glucagon secretion by the pancreas is inhibited by:

a) CCK

b) secretin

c) gastrin

d) cortisol

e) infection

24) Which of the following would indicate advanced diabetic retinopathy?

a) microaneurysm formation

b) pre-retinal haemorrhage

c) venous dilatation

d) hard retinal exudates

e) neovascularisation

25) Which of the following islet cell pathology is pathognomonic of diabetes mellitus type II?

a) beta cell degranulation

b) reduction in size and number of islets

c) increase in size and number of islets

d) leukocyte infiltration of islets (“insulitis”)

e) none of the above

26) Concerning diabetes mellitus:

a) type I has a 50% concordance in identical twins

b) type II has a 70% concordance in identical twins

c) type II affects less than 5% of people older than 70

d) type I affects 20% of children of first-order relatives

e) type I is characterised by more severe “end organ” damage than type II when compared in long term follow up studies

27) With regard to Zollinger-Ellison syndrome:

a) 60% of gastrinomas are malignant

b) 75% of gastrinomas are benign

c) 90% of gastrinomas are solitary

d) 50% of patients develop jejunal ulceration

e) duodenal ulceration predominates in the 3rd and 4th parts

Section 1

Gastrointestinal and Endocrine - Answers

1. A

2. B

3. C

4. E

5. D

6. D

7. C

8. E

9. B

10. A

11. A

12. E

13. A

14. E

15. B

16. E

17. C

18. B

19. A

20. D

21. E

22. C

23. B

24. E

25. E

26. A

27. A

Section 2

Liver / Biliary Tract

1) In the normal subject, bile is predominantly comprised of:

a) phospholipids

b) bile salts

c) protein

d) cholesterol

e) bilirubin

2) Gallstones:

a) afflict 1-2% of adult population in developed countries

b) are usually pigment stones

c) remain silent / asymptomatic in most cases

d) are more common in men than women

e) are associated with increased bile formation

3) The primary defect in the pathogenesis of cholesterol stones is:

a) gall bladder hypomobility

b) mucus hypersecretion in gall bladder

c) acceleration of cholesterol nucleation in bile

d) biliary hypersecretion of cholesterol

e) the presence of calcium salts in bile

4) Acalculons cholecystitis:

a) is the most common reason for emergency cholecystectomy

b) is rarely caused by primary bacterial infection

c) is usually caused by chemical irritation and inflammation

d) is a relatively common cause of acute cholecystitis

e) generally occurs in otherwise well patients

5) Acute fatty liver of pregnancy:

a) usually occurs in the third trimester

b) may be co-existent with pre-eclampsia in up to 40% of cases

c) usually runs a mild course

d) involves an intramitochondrial fatty acid oxidation defect

e) all of the above

6) Regarding the liver:

a) it usually weighs 150g

b) 1/3 of the blood supply comes from the portal vein

c) peripheral hepatocytes of each acinus receives the poorest blood supply

d) the hepatic venile is in the centre of the acinus

e) Ito cells secrete enzymes to degrade collagen

7) Which is the biggest cause of liver cirrhosis?

a) chronic hepatitis

b) biliary disease

c) haemochromatosis

d) α1 antitrypsin disease

e) ethanol

8) Which is NOT present in a person with chronic HBV infection?

a) HBsAg

b) HBeAg

c) HBV DNA

d) anti HBc

e) anti HBe

9) Which hepatitis virus contains DNA?

a) HAV

b) HBV

c) HCV

d) HDV

e) HEV

10) Regarding HDV:

a) it is a water borne infection

b) it only causes infection when encapsulated by HBcAg

c) acute co-infection with HBV often leads to chronic hepatitis

d) it has a high mortality rate in pregnancy women

e) IgM anti HDV is indicative of recent exposure

11) Regarding gallstones:

a) they are more common in men

b) there are no genetic links

c) 50% are asymptomatic

d) pigment stones are always associated with infection

e) become symptomatic at a rate of 1-3%/year

12) Which is a cause of conjugated hyperbilirubinaemia?

a) haemolytic anaemia

b) intrahepatic biliary obstruction

c) Gilbert syndrome

d) internal haemorrhage

e) physiologic jaundice of the newborn

13) Which hepatitis virus is waterborne?

a) HDV

b) HEV

c) HGV

d) HCV

e) HBV

14) Which hepatitis virus is associated with hepatocellular ????carcinoma?

a) HAV

b) HBV

c) HCV

d) HDV

e) HEV

15) Regarding the clinical syndromes developing to hepatitis virus:

a) HBV most commonly causes jaundice

b) chronic hepatitis is when there is evidence of ongoing hepatic disease for more than 3 months

c) vertical transmission of HBV produces a carrier state 50-60% of the time

d) the most common symptom of chronic hepatitis is fatigue

e) in acute viral hepatitis, the jaundice is caused predominantly by unconjugated hyperbilirubinaemia

16) Which is HBV NOT present in?

a) stool

b) semen

c) saliva

d) sweat

e) breast milk

17) Which is the least common end stage cause of death in alcoholic liver disease?

a) hepatic coma

b) GI bleed

c) infection

d) hepatorenal syndrome

e) hepatocellular carcinoma

18) Hepatitis A virus:

a) has a 5% fatality

b) is an enveloped ssRNA picornavirus

c) is shed in stool only after the onset of jaundice

d) has serum transmission

e) HAV IgM marks acute infection

19) Hepatitis C virus:

a) is a small enveloped dsRNA virus

b) has three subtypes

c) progresses to chronic disease in 10%

d) incubation period is 2-26 weeks

e) is known as the “delta agent”

Section 2

Liver / Biliary Tract – Answers

1. B

2. C

3. D

4. B

5. E

6. D

7. E

8. E

9. B

10. E

11. E

12. B

13. B

14. C + B

15. D

16. A

17. E

18. E

19. D

Section 3

Pancreas, Liver, Biliary Tract, Renal

1) In type I diabetes mellitus:

1. there is an insulin secretory defect without β cell loss

2. there is no HLA linkage

3. there is an amyloid deposition

4. concordance is 50%

5. there are no anti-islet cell antibodies

2) Which is NOT a digestive enzyme produced by the pancreas?

1. insulin

2. trypsin

3. chymotrypsin

4. elastase

5. phospholipase

3) Which enzyme catalyzes activation of other enzymes?

1. amylase

2. phospholipase

3. lipase

4. nuclease

5. trypsin

4) Which is the most common cause of acute pancreatitis?

1. shock

2. coxsackie virus

3. prescribed drugs

4. iatrogenic injury

5. biliary free disease

5) Regarding acute pancreatitis, which is INCORRECT?

1. trypsin activates the Hageman factor

2. ARDS is a serious complication

3. incidence is 10-20 cases per 100,000

4. hypocalcaemia is a poor prognostic sign if persistent

5. hypercalcaemia occurs commonly

6) The gallbladder contains all of the following histological structures, EXCEPT:

1. a mucosal lining of columnar cells

2. a muscularis mucosa and submucosal

3. a fibromuscular layer

4. subserosal fat, with arteries, veins and lymphatics

5. a peritoneal covering

7) After cholelithiasis, the most common cause of acute pancreatitis is:

1. scorpion bites

2. trauma

3. infection

4. alcohol

5. ischaemia

8) Which of the following is not considered to be a posthepatic cause of portal hypertension?

1. severe right-sided heart failure

2. Budd-Chiari syndrome

3. constructive pericarditis

4. hepatic veno-occlusive disease

5. splenomegaly

9) Which of the following gives rise to predominantly conjugated hyperbilirubinaemia?

1. haemolytic anaemias

2. physiologic jaundice of the newborn

3. fluke infestation

4. breast mild jaundice

5. resorption of blood from internal haemorrhage

10) Hepatitis B virus was identified in:

1. 1965

2. 1973

3. 1977

4. 1980

5. 1989

11) The likelihood of chronic hepatitis following acute infection with HAV can be summarised:

1. extremely rare

2. develops in more than 90% of neonates

3. develops in 5% of adults

4. develops in more than 50% of patients

5. HAV does not produce chronic hepatitis

12) Which of the following is not a common feature of type II diabetes?

1. onset beyond age 30

2. obesity

3. ketoacidosis

4. 90-100% concordance in twins

5. insulin resistance

13) Which of the following is not a feature of Zollinger-Ellison syndrome?

1. gastrinoma

2. recalcitrant peptic ulcer disease

3. gastric hypersecretion

4. pancreatitis islet cell tumour

5. β-cell tumours

14) Hepatitis:

1. causes fulminant hepatitis and death in about 5% of cases

2. progresses to chronic liver disease and cirrhosis in >50%

3. exhibits considerable genomic variability

4. usually causes chronic hepatitis in acute HCV co-infection

5. is non pathogenic

15) Regarding urolithiasis:

1. struvite stones contain calcium-ammonium-phosphate

2. uric acid stones are associated with urea-splitting bacterial infection

3. 10% of calcium containing stones are associated with hypercalcaemia

4. uric acid stones are due to hyperuricaemia

5. all stones are associated with TCCs

16) Cirrhosis:

1. in NZ is most commonly due to viral hepatitis

2. involves collagen synthesis by Kupffer cells

3. may completely resolve if causative pathology is removed

4. usually causes early jaundice

5. associated with hepatocellular carcinoma

17) Nephrotic syndrome:

1. is most commonly caused by rapidly progressing GN in adults

2. characteristically presents with haematuria

3. is characterised by a proteinuria of 3.5mg per day

4. is most commonly caused by lipoid nephrosis in children

5. is immunologically mediated

18) Polycystic kidney disease:

1. has a 70% co-association with Berry aneurysms

2. is an autosomal recessive condition in its adult form

3. is responsible for 10% of adult cases of chronic renal failure

4. often features unilateral polycystic changes

5. does not present with haematuria

19) Features of chronic renal failure include all of the following EXCEPT:

1. metabolic acidosis

2. a GFR < 5% of normal in end stage renal disease

3. hypophosphaturia

4. pulmonary oedema

5. anaemia

20) Urolithiasis:

1. is bilateral in 80% of cases

2. presents most commonly in young adult males

3. is usually associated with an acid urine

4. is associated with hypercalcuria in 60% of cases

5. is defined as occurring anywhere between the renal pelvis and the vessicoureteric junction

21) Which of the following statements is NOT TRUE of renal tubular acidosis?

1. it always presents with a normal anion gap

2. it may be caused by potassium sparing diuretics

3. it is associated with Addison’s disease in one of its forms

4. it has a good prognosis when associated with aminoaciduria, phosphaturia and glycosuria

5. it is characterised by hypokalaemia and hyperchloraemia

22) Malignant nephrosclerosis:

1. presents more commonly in females

2. is defined by a diastolic blood pressure > 110mmHg

3. is associated with hypo-aldosteronism

4. is characterised by hyaline arteriosclerosis

5. has a 2.5% five year mortality rate if treated

23) Regarding renal calculi:

1. most stones are uric acid stones

2. large stones typically present with colic

3. large stones are rarely composed of magnesium ammonium phosphate

4. stones are bilateral in about 20% of patients

5. enteric hyperoxaluria is an unusual congenital condition predisposing to calcium oxalate crystal

24) Regarding chronic renal failure:

1. urea and creatinine levels start rising when more than 50% of the nephrons are lost

2. the most common cause is hypertension

3. nephrosclerosis and glomerulosclerosis associated with aging causes loss of 10% of nephrons each 10y over 40

4. uraemia is a reflection of the acuity of the disease

5. approximately 75% of the usual number of nephrons are required to prevent retention of water and electrolytes

25) Acute renal failure is usually reversible as long as renal blood flow doest NOT fall below:

1. 5% of normal

2. 10% of normal

3. 20% of normal

4. 30% of normal

5. 40% of normal

26) Renal calculi are caused by:

1. calcium containing stones

2. magnesium, ammonia, phosphate stones

3. uric and stones (?????uric acid stones)

4. cystine stones

The order of commonest to least common is:

a) 1, 3, 2, 4

b) 2, 1, 3, 4

c) 1, 2, 3, 4,

d) 1, 2, 4, 3

e) 2, 1, 4, 3

27) In the kidney:

a) the proximal convoluted tubule is vulnerable to chemical damage, but rarely incurs ischaemic damage

b) the macula densa is the principal source of renin

c) the medulla is particularly resistant to ischaemic damage

d) mesangial cells have an important role in the pathogenesis of glomerulonephritis

e) monocyte macrophages are the principal phagocytic cells

28) In acute tubular necrosis:

a) decline in B.U.N. correspond with the onset of polyuria

b) ischaemic acute tubular necrosis is characterised by diffuse damage to the proximal convoluted tubule

c) nephrotoxic acute tubular necrosis is characterised by focal areas of necrosis in the proximal convoluted tubule

d) pigment-induced acute tubular necrosis looks morphologically similar to ischaemic acute tubular necrosis

e) the distribution of casts within the nephron helps distinguish nephrotoxic from ischaemic acute tubular necrosis

29) Regarding hepatitis:

a) hepatitis A virus is an enveloped ssRNA agent

b) hepatitis B virus is present in stool

c) chronic HBV/HDV hepatitis is more common with a HDV/HBV co-infection rather than a HDV super-infection in a HBV carrier

d) hepatitis G virus causes chronic hepatitis in 20% of cases

e) hepatitis C virus is from the Flaviridae family

30) Regarding diabetes:

a) Downs syndrome is associated with secondary diabetes

b) type II diabetes mellitus is HLA-D linked

c) there are three types of maturity onset diabetes of the young

d) Schiff bases are irreversibly glycosylated proteins

e) renal complications are solely through glomerular damage

31) In acute pancreatitis:

a) cytomegalovirus infection is a known etiologic factor

b) males are three times more likely to suffer gallstone pancreatitis

c) the pancreatic blood vessels are spared

d) calcium precipitates with free fatty acids in fat necrosis

e) secondary diabetes is a common sequelae

32) Regarding urolithiasis:

a) uric acid stones are commonly associated with infection

b) 50% of stones are composed of magnesium ammonium phosphate

c) 10% are cholesterol stones

d) uric acid stones may or may not form in the presence of hyperuricaemia

e) an organic matrix of mucoprotein makes up 50% of each stone by weight

33) All are commonly associated with alcoholic liver disease EXCEPT:

a) hepatocyte swelling and necrosis

b) mallory bodies

c) mesmic necrosis

d) reversibility of fatty change on abstaining from alcohol

e) fibrosis

34) Hepatitis – all are true EXCEPT:

a) infectiousness greatest at end of incubation period and onset of clinical symptoms

b) anti Hbs is detectable shortly after disappearance of HbsAg implying resolution of the disease

c) hepatitis B and C both associated with development of carcinoma of liver

d) HDV is dependent on HBV for its infectiousness

e) HEV has a mortality rate of up to 20% in pregnant woman

Section 3

Pancreas, Liver, Biliary Tract and Renal - Answers

1. D

2. A

3. E

4. E

5. E

6. B

7. D

8. E

9. C

10. A

11. A

12. C

13. E

14. C

15. C

16. E

17. D

18. C

19. C

20. B

21. E

22. E

23. D

24. C

25. C

26. C

27. D

28. D

29. E

30. A

31. D

32. D

33. C

34. B

Section 4

1) The anterior pituitary is comprised of all of the following EXCEPT:

a) GH producing cells

b) gonadotrophs

c) ADH – producing cells

d) basophils

e) chromophobes

2) With regard to ant. lobe pituitary tumours, which is INCORRECT?

a) carcinomas are rare

b) benign adenomas can be locally invasive

c) the acidophilic cells occur together in 33% of somatropic adenomas

d) variations in cell nucleus size, shape give an indicator of malignancy

e) microadenomas occur in 40% of people

3) Prolactinomas – which is INCORRECT?

a) are an infrequent form of pituitary adenoma

b) type symptoms may be caused by drugs

c) is the cause in 25% of cases of amenorrhoea

d) is a cause of male infertility

e) macroadenomas are more common than micro

4) Hypopituitarism is caused by all but:

a) a direct destructive process of 505 of tissue

b) metastatic neoplasms

c) haemorrhage

d) arteritis

e) sarcoidosis

5) Symptoms of hypopituitarism can include all EXCEPT:

a) testicular atrophy

b) hair loss

c) growth retardation

d) weight loss

e) amenorrhoea

6) WRT hyperthyroidism – which is INCORRECT?

a) multinodular goitre always presents as thyrotoxicosis

b) is a hypermetabolic state caused by increased T3 and T4

c) its causes are different from those of thyrotoxicosis

d) cardiac manifestations are common

e) cardiac myofibrils show increased mitochondrial concentration

7) Which is the least common cause of hyperthyroidism?

a) toxic multinodular goitre

b) toxic adenoma

c) Grave’s disease

d) acute / subacute thyroiditis

e) diffuse toxic hyperplasia

8) Which is the least common cause of hypothyroidism?

a) atrophic autoimmune thyroiditis

b) Hashimoto’s thyroiditis

c) primary idiopathic hypothyroidism

d) surgical resection

e) radiation treatment

9) Thyroiditis is least commonly caused by:

a) bacteria

b) fungi

c) virus

d) chemical

e) sarcoid

10) A solitary palpable thyroid nodule (choose INCORRECT):

a) is likely to be benign

b) occurs in 2-4% and has a female preponderance

c) if cancerous, is most likely papillary

d) hot nodules on scan are more likely benign than malignant

e) is more likely to be malignant in someone 40

11) With regard to intravascular haemolysis, which doesn’t occur?

a) increased haptoglobin

b) jaundice

c) cleaning of Hb bound to α2 globulin by the spleen

d) haemoglobinuria

e) haemosiderinuria

Section 4

1. C

2. D

3. A

4. A

5. D

6. A

7. D

8. B

9. D

10. C

11. A

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