Section 1

Gastroenterology and Endocrine

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

a) chronic obstructive pancreatitis has a lobular distribution of lesionsb) it may lead to the development of diabetes mellitusc) chronic calcifying pancreatitis is especially common in alcoholicsd) it can be precipitated by opiate usee) it may have a hereditary component to its aetiology

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

a) bodyb) headc) diffuse or disseminatedd) necke) tail

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

a) cigarette smoking significantly increases the risk of developmentb) it may be associated with migratory thrombophlebitisc) it more commonly arises in acinar cell than in ductal epithelial cellsd) the average survival time from diagnosis is 6 monthse) 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 weekb) it may be idiopathic in up to 50% of casesc) it involves activation of trypsinogend) fat necrosis may involve the omentum and mesenterye) 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 tailb) they have no connection or communication with surrounding ductal systemsc) they can become infected leading to generalised peritonitisd) they possess an epithelial lininge) they are usually solitary

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

a) islet cell antibodiesb) early insulitisc) beta cell depletiond) HLA-B linkede) severe insulin deficiency

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

a) idiopathic b) pancreas divisumc) alcoholismd) hypercalcaemiae) biliary tract disease

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

a) no HLA associationb) rare ketoacidosisc) no insulitisd) insulin resistancee) 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 hoursb) hypercalcaemiac) elevated serum lipase within 72-96 hoursd) glycosuria

e) metabolic acidosis

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

a) kidneyb) retinac) heartd) brain e) peripheral nerve

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

a) hyperthermiab) traumac) hyperlipoproteinaemiad) mumpse) hyperparathyroidism

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

a) hepatic fibrosis is reversible over 12 months if aetiological factors are removedb) oesophageal varices are seen in 95% of cases in advanced cirrhosisc) the vascular architecture is maintainedd) hepatic failure occurs only once the cirrhotic liver has decreased in masse) viral hepatitis is responsible for 10%

13) Acute pancreatitis:

a) may be caused by Helminth infectionb) causes hypercalcaemiac) develops in 50% of patients with gallstonesd) leads to inhibition of elastasee) involves acinar cell injury as a late event

14) The following is NOT associated with oesophageal carcinoma:

a) long standing oesophagitisb) smokingc) alcohol abused) vitamin A deficiency

e) blood group O positive

15) Pyloric stenosis:

a) occurs in females more than malesb) occurs in about 1:5000 live birthsc) is due to hypertrophy of pyloric muscularis mucosa in infantsd) is not associated with peptic ulcerse) is usually treated with gastrectomy

16) An usual site for peptic ulceration is:

a) within Barrett’s mucosab) within the stomachc) within the duodenumd) within the jejunum adjacent to Meckel’s diverticulume) upper oesophagus in Zollinger-Ellison syndrome

17) Gastric pH is NOT increased by:

a) ingestion alkalisb) multi trauma acutelyc) treatment with misoprostold) treatment with ranitidinee) vagotomy

18) Haemorrhoids:

a) affect 1% of general populationb) may be associated with portal hypertensionc) are due to venacaval obstruction in pregnancyd) are not painful when thrombosede) 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 casesc) is easily clinically differentiated from appendiceal mucocoeled) a clinical false positive diagnosis rate of 20% is far too highe) liver abscess is not a complication

20) Acute pancreatitis:

a) is caused by alcohol more commonly in women than in menb) occurs in 20% of patients with gallstonesc) is due to mumps virus infections in 20% of patientsd) is seen as a direct complication of SLEe) is caused by sulphonamides but not loop diuretics

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

a) association with ankylosing spondylitisb) an association with uveitisc) an associated pericholangitisd) the presence of chronic mucosal damage and fibrosise) the presence of granulomas

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

a) sodium and water retentionb) hypertensionc) generalised oedemad) hypokalaemiae) alkalosis

23) Glucagon secretion by the pancreas is inhibited by:

a) CCKb) secretinc) gastrind) cortisole) infection

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

a) microaneurysm formationb) pre-retinal haemorrhagec) venous dilatationd) hard retinal exudates

e) neovascularisation

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

a) beta cell degranulationb) reduction in size and number of isletsc) increase in size and number of isletsd) leukocyte infiltration of islets (“insulitis”)e) none of the above

26) Concerning diabetes mellitus:

a) type I has a 50% concordance in identical twinsb) type II has a 70% concordance in identical twinsc) type II affects less than 5% of people older than 70d) type I affects 20% of children of first-order relativese) 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 malignantb) 75% of gastrinomas are benignc) 90% of gastrinomas are solitaryd) 50% of patients develop jejunal ulceratione) duodenal ulceration predominates in the 3rd and 4th parts

Section 1

Gastrointestinal and Endocrine - Answers

1 A2 B3 C4 E5 D6 D7 C8 E9 B10 A11 A12 E13 A14 E15 B16 E17 C18 B19 A20 D21 E22 C23 B24 E25 E26 A27 A

Section 2

Liver / Biliary Tract

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

a) phospholipidsb) bile saltsc) proteind) cholesterole) bilirubin

2) Gallstones:

a) afflict 1-2% of adult population in developed countriesb) are usually pigment stonesc) remain silent / asymptomatic in most casesd) are more common in men than womene) are associated with increased bile formation

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

a) gall bladder hypomobilityb) mucus hypersecretion in gall bladderc) acceleration of cholesterol nucleation in biled) biliary hypersecretion of cholesterole) the presence of calcium salts in bile

4) Acalculons cholecystitis:

a) is the most common reason for emergency cholecystectomyb) is rarely caused by primary bacterial infectionc) is usually caused by chemical irritation and inflammationd) is a relatively common cause of acute cholecystitise) generally occurs in otherwise well patients

5) Acute fatty liver of pregnancy:

a) usually occurs in the third trimesterb) may be co-existent with pre-eclampsia in up to 40% of casesc) usually runs a mild coursed) involves an intramitochondrial fatty acid oxidation defecte) all of the above

6) Regarding the liver:

a) it usually weighs 150gb) 1/3 of the blood supply comes from the portal veinc) peripheral hepatocytes of each acinus receives the poorest blood supplyd) the hepatic venile is in the centre of the acinuse) Ito cells secrete enzymes to degrade collagen

7) Which is the biggest cause of liver cirrhosis?

a) chronic hepatitisb) biliary diseasec) haemochromatosisd) α1 antitrypsin diseasee) ethanol

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

a) HBsAgb) HBeAgc) HBV DNAd) anti HBc

e) anti HBe

9) Which hepatitis virus contains DNA?

a) HAVb) HBVc) HCVd) HDVe) HEV

10) Regarding HDV:

a) it is a water borne infectionb) it only causes infection when encapsulated by HBcAgc) acute co-infection with HBV often leads to chronic hepatitisd) it has a high mortality rate in pregnancy womene) IgM anti HDV is indicative of recent exposure

11) Regarding gallstones:

a) they are more common in menb) there are no genetic linksc) 50% are asymptomaticd) pigment stones are always associated with infectione) become symptomatic at a rate of 1-3%/year

12) Which is a cause of conjugated hyperbilirubinaemia?

a) haemolytic anaemiab) intrahepatic biliary obstructionc) Gilbert syndromed) internal haemorrhagee) physiologic jaundice of the newborn

13) Which hepatitis virus is waterborne?

a) HDVb) HEVc) HGVd) HCVe) HBV

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

a) HAVb) HBVc) HCVd) HDVe) HEV

15) Regarding the clinical syndromes developing to hepatitis virus:

a) HBV most commonly causes jaundiceb) chronic hepatitis is when there is evidence of ongoing hepatic disease for more

than 3 monthsc) vertical transmission of HBV produces a carrier state 50-60% of the timed) the most common symptom of chronic hepatitis is fatiguee) in acute viral hepatitis, the jaundice is caused predominantly by unconjugated

hyperbilirubinaemia

16) Which is HBV NOT present in?

a) stoolb) semenc) salivad) sweate) breast milk

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

a) hepatic comab) GI bleedc) infectiond) hepatorenal syndromee) hepatocellular carcinoma

18) Hepatitis A virus:

a) has a 5% fatalityb) is an enveloped ssRNA picornavirusc) is shed in stool only after the onset of jaundiced) has serum transmissione) HAV IgM marks acute infection

19) Hepatitis C virus:

a) is a small enveloped dsRNA virusb) has three subtypesc) progresses to chronic disease in 10%d) incubation period is 2-26 weekse) is known as the “delta agent”

Section 2

Liver / Biliary Tract – Answers

1 B2 C3 D4 B5 E6 D7 E8 E9 B10 E11 E12 B13 B14 C + B15 D16 A17 E18 E19 D

Section 3

Pancreas, Liver, Biliary Tract, Renal

1) In type I diabetes mellitus:

1 there is an insulin secretory defect without β cell loss2 there is no HLA linkage3 there is an amyloid deposition4 concordance is 50%5 there are no anti-islet cell antibodies

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

1 insulin2 trypsin3 chymotrypsin4 elastase5 phospholipase

3) Which enzyme catalyzes activation of other enzymes?

1 amylase2 phospholipase3 lipase4 nuclease5 trypsin

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

1 shock2 coxsackie virus3 prescribed drugs4 iatrogenic injury5 biliary free disease

5) Regarding acute pancreatitis, which is INCORRECT?

1 trypsin activates the Hageman factor2 ARDS is a serious complication3 incidence is 10-20 cases per 100,0004 hypocalcaemia is a poor prognostic sign if persistent5 hypercalcaemia occurs commonly

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

1 a mucosal lining of columnar cells2 a muscularis mucosa and submucosal3 a fibromuscular layer4 subserosal fat, with arteries, veins and lymphatics5 a peritoneal covering

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

1 scorpion bites2 trauma3 infection4 alcohol5 ischaemia

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

1 severe right-sided heart failure2 Budd-Chiari syndrome3 constructive pericarditis4 hepatic veno-occlusive disease5 splenomegaly

9) Which of the following gives rise to predominantly conjugated

hyperbilirubinaemia?

1 haemolytic anaemias2 physiologic jaundice of the newborn3 fluke infestation4 breast mild jaundice5 resorption of blood from internal haemorrhage

10) Hepatitis B virus was identified in:

1 19652 19733 19774 19805 1989

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

1 extremely rare2 develops in more than 90% of neonates3 develops in 5% of adults4 develops in more than 50% of patients5 HAV does not produce chronic hepatitis

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

1 onset beyond age 302 obesity3 ketoacidosis4 90-100% concordance in twins5 insulin resistance

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

1 gastrinoma2 recalcitrant peptic ulcer disease3 gastric hypersecretion4 pancreatitis islet cell tumour5 β-cell tumours

14) Hepatitis:

1 causes fulminant hepatitis and death in about 5% of cases2 progresses to chronic liver disease and cirrhosis in >50%3 exhibits considerable genomic variability4 usually causes chronic hepatitis in acute HCV co-infection5 is non pathogenic

15) Regarding urolithiasis:

1 struvite stones contain calcium-ammonium-phosphate2 uric acid stones are associated with urea-splitting bacterial infection3 10% of calcium containing stones are associated with hypercalcaemia4 uric acid stones are due to hyperuricaemia5 all stones are associated with TCCs

16) Cirrhosis:

1 in NZ is most commonly due to viral hepatitis2 involves collagen synthesis by Kupffer cells3 may completely resolve if causative pathology is removed4 usually causes early jaundice5 associated with hepatocellular carcinoma

17) Nephrotic syndrome:

1 is most commonly caused by rapidly progressing GN in adults2 characteristically presents with haematuria3 is characterised by a proteinuria of 3.5mg per day4 is most commonly caused by lipoid nephrosis in children5 is immunologically mediated

18) Polycystic kidney disease:

1 has a 70% co-association with Berry aneurysms2 is an autosomal recessive condition in its adult form3 is responsible for 10% of adult cases of chronic renal failure4 often features unilateral polycystic changes5 does not present with haematuria

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

1 metabolic acidosis2 a GFR < 5% of normal in end stage renal disease3 hypophosphaturia4 pulmonary oedema5 anaemia

20) Urolithiasis:

1 is bilateral in 80% of cases2 presents most commonly in young adult males3 is usually associated with an acid urine4 is associated with hypercalcuria in 60% of cases5 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 gap2 it may be caused by potassium sparing diuretics3 it is associated with Addison’s disease in one of its forms4 it has a good prognosis when associated with aminoaciduria, phosphaturia

and glycosuria5 it is characterised by hypokalaemia and hyperchloraemia

22) Malignant nephrosclerosis:

1 presents more commonly in females2 is defined by a diastolic blood pressure > 110mmHg3 is associated with hypo-aldosteronism4 is characterised by hyaline arteriosclerosis5 has a 2.5% five year mortality rate if treated

23) Regarding renal calculi:

1 most stones are uric acid stones2 large stones typically present with colic3 large stones are rarely composed of magnesium ammonium phosphate4 stones are bilateral in about 20% of patients5 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 hypertension3 nephrosclerosis and glomerulosclerosis associated with aging causes loss of

10% of nephrons each 10y over 404 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 normal2 10% of normal3 20% of normal4 30% of normal5 40% of normal

26) Renal calculi are caused by:

1 calcium containing stones2 magnesium, ammonia, phosphate stones3 uric and stones (?????uric acid stones)4 cystine stones

The order of commonest to least common is:

a) 1, 3, 2, 4b) 2, 1, 3, 4c) 1, 2, 3, 4,d) 1, 2, 4, 3e) 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 reninc) the medulla is particularly resistant to ischaemic damaged) mesangial cells have an important role in the pathogenesis of

glomerulonephritise) monocyte macrophages are the principal phagocytic cells

28) In acute tubular necrosis:

a) decline in B.U.N. correspond with the onset of polyuriab) ischaemic acute tubular necrosis is characterised by diffuse damage to the

proximal convoluted tubulec) 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 agentb) hepatitis B virus is present in stoolc) chronic HBV/HDV hepatitis is more common with a HDV/HBV co-infection rather

than a HDV super-infection in a HBV carrierd) 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 diabetesb) type II diabetes mellitus is HLA-D linkedc) there are three types of maturity onset diabetes of the youngd) Schiff bases are irreversibly glycosylated proteinse) renal complications are solely through glomerular damage

31) In acute pancreatitis:

a) cytomegalovirus infection is a known etiologic factorb) males are three times more likely to suffer gallstone pancreatitisc) the pancreatic blood vessels are sparedd) calcium precipitates with free fatty acids in fat necrosise) secondary diabetes is a common sequelae

32) Regarding urolithiasis:

a) uric acid stones are commonly associated with infectionb) 50% of stones are composed of magnesium ammonium phosphatec) 10% are cholesterol stonesd) uric acid stones may or may not form in the presence of hyperuricaemiae) 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 bodiesc) mesmic necrosisd) reversibility of fatty change on abstaining from alcohole) 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 liverd) HDV is dependent on HBV for its infectiousnesse) HEV has a mortality rate of up to 20% in pregnant woman

Section 3

Pancreas, Liver, Biliary Tract and Renal - Answers

1 D2 A3 E4 E5 E6 B7 D8 E9 C10 A11 A12 C13 E14 C15 C16 E17 D18 C19 C20 B21 E22 E23 D24 C25 C26 C27 D28 D29 E30 A31 D32 D33 C34 B

Section 4

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

a) GH producing cellsb) gonadotrophsc) ADH – producing cellsd) basophilse) chromophobes

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

a) carcinomas are rareb) benign adenomas can be locally invasivec) the acidophilic cells occur together in 33% of somatropic adenomasd) 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 adenomab) type symptoms may be caused by drugsc) is the cause in 25% of cases of amenorrhoead) is a cause of male infertilitye) macroadenomas are more common than micro

4) Hypopituitarism is caused by all but:

a) a direct destructive process of 505 of tissueb) metastatic neoplasmsc) haemorrhaged) arteritise) sarcoidosis

5) Symptoms of hypopituitarism can include all EXCEPT:

a) testicular atrophyb) hair lossc) growth retardationd) weight losse) amenorrhoea

6) WRT hyperthyroidism – which is INCORRECT?

a) multinodular goitre always presents as thyrotoxicosisb) is a hypermetabolic state caused by increased T3 and T4

c) its causes are different from those of thyrotoxicosisd) cardiac manifestations are commone) cardiac myofibrils show increased mitochondrial concentration

7) Which is the least common cause of hyperthyroidism?

a) toxic multinodular goitreb) toxic adenomac) Grave’s diseased) acute / subacute thyroiditise) diffuse toxic hyperplasia

8) Which is the least common cause of hypothyroidism?

a) atrophic autoimmune thyroiditisb) Hashimoto’s thyroiditisc) primary idiopathic hypothyroidismd) surgical resectione) radiation treatment

9) Thyroiditis is least commonly caused by:

a) bacteriab) fungic) virusd) chemical e) sarcoid

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

a) is likely to be benignb) occurs in 2-4% and has a female preponderancec) if cancerous, is most likely papillaryd) hot nodules on scan are more likely benign than malignante) is more likely to be malignant in someone <40 than >40

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

a) increased haptoglobinb) jaundicec) cleaning of Hb bound to α2 globulin by the spleend) haemoglobinuriae) haemosiderinuria

Section 4

1 C2 D3 A4 A5 D6 A7 D8 B9 D10 C11 A