Pathology Chapter 19 Review Pancreas*

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What laboratory measure is most likely to provide the best method of monitoring disease control in type 2 diabetes: Glycosylated hemoglobin. Nonenzymatic glycoslyation refers to the chemical process whereby glucose attaches to proteins without the aid of enzymes. The degree of glycoslyation is proportionate to the level of blood glucose. Because RBCs have a life span of about 120 days, the amount of glycosylated hemoglobin is a function of the blood glucose level over the previous 120 day period. The level of glycoslyated hemoglobin is not appreciably affected by short-term changes in plasma glucose levels
What is measurement of fasting glucose used for: Initial diagnosis of diabetes mellitus
Microalbuminuria may presage the development of what disease: Diabetic renal disease
33 year old woman has had several fainting spells over the past 6 months Each time, she has a prodrome of light-headedness followed by a brief loss of consciousness. After each episode, she awakens and on examination has no loss of motor or sensory funct: Islet cell adenoma. This histopathology is most suggestive of an islet cell adenoma. Secretion of insulin by these lesions causes hypoglycemia and the described symptoms. Many of these tumors are less than 1cm in diameter, making them difficult to detect. Most patients who have an islet cell adenoma have only mild insulin hypersecretion. The laboratory finding of an increased insulin-to-glucose ratio is helpful. Surgical excision is necessary in patients with marked symptoms
Adenocarcinomas of the pancreas are derived from what tissue: Ductal epithelium. They have no endocrine function
Is acute pancreatitis likely to increase islet cell release of insulin: No
What are pseudocysts: Complications of pancreatitis that are focal and do not produce insulin hypersecretion
What can happen to the pancreas with cystic fibrosis: Fatty replacement, and diminished number of islets
66 year old woman has had diabetes mellitus for more than 30 years. Now has decreasing visual acuity. Intraocular pressure is normal. BMI 31. What lesion is most likely to account for her visual problems: Proliferative retinopathy. A variety of retinal lesions occur in diabetes mellitus. Retinopathy, cataracts, and glaucoma result in acquired blindness in some diabetic patients. Glaucoma is marked by increased intraocular pressure, which is not present in this patient
Vitamin A deficiency can lead to what visual disorder: Keratomalacia
What visual defect may be seen in systemic autoimmune diseases, in ischemia from temporal arteritis, and in toxicity resulting from methanol poisoning: Optic neuritis
What type of retinitis is seen in immunocompromised patients, particularly those with AIDS: Cytomegalovirus retinitis
The prenatal course of a 25 year old woman is uncomplicated. She gives birth to a 4500g son whose Apgar scores are 8 and 10 at 1 and 5 minutes. Shortly after birth, he develops irritability with seizure activity. Infant appears normal. Lungs clear. Serum: Hyperplasia of the islets of Langerhans. Maternal diabetes can result in hyperplasia of the fetal islets because of the maternal hyperglycemic environment. This can occur if gestational diabetes is present or if the mother has had diabetes mellitus prior to the pregnancy. After birth, the hyperplastic islets continue to overfunction, resulting in neonatal hypoglycemia. Infants of diabetic mothers also tend to exhibit macrosomia because of the growth-promoting effects of increased insulin levels.
Amyloid deposition in pancreatic islets may be seen in some cases of what disease: Type 2 diabetes mellitus
Extensive fibrosis and fatty replacement of the pancreas is seen in patients with what disease: Those with cystic fibrosis who have survived for decades
Infiltration of T cells into pancreatic islets occurs with what: The insulinitis that presages overt clinial type 1 diabetes mellitus
Granulation tissue around a necrotic central region in the pancreas defines what: A pseudocyst, which can complicate pancreatitis
Neutrophilic infiltration with necrosis and hemorrhage in the pancreas are characteristic of what: Acute pancreatitis
A fibrous stroma with minimal chronic inflammation and scattered normal islets in the pancreas is seen in what: Chronic pancreatitis
A pancreatic mass with irregular glands and abnormal nuclear features could be what: Adenocarcinoma
A dilated pancreatic duct with concretions can be seen in what: Chronic pancreatitis
A mass of islet cells in the pancreas is what: An adenoma
A 28 year old man has been using insulin injections to control his diabetes mellitus for the past 10 years. One morning, his roommate is unable to awaken him. The man is unconscious when he arrives at the ER. 37C, pulse 91, resp 30 and forceful, BP 90/65: Hypoglycemic coma. He does not have detectable C peptide, which indicates that there is no endogenous insulin production, as would be expected in type 1 diabetes. The high insulin level is the result of the patient's use of exogenous insulin to treat diabetes. Because he has not eaten enough to maintain glucose at an adequate level, he has developed hypoglycemia. The lack of food intake has led to the ketosis
When does acute myocardial infarction occur in a diabetic patient: Usually later in the course of diabetes when more atherosclerosis has developed
Do insulin injections run the risk of infection: Insulin is not injected into the bloodstream, and the infections are almost never complicated by infection
Hyperosmolar coma can complicate what type of diabetes: Type 2 diabetes mellitus
Ketosis in a diabetic patient would be accompanied by what lab value: Hyperglycemia
73 year old woman has noticed a 10kg weight loss in the past 3 months. Increasingly icteric and has constant vague epigastric pain, nausea, and episodes of bloating and diarrhea. Afebrile. Mild tenderness to palpation in the upper abdomen, but bowel soun: Adenocarcinoma. The findings of weight loss and pain suggest a malignant tumor. The jaundice (a conjugated hyperbilirubinemia) occurs because of biliary tract obstruction by a mass in the head of the pancreas. Such a carcinoma may present with "painless jaundice" as well, but it is more likely to invade the nerves around the pancreas, causing pain.
In what region of the pancreas are most pseudocysts from pancreatitis located: In the region of the body or tail of the pancreas, not the head
A group of patients has had poorly controlled hyperglycemia for at least 20 years. As a consequence, they have had nonenzymatic glycosylation of free amino groups of proteins in body tissues. What pathologic abnormality is most likely to be caused by thi: Accelerated atherogenesis. Nonenzymatic glycosylation of collagen accelerates atherosclerosis, because it eventually leads to the formation of irreversible advanced glycosylation end products (AGEs), which accumulate over a period of time. Such changes in collagen in the arterial walls aid in trapping LDL and thus accelerate lipid deposition.
The neuropathy, retinopathy, and cataracts common in diabetes mellitus result from what: Sorbitol accumulation and subsequent osmotic cell injury
The amyloid replacement of islets in the pancreas is a feature of some cases of what: Type 2 diabetes mellitus
38 year old woman has had a low-volume watery diarrhea for the past 3 months. She now has midepigastric pain. Antacid medications do not relieve the pain. Afebrile, no ab masses or tenderness. Multiple 0.5-1.1cm shallow, sharply demarcated, ulcerations i: Gastrin. This patient has Zollinger-Ellison syndrome, with one or more islet cell adenomas of the pancreas secreting gastrin. This secretion leads to intractable peptic ulcer disease, with multiple duodenal or gastric ulcerations. Islet cell tumors may secrete a variety of hormonally active compounds.
Insulinomas may produce what lab finding: Hypoglycemia
Glucagonomas and somatostatinomas may produce a syndrome characterized by what disease: Mild diabetes mellitus
VIPomas may be associated with what symptoms and lab findings: Watery diarrhea, hypokalemia, achlorhydria
What laboratory feature will be common to patients with either type 1 or type 2 diabetes mellitus: Nonenzymatic glycosylation of proteins, which is a function of the level of blood glucose rather than the cause of hyperglycemia. Type 1 and type 2 diabetes mellitus are characterized by hyperglycemia, but the underlying pathogenetic mechanisms are different
What disease associated with the pancreas is an autoimmune disease that is associated with certain alleles of MHC class II molecules: Type I diabetes mellitus
A 40 year old man has been taking daily insulin injections for the past 25 years. Friend finds him on the floor in an obtunded state. Afebrile, pulse 90, resp 17, BP 90/60, HgbA1C 8.9%, serum glucose 11, serum osmolality 295. Urinalysis 4+ ketonuria with: He is in poor glycemic control and has had an insulin overdose. The increased hemoglobin A1c level suggests that this patient has poorly controlled hyperglycemia. The profound hypoglycemia is consistent with and overdose of insulin, and the ketonuria suggest that he has not been eating any food
36 year old woman has had several fainting spells in the past month. Becomes light headed and then collapses. Recovers within a few minutes but experiences diaphoresis and palpitations. During the episode she is 36.9C, pulse 88, resp 16, BP 100/55. What: Hypoglycemia. An islet cell tumor may be suspected as the cause of episodic hypoglycemia. Reactive hypoglycemia after meals may also be considered.
What abnormal lab value gives rise to tetany, characterized by muscle spasms: Hypocalcemia
Hypercarbia is likely to result from what: Decreased respirations
35 year old woman is admitted to the hospital with severe anginal pain of 4 hours duration. Afebrile, pulse 94, resp 18, BP 85/45. ECG shows evidence of left ventricular infarction, wh: This patient has diabetes. Nodular glomerulosclerosis is a characteristic feature of renal involvement in advanced diabetes mellitus. Myocardial infarction in this premenopausal woman strongly suggests an underlying predisposing condition such as diabetes mellitus. Proteinuria and evidence of renal failure support the likelihood of diabetes. Diabetic individuals are also prone to early and accelerated atherosclerosis of peripheral vessels. Thrombotic occlusion of arteries in the leg places these patients at a very high risk of developing gangrene.
52 year old man has had severe abdominal pain for 2 days. Boardlike rigidity of the ab muscles. No observable ab distension. Gross appearance shown. What is the mechanism that most lik: Dysregulation of trypsinogen inactivation. This patient has acute hemorrhagic pancreatitis with foci of chalky white fat necrosis. Fundamental to the causation of acute pancreatitis is inappropriate activation of digestive enzymes in the acini and the consequent autodigestion of the pancreas. These enzymes are present as proenzymes in the acini and are activated by trypsin. Trypsin itself is derived from trypsinogen, and any abnormality that prevents regulated inactivation of trypsinogen can lead to excessive trypsin-mediated activation of other digestive enzymes such as lipase, amylase, and elastase. Evidence for this mechanism comes from the observation that the rare disease hereditary pancreatitis, with germ-line mutations that affect a site on the cationic trypsinogen molecule essential for the cleavage of trypsin itself, results in trypsinogen and trypsin that become resistant to inactivation, and the abnormally active trypsin activates other digestive proenzymes, leading to development of pancreatitis
What is the most common event precipitating trypsinogen activation: Pancreatic duct obstruction by gallstone
What gene mutation can give rise to chronic pancreatitis, even in the absence of cystic fibrosis: A CFTR gene mutation
A K-RAS mutation is an early event in what disease: Pancreatic carcinogenesis
A patient with acute hemorrhagic pancreatitis is admitted to the hospital. Acute condition subsides within 7 days. What complication is most likely to occur in this patient: Pseudocyst formation. During acute pancreatitis, the extent of necrosis may be so severe that a liquefied area becomes surrounded by granulation tissue, forming a cystic mass. However, because there is no epithelial lining in the cyst, it is best called a pseudocyst.
In acute pancreatitis with hemorrhage, where in the pancreas is the hemorrhage likely to occur: It is confined to the body of the pancreas and surrounding fibroadipose tissue. The inflammation is unlikely to comprise the blood supply to abdominal organs and produce an infarction
In acute pancreatitis, does spread of inflammation from the pancreas to the stomach typically occur: No. Although the pancreas is inferior and posterior to the stomach, spread of inlammation to the stomach does not typically occur
Is lack of insulin a typical feature of pancreatitis: No. The islets of Langerhans usually continue to function despite marked inflammation of the parenchyma
What laboratory finding is most likely to be characteristic for patients who are hyperglycemic due to type 1 diabetes mellitus: Ketonuria. The markedly diminished insulin levels associated with type 1 diabetes mellitus coupled with absolute or relative increases in glucagon, result in catabolism of adipose tissue. The released fatty acids can then become oxidized to form ketone bodies and produce ketonuria and possible ketoacidosis. Patients with type 2 diabetes mellitus can have mild to moderately decreased insulin levels, but there is still sufficient insulin to prevent this complication
52 year old man with gradual weight gain over 30 years. Decreased sensation to pinprick and light tough over the lower extremities. Patellar reflexes are reduced. Glucose 169, creatinine 1.9, total chol 220, HDL 27, triglyc 261. Mild cardiomegaly. Fiver: Diabetes mellitus type II. This patient is at risk for gangrenous necrosis. Severe peripheral atherosclerotic disease is a common complication of long-standing diabetes mellitus. Atherosclerotic narrowing of the arteries to the lower legs can cause ischemia and gangrene. The foot is often involved with gangrene, which may necessitate amputation. Diabetic neuropathy with decreased sensation increases the risk of repeated trauma, which in turn enhances the risk of ulcerations that cause infection and inflammation that protmotes gangrene
A subset of subjects between ages 8 and 22 have no overt clinical illnesses and no hyperglycemia; however, autoantibodies to glutamic acid decarboxylase are present. Many in this subset have the HLA-DQA1 and HLA-DQB1 alleles. What pancreatic abnormality: Infiltration of T lymphocytes into the islets of Langerhans. The presence of HLA-DQA1 and HLA-DQB1 alleles of the MHC class II region has the strongest linkage to type I diabetes mellitus. Autoantibodies to islet cell antigens such as glutamic acid decarboxylase are present years before overt clinical diabetes develops. Similarly, an insulinitis caused by T cell infiltration occurs prior to the onset of symptoms or very early in the course of type I diabetes mellitus. The insulinitis in type I diabetes mellitus is associated with increased expression of class I MHC molecules and aberrant expression of class II MHC molecules on the Beta cells of the islets. These changes are mediated by cytokines such as interferon-gamma elaborated by CD4 cells (along with CD8 cells)
Amyloid deposition in pancreatic islets cells may be seen in some cases of what disease: Type 2 diabetes mellitus
Extensive fibrosis and fatty replacement of the pancreas is seen in what disease: Patients with cystic fibrosis surviving for decades
Pancreatic islet hyperplasia occurs in what patients: Infants of diabetic mothers
Neutrophilic infiltration with necrosis and hemorrage in the pancreas are characteristic of what disease: Acute pancreatitis
A fibrous pancreatic stroma with minimal chronic inflammation and scattered normal islets is seen in what disease: Chronic pancreatitis
A dilated pancreatic duct with concretions is seen in what disease: Chronic pancreatitis
72 year old woman admitted to hospital in an obtunded condition. 37C, pulse 95, resp 22, BP 90/60. Dehydrated and has poor skin turgor. Glucose 872, Urinalysis 4+ glucosuria but no ketones, protein, or blood. What factor is most important in the pathogen: Insulin resistance. This patient has type 2 diabetes mellitus with hyperosmolar, nonketotic coma. In type 2 diabetes mellitus, there is a decrease in plasma insulin or a relative lack of insulin, but there is still enough to prevent ketosis. The fundamental defect is insulin resistance. The resulting hyperglycemia tends to produce polyuria, leading to dehydration that further increases the serum glucose level. If enough fluids are not ingested, dehydration drives the serum glucose to very high levels.
For the past 24 years, a 70 year old man has had hemoglobin A1C values between 8-11%. He has hard exudates and cotton-wool spots, as well as foci of neovascularization, seen on funduscopy. He now has increasing serum urea nitrogen and creatinine levels a: Diffuse glomerulosclerosis. This, along with nodular glomerulosceris, is a change that is characteristic of diabetic nephropathy. The nephropathy takes years to develop, and renal function gradually diminishes. The other complication of diabetes mellitus in this man is retinopathy. The hard exudates and cotton-wool spots are part of a background retinopathy, but the neovascularization is part of the more ominous proliferative retinopathy
How does membranous glomerulonephritis commonly present: Trick question- it is usually idiopathic
38 year old woman with a lengthy history of gallbladder disease has a sudden onset of severe midabdominal pain. Marked abdominal tenderness, particularly in the upper abdomen, and bowel sounds are reduced. Ab radiograph shows no free air, but there is ma: Increased amylase level. The clinical features, as well as the preexisting gallbladder disease, are highly suggestive of acute pancreatitis. This can be confirmed by the appearance of the pancreas at laparotomy. The serum amylase level is rapidly elevated after an attack of acute pancreatitis. Serum and urine lipase levels are also elevated. These enzymes are released from necrotic pancreatic acini.
Hyperammonemia is a feature of what disease: Liver failure
56 year old woman with a lengthy history of diabetes mellitus dies suddenly and unexpectedly. She was 40kg over her ideal body weight. Her only previous serious medical problem was a poorly healing ulcer on the sole of her left foot. What lesion is most: Coronary artery thrombosis. The most common cause of death in diabetic patients is ischemic heart disease. Diabetic individuals have accelerated, advanced atherosclerosis. The heart, kidneys, and brain are most often affected by ischemia resulting from vascular narrowing, thrombosis, or thromboembolic disease. There can also be severe peripheral vascular disease, with poor tissue perfusion and poor wound healing. This complication would explain this woman's poorly healing foot ulcer
For the past 35 years, a 39 year old man has had numerous bouts of pneumonia caused by P. aeruginosa and Burkholderia cepacia. He now has mild-to-moderate volume diarrhea. Decreased breath sounds and dullness to percussion in both lungs. His stool guaiac: Acinar atrophy. This patient has cystic fibrosis, an autosomal recessive condition that results from an abnormal cystic fibrosis transmembrane conductance regulator (CFTR) gene. The most common mutation is deltaF508. The decreased bicarbonate secretion gives rise to abnormal viscid secretions affecting the pancreas. This results in ductal obstruction, and this leads to a form of chronic pancreatitis with acinar atrophy. Eventually, the exocrine function is gone
13 year old girl collapses while playing basketball. She is obtunded. Hypotensive and tachycardic with deep, rapid, labored respirations. Serum Na 151, K 4.6, Cl 98, CO2 7, glucose 521. Urinalysis 4+ glucosuria and 4+ ketonuria but no protein, blood, or: Loss of islets of Langerhans. Type I diabetes does not become overt until the Beta cells are markedly depleted and insulin levels are greatly reduced. In this case, the girl has ketoacidosis
50 year old man has a 35 year history of diabetes mellitus. Hem A1C 6-10%. He now has problems with sexual function, including difficult attaining an erection. He is also plagued by a mild but recurrent low-volume diarrhea and difficulty with urination.: Sorbitol accumulation. This patient has autonomic neuropathy caused by long-standing diabetes mellitus. It is thought that nerve cells do not require insulin for glusose uptake. In the presence of hyperglycemia, excess glucose diffuses into the cell cytoplasm and accumulates. The excess glucose is metabolized by intracellular aldose reductase enzyme to sorbitol and then to fructose. This increased amount of carbohydrate increases cellular osmolarity and free water influx, injuring the cell. Schwann cells are injured in this manner; the injury may lead to peripheral neuropathy.
40 year old woman has experienced chest pain on exertion for the past 2 months. A month ago she had pneumonia with S. pneumoniae. BMI 32. Random blood glucose is 132. The next day, fasting glucose is 122, followed by 128 the following day. Blood glucose: Activation of PPARgamma nuclear receptor in adipocytes. The clinical features of obesity with angina and glucose intolerance in this patient are strongly suggestive of type 2 diabetes mellitus. This is confirmed by her glucose tolerance test. The fundamental abnormality in type 2 diabetes mellitus is insulin resistance. Several adipocyte-derived molecules, such as adiponectin and resistin, have been implicated in the causation of insulin resistance, thus establishing the link between obesity and type 2 diabetes mellitus. The nuclear receptor PPARgamma has emerged as a key molecule in the regulation of insulin resistance through its actions on adipocytes hormones. TXDs bind to and activate PPARgamma in adipocytes and thereby increase the levels of the insulin-sensitizing hormone adiponectin and reduce the levels of free fatty acids and resistin, both of which increase insulin resistance
63 year old man who had worsening congestive heart failure with cardiac dysrhythmias in the last year of his life died of pneumonia. Pancreas is grossly small and densely fibrotic. Extensive atrophy of the acini with abundant collagenous interstitial fib: Chronic alcoholism. This patient has chronic pancreatitis. Alcohol promotes intracellular proenzyme activation that leads to acinar cell injury. Chronic alcoholism also causes secretion of protein-rich pancreatic fluid, which is inspissated and deposited in small pancreatic ducts. Ductal obstruction predisposes to acinar injury. Ongoing or repeated injury leads to chronic pancreatitis. A dilated cardiomyopathy can also occur in chronic alcoholism, as in this case.

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