Congenital Anomalies of Pancreas — MCQs
Double bubble sign is seen in -
Tail of pancreas develops from -
True about pancreatic pseudocysts is:
The duct of Wirsung is:
Tumour of the uncinate process of the pancreas will compress which artery
Most common complication of a pseudocyst of the pancreas is
What is the echogenic lesion size criterion for chronic pancreatitis?
A 6-week-old baby is brought in by the mother with complaints of vomiting. An X-ray shows a single bubble appearance. What is the most likely diagnosis?
The treatment of an annular pancreas is
Congenital cyanotic heart disease with pulmonary oligemia is seen with –
Congenital Anomalies of Pancreas Indian Medical PG Practice Questions and MCQs
Question 1: Double bubble sign is seen in -
- A. Duodenal atresia
- B. Annular pancreas
- C. Ladd's band
- D. All of the options (Correct Answer)
Explanation: ***All of the options*** - The **"double bubble sign"** on an X-ray indicates **duodenal obstruction**, which can be caused by intrinsic factors like **duodenal atresia** or extrinsic compressions such as an **annular pancreas** or **Ladd's bands** associated with malrotation. - While differing in etiology, all these conditions lead to fluid and air accumulation in the stomach and proximal duodenum, creating the characteristic two dilated loops. *Duodenal atresia* - This is an **intrinsic congenital obstruction** of the duodenum, preventing the passage of gastric and duodenal contents. - On imaging, it shows **two distinct air-filled bubbles** (one for the stomach, one for the proximal duodenum) separated by the pylorus. *Ladd's band* - **Ladd's bands** are peritoneal fibrous bands that can compress the duodenum in cases of **intestinal malrotation**, leading to extrinsic obstruction. - The resulting proximal duodenal dilation, along with gastric distension, presents as the **double bubble sign**. *Annular pancreas* - An **annular pancreas** is a congenital anomaly where pancreatic tissue completely encircles and obstructs the second part of the duodenum. - This extrinsic compression causes significant dilation of the stomach and proximal duodenum, mimicking the appearance of the **double bubble sign**.
Question 2: Tail of pancreas develops from -
- A. Hepatic diverticulum
- B. Ventral pancreatic bud
- C. Dorsal pancreatic bud (Correct Answer)
- D. All of the options
Explanation: Dorsal pancreatic bud - The dorsal pancreatic bud forms the majority of the pancreas, including the body, tail, and most of the head [1]. - It arises from the dorsal mesentery of the duodenum [1]. Hepatic diverticulum - The hepatic diverticulum gives rise to the liver, gallbladder, and bile ducts [2]. - It is separate from the pancreatic development and does not contribute to the pancreas. Ventral pancreatic bud - The ventral pancreatic bud forms only a small part of the pancreas, specifically the inferior portion of the head and the uncinate process [1]. - It rotates posteriorly with the duodenum to fuse with the dorsal bud [1]. All of the options - This option is incorrect because only the dorsal pancreatic bud forms the tail of the pancreas [1]. - The hepatic diverticulum does not contribute to pancreatic development at all, and the ventral pancreatic bud only forms the uncinate process and part of the head [1].
Question 3: True about pancreatic pseudocysts is:
- A. No epithelial lining (Correct Answer)
- B. Develops after 4 weeks
- C. Contains solid components
- D. Always needs surgery
Explanation: ***No epithelial lining*** - A pancreatic pseudocyst is defined by its lack of a true **epithelial lining**, distinguishing it from other cystic lesions of the pancreas. - Instead, its wall is formed by **fibrous and granulation tissue** surrounding a collection of pancreatic enzymes, inflammatory exudates, and necrotic debris. *Develops after 4 weeks* - While many pseudocysts do develop after an acute pancreatitis episode, the 4-week timeline is more specifically associated with the definition of a **pancreatic collection becoming a mature pseudocyst**. - However, pseudocysts can sometimes be observed earlier, and the defining characteristic is the absence of epithelium, not the time of formation. *Contains solid components* - Pancreatic pseudocysts are typically **fluid-filled collections** with a relatively uniform, anechoic appearance on imaging studies. - The presence of significant **solid components** would suggest a different lesion, such as a cystic tumor or a walled-off necrosis, rather than a simple pseudocyst. *Always needs surgery* - Many pancreatic pseudocysts, particularly smaller ones, can **resolve spontaneously** and thus do not always require surgical intervention. - Treatment often depends on size, symptoms, complications, and the duration of the pseudocyst, with conservative management or endoscopic drainage being viable options in many cases.
Question 4: The duct of Wirsung is:
- A. Parotid duct.
- B. Common bile duct
- C. Main Pancreatic duct (Correct Answer)
- D. Accessory Pancreatic duct
Explanation: ***Main Pancreatic duct*** - The **duct of Wirsung** is the primary duct that drains **pancreatic exocrine secretions** (digestive enzymes and bicarbonate) from the pancreas into the duodenum [1]. - It typically joins the **common bile duct** to form the **ampulla of Vater**, which then empties into the second part of the duodenum [3]. *Parotid duct* - The **parotid duct** (Stensen's duct) drains secretions from the **parotid salivary gland**. - It opens into the buccal mucosa opposite the second maxillary molar tooth, not related to the pancreas. *Common bile duct* - The **common bile duct** is formed by the union of the **common hepatic duct** and the **cystic duct**, carrying bile from the liver and gallbladder [2]. - While it often merges with the main pancreatic duct before entering the duodenum, it is not the duct of Wirsung itself. *Accessory Pancreatic duct* - The **accessory pancreatic duct** (duct of Santorini) is a smaller duct that drains a portion of the head of the pancreas directly into the duodenum. - It is present in many individuals but is distinct from the main pancreatic duct (Wirsung) and often has a separate opening proximal to the ampulla of Vater.
Question 5: Tumour of the uncinate process of the pancreas will compress which artery
- A. Superior mesenteric artery (Correct Answer)
- B. Inferior mesenteric artery
- C. Common hepatic artery
- D. Splenic artery
Explanation: ***Superior mesenteric artery*** - The **uncinate process** forms the lower and medial part of the head of the pancreas, hooking around and behind the **superior mesenteric vessels**. - A tumor in this region would therefore almost immediately compress the **superior mesenteric artery** and vein due to its close anatomical relationship. *Splenic artery* - The **splenic artery** runs along the superior border of the pancreas, primarily associated with the body and tail. - A tumor in the **uncinate process** (part of the head) would be anatomically distant from the splenic artery, making compression unlikely. *Inferior mesenteric artery* - The **inferior mesenteric artery** arises from the aorta much lower than the pancreas, typically at the L3 vertebral level. - Its anatomical position makes it spatially separated from the uncinate process of the pancreas, so compression is not expected. *Common hepatic artery* - The **common hepatic artery** runs anterior to the portal vein and to the left of the bile duct, supplying the liver. - It is located superior to the head of the pancreas and away from the uncinate process, hence not typically affected by tumors in that specific pancreatic region.
Question 6: Most common complication of a pseudocyst of the pancreas is
- A. Rupture into peritoneum
- B. Haemorrhage
- C. Infection (Correct Answer)
- D. Rupture into colon
Explanation: ***Infection*** - **Infection** is the most common and clinically significant complication of a pancreatic pseudocyst, often leading to sepsis and increased mortality. - While other complications can occur, **secondary infection** transforms a sterile pseudocyst into an abscess, requiring urgent intervention. *Rupture into peritoneum* - While possible, **rupture into the peritoneum** (free rupture) is a less frequent complication compared to infection. - This leads to acute peritonitis and is a highly morbid event, but statistically less common than infection. *Haemorrhage* - **Hemorrhage** (bleeding) into a pseudocyst is a serious and potentially life-threatening complication, but it is less common than infection. - It usually results from erosion into adjacent blood vessels, such as the splenic or gastroduodenal arteries. *Rupture into colon* - **Rupture into the colon** or other adjacent organs (like the stomach or duodenum) can occur, but these are less frequent compared to infection. - Such ruptures can lead to internal fistula formation, but infection remains the predominant complication.
Question 7: What is the echogenic lesion size criterion for chronic pancreatitis?
- A. > 2 mm
- B. > 3 mm (Correct Answer)
- C. > 1 mm
- D. > 4 mm
Explanation: ***> 3 mm*** - An echogenic lesion **greater than 3 mm** in size is a diagnostic criterion for **chronic pancreatitis** when observed on ultrasound imaging. - This represents one of the **major features** in ultrasound diagnosis of chronic pancreatitis, particularly when echogenic foci demonstrate acoustic shadowing (suggesting calcifications). - This criterion is part of established diagnostic frameworks and helps differentiate pathological calcifications from minor, non-specific findings. *> 4 mm* - While a **4 mm threshold** would indicate significant findings, the established diagnostic criterion for chronic pancreatitis uses **> 3 mm** as the cutoff. - Using a higher threshold would reduce sensitivity for detecting chronic pancreatitis. *> 2 mm* - A lesion larger than **2 mm** is generally considered below the established diagnostic threshold for **chronic pancreatitis**. - This size may represent early changes or incidental findings that are not yet definitive for diagnosis. *> 1 mm* - A lesion **greater than 1 mm** is too small to be a definitive criterion for **chronic pancreatitis** and could represent minor, non-pathological findings. - Such small echogenic foci lack sufficient specificity for diagnosing chronic pancreatic disease.
Question 8: A 6-week-old baby is brought in by the mother with complaints of vomiting. An X-ray shows a single bubble appearance. What is the most likely diagnosis?
- A. Duodenal atresia
- B. Annular pancreas
- C. Congenital hypertrophic pyloric stenosis (CHPS) (Correct Answer)
- D. Jejunal atresia
- E. Malrotation with midgut volvulus
Explanation: ***Congenital hypertrophic pyloric stenosis (CHPS)*** - The **single bubble appearance** observed in the X-ray, along with vomiting in a 6-week-old, is characteristic of an obstruction at the gastric outlet due to **pyloric stenosis**. The "bubble" represents the dilated stomach. - Infants with CHPS typically present with **non-bilious projectile vomiting** around 3-6 weeks of age, often accompanied by good appetite. *Duodenal atresia* - This condition classically presents with a **"double bubble" sign** on X-ray, representing dilation of the stomach and the proximal duodenum. - Vomiting is usually **bilious** and occurs earlier, often from birth. *Annular pancreas* - Annular pancreas can cause duodenal obstruction, leading to a **"double bubble" sign** similar to duodenal atresia. - The presentation would also be earlier, typically with **bilious vomiting** from birth or shortly thereafter. *Jejunal atresia* - Jejunal atresia would result in **multiple dilated loops of small bowel** proximal to the obstruction with air-fluid levels, rather than a single bubble. - The vomiting would be **bilious** and abdominal distension would be more prominent. *Malrotation with midgut volvulus* - This presents with **bilious vomiting** and can occur at any age, though commonly in the first few weeks of life. - X-ray findings include a **"corkscrew" or "whirl" sign** on contrast studies, or a gasless abdomen if complete obstruction occurs. - Unlike the single bubble of pyloric stenosis, malrotation typically shows abnormal bowel gas patterns or a paucity of gas in the abdomen.
Question 9: The treatment of an annular pancreas is
- A. Duodeno-duodenostomy
- B. Duodenojejunostomy (Correct Answer)
- C. Gastrojejunostomy
- D. Gastro-duodenostomy
Explanation: ***Duodenojejunostomy*** - An annular pancreas causes **duodenal obstruction**. A **duodenojejunostomy** bypasses this obstruction by connecting the duodenum to the jejunum, restoring intestinal flow. - This procedure aims to relieve the symptoms of obstruction without resecting the pancreatic tissue, which can be difficult due to its intimate relation with the duodenum. *Gastrojejunostomy* - This procedure connects the **stomach to the jejunum**, bypassing the duodenum. While it can relieve gastric outlet obstruction, it's not the primary or most appropriate treatment for duodenal obstruction specifically caused by an annular pancreas. - It might lead to **bile reflux into the stomach** and **marginal ulcers**, which are not ideal outcomes for this specific condition. *Duodeno-duodenostomy* - This procedure involves resecting a segment of the duodenum and reconnecting the remaining ends. It is not suitable for an annular pancreas because the **pancreatic tissue encircles the duodenum**, making simple resection and reconnection challenging and potentially risky to the pancreas. - The goal is to bypass the obstruction, not to directly resect the involved duodenal segment, which might be difficult given the **fibrous nature of the annular pancreas**. *Gastro-duodenostomy* - This procedure connects the **stomach to the duodenum** at a different point, often used after a **gastrectomy** (e.g., Billroth I). - It would not bypass the **duodenal obstruction caused by the annular pancreas** and thus would not resolve the patient's symptoms.
Question 10: Congenital cyanotic heart disease with pulmonary oligemia is seen with –
- A. VSD
- B. Hypoplastic left ventricle
- C. ASD
- D. Tricuspid atresia (Correct Answer)
Explanation: ***Tricuspid atresia*** - **Tricuspid atresia** is a **cyanotic congenital heart disease** where the tricuspid valve is absent, preventing blood flow from the right atrium to the right ventricle, leading to **pulmonary hypoperfusion** or **oligemia**. - Systemic venous return must shunt across an **atrial septal defect (ASD)** or **patent foramen ovale (PFO)** to the left atrium, mixing with oxygenated blood, resulting in cyanosis. - Chest X-ray characteristically shows **decreased pulmonary vascular markings** (oligemia). *VSD* - A **Ventricular Septal Defect (VSD)** typically causes a **left-to-right shunt**, leading to **pulmonary plethora (increased pulmonary blood flow)**, not oligemia. - While large VSDs can eventually lead to Eisenmenger syndrome with cyanosis, the initial presentation is usually characterized by increased pulmonary flow. *Hypoplastic left ventricle* - **Hypoplastic left heart syndrome (HLHS)** is a **cyanotic** condition, but it results in **pulmonary plethora (increased pulmonary blood flow)**, not oligemia. - All systemic venous return flows to the right ventricle, which pumps to both the pulmonary arteries (normal pathway) and to the systemic circulation via a **patent ductus arteriosus (PDA)**, resulting in normal or increased pulmonary blood flow. - The primary issue is a severely underdeveloped left side of the heart, which does not lead to pulmonary oligemia. *ASD* - An **Atrial Septal Defect (ASD)** usually causes a **left-to-right shunt**, leading to **pulmonary plethora (increased pulmonary blood flow)** and is typically an **acyanotic** heart condition. - Cyanosis only develops late if pulmonary hypertension leads to shunt reversal (Eisenmenger syndrome), which is not the primary presentation.
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