Chapter 13 Chapter Challenge Answers
Chapter Recall
1. A 65-year-old Hispanic female presents to the clinic complaining of mild abdominal pain,
nausea, and vomiting. Physical exam is notable for absence of jaundice and the presence of
an abdominal mass. She is sent for CT imaging which reveals a cyst. Subsequent fine needle
aspiration of the cyst, guided by ultrasound, reveals thin, clear, watery fluid and pieces of
pancreatic duct epithelium. What is your diagnosis?
B. Serous cystadenoma
2. While volunteering at a summer camp for diabetics, you observe one of your students who
appears ill. He is pale, sweating profusely, and trembling. When you take his wrist, his skin
is cool and clammy to the touch, and his heartbeat is erratic. What is the likely cause of his
symptoms?
C. Injection of too much insulin
3. Which of the following statements concerning type 2 diabetes is true?
D. The islets are gradually replaced by amyloid.
4. A 54-year-old African American male presents to the ER with nausea, vomiting, weight loss,
and upper abdominal pain radiating to the back. Physical exam demonstrates a welldeveloped, nonobese male with moderate abdominal tenderness; you note a mild scleral
icterus (yellowing of the eyes). A CT demonstrates a large pancreatic mass, and blood
studies are remarkable for elevation of nonalbumin protein, which is determined to be IgG4
on additional testing. What is the most likely etiology of his pancreatitis?
A. Autoimmune
5. Which of the following structures is a cyst lacking lining epithelium?
C. Pseudocyst
6. A 45-year-old Caucasian female presents for evaluation of a right leg pain. Physical exam
reveals a jaundiced, gaunt woman with a right leg that is twice the size of the left. Her
physical exam is also positive for abdominal tenderness. On further questioning, the patient
confirms recent unintentional weight loss. In the context of these textbook symptoms, you
recognize the blood clot in her leg as Trousseau’s sign. Which of the following tumors is
responsible for her symptoms?
A. Pancreatic adenocarcinoma
7. All of the complications of diabetes are caused by which one of the following?
C. Hyperglycemia
8. True or false? A fasting blood glucose of ≥ 126 mg/dL is diagnostic of diabetes.
True
9. True or false? Women with gestational diabetes are not at increased risk of developing
diabetes.
False: About one-third of affected mothers will become frankly diabetic within 10 years.
10. True or false? Chronic pancreatitis is one possible cause of diabetes.
True
11. Match the following hormones with their mechanism of action.
i. Insulin
ii. Glucagon
iii. Pancreas polypeptide
iv. Somatostatin
A. Inhibits glucagon and insulin secretion; slows GI and biliary peristalsis = iv:
Somatostatin
B. Stimulates cell uptake of glucose from blood = i: Insulin
C. Stimulates gastric enzymes secretion and inhibits small bowel motility = iii: Pancreas
polypeptide
D. Stimulates liver output of glucose (via glycogen breakdown or amino acid conversion)
and breakdown of fat for energy = ii: Glucagon
Conceptual Understanding
12. What methods are available for diagnosing a patient with chronic pancreatitis in the absence
of elevated amylase and/or lipase?
Blood amylase and lipase levels may be elevated during an acute flare-up of pancreatitis, but
in some cases the gland is destroyed to such an extent that little normal, enzyme-bearing
tissue remains and blood amylase and lipase levels are not elevated despite continuing
pancreatic damage and inflammation. In these cases, ultrasound and a variety of other
abdominal imaging techniques are helpful to demonstrate ductal dilation or obstruction and
destruction/scarring. Stippled calcification is a highly specific radiographic finding, but
occurs late, and then only in about one-third of patients.
13. Name the two types of diabetic coma and the pathogenesis of each.
Diabetic coma can occur as a result of ketoacidosis or hyperosmolarity (dehydration).
Ketoacidosis arises because, in the absence of glucose, the body must burn fat for fuel.
The fat is broken down into fatty acids, which are transported to the liver and converted into
ketones—small, acidic, glucose-size molecules. The accumulation of ketones lowers blood
pH (acidosis), which, when severe, may produce diabetic coma.
Hyperosmolar coma can occur if water loss is especially severe and blood glucose levels
rise, as together these produce high blood osmolarity (and subsequently dehydration). As
glucose spills into the urine, water and electrolytes go with it causing severe dehydration and
the ensuing coma. This is especially prominent in patients unable to drink enough water to
make up for fluid loss from prolonged osmotic diuresis.
14. Most of the enzymes secreted by the exocrine pancreas are inactive when secreted. How is
this accomplished and what are the exceptions?
The exocrine pancreas excretes a high pH (alkaline) pancreatic juice containing about 20
digestive agents, water, bicarbonate, and mucus. Many of these digestive agents (the
proteases) are secreted in inactive forms as zymogens that must be converted to their active
form for digestion to proceed. As additional insurance against self-digestion, pancreatic juice
contains protease inhibitors, which become inactive in the intestine. The exceptions are lipase
and amylase which are secreted in active forms because the walls of the pancreatic ducts are
composed of protein and thus are impervious to the action of these two enzymes (which
digest fat and carbohydrates respectively).
Application
15. Why is it important for diabetics to perform foot checks?
Foot checks are an important part of preventing amputations in patients with diabetes. The
reasons are four-fold.

Most diabetics are overweight and thus do not spend much time observing their feet,
allowing a potentially minor injury to go unnoticed.

Diabetic neuropathy (which manifests first as nerve irritation, pain, or abnormal
sensations and later as loss of sensation) can result in patients ignoring or being
unaware of irritation or injury to their feet.

High blood glucose levels can damage capillaries and other small blood vessels
(diabetic microvascular disease) slowing blood flow and diffusion of critical
substances into tissues.

Diabetic patients have impaired neutrophil and macrophage function and their
vascular disease limits the delivery of circulating cells and molecules that are
necessary for host defense, thus rendering them even more susceptible to infection. >
By performing foot checks an injury can be observed early and steps taken to prevent
additional injury or infection. If the injury goes undiagnosed and becomes more serious,
amputation can become necessary.
16. At his three-month follow-up, your patient reports that his diabetes has been well-controlled.
Although his lab results reveal normal blood glucose today, his HgbA1C is 10.3%. What
advice should you offer your patient?
It is important to redefine what well-controlled diabetes means to your patient, and to
reinforce the necessity of monitoring and controlling his sugars through lifestyle
modifications and medication. Even if your patient insists that his sugars have been well
controlled, glycohemoglobin (HgbA1C) doesn’t lie and in this case demonstrates that the
patient’s sugars have been extraordinarily high over the last 120 days. His goal HgbA1C, to
limit the risk of long-term complications, should be below 7% which leads to the second
point. It is also important to remind the patient that the long-term complications of his
disease (atherosclerosis, retinopathy, neuropathy, and nephropathy) are proportional to the
severity and duration of his hyperglycemia. Strict control of blood glucose is associated with
fewer complications: patients have fewer strokes and heart attacks, and less kidney,
peripheral nerve, and eye disease.