Abdomen Flashcards
A patient presents with RUQ pain. What’s on the differential diagnoses?
Gall bladder issues, liver, RLL pneumonia, cardiac ischemia
A patient presents with epigastric pain. What’s on the differential?
Anything with pancreas, stomach, PUD, dyspepsia, cardiac ischemia, early appendicitis
A patient presents with flank pain. What’s on the differential?
Renal colic, pyelonephritis, AAA
A patient presents with generalized pain. What’s on the differential?
Mesenteric ischemia, AAA, bowel obstruction, endometriosis
A patient presents with dermatomal pain. What’s on the differential?
Herpes zoster
What quadrant is the GB located?
RUQ
What quadrant is the pylorus and duodenum located in?
RUQ
What quadrant is the spleen located in?
LUQ
What quadrant is the cecum and appendix located in?
RLQ
What quadrant is the sigmoid colon in?
LLQ
What is something else to consider in LLQ pain in males and females?
diverticulitis
Vena caval foramen, area for liver is near what vertebra?
T8
Esophageal hiatus leads to stomach near what vertebra?
T10
Abdominal aorta enters abdomen anterior to lumbar and what vertebra?
T12
Abdominal aorta bifurcates at what vertebra?
L4
Long fibrous sheath made from the aponeuroses of the 3 flat abdominal muscles
Rectus sheath
What does the rectus sheath contain?
The rectus abdominus muscle, pyramidalis muscle if present, anterior rami of lower 6 thoracic nerves, superior and inferior epigastric vessels and lymph nodes.
All 3 aponeuroses pass _______ to the rectus muscle, leaving the rectus sheath deficient ________ at this level at the ___________.
Anterior, posterior, arcuate line
Aponeurosis of external abdominal oblique muscle joins _____ layer of rectus sheath
Anterior
Aponeurosis of transversus abdominis muscle joins _______ layer of rectus sheath
posterior
What ribs do external obliques run off of?
5-12
What ribs do internal obliques run off of?
9-12
What ribs do transverse abdominal muscles run off of?
6-12 at costal margin, thoracolumbar fascia and iliac crest
True or false: External oblique, internal oblique, and transversus abdominus are NOT considered true posterior structures.
True
Strain of what muscle causes a lot of lower back pain?
Quadratus lumborum
Valsalva maneuver
When the airway is closed and increased intra-abdominal pressure expels contents of rectum, bladder, uterus
What are the branches of the lumbar plexus?
Interested In Getting Lunch On Friday? Iliohypogastric (T12-L1) Ilioinguinal (L1) Genitofemoral (L1, L2) Lateral femoral cutaneous (L2,L3) Obturator (L2-L4) Femoral (L2-L4)
Compression of what nerve can cause neuralgia paresthetica? Can also be from pregnancy and obesity or tight clothing
Femoral nerve
What nerve runs anterior to psoas, runs between the transversus and internal oblique, and gives motor supply to those two muscles and sensory supply to lateral hip and skin over hypogastric area and iliac crest?
Iliohypogastric nerve
What nerve gives motor supply to transversus abdominus, internal oblique and sensory supply to pubic symphasis, lateral labia majora/scrotum, and superiomedial thigh?
Ilioinguinal nerve
What nerve passes through deep inguinal ring and gives sensory info to scrotum/labia majora and motor component to cremaster muscle?
Genital branch of genitofemoral nerve
What nerve passes underneath the inguinal ligament and DOES NOT run through the canal? It gives sensory input to upper, anterior thigh and travels with what artery?
Femoral branch of genitofemoral nerve. Travels with external iliac artery.
What nerve is sensory only and gives info to lateral thigh? It passes UNDER inguinal ligament and is related to meralgia paresthetica
Lateral femoral cutaneous nerve
Arterial supply of rectus abdominus and superior part of anteriolateral wall
Superior epigastric A off internal thoracic artery
Arterial supply of rectus abd. m and medial part of anterolateral wall?
Inferior epigastric A off external iliac A
Arterial supply of iliacus and inferior part of anterolat. wall?
Deep circumflex iliac A off external iliac A
Arterial supply of subcutaneous tissue and skin over inferior part of anterolat wall?
Superficial circumflex iliac A off femoral A
Arterial supply of subcutaneous tissue and skin over suprapubic region?
Superficial epigastric A off femoral A
Transverse incisions ar emade between what two things?
Linea alba at midline to linea semilunaris
What kind of abdominal incision is muscle splitting?
Gridiron (over ASIS)
What kind of abdominal incision is good for gallbladder removal?
Subcostal incision
What kind of abdominal incision is good for appendectomy?
Transverse incision
What kind of abdominal incision is good for exploratory operations?
Median or midline incision or left paramedian incision
When Scarpa’s fascia attaches to the pubic arches, what is it called?
Colles’ fascia
What forms the tubular sheath for the penis or clitoris?
Scarpa’s fascia and fascia lata of thigh
What fascia plays a role with DIRECT hernias?
Transversalis fascia
Around what vertebra does the abdominal aorta begin?
T12, bifurcates at L4
Dilation of all walls of the vessel
Aneurysm
Tear of the intima (within the wall tear) or longitudinal cleavage (end up with a double lumen)
Dissection
Where do most aortic aneurysms rupture?
Retroperitoneal space (presents as back pain)
Who is most likely to get an aortic aneurism, and where do they usually occur?
Males 4-8x more than females.
98% are infrarenal (inferior from where renal vessels take off from abdominal aorta).
Repair all aneurysms >5cm
Signs of retroperitoneal hemorrhage
Cullen’s sign, Grey-Turner’s sign, Scrotal hematoma. Most common misdiagnosis is renal colic
What is an aortic dissection and who will get it?
Hemodynamic forces cause tear in aortic wall. Male > females 2-3:1. 2-3 times more common than ruptured AAA.
How does an aortic dissection present?
Pain occurs in 75% (sudden, tearing, ripping, often migrates to chest, neck, back)
Where does an aortic dissection usually occur?
Ascending aorta is most common location (needs surgical repair). Descending aorta can usually be managed with meds.
Where do most aortic aneurysms rupture?
Into the retroperitoneal space,
98% are infrarenal
Treatment of aortic aneurysm?
repair all that are over 5 cm.
How do aortic aneurysms present?
back pain, hypotension, tachy, cullen’s sign, grey-turner’s sign, scrota hematoma
What is more common, an aortic dissection or ruptured AAA?
Aortic dissection is 2-3 times more common
Cutaneous lymph vessels above umbilicus drain to:
Anterior axillary lymph nodes
Cutaneous lymph vessels BELOW the umbilicus drain to:
Superficial inguinal lymph nodes
Deep lymph vessels follow what? Where do they drain?
they follow the arteries. They drain into internal thoracic, external thoracic, posterior mediastinal and lumbar (para-aortic) lymph nodes
GI innervation that is INTRINSIC
enteric nervous system (3rd division of the ANS)
GI innervation that is EXTRINSIC
parasympathetic and sympathetic nervous system
Two plexuses of the ENS
Myenteric plexus (Auerbach's plexus) in muscularis externa Submucosal plexus (Meisner's plexus) located in the submucosal layer
Neurons in the ENS can inhibit or stimulate what?
Motility, secretion, absorption, immune function
ENS can control GI tract without input from CNS. What’s another name for the ENS?
“little brain”
When the CNS influences the ENS, it has more influence on _____ and less influence on ______.
more influence in esophageal function and gastric motility
Less influence on intestinal peristalsis/secretion
Enteric N.S. is deinnervated in the colon, typically diagnosed in childhood. Can develop distended colon and fecal impaction
Hirschsprung’s Disease
What innervates the esophagus, stomach, gallbladder, pancreas, proximal intestine, cecum and proximal colon?
vagus nerve
what innervates distal colon and rectum?
pelvic nerve
At the time of synapse both PNS and SNS preganglionic nerves release what? What does this activate?
Acetylcholine
nicotinic receptors
Postganglionic PNS nerves release _________. Postganglionic SNS nerves release _______.
PNS: ACh and peptides
SNS: Norepinephrine
Under normal circumstances, does PNS or SNS dominate?
PNS dominates SNS
During stressful situations, does the PNS or SNS dominate?
SNS dominates
What secretes serous fluid to lubricate and facilitate free movement between the viscera?
Peritoneum
Potential space between parietal and visceral layers. Closed in males, open in females
Parietal cavity
Pain arising from foregut comes from where? Localizes where?
Comes from esophagus, stomach, pancreas, duodenum, liver, biliary tree.
Localizes to epigastric region
Pain arising from midgut comes from where? Localizes where?
Comes from small intestine distal to bile duct, cecum, appendix, ascending colon, transverse colon. Localizes in periumbilical region
Pain arising from hindgut comes from where? Localizes where?
Comes from distal transverse colon, descending colon, sigmoid and rectum. Localizes in the hypogastric region
Inflamed parietal peritoneum is extremely sensitive to what? What kind of tenderness does this cause?
Sensitive to stretching. Causes rebound tenderness.
T of F: Tenderness due to irritation of nerves by unilateral lesion is not usually felt on the opposite side of the body.
True
Connects the stomach to the liver and encloses the portal triad
Lesser omentum
Hepatoduodenal ligament
Connects the stomach to the spleen
Gastrosplenic omentum
Connects the stomach to the transverse colon
Greater omentum
Organs with mesentery have more/less mobility?
More
Space between parietal and visceral layers of the peritoneum
Greater sac
How does the greater sac communicate with the lesser sac?
Omental (epiploic) foramen of winslow
Extends from the diaphragm into the pelvis
Greater sac (main compartment)
Lies behind the stomach and lesser omentum. Extends upward to diaphragm and downward between layers of greater omentum
Lesser sac (omental bursa)
Formed by spleen, gastrosplenic omentum, and lienorenal ligament
Left margin of lesser sac
Opens into the greater sac of peritoneal cavity through foramen of Winslow
Right margin of lesser sac
Area of potential herniation of small bowel
Foramen of Winslow
If the cystic artery is cut during a cholecystectomy, hemorrhage is controlled by compressing what?
The proper hepatic artery in the foramen winslow
What are the two fossas found in the peritoneum?
Duodenal fossa, cecal fossa
What area lies between the diaphragm and the liver/spleen and provides sites for pus to drain?
Subphrenic spaces
What area should you assess for fluid after trauma, abscess, or suspected peritonitis?
Morrison’s pouch (subphrenic space continuous with heptaorenal recess)
Lies on the lateral and medial sides of the ascending and descending colons respectively. Provides channels for accumulation and movement of fluid in the peritoneal cavity
Paracolic gutters
Hernia through linea alba, obesity, age >40 years
epigastric hernia
Hernia occurring at any incision site, more common with infection
Incisional hernia
True or false: Inguinal canal runs the same length as the ligament.
False
Inguinal canal runs parallel and just superior to the (medial/lateral) half of the inguinal ligament.
Medial
What tendon reinforces the posterior wall of the posterior wall?
Conjoint tendon
Hernia passes through anterior abdominal wall. Sac is a persistent process vaginalis, bulge occurs over inguinal ligament and may herniate into scrotum
Indirect inguinal hernia
Indirect inguinal hernia may extend _______ to pubic tubercle
Superior and medial
Femoral hernia extends ______ to pubic tubercle
Inferior and lateral
Herniating bowel passes ______ to inferior epigastric vessels in indirect inguinal hernias.
Lateral
Protrudes through posterior wall of the inguinal canal
Direct inguinal hernia
Results from a weakness in the anterior abdominal wall musculature. Hernia sac is peritoneum and transversalis fascia
Direct inguinal hernia
Where are you most likely to have an inguinal hernia?
Hesselbach’s triangle (inguinal ligament, rectus abdominus, and inferior epigastric artery)
Herniating bowel passes ____ to inferior epigastric vessels in direct hernia.
Medial
Gastric arteries supply what part of the stomach?
Lesser curvature
Gastroepiploic arteries supply what part of the stomach?
Greater curvature
Short gastric arteries supply what part of the stomach?
Fundus
Nerve supply of the stomach comes off what spinal nerves?
T6-T9
All lymph from the stomach eventually passes to the ______ nodes.
celiac
How many liters of gastric secretion occur daily?
7
True or false: The duodenum is mostly retroperitoneal
True
How many parts are the duodenum divided into?
4
Common bile and pancreatic ducts unite at the duodenum and form what?
Major duodenal papilla
Controls bile and pancreatic secretions into small bowel
Sphincter of Oddi
Arteries proximal to the bile duct entry
Superior Pancreaticoduodenal artery
Arteries distal to bile duct entry
Inferior pancreaticoduodenal artery
Second half of duodedum drains to what nodes?
Superior mesenteric nodes
What part of the small intestine is wider, thicker, and more red than the ileum?
Jejunum
Occupies lower right abdominal cavity, has Peyer’s patches
Ileum
SNS nerve supply of small intestines
superior mesenteric plexus
Pain fibers to large intestine
T10-L2
Pain fibers to distal sigmoid colon/rectum
L1-S4
Blind-ended pouch in right iliac fossa covered with peritoneum with no mesentery
Cecum
Where is the ascending colon located?
Retroperitoneal
What artery supplies the proximal 2/3 of the transverse colon? What about the distal 1/3?
Proximal: Middle colic artery
Distal: Left colic artery
Drained by SMV and IMV veins
Nerve supply of transverse colon?
SNS: Sup. and Inf. mesenteric plexus
PNS: pelvic splanchnic nerve
Proximal 2/3 of transverse colon drains where? (lymph) distal 1/3 drains where?
Proximal: colic lymph nodes then SML
distal: colic lymph nodes then IML
SNS and PNS supply of sigmoid colon
SNS: inf. mesenteric plexus
PNS: splanchnic nerves
What is the most common cause of intestinal obstruction in children? Adults?
Children: hernia 38%
adults: adhesions
Where does the bare area of the liver lie?
between coronary ligaments, directly in contact with diaphragm
What vessels enter the hilus of the liver?
proper hepatic artery
Portal vein
Hepatocytes are surrounded by a “cage” of supporting __________ cells, which also play a role in what?
reticuloendothelial cells
phagocytosis and cytokine secretion.
When not functioning, they contribute to hepatic necrosis and cirrhotic fibrosis
What vein drains blood from small intestine?
SMV
What does the splenic vein drain blood from?
spleen, IMV, pancreatic vein, gastroepiploic veins
The hepatic portal vein is formed by the union of what?
superior mesenteric and splenic veins
What type of blood does the portal vein connect?
Deoxygenated, nutrient rich blood
What type of blood does the liver receive from hepatic artery?
oxygenated blood
Normal liver span
4-8 cm in midsternum
6-12 cm in right midclavicular line
What is at the neck of the gallbladder?
Hartmann’s pouch (infundibulum)
Portion of common bile duct prior to entry of the cystic duct
common hepatic duct
portion after the entry of the cystic duct
common bile duct
Nerve supply of gall bladder
Celiac plexus T6-9
Connects neck of GB to common hepatic duct; forms the common bile duct
cystic duct
union of common hepatic and cystic ducts
common bile duct
Irritation of the phrenic nerve can cause referred pain where?
shoulder
What is a sensitive test that can show cystic duct obstruction but can’t identify stones?
HIDA scan
The tail of the pancreas extends to the spleen via what ligament?
lienorenal ligament
Nerve supply of pancreas
Vagal nerves from celiac, splanchnic, and superior mesenteric plexuses (T5-9)
How many liters of fluid does the pancreas secrete/day?
1.5
True or false: pancreatic secretions are acidic.
False—
Alkaline. Help neutralize acid from the stomach
CCK is released in response to what?
fats
What type of bacteria in particular does the spleen help protect you from?
encapsulated
What modifications do you have to take on if you lose your spleen?
Immune support with pneumovax, HIB, and meningococcal vaccines
What level (vertebrae) do the kidneys lie at?
T12 to L3
Renal veins drain into the ______, ureteral veins drain into ________.
renal = IVC ureteral = testicular or ovarian veins
where does renal lymph drain to?
lateral aortic lymph nodes. Ureters also drain to iliac nodes
The right adrenal gland has a ______ shape while the left has a ______ shape.
R: triangular
L: semilunar
Produces aldosterone (renin-angiotensin-aldosterone axis). Most superficial
Zona glomerulosa (most superficial layer of adrenal cortex)
Produces glucocorticoids (cortisol)
Zona fasciculata (middle layer of cortex)
Produces androgens
Zona reticularis (deepest layer)
What does the adrenal medulla produce?
Chromaffin cells—Epinephrine (80%) and NE (20%)
Where does renal lymph drain?
aortic lymph nodes
