Abdomen 9A Flashcards

Question

Clinical Implications of the Inguinal Canal

Answer 1

• Indirect inguinal hernia (i) Bowel protrudes through deep ring and descends through canal • Direct inguinal hernia (i) Bowel protrudes through defect in anterior abdominal wall (ii) Most common site of defect is Hesselbach’s triangle (iii) Where is Hesselbach’s triangle? 1. Lateral border of rectus abdominis 2. Inguinal ligament 3. Inferior epigastric artery and vein

Answer 2

* Superficial (external) ring: formed by an arch in the external oblique aponeurosis * Deep (internal) ring: formed by transverse fascia

Answer 3

* Anterior: aponeurosis of external & internal oblique * Posterior: transverse fascia * Superior: fibers of the transverse abdominal and internal oblique arch over * Inferior: inguinal ligament (remember formed by the inferior fold of external oblique)

Answer 4

* Males: spermatic cord and ilioinguinal nerve | * Female: round ligament of uterus and ilioinguinal nerve

Answer 5

* thin potential space between the visceral and parietal peritoneum * NOTE: the peritoneal cavity is NOT same as the abdominal cavity the peritoneal cavity is within the abdominal cavity

Answer 6

* double layered fold of peritoneum d/t the organ invaginating on the peritoneum (again…visualize the pressing in on a balloon) * “suspends” or connects the organ to the posterior abdominal wall * Contains blood vessels, lymphatic vessels and nerves that supply structure suspended by the mesentery

Answer 7

peritoneal fold that hangs down from the greater curvature of the abdomen and loops back up to attach to the transverse colon

Answer 8

double layer of peritoneum that attaches to the stomach (and proximal duodenum) and then attaches to the liver

Answer 9

doubled layer of peritoneum that attaches an organ to the abdominal wall or another organ…two examples are…. • Falciform ligament…attaches liver to anterior abdominal wall • Gastrosplenic ligament…attaches spleen to the stomach

Answer 10

a. Parietal layer – lines internal walls of abdominopelvic cavity b. Visceral layer – lines the abdominal viscera c. Mesentery d. Greater omentum e. Lesser omentum f. Peritoneal ligament g. Peritoneal cavity h. Retroperitoneal vs intraperitoneal space

Answer 11

Foregut Hindgut Midgut

Answer 12

a. distal 1/3 of transverse colon to anus | b. Blood supply - inferior mesenteric artery

Answer 13

a. hepatopancreatic ampulla (of Vater) to distal approximately 1/3 of transverse colon b. Blood supply - superior mesenteric artery

Answer 14

a. oropharynx to hepatopancreatic ampulla (of Vater) located in duodenum b. blood supply – celiac trunk

Answer 15

a. MC s/s of esophagus disease = heartburn • Esophageal reflux (i) Dysfunction of the lower esophageal sphincter (LES) • Hiatal hernia…two types (i) Sliding hiatal hernia – cardia of stomach and esophagus herniate through diaphragm (ii) Paraesophageal hiatal hernia – fundus herniates through diaphragm..no heartburn…possible strangulation/obstruction may occur

Answer 16

a. Muscular tube connects pharynx to the stomach b. Descends in superior and posterior mediastinum c. Passes through diaphragm in esophageal hiatus d. Gastroesophageal junction is location where esophagus and stomach meet e. Upper esophageal sphincter (UES) f. Lower esophageal sphincter (LES)

Answer 17

* Junction of esophagus and stomach | * Smooth muscle…not easily identified

Answer 18

* junction of pharynx and esophagus | * inferior pharyngeal constrictor muscles and cricopharyngeus muscle

Answer 19

a. MC s/s stomach disease = nausea/vomit • Gastric ulcer (i) Usually in body along lesser curvature (ii) Caused by damage to mucosal barrier…d/t smoking, aspirin or NSAID’s (iii) Helicobacter pylori infection in 70% of patients

Answer 20

a. Divisions – cardia, fundus, body & pylorus b. greater and lesser curvatures c. stomach wall • 3 muscular layers…oblique, circular, longitudinal d. rugae (gastric folds) • large longitudinal in mucosal folds of stomach • will flatten out with food in stomach e. pyloric sphincter • connects stomach to small intestine

Answer 21

• Duodenal ulcer (usually proximal portion) • Caused by … (i) hypersecretion of gastric acid (ii) damage to mucosa • Helicobacter pylori infection in100% of patients (he-lick-oh-back-ter pie-lorrie) • worse on an empty stomach and relieved temporarily by food, antacids, or milk.

Answer 22

* Crohn’s disease * Chronic inflammatory bowel disease…MC in the ileum * Often will see “skip areas” in the small intestine * Obstruction = colicky pain = smooth contractions of small intestine (ilium)

Answer 23

* Approximately 25 cm (approximately 10 inches) * Proximal portion has mesenteric attachments and is “intraperitoneal” * Then duodenum becomes “retroperitoneal”

Answer 24

(i) Common bile duct and the main pancreatic duct (of Wirsung) enter the SI along the descending portion of the duodenum via the heptopancreatic ampulla (of Vater) and the main duodenal ampulla 1. Pancreas…secrete digestive enzymes 2. Gall bladder…secrete bile

Answer 25

• Loops tend to be found in the LUQ • Landmark of jejunum: Ligament of Treitz (i) Peritoneal fold at junction of duodenum and jejunum

Answer 26

* loops tend to be found in the RLQ * terminates at ileocecal valve…connection to cecum of large intestine * site of vitamin B12 absorption

Answer 27

• Ulcerative colitis (i) Ulcerations of colon and rectum, rectal bleeding, mucosal abcesses (ii) Can cause anemia, electrolyte imbalances…potential for peritonitis, toxic megacolon (dilation of transverse colon and may perforate the wall of the intestine) and cancer

Answer 28

• Celiac disease (celiac sprue) (i) Hypersensitivity to gluten found in wheat, barley, rye and other whole grains (ii) When gluten is ingested causes excessive immune response (lymphocytes, plasma cells, eosinophils, macrophages accunulate in lamina of mucosa….end result = damage to mucosa)

Answer 29

a. MC s/s of colon disease = diarrhea | b. MC s/s of anorectal disease = bleeding

Answer 30

• Appendicitis (i) Appendix becomes obstructed (fecal matter or lymphoid hyperplasia) causing dilation of appendix (distention of causes pain) (ii) McBurney’s Point – located midway between ASIS and umbilicus (iii) Complication if rupture = Peritonitis

Answer 31

• Appendix (vermiform appendix)…located in RLQ (will vary), McBurney’s point (approximately halfway between ASIS and umbilicus) • Cecum….junction of ileum and large intestine….ileocecal valve separates • Ascending colon….retroperitoneal • Transverse colon….intraperitoneal • Descending colon…retroperitoneal • Sigmoid colon…becomes intraperitoneal again (i) Diverticula = abnormal sacs or pouchs (ii) Diverticulitis = inflammation or rupture (perforation) of the diverticula (iii) Primary function = storage of feces • Rectum

Answer 32

a. 1.5 meters long (approximately 4-5 feet) b. external wall of large intestine • taeniae coli - 3 bands of longitudinal muscle…converge at appendix • haustra - sacculations of the LI formed by contractions of the taeniae coli

Answer 33

• Spleen (i) Splenectomy might be appropriate (ii) Complications of spleenctomy 1. atelactasis (collapse) of left lung 2. thrombocytosis (increased platelets in the blood)…thus increased risk of thrombus formation…anticoagulation therapy indicated (iii) Bone marrow and liver remove RBCs after splenectomy

Answer 34

a. located in LUQ and is “protected” by lower ribs 9-12, difficult to palpate if WNL b. located “intraperitoneal” c. attached to stomach (gastrosplenic ligament) and left kidney (splenorenal ligament) d. spleen located near tail of pancreas e. if enlarged can be palpated with patient right lateral decubitus position

Answer 35

a. Filter RBC’s – removes old or abnormal RBC’s b. Storage of platelets c. Lymphatic/immune functions...protect against infection, produce immunoglobulin M (IgM), etc..

Answer 36

* Acute pancreatitis | * Also caused by biliary tract disease…example stone lodged in ampulla

Answer 37

Pancreatic cancer (pancreatic adenocarcinoma)

Answer 38

* Beta Cells of Islets of Langerhans – damage to cells cause decrease in insulin * Elevated blood glucose levels (prolonged GTT) and in urine… * Chronic…neuropathies, retinopathy, nephropathy, degenerative changes in large and small blood vessels

Answer 39

a. 4 divisions of pancreas…..head, neck, body & tail b. location of pancreas • retroperitoneal space • crosses midline of abdomen (clinical pain may cross midline…) • head in close contact with duodenum • tail in close contact with spleen

Answer 40

• Main pancreatic duct (of Wirsung) (i) Joins with bile duct to form the hepatopancreatic ampulla (of Vater) and opens into the descending portion of the duodenum via the major duodenal papilla (see description below) • Accessory duct (of Santorini) (i) Also enters the duodenum

Answer 41

a. Endocrine…Islets of Langerhans release endocrine hormones (glucagons, insulin, somatostatin & pancreatic polypedtide) b. Exocrine – digestive enzymes split carbohydrates, fats and proteins

Answer 42

• Right and left portions of the lobe that operate independently of each other • An imaginary line between the gall bladder and the IVC demarcate the functional divisions…this line is known as Cantlie’s Line • Each division has it’s own blood supply, portal system and bile drainage system • NOTE: 4 anatomical lobes = left lobe, caudate lobe, quadrate lobe & right lobe (i) Functional right lobe = anatomical right lobe (ii) Functional left lobe = anatomical left, quadrate and caudate lobes

Answer 43

• Diaphragmatic surface– dome shaped to match the contour of the diaphragm (i) Anterior, superior, posterior portion of the liver • Visceral surface – primarily posterior and inferior

Answer 44

a. Located in right and left upper quadrants b. Located in “intraperitonel” space c. “Suspended or attached” in peritoneal cavity via… • Falciform ligament – peritoneal fold attaches to the anterior abdominal wall • Lessor omentum – peritoneal fold attaches to lesser curvature of the stomach • Hepatic veins that connect to the IVC

Answer 45

* Filter circulating toxins, drugs, hormones, old blood cells, etc… * Active role in metabolism of carbohydrate, protein and fat * Endocrine functions * Plays role in activation of Vitamin D * Synthesis and secretion of bile

Answer 46

1. bile secreted from liver via R/L hepatic ducts… 2. these ducts merge into the common hepatic duct which… 3. drains into bile duct which… 4. merges with the main pancreatic duct and forms the hepatopancreatic ampulla (of Vater)… 5. opens into the small intestine via the major duodenal papilla 6. NOTE: bile will be stored in & released from the gallbladder via the cystic duct

Answer 47

1. composed of H2O, electrolytes, bilirubin (bile pigment), cholesterol, calcium and cholic/chenodeoxycholic acids conjugated to glycine or taurine to form bile salts 2. Bile salts function is to a. emulsify fats (breaks down fats into smaller globules) b. assist in transporting fats across small intestine membrane 3. The bilirubin in the bile is the remainder of the broken down RBC and can be excreted a. RBC breaksdown – HAEM is converted to bilirubin and attaches to albumin in the blood (this known as unconjugated bilirubin) b. It travels to the liver where it becomes conjugated bilirubin

Answer 48

1. bile enters SI a. some of the bile salts and bilirubin are reabsorbed and returns to the liver b. some of the bile salts breakdown fats c. the remaining unconjugated bile salts will follow two pathways i. the unconjugated bile salts are reabsorbed and return to the liver ii. the unconjugated bile salts are excreted in the feces d. the remaining bilirubin is excreted in the feces

Answer 49

1. excessive unconjugated bilrubin in the bloodstream if liver is damaged…pigment causes yellow discoloration of sclera (icterus) and the skin (jaundice)…may see also bilirubinuria – gold/brown discoloration in the urine

Answer 50

* The liver also has a direct arterial supply from the heart via the hepatic artery * 30% of the blood flow to the liver is from the direct arterial (oxygen rich) supply of the hepatic artery * 70% of the blood flow to the liver is via the oxygen-poor blood from portal vein

Answer 51

* It is the exit/entrance for the portal vein, hepatic ducts (drain bile) & hepatic artery * Located on the visceral surface of the liver

Answer 52

a. “Portal” refers to a vein located between two capillary beds b. In this case…the capillary beds are those of the gastrointestinal tract and the liver c. So how does it work? • Blood travels from the heart to the GI tract • There it delivers O2 to the GI structures and picks up the nutrients from the GI tract • It takes the nutrients directly to the liver via the portal vein • After filtering through the liver the blood leaves the liver via the hepatic veins and eventually drain into the IVC

Answer 53

(i) Accumulation of fluid within the peritoneal cavity d/t portal hypertension

Answer 54

• Cirrhosis (destruction of hepatocytes and replacement with fibrous tissue) and other pathologies will impair the flow of blood through the liver • The blood flow will “reverse” and flow into the IVC system via 3 anastomoses • Where are the 3 anastomoses that provide reversed blood flow in portal hypertension? (i) Esophagus…forms esophageal varices, can bleed causing blood in vomit (ii) Rectum…forms hemorrhoids (iii) Epigastric veins in anterior abdominal wall…forms “caput medusae” 1. caput medusae = dilated superficial veins of abdomen (iv) sometimes the 3 pathways memorized as “gut, butt and caput”

Answer 55

• Gallstone obstruction in cystic duct (i) Initial epigastric pain…obstruction of cystic duct (biliary colic) (ii) Gallbladder itself becomes inflamed (acute cholecystitis) (iii) No jaundice…bile flow from the liver okay • Obstruction within common bile duct (i) Stone will obstruct bile flow from gallbladder and liver (jaundice) (ii) Rarely obstructs whole duct…moderate jaundice (fluctuates) (iii) Obstruction causes inflammation of gall bladder and liver • Obstruction at hepatopancreatic ampulla (i) Stone will obstruct bile flow from gallbladder and liver (jaundice) (ii) Stone may also obstruct pancreatic duct (pancreatitis) Note: 3 types of stones… Cholesterol stones- obesity, CF, wt loss, Crohn’s, estrogen use MOST COMMON form of gallstones Bile is the only way to excrete cholesterol so if too much cholesterol it will form stones Bilirubin stones – chronic RBC hemolysis, alcoholic cirrhosis, biliary infection Calcium stones – infection or inflammation of biliary tree

Answer 56

• Located in gallbladder fossa of visceral surface of the liver • Also in close proximity with the proximal duodenum • Cystic duct – leaves gall bladder to merge with common hepatic duct (i) Bile travels to and from the gallbladder via cystic duct (ii) As bile leaves the cystic duct it merges with the bile duct which in turn merges with the main pancreatic duct to form the hepatopancreatic ampulla (of Vater)… (iii) which opens into the duodenum via the main duodenal papilla (iv) sphincter of the bile duct is located at the distal end if the bile duct 1. if contracted – bile is unable to flow to SI and backs up into the gallbladder for storage

Answer 57

a. Duodenum except proximal portion b. Ascending colon c. Descending colon d. Rectum e. Pancreas except the tail f. Suprarenal glands g. Kidneys h. Ureter i. Abdominal Aorta and IVC

Answer 58

a. Stomach b. Proximal duodenum c. Jejunum d. Ileum e. Transverse colon f. Sigmoid colon g. Liver & gallbladder h. Tail of pancreas i. Spleen

Answer 59

* Triple “A”…AAA = abdominal aortic aneurysm * Common sites = just inferior to renal arteries or just proximal to bifurcation into common carotid arteries * Inferior mesenteric artery often part of the balloon of the aneurysm * If patient survives rupture…potential surgery risks = ischemic colitis…what part of the gut?..hindgut supplied by inferior mesenteric artery, spinal cord ischemia also risk if great radicular artery is damaged during surgery = anterior spinal cord syndrome

Answer 60

(i) Which part of the gut does it supply? 1. Foregut (oropharynx to hepatopancreatic ampulla (of Vater) located in duodenum) (ii) So which structures are supplied by celiac trunk? 1. Esophagus, stomach, proximal duodenum, liver/gall bladder, pancreas and spleen (iii) 3 branches of celiac trunk…common hepatic artery, splenic artery, left gastric artery

Answer 61

Small intestine (distal to heptopancreatic ampulla), large intestine (cecum, appendix, ascending colon, proximal 2/3 of transverse colon)

Answer 62

Midgut …hepatopancreatic ampulla (of Vater) to distal approximately 1/3 of transverse colon

Answer 63

1. via the mesentery 2. mesentery provides route for artery, vein, nerves and lymphatics (lacteals “drain” ingested fats from small intestine)

Answer 64

* Right/left renal arteries – supply kidneys * Right/left gonadal arteries – supply testes or ovaries (also passes through inguinal canal with ductus deferens or round ligament of the uterus)

Answer 65

1. Hindgut….distal 1/3 of transverse colon to anus

Answer 66

(i) terminal branches of abdominal aorta | (ii) bifurcation at L4