Abdomen and Pelvis I

Question 1

Lies anterior to the left common iliac vein.

Answer 1

Left common iliac artery

Question 2

Is superior to the splenic vein in the midline.

Answer 2

Coeliac trunk

Question 3

Runs a tortuous course along the superior border of the pancreas.

Answer 3

Splenic artery

Question 4

Passes anterior to the third part of the duodenum.

Answer 4

Superior mesenteric artery

Question 5

To which of the listed group of lymph nodes do the following structures first drain?
Testis

Answer 5

Para-aortic
Lymphatics run back with the testicular artery to the para-aortic nodes lying alongside the aorta at the level of origin of the testicular arteries (L2).

Question 6

To which of the listed group of lymph nodes do the following structures first drain?

Scrotum

Answer 6

Superficial inguinal

Unlike the testis the lymphatic drainage of the scrotum is to the superficial inguinal nodes.

Question 7

To which of the listed group of lymph nodes do the following structures first drain?

Cervix

Answer 7

Iliac
The cervix drains to external and internal iliac nodes by lymphatic channels that run respectively in front of or behind the ureter, and also to the sacral nodes via the uterosacral ligaments.

Question 8

To which of the listed group of lymph nodes do the following structures first drain?

Cervix

Lower rectum

Answer 8

Iliac
The lower 1/3 rectum and upper anal canal drain to the internal and common iliac nodes along the middle rectal and inferior rectal vessels. There is also drainage to the sacral nodes and along the superior rectal (from IMA) arteries to the pre-aortic nodes.

Cancer of the rectum commonly spreads via the lymphatic vessels, thus surgical attempts at cure must include removal of all these lymphatics.

Question 9

n the following which artery and the region that it primarily supplies are incorrectly paired?
(Please select 1 option)
Left gastric:cardiac part of stomach IncorrectIncorrect answer selected
Middle colic: descending colon This is the correct answerThis is the correct answer
Right colic: ascending colon
Right gastric : pylorus of stomach
Right gastroepiploic : greater curvature

Answer 9

The middle colic supplies the transverse colon.

Question 10

Afferent fibres from the carotid sinus travel via which of the following?
(Please select 1 option)
Accessory nerve. IncorrectIncorrect answer selected
Cervical sympathetics
Glossopharyngeal nerve. This is the correct answerThis is the correct answer
Recurrent laryngeal nerve.
Vagus nerve

Answer 10

The sinu-carotid nerve (a branch of the glossopharyngeal nerve) supplies the carotid sinus and carotid body.

The fibres pass centrally to the vasomotor centre.

Question 11

A 24-year-old actress has generalised lymphadenopathy and splenomegaly. She is diagnosed to be suffering from acute myeloid leukaemia.

Answer 11

Myelocyte precursors
Acute myeloid leukaemia is characterised by a clonal proliferation of myeloid precursors with reduced capacity to differentiate into more mature cellular elements.

Question 12

A 8-year-old girl with a paravaginal mass. Biopsy confirms a diagnosis of rhabdomyosarcoma.

Answer 12

Skeletal muscle cell

The classification of a tumour as rhabdomyosarcoma requires the identification of features of skeletal muscle lineage.

Question 13

A 40-year-old teacher presents with a well circumscribed non-tender lump on her back. A diagnosis of lipoma is made.

Answer 13

Adipocyte

Lipoma is a benign tumour of predominantly adipocytes.

Question 14

The position of the ‘transpyloric plane of Addison’ is located at a point half way between the suprasternal notch of the manubrium and the symphysis pubis.
Which of the following is found at this level?
(Please select 1 option)
Bifurcation of the aorta
Entry of the ureters into the bladder
Origin of the superior mesenteric artery
Passage of the inferior vena cava through the diaphragm
Termination of the inferior mesenteric vein

Answer 14

Origin of the superior mesenteric artery

The transpyloric plane of Addison is important as it is a constant landmark even in the obese patient.

It corresponds to the body of the first lumbar vertebra.

A number of important structures are found at this level:

Spinal cord ends
Origin of superior mesenteric artery
Hilum of the kidneys
Origin of the portal vein (from the superior mesenteric and splenic veins)
Gall bladder.
The aorta terminates at the level of the fourth and fifth vertebra into the iliac arteries. The distal ureter passes over these vessels.

Question 15

On reviewing the CT films of a 65-year-old male with chronic pancreatitis the radiologist notes a structure lying posterior to the head of the pancreas.
Which of the following structures lies posterior to the head of the pancreas?
(Please select 1 option)
	 Abdominal aortic area
	 Cystic artery
	 Duodenum
	 Inferior vena cava
	 Right kidney

Answer 15

IVC

The pancreas can be divided into a head, neck, body and tail.

The head of the pancreas lies at the L2 vertebra level.

It overlies the inferior vena cava, as well as the right and left renal veins, the common bile duct and the superior mesenteric vein and artery.

Question 16

When looking at a CT scan of the pelvis, which of the following would be seen as the superior relation of the male bladder?
(Please select 1 option)
	 Levator ani
	 Obturator internus
	 Pubic symphysis
	 Rectum
	 Sigmoid colon

Answer 16

Sigmoid colon This is the correct answerThis is the correct answer
The relations of the bladder are:

Superior - Sigmoid colon, small intestine (uterus in females)
Anterior - Pubic symphysis
Posterior - Rectum, seminal vessels (vagina and cervix in females)
Lateral - Levator ani and obturator internus.

Question 17

You are assisting in a laparoscopic cholecystectomy.
During the operation the arterial supply to the gallbladder, the cystic artery, is ligated.
Of which of the following is the cystic artery a direct branch?
(Please select 1 option)
Abdominal aorta
Gastroduodenal artery
Left hepatic artery
Right hepatic artery
Splenic artery

Answer 17

Right hepatic artery

The gallbladder is normally supplied by the cystic artery which is a branch of the right hepatic artery.

The cystic artery is formed within the hepatoduodenal ligament.

The right hepatic artery is a branch of the hepatic artery.

The gastroduodenal artery also arises from the hepatic artery.

The hepatic artery is a branch of the celiac trunk, as are the splenic and left gastric arteries.

The cystic artery can be identified during surgery as it lies in the triangle formed by the liver, cystic duct and common hepatic duct.

Question 18

A 44-year-old lady with a history of alcohol abuse is brought to the emergency department after a large haematemesis.
Fluid resuscitation is started but it appears that bleeding is ongoing.
An emergency endoscopy is arranged. The gastroenterologist notes that she is bleeding from varices in the lower part of her oesophagus.
Which vein drains this area into the portal system?
(Please select 1 option)
Azygous vein
Inferior mesenteric vein
Left gastric vein
Lower oesophageal vein
Thoracic vein

Answer 18

Left gastric vein

Varicosities are formed at areas of connection between the systemic venous and portal venous systems. The most important area clinically is in the lower osesophagus, haemorrhage in this area can be fatal. The left gastric vein drains this area into the portal vein. The azygous vein is part of the systemic venous system.

Other important sites of anastamosis are the peri-umbilical region, the bare area of the liver, the retroperitoneum and the anal canal.

Question 19

A 23-year-old male attends casualty with a nose bleed following a blow to his face during a rugby match.
On examination the blood appears to be coming from the anterior inferior part of the left nostril.
What artery is likely to be the source of the bleeding?
(Please select 1 option)
The anterior ethmoidal artery
The greater palatine artery
The posterior ethmoidal artery
The sphenopalatine artery
The superior labial artery

Answer 19

The superior labial artery This is the correct answerThis is the correct answer
The superior labial artery is a branch of the facial artery and supplies the anterior inferior part of the nasal cavity.

The rest of the inferior nasal cavity is supplied by branches derived from the maxillary artery, namely the sphenopalatine and greater palatine arteries.

The superior part of the nasal cavity is supplied by the anterior and posterior ethmoidal arteries which are branches of the ophthalmic artery.

Question 20

During a road traffic accident a 76-year-old patient sustains a sternal injury and is tender over the manubriosternal joint.
Of which type of joint is the manubriosternal joint an example?
(Please select 1 option)
	 A double synovial joint
	 A fibrous joint
	 A primary cartilaginous joint
	 A single synovial joint
	 A symphysis

Answer 20

A symphysis This is the correct answerThis is the correct answer
The manubriosternal joint is a symphysis or secondary cartilaginous joint. Both articular surfaces are covered with hyaline cartilage and united by fibrocartilage.

Question 21

The greater splanchnic nerves usually synapse in which of the following?
(Please select 1 option)
Coeliac ganglion
Ganglia of the lower thoracic sympathetic trunk
Hypogastric plexus
Inferior mesenteric ganglion
Superior mesenteric ganglion

Answer 21

Coeliac ganglion

The greater splachnic nerves arise from T5-T9 and pass forwards and downwards on the sides of the vertebral bodies.

They pierce the crus of the diaphragm and then join the coeliac ganglion.

Question 22

A 67-year-old gentleman is brought to the emergency department vomiting large volumes of fresh blood. He is in a state of hypovolaemic shock.
Following resuscitation, an upper GI endoscopy is performed and a bleeding vessel is injected in the posterior aspect of the first part of the duodenum.
Which vessel is the cause of the bleeding?
(Please select 1 option)
Gastroduodenal artery
Inferior pancreaticoduodenal artery
Left hepatic artery
Right gastric artery
Right gastroepiploic artery

Answer 22

The gastroduodenal artery is a posterior relation of the first part of the duodenum. Erosion of an ulcer through the arterial wall results in severe haemorrhage.

The inferior pancreaticoduodenal artery is a branch of the superior mesenteric artery (SMA).

The gastroduodenal artery is a branch of the hepatic artery.

Question 23

A 73-year-old gentleman presents to the outpatient clinic with a swelling in the scrotum.
Further examination demonstrates that the spermatic cord cannot be palpated separately from the swelling and the lump does not transilluminate.
What is the most likely diagnosis?
(Please select 1 option)
	 Direct inguinal hernia
	 Epidydimal cyst
	 Hydrocele
	 Indirect inguinal hernia
	 Testicular tumour

Answer 23

Indirect inguinal hernia

The fact the cord cannot be palpated separately suggests that the swelling is arising from above the testicle and cord. This makes an inguinal hernia the most likely diagnosis.

Almost all direct inguinal hernias are limited to the inguinal canal and do not enter the scrotum.

A hydrocele would transilluminate.

Epidydimal cysts and testicular tumours cause scrotal swelling but the cord would be able to be palpated.

Question 24

A 46-year-old homosexual man presents to clinic complaining of a lump that has appeared from his anus.
Per rectal examination and proctoscopy reveal a hard irreducible mass arising from the lower half of the anal canal.
Which additional finding would suggest a diagnosis of squamous cell carcinoma rather than adenocarcinoma?
(Please select 1 option)
Inguinal lymphadenopathy
Liver metastases
Previous haemorrhoids
Pruritus ani
Rectal bleeding

Answer 24

inguinal lymphadenopathy

The upper half of the anal canal is lined by columnar epithelium and the lower half of the anal canal is lined by squamous epithelium.

The lymphatic drainage between the two areas is different; the upper half drains along the superior rectal vessels to the abdominal nodes whereas the lymph drains from the lower anus to the inguinal nodes.

Question 25

A 38-year-old lady presents with a pigmented lesion on her right thigh which has the appearance of a malignant melanoma.

Answer 25

Longitudinal chain of inguinal nodes
The superficial inguinal group of lymph nodes consist of a longitudinal chain and a horizontal chain of nodes. The longitudinal chain drains most of the superficial tissue of the lower limbs. The horizontal chain drains the superficial tissues of the lower trunk, buttock, external genitalia and the lower part of the anus.

Question 26

A 26-year-old male presents with right iliac fossa pain and is taken to theatre for an appendicectomy. An incision is made through the skin and onto muscle with fibres passing inferiorly in an oblique direction.

Answer 26

External oblique
The fibres of the external oblique muscle run forwards and downwards.

The fibres of the internal oblique muscle run forwards and upwards.

The tranversus abdominis has fibres running in a transverse direction.

Question 27

Whilst examining the abdomen of a 21-year-old male with abdominal pain you notice a well defined ‘six-pack’.

Answer 27

Rectus abdominis
The rectus abdominis are a pair of muscles which run from the bottom of the costal cartilages to the pubic symphysis. Three tendinous intersections firmly attach the anterior rectus sheath wall to the muscle. This produces a six pack appearance in athletic individuals.

Question 28

A 26-year-old male presents with right iliac fossa pain and is taken to theatre for an appendicectomy. An incision is made through the skin and onto muscle with fibres passing superiorly in an oblique direction.

Answer 28

Internal oblique
The fibres of the external oblique muscle run forwards and downwards.

The fibres of the internal oblique muscle run forwards and upwards.

The tranversus abdominis has fibres running in a transverse direction.
The anterior abdominal wall also comprises of the external and internal oblique muscles, transversus abdominis, pyramidalis and cremaster.

Question 29

A 70-year-old female presents with fresh red rectal bleeding and a palpable mass on digital rectal examination.

Answer 29

Rectum

It may be possible to palpate a rectal tumour during rectal examination. Rectal tumours commonly present with fresh red rectal bleeding.

Question 30

A 68-year-old male presents as an emergency with left iliac fossa pain and diarrhoea. He is pyrexial and has a high white cell count.

Answer 30

Sigmoid colon

Diverticular disease can involve any part of the gastrointestinal tract. However, the sigmoid colon is the most commonly affected site. Diverticular disease can involve the descending, ascending, and transverse colon as well as the small intestine.

Question 31

A 64-year-old man presents with weight loss and anaemia. You feel a mass in the right iliac fossa.

Answer 31

Caecum
In contrast caecal tumours are more likely to be ‘silent’ tumours with few symptoms until the tumour is advanced. They more commonly present with non-specific symptoms such as weight loss and iron deficiency anaemia.

Question 32

A 21-year-old undergoes surgery for presumed appendicitis but is found to have a normal appendix. There is a Meckel’s diverticulum on examination of the small intestine.

Answer 32

Ileum

A Meckel’s diverticulum is a true diverticulum of the ileum containing all layers of the bowel wall. It is present in approximately 2% of the population two feet from the ileocolic junction and is typically reported to be about two inches long.

Question 33

An elderly lady presents with vomiting and abdominal pain. She has a long history of recurrent right upper quadrant pain. She has not had any previous abdominal surgery, and there are no hernias on abdominal examination. An abdominal x ray suggests small bowel obstruction.

Answer 33

Ileum

Gallstone ileus is an uncommon cause of small bowel obstruction. Stones enter the gastrointestinal system via a cholecysto-duodenal fistula and migrate distally until they exit the rectum or become lodged in the narrowest part of the intestine the terminal ileum.

Question 34

Which of the following is true of the sacroiliac joint in a 20-year-old woman?
(Please select 1 option)
It has smooth articulating surfaces
It has weak ligamentous attachments
It is a fibrous joint
It is in the same sagittal plane as the common iliac artery bifurcation
The sacral sympathetic trunks descend posterior to it

Answer 34

It is in the same sagittal plane as the common iliac artery bifurcation

The common iliac artery usually bifurcates in front of the sacroiliac (SI) joint.

The SI joint is a synovial joint although it fibroses with increasing age (after the menopause in females, earlier in males).

The articulating surfaces are jagged and allow little movement due to the strength of the surrounding ligaments.

The sacral sympathetic trunks descend on the pelvic surface of the sacrum.

Question 35

In the inguinal canal, which of the following is true?
(Please select 1 option)
Lateral to the deep ring runs the inferior epigastric artery
Posterior and lateral to the deep ring runs the femoral artery
The conjoint tendon is a fusion of transversus abdominis and internal oblique
The deep ring is an aperture in the transversus abdominis muscle
The superficial ring is an aperture in the internal oblique aponeurosis

Answer 35

The conjoint tendon is a fusion of transversus abdominis and internal oblique

The deep inguinal ring is an aperture in the transversalis fascia.

The femoral artery runs behind the inguinal canal but medial to the deep inguinal ring. The inferior epigastric artery also lies medial to the deep inguinal ring, but superficial to the femoral artery. It forms a triangle (Hasselbach’s triangle) with the lateral border of the rectus abdominis muscle (medially) and the inguinal ligament (inferiorly).

A direct inguinal hernia always lies medial to the inferior epigastric artery, that is, in the Hasselbach’s triangle.

Conjoint tendon forms the medial part of the inguinal canal and is formed by the fusing fibres of transversus abdominis and internal oblique muscles.