anatomy 3 - Portosystemic anastomoses-Pectinate (dentate) line Liver anatomy-Biliary structures-

Question 1

Name three clinical signs of portal hypertension, detectable on physical exam.

Answer 1

Esophageal varices, anorectal varices, and caput medusae (gut, butt, and caput)

Question 2

A patient with portal hypertension has rectal bleeding from prolapsed, dilated veins around the anus. How did this result?

Answer 2

Portosystemic anastomoses between the superior and middle rectal arteries created anorectal varices (not internal hemorrhoids)

Question 3

What clinical finding results from portosystemic anastomoses when it involves the inferior epigastric and superior epigastric veins?

Answer 3

Caput medusae in the abdomen

Question 4

An alcoholic patient has refractory gastrointestinal bleeding secondary to cirrhosis. What surgical procedure can be used to stabilize him?

Answer 4

Transjugular intrahepatic portosystemic shunt (TIPS) moves blood from the portal to hepatic veins, shunting blood to systemic circulation

Question 5

Trace the blood flow from the anus to the IVC

Answer 5

Superior rectal vein to middle inferior rectal vein to IVC

Question 6

Trace the blood flow from the esophagus to the IVC.

Answer 6

Left gastric vein to esophageal veins to azygos vein to IVC

Question 7

Trace the blood flow from the umbilicus to the IVC.

Answer 7

Paraumbilical vein to epigastric vein to IVC

Question 8

The pectinate line is formed where the embryonic ____ derivatives meet the ____.

Answer 8

Endoderm (hindgut), ectoderm

Question 9

What type of hemorrhoids occur above the pectinate line? Below the pectinate line?

Answer 9

Internal; external

Question 10

A patient presents with pain on defecation. You find that he has somatically innervated swollen masses on exam. What nerve innervates them?

Answer 10

Innervated by somatic nerves (the pudendal nerve) (these are external hemorrhoids) and thus are painful (internal hemorrhoids are not)

Question 11

A patient is diagnosed with cancer occurring above the pectinate line. What kind is it? What if it were below the pectinate line?

Answer 11

Adenocarcinoma (endodermal derivation); squamous cell carcinoma (ectodermal derivation)

Question 12

Above the pectinate line, lymphatic drainage is to what nodes?

Answer 12

Deep nodes

Question 13

Below the pectinate line, lymphatic drainage is to what nodes?

Answer 13

Superficial inguinal nodes

Question 14

Above the pectinate line, the blood supply comes from what artery?

Answer 14

The superior rectal artery (branch of the inferior mesenteric artery)

Question 15

The superior rectal artery is a branch of what artery that comes off the aorta?

Answer 15

The inferior mesenteric artery

Question 16

Innervation below the pectinate line is somatic or visceral?

Answer 16

Somatic innervation (hemorrhoids there are painful)

Question 17

Below the pectinate line, the arterial supply is from what artery?

Answer 17

The inferior rectal artery

Question 18

A 52-year-old man has rectal bleeding and a painful mass that flares up during defecation. Which nerve is involved?

Answer 18

Inferior rectal branch of the pudendal nerve (this is most likely an external hemorrhoid, which received somatic innervation)

Question 19

A patient has a tear in the anal mucosa below the pectinate line. What is this called? Where is it most likely found on the anus?

Answer 19

Anal fissure; Posteriorly (below Pectinate line, Pain on Pooping, blood on Paper; located Posteriorly where it is Poorly Perfused

Question 20

A patient with cirrhosis has internal hemorrhoids. Describe the pathway for venous drainage to the portal system, which is likely impaired.

Answer 20

Superior rectal vein to inferior mesenteric vein to portal system

Question 21

The ____ surface of hepatocytes faces the canaliculi, whereas the ____ surface faces the sinusoids

Answer 21

Apical; basolateral

Question 22

• In a patient with viral hepatitis, what zone of the liver is first affected?

Answer 22

Zone I, the periportal zone

Question 23

A patient suffers septic shock and becomes hypotensive. Which zone of the liver is first to suffer necrosis?

Answer 23

Zone III, the pericentral vein zone, which is a watershed area

Question 24

Drugs metabolized by the P-450 system are most likely to be found in which zone of the liver?

Answer 24

Zone III

Question 25

List the three parts of the liver that make up the portal triad.

Answer 25

Bile ductule, portal vein, and hepatic artery

Question 26

A man visiting from South Africa has worsening fever and hematemesis, and unfortunately dies. A postmortem liver biopsy would reveal what?

Answer 26

Hepatic necrosis in zone II (classic for yellow fever)

Question 27

Lymph drains from the liver via which histologic structure?

Answer 27

The space of Disse

Question 28

A teenaged cocaine addict presents with elevated liver enzymes. What zone of the liver is cocaine most likely affecting?

Answer 28

Zone I

Question 29

A patient has RUQ abdominal pain and a stone obstructing the common bile duct (CBD). Which two biliary ducts drain directly into the CBD?

Answer 29

The cystic duct and common hepatic duct

Question 30

Bile passes through this sphincter to enter the duodenum.

Answer 30

The sphincter of Oddi

Question 31

A patient has a colicky abdominal pain with elevated amylase, lipase, and alkaline phosphatase. What structure has become involved?

Answer 31

Ampulla of Vater (this is a gallstone that is now obstructing both biliary and pancreatic ducts)