Blue Boxes IV

Question 1

guarding

Answer 1

Involuntary contraction of anterior abdominal muscles.

Occurs with cold hands or organ inflammation (acute abdomen) in order to protect viscera from pressure.

Question 2

Injury to inferior thoracic spinal nerves (T7-T12) and iliohypogastric/ilioinguinal nerves (L1)

Answer 2

Supply motor innervation to rectus abdominis and oblique muscles in their dermatomal distributions.

If damaged during incision, will weaken muscles and predispose patient to inguinal hernias.

Incisions should follow Langer Lines to ensure proper healing.

Question 3

median incision

Answer 3

longitudinal incision along linea alba from xiphoid process to pubic symphysis.
No neurovascular damage unless well vascularized fat is exposed.

Misalignment of linea alba on closure may lead to necrosis and degeneration.

Question 4

paramedian incision

Answer 4

muscle retracted laterally to protect neurovasculature above posterior rectus sheath

Question 5

gridiron incision

Answer 5

oblique incision often used for appendectomy (splits muscle)

Question 6

McBurney Incision

Answer 6

cuts external oblique aponeurosis in direction of its fibers for retraction to reveal internal oblique/transversus abdominis muscles for splitting/retraction

Iliohypogastric n. must be preserved. If done properly, will damage no musculoaponeurotic fibers

Question 7

suprapubic incision (pfannenstiel)

Answer 7

horizontal incision above pubic symphysis.

Used for OB operations

Question 8

transverse incision

Answer 8

Not made through tendinous rectus abdominis intersections to avoid cutaneous nerves and branches of superior epigastric artery

Question 9

subcostal incision

Answer 9

used on RIGHT to access gallbladder/biliary ducts

used on LEFT to access spleen.

Question 10

pararectus/inguinal incisions

Answer 10

High risk.
Along lateral border of rectus sheath or inguinal ligament.
May damage nerve supply to rectus abdominis or ilioinguinal nerve.

Question 11

incisional hernia

Answer 11

omental or visceral herniation thru a surgical incision that has failed to heal

Question 12

direct inguinal hernias

Answer 12

Protrusion of parietal peritoneum and viscera.

Acquired herniation MEDIAL to inferior epigastric vessels.
Pushes through peritoneum and transversus fascia and into the inguinal canal Exits through the superficial inguinal ring.
Parallel and lateral to spermatic cord.

Distinguished from indirect by palpating an impulse on coughing in the inguinal canal and medial to the epigastric vessels, inguinal ligament, and rectus abdominis muscles.

Question 13

indirect inguinal hernia

Answer 13

Protrusion of parietal peritoneum and viscera.

Congenital herniation of persistent processus vaginalis.
Passes LATERAL to inferior epigastric vessels.
Pushes thru deep inguinal ring, out to superficial inguinal ring, WITHIN the spermatic cord, and superior to the testes.

Question 14

cremasteric reflex

Answer 14

Supplied by ilioinguinal nerve (L1).
Seen as a rapid testicular elevation.
Caused by a light stroke on medial, superior aspect of inner thigh.
Hyperactive in children, stimulating undescended testes.

Question 15

cancer of testis/scrotum

Answer 15

Common lymphogenous metastasis.
Testes descend from posterior abdominal wall to scrotum during development, providing separate lymphatic drainage from scrotum.

Question 16

testicular cancer

Answer 16

initial metastasis to retroperitoneal lumbar lymph nodes inferior to renal veins.
Then to mediastinal/supraclavicular nodes.
May also exhibit hematogenous spread.

Question 17

scrotal cancer

Answer 17

initial metastasis to superficial inguinal lymph nodes sitting superior to inguinal ligament along great saphenous vein.

Question 18

peritonitis

Answer 18

Inflammation of peritoneum.
Due to infection in the peritoneal cavity.
Causes exudation of serum, fibrin, and pus.
Referred pain to overlying skin, and guarding occurs.
If allowed to become generalized, (or spread throughout cavity), it may be lethal due to rapid absorption of material by the viscera.

Question 19

ascites

Answer 19

General peritonitis may occur with ulceration of stomach or duodenum, spilling acidic chyme into the peritoneal cavity, known as ascitic fluid.

May also be caused by internal bleeding, portal hypertension causing transudation, starvation (decreased plasma proteins causing decreased plasma oncotic pressure and edema, distending the abdomen).

May cause paradoxical abdominothoracic rhythm (abdomen drawn in with inspiration), shallow/rapid breathing, and shifting dullness.

Ascitic fluid or free cancer cells will flow into paracolic gutters at the lateral abdominal edges, spreading intraperitoneal infections into the pelvis, especially when upright.
May also spread up gutters from pelvis to subphrenic recess when supine.

Question 20

fluid in omental bursa

Answer 20

Perforation of posterior stomach wall or pancreatic inflammation can leak fluid into omental bursa forming a pseudo-cyst

Question 21

esophageal varices

Answer 21

Inferior esophageal veins drain to both portal and systemic venous systems, forming portosystemic anastamoses.

With portal hypertension, blood flow reverses, from portal vein through submucosal esophageal veins (to azygous v) enlarging them.
Risk of rupture and severe hemorrhage.

Question 22

hepatopancreatic ampulla blockage

Answer 22

Common bile duct and pancreatic duct join at hepatopancreatic ampulla (of Vater) to enter duodenum via sphincter of Oddi (major duodenal papilla)
May be occluded by descending gallstone causing bile backup in both ducts (or reflex caused by sphincter spasms), causing pancreatitis.
Pancreatic duct has its own pancreatic duct sphincter to prevent reflux, but is easily overwhelmed with blockage.
Accessory pancreatic duct (if present) provides a collateral through which the blockage and pressure may release.

Question 23

liver cirrhosis

Answer 23

Progressive destruction of hepatocytes with fibrous tissue replacement due to toxin exposure.
Alcoholic cirrhosis causes hepatomegaly, portal hypertension, hobnail appearance.
Portosystemic/portocaval shunts from portal venous system to IVC or left renal vein allows reduction of portal hypertension.

Question 24

cholelithiasis

Answer 24

Gallstones.
Concretion of cholesterol crystals in gallbladder, cystic or bile duct.
More common in females.
Asymptomatic unless stone is large enough to cause injury or obstruct biliary tract. Could lead to jaundice if bile backs up and goes into bloodstream.

Question 25

cholecystitis

Answer 25

Gall bladder inflammation.
Gallstone lodged in cystic duct.
Sx: biliary colic (intense spasmodic pain)

Pain in posterior thoracic wall or right shoulder due to diaphragm irritation.
May lodge in Hartmann pouch (abnormal sacculation at neck of gallbladder and cystic duct) which can empty stones into duodenum if peptic duodenal ulcer ruptures, forming a false passage between them.

Question 26

gallbladder impaction

Answer 26

Pain in epigastric region, shifting to R hypochondriac region at junction of 9th costal cartilage and linea semilunaris.

Question 27

portal hypertension

Answer 27

Produces varicosities at portosystemic anastamoses, which may rupture, causing hemorrhage.
May cause esophageal varices, caput medusa

Question 28

caput medusa

Answer 28

Recanalization of ligamentum teres to umbilicus with subsequent distention of anterior abdominal veins and paraumbilical veins

Question 29

pylorospasm

Answer 29

Spasm of pyloric stomach (infants 2-12 weeks).
Causes failure to pass food to duodenum.
Subsequent vomiting.

Question 30

congenital hypertrophic pyloric stenosis

Answer 30

Hypertrophy of pyloric smooth muscle.
Common in male infants.
Narrowing of pyloric canal causes proximal dilation of stomach due to failure to normally push chyme into duodenum by gastric peristalsis

Question 31

gastric ulcer

Answer 31

Open lesion of mucosa of stomach.

Question 32

posterior gastric ulcer

Answer 32

May erode through stomach to pancreas, referring pain to the back (via visceral afferent sympathetic fibers).
Causes erosion to splenic artery.
Severe hemoperitoneum.

Question 33

peptic (duodenal) ulcer

Answer 33

Lesion of mucosa of pyloric canal or duodenum.
Associated w/ H.pylori, chronic anxiety.
Pepsin digests mucosa.
Usually in posterior wall of superior duodenum near pylorus.
May cause adherence of liver, gallbladder, or pancreas to inflamed duodenum or secondary ulceration.

May cause ulceration of gastroduodenal a w/ hemorrhage and spillage into abdomen (peritonitis).

Question 34

vagotomy

Answer 34

Parasympathetic vagus n stimulates gastric parietal cells to secrete HCl.
Surgical section of vagal innervation will reduce acid production.
For those w/ chronic ulcers.
May occur w/ resection of ulcerated area.

Question 35

truncal vagotomy

Answer 35

rare.

Due to damage to downstream gut structures innervated by vagus

Question 36

selective gastric vagotomy

Answer 36

stomach denervated, but other structures untouched.

Question 37

selective proximal vagotomy

Answer 37

Denervates only region of stomach with parietal cells to spare gastric motility

Question 38

visceral referred pain: organ pain

Answer 38

Dull pain.
Poorly localized.
Referred to dermatome level via visceral sympathetic afferent fibers.

Question 39

visceral referred pain: gastric ulcer

Answer 39

Referred by pain afferents to T7/T8 via greater splanchnic n (synapsed at celiac ganglion).

Seen as pain in epigastric region, supplied by sensory afferents of dermatomal ventral primary rami at T7/T8

Question 40

visceral referred pain: parietal peritoneum

Answer 40

Somatic pain.
More severe and localizable due to innervation by somatic sensory fibers form thoracic nerves (ventral primary rami).
Visceral peritoneum only has sympathetic innervation.

Stretch sensitive –> rebound tenderness

Question 41

rebound tenderness

Answer 41

Extreme localized tenderness when fingers are removed after palpation

Question 42

appendicitis

Answer 42

Acute appendix inflammation.
Worsened by pressure over McBurney point.
Caused by hyperplastic lymphatic follicles occluding the appendix lumen (younger) or obstruction by fecalith that occludes lumen (older).

Appendicular lumen occlusion prevents secretion escape, causing swelling and stretching of visceral peritoneum.
Referred pain to T10 periumbilical region and RLQ.
Guarding due to pain.

May cause thrombosis of appendicular artery and perforation/ischemic necrosis of appendix.
If ruptures, leads to peritonitis.

Question 43

colonoscopy

Answer 43

Colonoscope inserted thru anus and rectum into colon to observe for tumors in sigmoid colon or rectum.
Often at rectosigmoid junction.

Question 44

diverticulosis

Answer 44

Multiple false diverticula (external evaginations of colonic mucosa) develop along intestine.
Formed from protrusions of mucous membrane only thru separations in muscle fibers – true diverticula involves entire colonic wall.

Usually occur on mesenteric side of the two nonmesenteric teniae coli at points where nutrient arteries perforate muscular layer to reach submucosa.

May rupture causing diverticulitis
May distort/erode nutrient arteries causing hemorrhage.

Mid-age to elderly.
Reduced occurrence with high fiber diet.

Question 45

greater splanchnic n (levels, synapse)

Answer 45

T5-T9

celiac ganglion

Question 46

lesser splanchnic n (levels, synapse)

Answer 46

T10-T11

superior mesenteric ganglion

Question 47

least splanchnic n (levels, synapse)

Answer 47

T12

aorticorenal ganglion